Primary Mini-Cystoscopic Ablation of Posterior Urethral Valve Mandates Second Look Cystoscopic Follow-Up
Andrew S. Nisbet, MD1, Fernando A. Ferrer, Jr., MD1,2, Katherine W. Herbst, BA2, Christina Kim, MD1,2, John H. Makari, MD1,2.
1University of Connecticut, Farmington, CT, USA, 2Connecticut Children's Medical Center, Hartford, CT, USA.
BACKGROUND: Primary endoscopic valve ablation has emerged as a preferred intervention for posterior urethral valve (PUV). Technological refinements have produced "mini-cystoscopes" with adequate working channels to facilitate valve ablation in term and even premature neonates. An additional potential advantage to mini-cystoscopic valve ablation is a reduced rate of urethral stricture. Yet, little data exist regarding the effectiveness of and appropriate follow-up after primary valve ablation with the mini-cystoscope.
METHODS: We reviewed the medical records of all patients who underwent primary endoscopic ablation of PUV with a 6 French mini-cystoscope using a 3 French hook electrode at our institution between 2002 and 2008 and who had follow-up with either voiding cystourethrography (VCUG) or second-look cystoscopy. We recorded patient characteristics, operative features, complications and the presence or absence of residual valve tissue at follow-up.
RESULTS: During this period 23 patients underwent primary endoscopic valve ablation at our institution. Of these, 10 patients underwent primary endoscopic ablation of PUV with a 6 French mini-cystoscope using a 3 French hook electrode. All 10 patients underwent postoperative VCUG and 8 underwent second-look cystoscopy. All patients were under 3 months of age at the time of initial ablation (median 11 days, range 4-85 days). 2 patients were premature (<37 weeks gestational age) and the youngest was 33 6/7 weeks gestational age. 2 patients (20%) had residual valve tissue by VCUG and 2 patients (20%) had secondary signs suggestive of residual tissue on VCUG. 6 of 8 patients (75%) who underwent second-look cystoscopy (60% of the entire cohort) were found to have residual tissue requiring repeat resection. Repeat resection was required in all patients with any positive finding on VCUG and 2 patients with negative VCUGs. 2 patients required two repeat resections. No patient developed urethral stricture after valve ablation nor were other perioperative complications observed.
CONCLUSIONS: Primary endoscopic valve ablation with the mini-cystoscope can be performed safely in term and preterm infants without producing urethral stricture. VCUG alone may be inadequate for the assessment of residual valve tissue following primary mini-cystoscopic valve ablation. Second-look cystoscopy identifies a high incidence of residual valve tissue after ablation. Repeat resection is frequently required following primary mini-cystoscopic valve ablation.