PUV. However, our results cannot prove efficacy of BNI inpreventing the development of CRF and ESRD.

The major concern regarding the application of BNI is thepossible development of retrograde ejaculation and infertil-ity. At our center no patient with PUV followed throughpuberty reported retrograde ejaculation following valve ab-lation and BNI. Until now the results of semen analysis hadbeen obtained in 6 adult patients (older than 18 years) whounderwent valve ablation with BNI. None of these patientswas included in the present series. The results were com-pletely normal in all cases except 1. In that case the ejacu-lation volume was low (approximately 1 ml), with normalsperm concentration, motility, forward progression and mor-phology. Although the number of cases in which semenanalysis was performed was too small, the procedure seemsto preserve antegrade ejaculation.

CONCLUSIONS

This study demonstrates that valve ablation with BNI is asimple and valuable treatment modality for PUV. The pro-cedure effectively improves bladder dysfunction compared tosimple valve ablation. We also suggest that the method mayprevent (or at least postpone) the development of myogenicbladder failure and CRF/ESRD in patients with PUV. More-over, the present modified technique of BNI seems to mini-mize the possibility of future retrograde ejaculation. How-ever, further studies with long-term followup throughpuberty are required to confirm this hypothesis.

Abbreviations and Acronyms

BNI � bladder neck incisionCIC � clean intermittent catheterizationCRF � chronic renal failure

ESRD � end stage renal diseasePdetmax � maximum voiding detrusor pressure

PUV � posterior urethral valvesQmax � maximum flow rateUDS � urodynamic studyUTI � urinary tract infection

VCUG � voiding cystourethrogramVUR � vesicoureteral reflux

REFERENCES

1. Podesta ML, Ruarte A, Gargiulo C, Medel R and Castera R:Urodynamic findings in boys with posterior urethral valvesafter treatment with primary valve ablation or vesicostomyand delayed ablation. J Urol 2000; 164: 139.

2. Smith GH, Canning DA, Schulman SL, Snyder HM and DuckettJW: The long-term outcome of posterior urethral valvestreated with primary valve ablation and observation. J Urol1996; 155: 1730.

3. Misseri R, Combs AJ, Horowitz M, Donohoe JM and GlassbergKI: Myogenic failure in posterior urethral valve disease:real or imagined? J Urol 2002; 168: 1844.

4. Parkhouse HF, Barratt TM, Dillon MJ, Duffy PG, Fay J, RansleyPG et al: Long-term outcome of boys with posterior urethralvalves. Br J Urol 1988; 62: 59.

5. Lopez Pereira P, Espinosa L, Martinez Urrutina MJ, Lobato R,Navarro M and Jaureguizar E: Posterior urethral valves:prognostic factors. BJU Int 2003; 91: 687.

6. Koff SA, Mutabagani KH and Jayanthi VR: The valve bladdersyndrome: pathophysiology and treatment with nocturnalbladder emptying. J Urol 2002; 167: 291.

7. Naghizadeh S, Kefi A, Dogan HS, Burgu B, Akdogan B andTekgul S: Effectiveness of oral desmopressin therapy inposterior urethral valve patients with polyuria and detec-tion of factors affecting the therapy. Eur Urol 2005; 48: 819.

8. Trockman BA, Gerspach J, Dmochowski R, Haab F, ZimmernPE and Leach GE: Primary bladder neck obstruction: uro-dynamic findings and treatment results in 36 men. J Urol1996; 156: 1418.

9. Androulakakis PA, Karamanolakis DK, Tsahouridis G,Stefanidis AA and Palaeodimos I: Myogenic bladder decom-pensation in boys with a history of posterior urethral valvesis caused by secondary bladder neck obstruction? BJU Int2005; 96: 140.

10. Kaefer M, Andler R, Bauer SB, Hendren WH, Diamond DAand Retik AB: Urodynamic findings in children with iso-lated epispadias. J Urol 1999; 162: 1172.

11. De Gennaro M, Capitanucci ML, Mosiello G, Caione P andSilveri M: The changing urodynamic pattern from infancyto adolescence in boys with posterior urethral valves. BJUInt 2000; 85: 1104.

12. Kajbafzadeh AM, Habibi Z and Tajik P: Endoscopic subu-reteral urocol injection for the treatment of vesicoureteralreflux. J Urol 2006; 175: 1480.

13. Ghanem MA, Wolffenbuttel KP, De Vylder A and Nijman RJ:Long-term bladder dysfunction and renal function in boyswith posterior urethral valves based on urodynamic find-ings. J Urol 2004; 171: 2409.

14. Glassberg KI: The valve bladder syndrome: 20 years later.J Urol 2001; 166: 1406.

15. Waterhouse K: The dilated posterior urethra. I. Male. J Urol1964; 91: 71.

16. Christensen MG, Nordling J, Andersen JT and Hald T: Func-tional bladder neck obstruction. Results of endoscopic blad-der neck incision in 131 consecutive patients. Br J Urol1985; 57: 60.

17. Moisey CU, Stephenson TP and Evans C: A subjective andurodynamic assessment of unilateral bladder neck incisionfor bladder neck obstruction. Br J Urol 1982; 54: 114.

18. Kaplan SA, Te AE and Jacobs BZ: Urodynamic evidence ofvesical neck obstruction in men with misdiagnosed chronicnonbacterial prostatitis and the therapeutic role of endo-scopic incision of the bladder neck. J Urol 1994; 152: 2063.

19. Webster GD, Lockhart JL and Older RA: The evaluation ofbladder neck dysfunction. J Urol 1980; 123: 196.

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EDITORIAL COMMENTS

The authors are to be congratulated for presenting a largecase-control series of patients treated for posterior urethralvalves, meticulously followed with serial urodynamic stud-ies. This endeavor required significant effort and resources.

There is a significant incidence of bladder dysfunctionpreceding and following the treatment of urethral valves.The question that needs to be answered is whether bladderneck incision reduces the incidence of bladder dysfunctionfollowing successful treatment. The data presented suggestthat it does, with a reported improvement in compliance anddecrease in the incidence of myogenic failure.

Whenever a treatment is assessed consideration needs tobe given to the benefits of the treatment and to the sideeffects. The benefits are well covered in this article but the

BLADDER NECK INCISION IN CHILDREN WITH POSTERIOR URETHRAL VALVES 2147

side effects are not. The followup is too short to look at theincidence of retrograde ejaculation. However, if bladder neckincision improves bladder function, then a small incidence ofretrograde ejaculation would be acceptable. Incontinence isa recognized complication after valve ablation, and incisingthe bladder neck may well increase the incidence. Improvingbladder emptying at the expense of continence would not beacceptable. It is noteworthy that the authors did not reportincontinence as a problem in either of the study groups.

The patients in this series presented at a significantlyolder age (median 1 year) than the patients at European,American and Australian centers. Perhaps irreversiblechanges occur at the bladder neck in this older group. Themajority of patients at my unit are now diagnosed prena-tally, and present within days of birth. Although this studysuggests that bladder neck incision is useful in this oldergroup, it may not be required in patients treated as neo-nates. Furthermore, if bladder neck incision does, indeed,improve bladder function, then it may be possible to reserveits use for patients with persisting poor bladder complianceor high residuals.

It is my view that adequate valve ablation alone is allthat is required. The valve causes bladder damage and ab-lating it allows the bladder changes to reverse. The level 3evidence the authors have presented is certainly interesting.However, a randomized trial comparing valve ablation withbladder neck incision to valve ablation alone would be re-quired to change my mind.

Grahame SmithChildrens Hospital at Westmead

Sydney, Australia

The small patient numbers and short followup presented inthis article preclude adopting initial incision of the bladderneck in all patients presenting with posterior urethralvalves. However, this study should cause proponents of pri-mary valve ablation alone to rethink their approach.

The take home point of this article should be that there isa subset of patients in whom primary endoscopic ablationdoes not adequately relieve the obstructive component asso-ciated with posterior urethral valve disease. Many of us whotreat pediatric patients with lower urinary tract dysfunctionhave come to understand the complexity of the lower urinarytract response to obstruction. Posterior urethral valve dis-ease is a spectrum not only of severity, but also of lowerurinary tract response. These authors demonstrate that in-cision of the bladder neck along with primary valve ablationdecreases the amount of lower urinary tract dysfunctionin comparison to patients undergoing primary valve abla-tion alone. However, the followup is too short to determine ifincision of the bladder neck is associated with increasedincontinence or retrograde ejaculation in adulthood.

The fact that there is a subset of patients who do notrespond to primary valve ablation alone should not result ina more aggressive surgical approach. Instead, it should re-sult in a more aggressive medical approach. The focus of oureffort should be to identify the subset of patients who con-tinue to have obstruction after primary valve ablation.These patients should be treated with the appropriate med-ical therapy, or vesicostomy. It appears that this subsetrepresents approximately 20% of the affected patient popu-lation. Potential therapy directed at persistent obstruction

after primary valve ablation could include alpha-blockers orclean intermittent catheterization. Children have a remark-able recuperative ability, and if the obstruction is completelyrelieved, the bladder function should return to normal.

This report should move us past the simple concept ofbladder cycling, and stimulate tertiary centers to evaluateinfants better after primary valve ablation to determine ifthe bladder is completely unobstructed. If it is not, thenaggressive medical therapy should be instituted. If medicaltherapy does not result in improved urodynamics, vesicostomyshould be considered. Primary incision of the bladder neckshould be avoided until its long-term consequences are bet-ter understood.

Patrick H. McKennaDivision of Urology

Southern University School of MedicineSpringfield, Illinois

REPLY BY AUTHORS

Although it is accepted that urethral valves must eventuallybe ablated, there is strong evidence indicating that treat-ment of PUV involves more than valve removal. Severalstudies have confirmed that despite successful ablation,bladder dysfunction and progressive decrease in renal func-tion may persist in a subset of patients with PUV. Ourresults suggest that simultaneous single 6-o’clock BNI cansubstantially reduce the incidence of urodynamic abnormal-ities in these patients after treatment.

However, Smith argues that further surgical interventionshould be reserved for patients with late presentation orwho require repeat ablation. Theoretically, delayed valveablation and prolonged bladder outlet obstruction canworsen bladder function. However, Ziylan et al reported thatchildren with late presentation PUV only had a 15% lowerincidence of detrusor overactivity but significantly impairedrenal function.1 They postulated that there is a similarpattern of bladder dysfunction independent of the age atvalve ablation. Moreover, a recent report by Bani Hani et alrevealed that 5 of 20 infants with PUV required repeatendoscopic ablation,2 compared to none of the patients whounderwent valve ablation/BNI at our center.

McKenna suggests a more aggressive medical approachor vesicostomy in nonresponders following simple valve ab-lation. Our unpublished results have shown improved void-ing and decreased upper tract dilatation in children treatedwith �-blockers following simple valve ablation which is inagreement with other reports (reference 9 in article).3,4

However, one should consider the differences in costs, side-effects and efficacy when comparing aggressive long-termmedical therapy with single stage valve ablation/BNI.

We believe that vesicostomy may have little advantagefor patients with PUV.5 Veenema et al6 and Tanagho7 dem-onstrated that bladder defunctionalization by high urinarydiversion led to decreased passive capacity. They believedthat congenitally obstructed bladders, if diverted early afterbirth, might contract and never regain function. This obser-vation was later supported by Duckett who argued that theetiology of the valve bladder was injudicious overuse of su-pravesical urinary diversion rather than an inherent detru-sor abnormality.8 Thus, application of vesicostomy for PUVmay not be generally accepted.

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