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 weeks by ultrasound. There was bladder distension also signifying that it was not emptying suggesting an obstruction in the urethra or lower urinary tract. Most common cause of this is Posterior urethral valves.
 
The mother was advised weekly ultrasounds to see for any decrease in amniotic fluid (liquor) occurs as it was already borderline. At 34 weeks of pregnancy, the liquor started decreasing in quantity, so an early delivery was planned to tackle the urinary obstruction.  Preterm labor was induced and the baby was delivered. The baby went into urinary retention 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 for 3-4 days.
 
At this stage we were consulted. A MCU was done and it showed features of posterior urethral valves. As soon as the baby’s respiratory status improved we undertook a cystoscopy on the baby (baby was just 1.6kg). A successful endoscopic ablation of the valves was performed and the baby was sent home on day 5. 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 long term renal insufficiency.
 
MCU (VCUG) showing obstruction to urine flow
due to Posterior urethral valves
Baby in operation theatre at end of cystoscopy
Cystoscopic ablation of Posterior urethral valves
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 (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 catheterised and urine output charting started. A MCU or VCUG is done and diagnosis 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 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 two years, more than 40 babies with PUV have received a successful PUV ablation at our services. They are being followed up for renal function and urinary continence by our team.
 
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