Jain Prashant, Prasad Ashish, Jain Sarika
Department of Paediatric Surgery and Paediatric Urology, BLK Centre for Child Health, BLK Super Speciality Hospital, New Delhi, India.
Department of Paediatric Surgery and Paediatric Urology, BLK Centre for Child Health, BLK Super Speciality Hospital, New Delhi, India.
J Pediatr Urol. 2021 Feb;17(1):101.e1-101.e9. doi: 10.1016/j.jpurol.2020.11.002. Epub 2020 Nov 4.
Anterior urethral valve (AUV) and anterior urethral diverticulum (AUD) are two rare causes of anterior urethral obstruction with variable presentation and anatomy. Their existence as the same or different entity is still debatable, and management has not yet been standardized.
This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD.
A retrospective review of cases diagnosed with AUV and AUD, between May 2013 and February 2020 is presented. The presentation, laboratory, radiological and endoscopic anatomy along with the management required was reviewed. A special emphasis has been given on the correlation of radiological and endoscopic anatomy and an attempt has been made to standardize the management.
A total of 8 patients with age ranging from 2 months to 9 years were reviewed. Poor urinary stream and recurrent UTI was the commonest presentation. The anatomy of the anterior urethra on VCUG (voiding cystourethrogram) and Urethrocystoscopy was correlated. Two sets of patients were identified. In the first set, five cases on endoscopy had findings of the classical valve-like fold in the anterior urethra with immediate proximal dilation of the urethra giving the appearance of a 'pseudodiverticula' without any definite opening. In three of these cases, endoscopic findings correlated well with radiological findings of 'pseudodiverticula' in which dilated proximal urethra formed an obtuse angle with the ventral floor of the urethra. The other set of four patients had a 'true diverticula' on endoscopy with a well-defined mouth and prominent distal lip, correlating well with radiological findings of a 'true diverticula' forming an acute angle with the ventral floor of the urethra. One case on endoscopy had both an anterior urethral valve with a proximal 'pseudodiverticula and a large wide-mouthed bulbar 'true diverticula'. All the patients with classical valves were successfully treated using a resectoscope while two patients with 'true diverticula' were successfully managed by incising the distal lip. One of the patients previously managed for the posterior urethral valve (PUV) had both classical valves in the anterior urethra with proximal 'pseudodiverticula' and a bulbar 'true diverticula'. The AUV was ablated with a resectoscope while 'true diverticula' required diverticulectomy. All the patients after follow up of 3 months-8 years, were asymptomatic except the one with 'true diverticulum' who remained symptomatic after TUR (Trans-urethral resection) and required vesicostomy.
AUV and AUD both can cause obstructive uropathy. The proximal dilatation related to AUV cannot be labeled as a 'true diverticula', which lacks a classical orifice. The distal obstructing lip of 'true diverticula' should not be confused with a classical mucosal valve-like fold seen in AUV. While AUV and small AUD can be treated with endoscopic ablation, large diverticula as a result of wide spongiosal defects require surgical excision. A good understanding of their radiological and endoscopic anatomy is required to differentiate them and decide for appropriate management.
Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities.
前尿道瓣膜（AUV）和前尿道憩室（AUD）是前尿道梗阻的两种罕见病因，表现和解剖结构各异。它们是否为同一实体或不同实体仍存在争议，且治疗方法尚未标准化。
本研究对诊断为前尿道梗阻的病例进行回顾性分析，并对AUV和AUD的放射学及内镜解剖结构进行相关性研究。
对2013年5月至2020年2月期间诊断为AUV和AUD的病例进行回顾性分析。回顾了临床表现、实验室检查、放射学及内镜解剖结构以及所需的治疗方法。特别强调了放射学和内镜解剖结构的相关性，并尝试对治疗方法进行标准化。
共纳入8例年龄在2个月至9岁之间的患者。尿流不畅和反复尿路感染是最常见的表现。对排尿性膀胱尿道造影（VCUG）和尿道膀胱镜检查中前尿道的解剖结构进行了相关性分析。确定了两组患者。第一组5例患者在内镜检查中发现前尿道有典型的瓣膜样褶皱，尿道近端立即扩张，形成“假性憩室”外观，且无明确开口。其中3例患者的内镜检查结果与“假性憩室”的放射学表现密切相关，即扩张的近端尿道与尿道腹侧底部形成钝角。另一组4例患者在内镜检查中有“真性憩室”，开口明确，远端唇突出，与“真性憩室”的放射学表现密切相关，即与尿道腹侧底部形成锐角。1例患者在内镜检查中既有前尿道瓣膜伴近端“假性憩室”，又有一个大的宽口球部“真性憩室”。所有有典型瓣膜的患者均使用电切镜成功治疗，而2例有“真性憩室”的患者通过切开远端唇成功治疗。1例曾接受后尿道瓣膜（PUV）治疗的患者，前尿道既有典型瓣膜伴近端“假性憩室”，又有球部“真性憩室”。用电切镜切除AUV，而“真性憩室”需要进行憩室切除术。所有患者随访3个月至8年，除1例有“真性憩室”的患者在经尿道切除术（TUR）后仍有症状且需要膀胱造瘘外，其余患者均无症状。
AUV和AUD均可导致梗阻性肾病。与AUV相关的近端扩张不能被称为“真性憩室”，因为它缺乏典型的开口。“真性憩室”的远端梗阻唇不应与AUV中所见的典型黏膜瓣膜样褶皱相混淆。虽然AUV和小的AUD可通过内镜消融治疗，但由于海绵体广泛缺损导致的大憩室需要手术切除。需要很好地了解它们的放射学和内镜解剖结构，以进行鉴别并决定合适的治疗方法。
根据我们的经验，AUV和AUD应予以鉴别，并应视为两个不同的实体。
