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LETTER TO THE EDITOR Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 2  |  Page : 260-262
Transvesical direct visualization of Fogarty balloon catheter ablation of posterior urethral valves in the newborn


1 Department of Surgery, Shiraz and Hormozgan University of Medical Sciences, Shiraz, Iran
2 Department of Surgery, Hormozgan University of Medical Science, Shiraz, Iran
3 Department of Forensic Sciences, Iranian Legal Medicine Research Center, Shiraz, Iran
4 Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Web Publication14-Oct-2011
 

How to cite this article:
Vahid Hosseini SM, Khoshnavaz R, Zarenezhad M, Paydar S. Transvesical direct visualization of Fogarty balloon catheter ablation of posterior urethral valves in the newborn. Afr J Paediatr Surg 2011;8:260-2

How to cite this URL:
Vahid Hosseini SM, Khoshnavaz R, Zarenezhad M, Paydar S. Transvesical direct visualization of Fogarty balloon catheter ablation of posterior urethral valves in the newborn. Afr J Paediatr Surg [serial online] 2011 [cited 2014 Dec 19];8:260-2. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/2/260/86083
Sir,

Posterior urethral valves (PUVs) are the most common cause of congenital bladder outlet obstruction in boys [1],[2] and cause renal failure in 25-30% of cases before adolescence. [3] Several options for surgical management of infants with PUVs are available and the mainstay urinary diversion does not have an advantage over valve ablation in renal and bladder functions. [4],[5],[6],[7] The tiny caliber of the urethra in neonates presents a challenge for even the smallest commercially available paediatric resectoscope for primary ablation of PUVs meanwhile, in developing countries, costly endoscopic instruments may or may not be equipment. Transurethral ablation by Fogarty embolectomy catheter under transvesical visualization was ventured to evaluate the efficacy and safety of using Fogarty balloon catheter, which is much less costly and more readily available.

In a 3-year period from September 2006 to September 2009, we ablated PUV in 15 newborn boys, age median 3.5 days old (range 2-7 days) who had severe obstructive uropathy caused by PUVs. Five out of 15 had severe acidosis, dehydration and renal failure and the rest with obstructive uropathy.

Ultrasound scan of the abdomen confirmed the presence of the dilated kidneys, ureters and prostatic urethra together with distended and hypertrophied bladder in the babies. With a diagnosis of PUV, a size 6 F infant feeding tube was inserted into the urethra in all babies, except in five patient to empty the bladder. All bladder were drained with a suprapubic 8 F catheter. After stabilization, micturating cystourethrogram (MCU) was performed to confirm the diagnosis. After confirmation, through direct transvesical visualization with 10 F cystoscope that passed to bladder via site of cystostomy under general anesthesia a size 6FFogarty catheter was inserted into the bladder and withdrawn further into the prostatic urethra then reinflated and a sharp pull was then made on the catheter to rupture the valves. The patients were discharged with an indwelling urethral catheter for 2 weeks and cystostomy tract was kept opened until MCU was repeated after 2-months to document the success. [Figure 1] and [Figure 2] In our 15 patients, relief of obstruction was dramatic in all patients except in three patients for whom two attempts at ablation repeated. Patients remained in good health at follow-up 3-6 months after balloon ablation. All patients showed improvement in reflux, renal and bladder function.
Figure 1: Direct visualization of PUV by cystoscopy throgh cystostomy site and inflated baloon fogarty shows PUV

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Figure 2: Two month later VCUG-PUV ablation

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In older children, valve ablation can be performed with relative ease by endoscopic resection or diathermy fulguration. This would be the treatment of choice. For very small neonates, however, it may be difficult and the risk of stricture formation is greatly as if electric current causing deep tissue injury. [8] Urethral stricture was seen in 50% when treatment was instituted in boys less than 1 year old and urinary incontinence is as high as 30%. [8] In the Diamond and Ransley study, [9] the patients were put under anesthesia, and placement of the Fogarty balloon catheter against the valves was done under radiologic control.

We modified the technique first by making a diagnosis of PUV based on clinical and ultrasound and obtained bladder drainage and patients stabilized. The Fogarty balloon was inserted under transvesical visualization for seeing the complete ablation. Therefore, in developing countries where neonatal urologic endoscopes are not always available, Fogarty balloon ablation is a safe alternative to endoscopic procedures Although complications such as stricture and damage to the sphincter were not encountered in this series of neonates with a short follow-up, studies of more patients with a longer follow-up needed to prove the safety of the procedure.

 
   References Top

1.Chertin B, Cozzi D, Puri P. Long-term results of primary avulsion of posterior urethral valves using a Fogarty balloon catheter. J Urol 2002;168:1841-3.  Back to cited text no. 1
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2.Farhat W, McLorie G, Capolicchio G, Khoury A, Bägli D, Merguerian PA. Outcome of primary valve ablation versus urinary tract diversion in patients with posterior urethral valves. Urology 2000;56:653-7.  Back to cited text no. 2
    
3.Ghanem MA, Wolffenbuttel KP, De Vylder A, Nijman RJ. Long-term bladder dysfunction and renal function in boys with posterior urethral valves based on urodynamic findings. J Urol 2004;171:2409-12.  Back to cited text no. 3
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4.Smith GH, Canning DA, Schulman SL, Snyder HM 3 rd , Duckett JW. The long-term outcome of posterior urethral valves treated with primary valve ablation and observation. J Urol 1996;155:1730-4.  Back to cited text no. 4
    
5.Williams DI, Whitaker RH, Barratt TM, Keeton JE. Urethral valves. Br J Urol 1973;45:200-10.   Back to cited text no. 5
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6.Whitaker RH, Sherwood T. An improved hook for destroyingposterior urethral valves. J Urol 1986;135:531-2.   Back to cited text no. 6
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7.Zaontz MR, Firlit CF. Percutaneous antegrade ablation of posteriorurethral valves in infants with small caliber urethras: An alternativeto urinary diversion. J Urol 1986;136:247-8.   Back to cited text no. 7
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8.Crooks KK. Urethral strictures following transurethral resection of posterior urethral valves. J Urol 1982;127:1153-4.   Back to cited text no. 8
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9.Diamond DA, Ransley PG. Fogarty balloon catheter ablation of neonatal posterior urethral valves. J Urol 1987;137:1209-11.  Back to cited text no. 9
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Correspondence Address:
Seyed Mohammad Vahid Hosseini
Department of Surgery, Division of Pediatric Surgery, Shiraz and Hormozgan University of Medical Sciences, Nemazi Hospital
Iran
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DOI: 10.4103/0189-6725.86083

PMID: 22005384

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