Bajpai M, Dave S, Gupta D K
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi.
Pediatr Surg Int. 2001;17(1):11-5. doi: 10.1007/s003830000496.
Children with posterior urethral valves (PUV) are at high risk for renal failure (RF). The outcome of renal function is significantly influenced by early diagnosis and the choice of primary therapy. We reviewed the outcome of renal function in 58 children with PUV. The choice of therapy in each case primary valve fulguration, vesicostomy, or high ureterostomy--was individually decided on the basis of the response to initial catheter drainage of the bladder. Patient age at diagnosis varied from newborn to 5.5 years, and follow-up ranged from 1.6 to 6 years (mean 3.9 years). The most common procedure was primary endoscopic valve ablation, which was carried out in 56.8% of cases. The other procedures were vesicostomy in 32.75% and high ureterostomy in 10.45%. Most neonates (66.6%) had RF at presentation, but one-half of them had achieved normal serum creatinine values at last follow-up. The recovery of renal function was lowest (33%) in older children where the diagnosis was delayed. A comparison between two groups of neonates and infants who differed on the basis of creatinine concentrations at 1 year of age suggested a statistically significant trend: children with normal or near-normal serum creatinine (0.8 mg/dl or less) by 12 months of age maintained good renal function at the time of final evaluation (1.0 mg/dl or less). Children with higher creatinine values at 1 year of age continued to have progressive RF. Seventy-five percent of the patients who had undergone early high ureterostomy after failure to respond to initial catheter drainage had regained normal renal function. We conclude that: serum creatinine at presentation is not predictive of subsequent renal function, but the values after a period of urinary-tract decompression are prognostically more useful; delay in diagnosis results in a poor outcome of renal function; and for optimal recovery of renal function, the choice of the primary procedure varies from case to case and can be determined by a systematic, stepwise approach (stepladder protocol).
患有后尿道瓣膜（PUV）的儿童面临肾衰竭（RF）的高风险。肾功能的结果受到早期诊断和初始治疗选择的显著影响。我们回顾了58例患有PUV儿童的肾功能结果。每种情况下的治疗选择——原发性瓣膜电灼、膀胱造瘘术或高位输尿管造口术——都是根据膀胱初始导管引流的反应单独决定的。诊断时患者年龄从新生儿到5.5岁不等，随访时间为1.6至6年（平均3.9年）。最常见的手术是原发性内镜瓣膜消融术，占病例的56.8%。其他手术是膀胱造瘘术占32.75%，高位输尿管造口术占10.45%。大多数新生儿（66.6%）在就诊时患有肾衰竭，但其中一半在最后一次随访时血清肌酐值已恢复正常。在诊断延迟的大龄儿童中，肾功能恢复最低（33%）。对两组根据1岁时肌酐浓度不同的新生儿和婴儿进行比较，显示出统计学上的显著趋势：12个月龄时血清肌酐正常或接近正常（0.8mg/dl或更低）的儿童在最终评估时（1.0mg/dl或更低）肾功能良好。1岁时肌酐值较高的儿童继续有进行性肾衰竭。在对初始导管引流无反应后早期接受高位输尿管造口术的患者中，75%恢复了正常肾功能。我们得出结论：就诊时的血清肌酐不能预测随后的肾功能，但尿路减压一段时间后的肌酐值在预后方面更有用；诊断延迟导致肾功能预后不良；为了实现肾功能的最佳恢复，初始手术的选择因病例而异，可以通过系统的逐步方法（阶梯方案）来确定。
