Dr. A.K. Singal MBBS (Gold Medalist), DNB, MNAMS
M.CH (AIIMS, Gold Medalist)
Stecker Scholar Pediatric Urology (USA)

Index Cases

A newborn with urinary retention due to Posterior urethral valve

B/o A.S., was found to have swelling of both kidneys (bilateral hydronephrosis) before birth at 28 week of pregnancy by ultrasound, the diagnosis of fetal or also antenatal hydronephrosis was made. The ultrasound before birth also showed bladder distension signifying that it was not emptying suggesting an obstruction in the urethra or lower urinary tract. Also, the liquor in uterus was also less than normal (oligohydramnios). Most common cause of this both sided kidneys swelling before birth is Posterior urethral valves.

The mother was advised weekly antenatal ultrasounds to see for any decrease in amniotic fluid (liquor) as it was already borderline. At 34 weeks of pregnancy, the liquor started decreasing even more in quantity, so an early delivery was planned to tackle the urinary obstruction. Preterm labor was induced and the baby was delivered. The newborn baby went into urinary retention and was catheterized immediately after birth. Due to deficiency of liquor, the baby’s lungs were also not fully developed, and the baby had mild respiratory insufficiency requiring NICU care and oxygen for 3-4 days.

At this stage, the newborn child was referred to our hospital for an expert pediatric urologist opinion and a MCU test to confirm the diagnosis or urinary obstruction. MCU test was done and it showed features of posterior urethral valves. As soon as the baby’s respiratory status improved, we undertook a newborn cystoscopy on the baby (baby was just 1.6kg). A successful endoscopic ablation of the valves was performed to relieve the urine obstruction and the baby was sent home after surgery on day 5 after removing the catheter. The baby was checked again at 3 months, one year and 5 years of age. The baby has been doing well and is passing urine in a good stream. A pediatric nephrologist is also following up the baby as some of these kids may have a risk of long-term renal insufficiency.

posterior urethral valves
MCU (VCUG) showing obstruction to urine flow due to Posterior urethral valves
PUV in a child
Baby in operation theatre at end of cystoscopy

Cystoscopic ablation of Posterior urethral valves (Endoscopic surgery for PUV in a newborn)

Posterior urethral valve is one of the common causes of renal failure in childhood. In the present era, most of the cases are diagnosed before birth as the antenatal USG in fetus (ultrasound) may show swelling in both the kidneys, large distended bladder and in severe cases decrease in amniotic fluid (oligohydramnios). Babies with suspected PUV are kept on close follow-up before and after birth. Prenatal care includes planning the delivery at a tertiary centre and USG is done every 1-2 weeks in the last trimester to check for adequacy of liquor. An early delivery may be planned if amniotic fluid decreases.

After birth, the baby is immediately catheterized and urine output charting started. A MCU or VCUG test is done and diagnosis of PUV established. Once the baby is stable, a cystoscopy is planned under anesthesia in operation theatre, sometimes as early as second or third day of life. After the ablation of valves, a catheter is kept to drain urine and also to allow healing and is removed after 5-7 days. Follow-up is mandatory with both the Pediatric Urologist and Nephrologist.

Some of the babies may have renal dysplasia at birth and have renal failure. This occurs due to kidney damage sustained even before birth. Some of the PUV babies may have borderline kidney function and ablation of valves may help in preserving that. About 25-40% of the PUV cases may require kidney transplant at some stage in their life. Early diagnosis and cystoscopy can halt the kidney damage.

We have a miniature cystoscope which can be used for cystoscopy even in babies as small as 1.5 kg. Cystoscopy in such small babies requires a lot of patience and expertise.

Over the last 12 years, more than 300 newborn babies with PUV have received a successful PUV ablation at our pediatric urology centre & hospital. They are being followed up for renal function and urinary continence by our team.

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