Robert L. Lebowitz, M.D. Children' s Hospital, Harvard Medical School Boston, Massachusetts

Posterior Urethral Valves

Black baby boy with prenatal diagnosis of hydroureteronephrosis, a thick bladder wall, and oligohydramnios. After delivery in another country, his serum sodium began to rise, his serum potassium began to decrease and his creatinine level began to rise as well. VCUG elsewhere (Figure 1) showed a very thick bladder wall. The bladder was filled so full that trabeculations were effaced. There was a large bladder diverticulum but no left-sided reflux was seen. Posterior urethral valves were diagnosed (Figure 2). Ultrasonography of the kidneys and bladder with a catheter in the bladder showed bilateral hydroureteronephrosis and a very thick-walled bladder with an empty lumen (Figure 3). He was transferred to Children's Hospital and three days later, after three days of catheter drainage, a repeat VCUG was performed. The scout film showed nondiluted contrast material, previously undetected reflux from the VCUG three days ago, still filling a dilated left pelvicaliceal system and dilated tortuous ureter (Figure 4). This meant that:

1. there had been left reflux,
2. there was left distal ureteral obstruction, and
3. the contrast material had not been diluted so that the left kidney must not be making urine.

The VCUG showed that there was a very thick-walled bladder. There was also a left bladder diverticulum and the left distal ureter was obstructed at the wall of the diverticulum (Figure 5). Posterior urethral valves were confirmed. DMSA scan confirmed no function in the left kidney. Serum creatinine rose to 2.4 and so high loop ureterostomies were created, an unusual operation in this era, and done because of his worsening and precarious condition. His serum creatinine stabilized at 1.5. He will return in several months for left nephroureterectomy, closure of right ureterostomy, and fulguration of valves.