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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 7-10

Foley catheter avulsion of posterior urethral valves: An alternative in resource poor setting


1 Department of Surgery, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, Nigeria
2 Department of Radiology, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, Nigeria

Date of Web Publication13-Mar-2015

Correspondence Address:
O A Sowande
Department of Surgery, Paediatric Surgery Unit, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, P M B 5538 Ile Ife, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.153141

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  Abstract 

Background: The gold standard for the treatment of posterior urethral valves (PUV) in children is endoscopic ablation of the valves under direct vision. This study reports the use of Foley's catheter balloon in the ablation of posterior urethral valves in children in a developing center in Nigeria.
Patients and Methods: Thirteen patients with PUV seen at the Obafemi Awolowo University Teaching Hospital in Ile Ife between January 2004 and March 2008 were included. The patients' age ranged from 7 days to 3 years.
Results: The obstruction was completely relieved in 12 out of the 13 patients(88.9%). There were no cases of significant hemorrhage, perineal hematoma, or urinary extravasations. All mothers reported good urinary stream and absence of straining at micturition. Six patients had bilateral hydronephrosis on pre-avulsion USS while 4 had vesico-ureteric reflux on micturating cystourethrogram. All patients had resolution of the hydronephrosis on follow up USS and the electrolytes and urea status has remained normal during the follow-up period ranging from 3 months to 1 year.
Conclusion: Foley catheter ablation of PUV in children is a simple and cost-effective technique and may offer an alternative in resources limited environment.

Keywords: Urethral valve ablation, foley catheter, posterior urethral valves


How to cite this article:
Sowande O A, Salako A, Adewale O T, Adesoji A, Olusegun T A, Mopelola A C. Foley catheter avulsion of posterior urethral valves: An alternative in resource poor setting . Arch Int Surg 2015;5:7-10

How to cite this URL:
Sowande O A, Salako A, Adewale O T, Adesoji A, Olusegun T A, Mopelola A C. Foley catheter avulsion of posterior urethral valves: An alternative in resource poor setting . Arch Int Surg [serial online] 2015 [cited 2022 Dec 1];5:7-10. Available from: https://www.archintsurg.org/text.asp?2015/5/1/7/153141


  Introduction Top


Posterior urethral valves (PUV) are the most common cause of urinary tract obstruction in male children. Worldwide, the incidence varies from 1 in 3000 to 25000 live births. [1],[2],[3] The incidence among Nigerian children, as in most developing nation, is unknown. Untreated prolonged urinary obstruction leads to back pressure effects culminating in bladder hyperplasia, sacculation, diverticulum, hydroureter, and hydronephrosis and ultimately renal failure and death. In the fetus, bladder outlet obstruction can lead to renal dysplasia and may interfere with normal lungs developments. [4] Early intervention is important to prevent these complications. In most developed countries, prenatal diagnosis by renal ultrasonography (USS) is possible with possible prenatal shunting procedures to prevent damage to the developing kidneys. In developing countries, [5] most children present postnatally and often with complications.

The gold standard for the treatment of PUV is endoscopic ablation of the valves under direct vision using electrocautery or NDYAG laser. [6],[7] These facilities are rarely available in developing centers such as ours. In 1986, Diamond and Ramsley [8] introduced the technique of primary ablation of PUV using Fogarty's catheter as a potentially useful technique for developing countries. The procedure has been found to be safe and effective even in the neonatal period. [9],[10] In 1988, Kalicinski also reported on the use of Foley's catheter to disrupt the valves in children. [11] At the Obafemi Awolowo University Teaching Hospital in Ile Ife, Nigeria, patients with PUV had to undergo open resection of the valves via the bladder because of non-availability of suitable scopes. This approach is fraught with danger of injury to the sphincteric mechanism and is difficult to accomplish because of the narrow male pelvis.

The aim of this study is to report the use of Foley's catheter balloon avulsion of posterior urethral valves in children in a developing center in Nigeria.


  Patients and Methods Top


Thirteen patients with PUV seen at the Obafemi Awolowo University Teaching Hospital in Ile Ife between January 2004 and March 2008 were included in the study. All children were stabilized; fluid, electrolytes, and anemia were corrected, while any infection was treated with parenteral antibiotics. The patients were placed on continuous urethral catheter drainage until surgery. The diagnosis of PUV was confirmed with USS and Micturating Cystourethrogram (MCUG) [Figure 1]. None of the patients had evidence of chronic renal failure (Serum creatinine less than 1mg/dl).
Figure 1: Pre-ablation Micturating Cystourethrogram in a 3-year-old boy showing the classical spinning top appearance in PUV

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Technique

Under general anesthesia in the supine position, the bladder was filled with normal saline, and the urinary stream and the force required to empty the bladder was assessed by suprapubic pressure [Figure 2]. A size 6 Foley's catheter is inserted into the bladder and the balloon filled with 3 cc of sterile water. For the neonate who is uncircumcised, the prepuce is freed from the glans and retracted back. The inflated catheter balloon is drawn against the bladder neck and the sterile water in the balloon is gradually withdrawn until there is a give and sudden elongation of the catheter indicating that the partially deflated balloon has slipped into the dilated posterior urethra. The catheter is then forcefully pulled out of the urethra, which also causes the balloon to burst in the process. The procedure is repeated at least two times. After each procedure, the urine is assessed for the presence of any remnant of the valves. The urinary bladder is filled once again with normal saline, and the urinary stream and force required to empty the bladder is again assessed using suprapubic pressure [Figure 3]. A size 6-8 Foley's catheter is inserted into the bladder and left in place for 5 days following which, the child is allowed to micturate spontaneously. Any post-avulsion bleeding, hematoma, or extravasations of urine was noted. The electrolyte and urea status of the patients were monitored postoperatively. The post ablation MCUG was not done routinely unless patient can afford it before discharge [Figure 4]. Postprocedure USS is done 2 weeks later and during subsequent follow up to evaluate the upper tract. At follow up, maternal assessment of the urinary stream in those out of diaper, presence of continuous urinary leak from the meatus (incontinence), and presence of straining at micturition was also documented.
Figure 2: Pre-ablation photograph of a neonate showing poor bladder emptying from suprapubic pressure

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Figure 3: Post-ablation urinary stream has improved significantly after balloon avulsion (same patient as in Figure 2)

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Figure 4: Same patient as in Figure 1 showing absence of posterior urethral dilatation 2 weeks after balloon ablation of the PUV

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  Results Top


The patients' age ranged from 7 days to 3 years (median, 2 months). Five of the patients were neonates. All valves were type 1 variant on MCUG. Six of the patients had bilateral hydronephrosis on pre-avulsion USS while 4 had vesico-ureteric reflux (grades 2-3) on MCUG. There were no cases of frank hemorrhage (although the initial urine was blood stained in some patient), perineal hematoma, or urinary extravasations. Twelve out of the 13 patients (88.9%) reported consistent good urinary stream without biochemical evidence of renal deterioration. The procedure failed in a 3-year-old who continued to experience straining at micturition in the immediate post-avulsion period. He later underwent open trans-vesical excision of the valves with good results. All mothers reported absence of straining at micturition and were satisfied with the outcome of treatment. There was complete resolution of the hydronephrosis in 4 of the 6 patients with bilateral hydronephrosis on follow-up USS, and the postoperative urinary stream and electrolytes and urea and creatinine status remained normal during follow-up period ranging from 3 months to 1 year.


  Discussion Top


The treatment of posterior urethral valves has evolved over the years from the days of open transvesical excision through perineal urethrotomy and excision, the use of various hooks under fluoroscopy or blindly, and cystoscopic excision via the suprapubic approach to the modern endoscopic fulguration of valves using electrocautery or Nd-YAG laser. [6],[7] Early diagnosis, improved patient care, and technology as well as improved surgical techniques and availability of antibiotics contributed to improved outcome in this group of patients. [6] This is however not the case in many developing countries where late presentation and absence of appropriate instruments is the norm. Therefore, there is a need to find a cheaper and easily available means of treating patients with PUV in these developing centers.

This study showed that balloon ablation using the commonly available Foley's catheter is a good and effective means of achieving relieve of urinary obstruction in children with posterior urethral valves. The technique of balloon avulsion was introduced as a possible cheap means of valve ablation for newborn in developing countries by Diamond and Ramsley [8] using the Fogarty catheter. This has been confirmed by other authors to be useful in newborns with PUV in whom there is no appropriate sized cystoscope. [9],[10] We however did not limit the use of the balloon to newborns, as only 5 of the 13 children reported in this study were newborns. The technique was especially useful in the newborn as it avoids the need to do a vesicostomy in these infants, which may lead to skin excoriation and social alienation because of the urine smell.

Earlier studies were conducted using Fogarty's catheter balloon under fluoroscopy whereby the pull of the catheter can be controlled. The Fogarty's catheter is difficult to obtain in our center and the fluoroscopic machine was not available. We decided to use the Foley's catheter as an alternative, which is cheap and easily available. In our observation, the balloon usually ruptures during the withdrawal of the catheter. This procedure was well tolerated by all patients and it helped to achieve complete relief from the obstruction in majority of the patients. Only one patient required conversion to the open transvesical approach. Our technique using the Foley's catheter was blind, thereby increasing the risk of urethral injuries and possibility of urethral stricture in the future. We did not encounter any obvious urethral injuries in this series although the withdrawal of the catheter is usually followed by minimal bleeding, which was not significant. Even with endoscopic procedures, the incidence of post-ablation stricture is reported to vary from 0% to 50 %, especially in the first year of life; [12],[13],[14],[15] none of our patients had any features of stricture during the short follow-up period.

Another possible complication is urinary incontinence, which after endoscopic valve ablation can be as high as 30%. [16] This incontinence has been attributed to dilatation of the posterior urethra, the non-compliant valve bladder, or due to valve ablation itself. [17] None of the patients that had successful balloon ablation had incontinence (continuous dribbling of urine from the meatus) in the immediate period or during follow up.

The primary aim of managing a child with PUV is not only to save life but also to improve the long-term functional outcome. Therefore, long-term follow up is essential irrespective of the method of ablation is used. However, despite the advances in the management of PUV, 24-45% of patients suffer progressive deterioration leading to renal failure and subsequently renal transplantation. [18],[19],[20],[21],[22] Although reports on the long-term outcome of using the Fogarty's balloon catheter avulsion for primary ablation of PUV are few, Boris et al. [23] reported a good outcome in their patients. However, the long-term outcome of this approach in the management of posterior urethral valve in a resource-limited setting is unknown. Careful follow up of these patients is necessary, but this has always being a major problem in most developing centers. Therefore, adoption of blind avulsion of posterior urethral valves in children should be undertaken with caution.

In contrast to many other reports where the use of the balloon catheter has been limited to newborns, we have used this technique even in older children up to 3 years of age with good results. We believe that the Foley's catheter balloon avulsion technique can be useful in the relieving urinary obstruction secondary to PUV where endoscopic techniques are not available but care must be taken, especially since it is a blind procedure. Inability to visually confirm avulsion by endoscopy and inability to obtain post avulsion MCU is a big limitation in this study. A larger cohort of patients and long-term follow up is necessary to confirm its role in the management of these patients further, especially in the developing countries.

In conclusion, Foley's catheter, which is easily available, may be useful for ablation of PUV in children in developing centers but its safety and effectiveness requires further evaluation in a larger study with radiological and endoscopic guidance and assessment.

 
  References Top

1.
Yohannes P, Hanna M. Current trends in the management of posterior urethral valves in the paediatric population. Urol 2002;60:947-53.  Back to cited text no. 1
    
2.
Casale AJ. Early ureteral surgery for posterior urethral valves. Urol Clin North Am 1990;17:361-72.  Back to cited text no. 2
    
3.
Atwell JD. Posterior Urethral valves in the British Isles: A multicenter B.A.P.S review. J Pediatr Surg 1983; 18:70-4.  Back to cited text no. 3
    
4.
Clifton MS, Harrison MR, Ball R, Lee H. Fetoscopic transuterine release of posterior urethral valves: A new technique. Fetal Diagn Ther 2008;23:89-94.  Back to cited text no. 4
    
5.
Okafor HU, Ekenze SO, Uwaezuoke SN. Posterior urethral valves: Determinants of outcome in a developing country. J Paediatr Child Health 2013;49:115-9.  Back to cited text no. 5
    
6.
Puri P, Ninan G. Posterior urethral valves. In: Puri P, editor. Surgery of the Newborn. Vol. 87. Oxford: Butterworth-Heinemann; 1996. p. 623-34.  Back to cited text no. 6
    
7.
Mathews R. Endoscopy of the lower urinary tract. In: Gearhart JP, Rink RC, Mouriquand PD, editors. Pediatric Urology. Vol. 37. Philadelphia: WB Saunders Co 2001. p. 595-606.  Back to cited text no. 7
    
8.
Diamond DA, Ransley PG. Fogarty balloon catheter ablation of neonatal posterior urethral valves. J Urol 1987;137:1209-11.  Back to cited text no. 8
[PUBMED]    
9.
Kyi A, Maung M, Saing H. Ablation of Posterior urethral valves in the newborn using Fogarty balloon catheter: A simple method for developing countries. J Pediatr Surg 2001;36:1713-6.  Back to cited text no. 9
    
10.
Waheed T, Rehman I, Khan Z, Rehman H, Jan QA, Imran M. Fogarty balloon catheter ablation of posterior urethral valves in neonates. J Med Sci 2008;6:46-9.  Back to cited text no. 10
    
11.
Kalicinski ZH Foley's balloon procedure in posterior urethral valves. Dialogues in Paediatr Urol 1988;11:7.  Back to cited text no. 11
    
12.
Lal R, Bhatnagar V, Mitra DK. Urethral strictures after fulguration of posterior urethral valves. J Pediatr Surg 1988;33:518-9.  Back to cited text no. 12
    
13.
Hendren WH. Complications of urethral valves surgery. In: Smith RB, Skinner DG, editors: Complications of urologic surgery, Prevention and management. Philadelphia: PA Saunders; Vol. 16. 1976. p. 305-35.  Back to cited text no. 13
    
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Myers DA, Walker RD 3rd. Prevention of urethral strictures in the management of posterior urethral valves. J Urol 1981:126:655-7.  Back to cited text no. 14
    
15.
Nijman RJ, Scholtmeijer RJ. Complications of transurethral electro-incision of posterior urethral valves. Br J Urol 1991;67:324-6.  Back to cited text no. 15
    
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Whitaker RH, Keeton JE, Williams DI. Posterior urethral valves: A study of urinary control after operation. J Urol 1972;108:167-71.  Back to cited text no. 16
    
17.
Campaiola JM, Perlmutter AD, Steinhardt GF. Non-compliant bladder resulting from posterior urethral valves. J Urol 1985;134:708-10.  Back to cited text no. 17
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18.
Bryant JE, Joseph DB, Kohaut EC, Diethelm AG. Renal transplantation in children with posterior urethral valves. J Urol 1991:146:1585-7.  Back to cited text no. 18
    
19.
Parkhouse HF, Woodhouse CR. Longterm status of patients with posterior urethral valves. Urol Clin North Am 1990;17:373-8.  Back to cited text no. 19
    
20.
Ross JH, Kay R, Novick AC, Hayes JM, Hodge EE, Streem SB. Long-term results of renal transplantation into the valve bladder. J Urol 1994;151:1500-4.  Back to cited text no. 20
    
21.
Groenewegen AA, Sukhai RN, Nauta J, Scholtmeyer RJ, Nijman RJ. Results of renal transplantation in boys treated for posterior urethral valves. J Urol 1993:149:1517-20.  Back to cited text no. 21
    
22.
Holmdahl G, Hanson E, Hanson M, Hellström AL, Sillén U, Sölsnes E. Four-hour voiding observation in young boys with posterior urethral valves. J Urol 1998:160:1477-81.  Back to cited text no. 22
    
23.
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. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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[Pubmed] | [DOI]



 

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