A Method to Assess Posterior Urethral Valve Ablation

O. Bani Hani, K. Prelog and G. H. H. Smith*

From the Childrens Hospital at Westmead (Royal Alexandra Hospital for Children), Westmead, New South Wales, Australia

Purpose: There are few published reports addressing the assessment of posterior urethral valve ablation. This study was
performed to provide a ratio to measure successful treatment of posterior urethral valves.
Materials and Methods: A total of 35 patients with posterior urethral valves were treated by a single surgeon between 1995
and 2004. Of these patients 23 were younger than 1 year at diagnosis and were selected for this study. A urethral ratio was
calculated by dividing the posterior urethral diameter by the anterior urethral diameter. A total of 31 males undergoing
cystography for urinary tract infections were evaluated as normative controls. The urethral ratio was also measured and
calculated for these patients.
Results: Median patient age was 1.5 months. In 13 patients preoperative cystograms were available and in 20 patients
postoperative cystograms were available for review. Measurements were made of the posterior urethral and anterior urethral
diameters. Median preoperative ratio in 13 patients was 8.6. This ratio decreased postoperatively to 3.1 in 15 patients who
only required 1 ablation and 8.0 in 5 patients who required a second ablation. After a second ablation the ratio decreased to
3.1. The 5 cases requiring a second ablation were initially managed by cystoscopy and a flexible electrode. None of the patients
treated initially with a resectoscope required a second ablation. Urethral ratio was 2.6 in 31 normal males undergoing
cystogram for investigation of a urinary tract infection.
Conclusions: Calculating urethral ratio in patients with posterior urethral valves allows objective measurement of the
technical success of valve ablation.

Key Words: urethra, urethral obstruction, vesico-ureteral reflux, pediatrics

he management of PUVs remains controversial. Most MATERIALS AND METHODS

T authors now agree that valve ablation is the best

primary treatment.1–3 However, there are no clear
guidelines to assess the technical success of this therapy.
The indications for vesicostomy and high diversion are dis-
puted among authors.3 Most would agree that monitoring
renal function, hydronephrosis, vesicoureteral reflux, uri-
nary stream and bladder emptying is essential.4,5 However,
these parameters often change slowly, during the course of
several months. The bladder is able to compensate for con-
tinuing partial outlet obstruction.
A pediatric urology specialist may treat 3 to 4 patients
with PUVs annually. However, a pediatric surgeon or urol-
ogist with a combined adult and pediatric practice may treat
only 1 patient every few years. To our knowledge there are
no data available to compare outcomes in patients treated by
these different groups of surgeons.
How can the adequacy of valve ablation be assessed?
Some authors recommend followup VCUG,6 while others
recommend followup cystoscopy.7 In both instances postop-
erative assessment is based on qualitative factors and clin-
ical judgment. Does the posterior urethra look less dilated?
Is the valve leaflet still visible? No quantitative guidelines
have been given. In this study we attempted to develop a
simple, objective, quantitative measurement of the success
of valve ablation.
Submitted for publication September 29, 2005.
* Correspondence: Department of Urology, Childrens Hospital at
Westmead, Westmead, New South Wales, 2145, Australia.
A total of 35 cases of PUVs were diagnosed and managed by
a single surgeon between 1995 and 2004. Patient identifica-
tion and demographic information were collected prospec-
tively. Median patient age at diagnosis was 3.5 months
(range 1 to 130). Of the patients 23 were younger than 1 year
at diagnosis, and this group was selected for the study.
Patients older than 1 year were excluded because this group
generally had a good prognosis and we were always able to
treat them with 1 valve ablation. In almost all cases cysto-
grams were done elsewhere and were not available for re-
view.
A total of 16 patients presented following prenatal diag-
nosis and 7 presented after a urinary tract infection. The
diagnosis was confirmed by VCUG. The standard manage-
ment plan was to perform valve ablation and then to repeat
the VCUG at 6 to 8 weeks postoperatively. Depending on the
clinical progress and VCUG appearance, a repeat ablation
was performed.
We retrospectively collected data on the cystoscopic
method of valve ablation from the operative reports. Sur-
geon preference was to use an 11Fr resectoscope with a
Collins knife and a cutting diathermy current. When the
urethra was too small for this instrument a 9Fr cystoscope
with a 2.4Fr flexible electrode was used.
In most cases VCUG images were stored in the hospital
picture archiving and communications system. The preoper-
ative and postoperative x-rays of 3 patients were performed
elsewhere and could not be traced. In 13 patients preopera-
tive and postoperative images were available for review, and

0022-5347/06/1761-0303/0 303 Vol. 176, 303-305, July 2006

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/S0022-5347(06)00562-3
304 METHOD TO ASSESS POSTERIOR URETHRAL VALVE ABLATION

FIG. 1. Preoperative urethral measurement in patient with PUV FIG. 3. Urethral measurement in control patient

in 7 patients only postoperative images were available for

ablation was 8.6 (range 4 to 14.7). A catheter was left in-
review, giving a total of 20 patients with postoperative im-
dwelling in 4 of these patients.
ages available for the study.
Postoperative films were available in 20 patients and the
We defined UR as the diameter of the posterior urethra
median UR was 3.4 (range 1.9 to 15.5). The postoperative
divided by the diameter of the anterior urethra measured
group was divided into patients requiring only 1 valve abla-
during the voiding phase on an oblique film (figs. 1 and 2).
tion and those requiring a second ablation. In the 15 pa-
The diameter of the posterior urethra was measured trans-
tients requiring 1 ablation the ratio decreased to 3.1 (range
versely at a point halfway between the bladder neck and the
1.9 to 4) postoperatively. In the 5 patients requiring a second
distal end of the membranous urethra. The diameter of the
ablation the ratio decreased to 8.0 (range 5 to 15.5) after the
anterior urethra was measured as a transverse diameter at
first ablation and to 3.1 (2.9 to 6.4) after the second ablation
the point of the maximum distention in the bulbar urethra.
(fig. 4). A catheter was left indwelling in 2 of the 5 patients
We aimed to measure these diameters on a voiding film
requiring a second ablation.
without a catheter. Both measurements were taken on the
We judged an arbitrary UR value of 3.5 to be represen-
same film.
tative of adequate valve ablation and relief of obstruction. To
If several films were available, measurements were made
demonstrate reproducibility of the ratio, 15 measurements
on the image where the anterior urethra was most dis-
were taken by the first and third authors (OBH, GHHS) and
tended. The measurements were made separately by 2 au-
compared. There was agreement on satisfactory or unsatis-
thors (OBH, KP) and then a consensus was reached. To show
factory valve ablation in 11 patients and disagreement in 4
reproducibility, another set of 15 measurements was made
(see table). All of the films where disagreement occurred
by the first and third authors (OBH, GHHS) and compared.
revealed a catheter in the urethra on voiding, which compli-
As a control group, the same urethral ratio was calculated for
cated the measurement.
31 age matched males who had a normal VCUG as part of the
A pediatric resectoscope was used in 8 of 21 cases for the
evaluation for suspected urinary tract pathology (fig. 3).
initial ablation, and the remaining 13 were managed by
cystoscope and flexible electrode. All of the patients requir-
RESULTS ing a second ablation were treated initially with the cysto-
Median age for the controls was 4 months (range 1 to 11), scope and flexible electrode.
and median UR was 2.6 (1.3 to 5.5). Median age for the study
group was 1.5 months (range 1 to 12). Preoperative films
were available in 13 patients and the median UR before

FIG. 4. Change in urethral ratio with ablation and repeat ablation.

FIG. 2. Postoperative urethral measurement in patient with treated
PUV.
Paired t test comparing ratio of preoperative group to that of post-
operative group revealed mean UR in 12 patients with paired films
decreased from 9.7 to 5.1 (p ⬍0.01) after first procedure. After
second procedure mean ratio in 5 patients with paired films de-
creased from 8.7 to 3.8 (p ⬍0.02).
 METHOD TO ASSESS POSTERIOR URETHRAL VALVE ABLATION
No. GHHS
No. OBH, KP Satisfactory Unsatisfactory
Satisfactory 3 4
Unsatisfactory 0 8
This group of 20 patients was followed for a median of
27.5 months (range 6 to 97). One patient required a renal
transplant and 1 is receiving dialysis.
DISCUSSION
Shopfner and Hutch studied the normal urethra on VCUG
and described its radiological and anatomical features.8 Po-
pek et al looked at the histological and pathological changes
in the urethra with development and with obstruction.9
Both groups hypothesized that the posterior urethra has the
capacity to stretch with increased voiding pressure due to its
unique histological and anatomical configuration, in con-
trast to the anterior urethral segment. There is variability of
urethral measurement depending on the stage of voiding,
voided volume and position of the penis.
Ideally, a catheter should not be left in the urethra on
voiding films. In reality some patients do not void without a
catheter, and a film showing the urethra with a catheter in
place is better than no film at all. An indwelling catheter will
tend to decrease the urethral ratio by decompressing the
posterior urethra and opening the anterior urethra.
Endoscopic valve ablation is the preferred treatment for
posterior urethral valves. The aim of the procedure is to
relieve infravesical obstruction. Duckett and Snow observed
that approximately 20% to 30% of patients require a second
procedure to achieve satisfactory valve ablation.10 They
stated that it was preferable to undercut rather than to
overcut, to avoid the risk of urethral stricture or inconti-
nence. Our incidence of repeat valve ablation was slightly
higher than that of Duckett and Snow. All patients who
required a second ablation were younger than 1 month, and
were initially treated with cystoscopy and flexible electrode
ablation.
Some authors recommend routine cystoscopic followup
after valve ablation.7 This procedure has the advantage of
allowing assessment of the valve ablation and further ther-
apy if needed. However, it has the disadvantage of being
more expensive and more invasive than repeat VCUG. Most
authors accept that repeat VCUG at 6 weeks after valve
ablation is the best method of assessing surgical outcome.4
We have demonstrated that urethral ratio can be measured
and that a decrease in this ratio appears to correlate with
our clinical assessment of a satisfactory valve ablation.
It could be argued that a better assessment of PUV ab-
lation could be made with preoperative and postoperative
urodynamic studies. To perform urodynamic studies in in-
fants, it is necessary to insert a suprapubic catheter to avoid
interfering with urethral resistance during voiding. We be-
305
lieved that this procedure was too invasive in infants who
were often unwell and had impaired renal function.
Reviewing our data, we believed that a ratio of 3.5 rep-
resented an acceptable result postoperatively. This estimate
meant that 4 of 31 controls had a UR greater than 3.5 and 1
patient with PUV had a UR of more than 3.5 after we had
completed what we considered a successful ablation. Fur-
ther studies will be needed to adjust the UR considered
acceptable after treatment, and to confirm these findings.
CONCLUSIONS
Urethral ratio is a simple measurement that allows quanti-
tative assessment of valve ablation. It allows preoperative
and postoperative VCUGs from different facilities to be com-
pared. Perhaps with further data it can become a validated
method of assessing satisfactory valve ablation.
Abbreviations and Acronyms
PUV ⫽ posterior urethral valve
UR ⫽ urethral ratio
VCUG ⫽ voiding cystourethrogram
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