İdrar Yolu Enfeksiyonu ile Başvuran 9 Aylık Erkek Olgu
Özet
Bu çalışma, posterior üretral valv (PUV) tanılı ve antenatal takipsiz olup yenidoğan döneminde cerrahi öyküsü bulunan, dokuz aylık bir erkek olguyu sunmaktadır. Ateş yüksekliği ve idrar yolu enfeksiyonu ile başvuran hastada, yapılan ultrasonografide çift taraflı evre 4 hidronefroz, üreteral dilatasyon saptanmış ve fışkırtarak işeyemediği öğrenilmiştir. Laboratuvar tetkiklerinde idrar kültüründe Klebsiella pneumoniae üreyen hastaya yatırılarak tedavi uygulanmış, yapılan değerlendirmeler ve DMSA sintigrafisi sonucunda sağ böbrekte belirgin boyut ve fonksiyon kaybı saptanmıştır. Erkek çocuklarda alt üriner sistem tıkanıklığının en sık nedeni olan PUV; mesane hipertrofisine, hidroüreteronefroza ve böbrek hasarına yol açmaktadır. Takipsiz kalan bu olguda, yüksek mesane basıncını ve ikincil gelişen vezikoüreteral reflüyü (VUR) kontrol altına almak amacıyla antikolinerjik tedavi, temiz aralıklı kateterizasyon (TAK) ve nihayetinde vezikostomi uygulanmıştır. Cerrahi ve medikal tedavilere rağmen olgu iki yaşında Evre 3 kronik böbrek hastalığı (KBH) olarak değerlendirilmiş ve takibine devam edilmiştir. PUV'lu çocuklarda uzun vadeli morbidite ve son dönem böbrek yetmezliği gelişme riski yüksek olduğundan, hastaların antenatal dönemden puberteye kadar klinik, laboratuvar ve ürodinamik yöntemlerle yakın takibi hayati önem taşımaktadır.
This study presents a nine-month-old male patient diagnosed with posterior urethral valve (PUV), who was without antenatal follow-up and had a surgical history in the neonatal period. In the patient presenting with high fever and urinary tract infection, ultrasonography revealed bilateral stage 4 hydronephrosis and ureteral dilatation, and it was learned that he could not void with a stream. In laboratory tests, Klebsiella pneumoniae grew in the urine culture, leading to inpatient treatment; evaluations and DMSA scintigraphy revealed significant loss of size and function in the right kidney. PUV, which is the most common cause of lower urinary tract obstruction in male children, leads to bladder hypertrophy, hydroureteronephrosis, and kidney damage. In this patient who missed follow-ups, anticholinergic therapy, clean intermittent catheterization (CIC), and eventually vesicostomy were performed to control high bladder pressure and secondary vesicoureteral reflux (VUR). Despite surgical and medical treatments, the patient was evaluated as Stage 3 chronic kidney disease (CKD) at two years of age and follow-up was continued. Since the risk of long-term morbidity and end-stage renal disease is high in children with PUV, close monitoring of patients from the antenatal period to puberty with clinical, laboratory, and urodynamic methods is of vital importance.
Referanslar
Bingham G, Rentea RM. Posterior Urethral Valve. 2021 Aug 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
Diamond DA, Chan IHY, Holland AJA, Kurtz MP, Nelson C, Estrada CR Jr, Bauer S, Tam PKH. Advances in paediatric urology. Lancet 2017;390(10099):1061-1071. doi: 10.1016/S0140-6736(17)32282-1.
Casella DP, Tomaszewski JJ, Ost MC. Posterior urethral valves: renal failure and prenatal treatment. Int J Nephrol. 2012:351067.
Krishnan A, de Souza A, Konijeti R, Baskin LS. The anatomy and embryology of posterior urethral valves. J Urol 2006;175(4):1214-20.
Rodriguez MM. Congenital Anomalies of the Kidney and the Urinary Tract (CAKUT). Fetal Pediatr Pathol. 2014;33(5-6):293-320. doi: 10.3109/15513815.2014.959678.
Mitchell ME: Persistent ureteral dilatation following valve ablation. Dialogues Pediatr Urol 1982; 5: 2.
Farrugia MK. Fetal bladder outflow obstruction: Interventions, outcomes and management uncertainties. Early Hum Dev 2020; 150:105189. doi: 10.1016/j.earlhumdev.2020.105189.,
Stonebrook E, Hoff M, Spencer JD. Congenital Anomalies of the Kidney and Urinary Tract: A Clinical Review. Curr Treat Options Pediatr. 2019;5(3):223-235. doi: 10.1007/s40746-01900166-3.
Khursigara N, McGuire BB, Flood H. Late presentation of posterior urethral valves. Can J Urol. 2011;18(3):5739-41.
Stonebrook E, Hoff M, Spencer JD. Congenital Anomalies of the Kidney and Urinary Tract: A Clinical Review. Curr Treat Options Pediatr 2019;5(3):223-235. doi: 10.1007/s40746-01900166-3.
Deshpande AV. Current strategies to predict and manage sequelae of posterior urethral valves in children. Pediatr Nephrol 2018;33(10):1651-1661. doi: 10.1007/s00467-017-3815-0.
Sharma S, Joshi M, Gupta DK, et al. Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty. J Indian Assoc Pediatr Surg 2019;24(1):4-14. doi: 10.4103/jiaps.JIAPS_148_18.
Sanna-Cherchi S, Ravani P, Corbani V, et al.. Renal outcome in patients with congenital anomalies of the kidney and urinary tract. Kidney Int 2009; 76: 528–533.
Smith EA. Role of a Preoperative Catheter Regimen in Achieving Early Primary Endoscopic Valve Ablation in Neonates with Posterior Urethral Valves. Reply. J Urol 2022;207(1):246. doi: 10.1097/JU.0000000000001817.
de Jesus LE. Bladder dysfunction depends on many variables in children with posterior urethral valves. Int Braz J Urol 2022;48(1):87-88. doi: 10.1590/S1677-5538.IBJU.2021.0046.1.
Basak D. Evolution of Management of Posterior Urethral Valve. J Indian Assoc Pediatr Surg 2021;26(6):367-369. doi: 10.4103/jiaps.jiaps_119_21.
Vasconcelos MA, E Silva ACS, Gomes IR, et al.. A clinical predictive model of chronic kidney disease in children with posterior urethral valves. Pediatr Nephrol 2019;34(2):283-294. doi: 10.1007/s00467-018-4078-0.
Chiodini B, Ghassemi M, Khelif K, et al. Clinical Outcome of Children With Antenatally Diagnosed Hydronephrosis. Front Pediatr 2019;7:103. doi: 10.3389/fped.2019.00103.
Long CJ, Bowen DK. Predicting and Modifying Risk for Development of Renal Failure in Boys with Posterior Urethral Valves. Curr Urol Rep. 2018;19(7):55. doi: 10.1007/s11934-0180801-4.
