
==== Front
Urol Ann
Urol Ann
UA
Urol Ann
Urology Annals
0974-7796
0974-7834
Wolters Kluwer - Medknow India

UA-16-218
10.4103/ua.ua_105_23
Original Article
The effect of use of alpha-blockers in posterior urethral valve pediatric patients postvalve ablation in the absence of further outlet obstruction
Aboulela Waseem Nabil
Eladawy Mahmoud Shoukry 1
Latif Ahmed Abdel 2
Department of Urology, Cairo University, Cairo, Egypt
1 Department of Urology, Fayoum University, Fayoum, Egypt
2 Department of Urology, Beni-suef University, Beni-suef, Egypt
Address for correspondence: Dr. Waseem Nabil Aboulela, Kasr Al Ainy Hospital, Cairo University, Kasr Al Ainy Street, Cairo, Egypt. E-mail: Waseem.nabil@kasralainy.edu.eg
Jul-Sep 2024
03 7 2024
16 3 218220
25 10 2023
02 4 2024
Copyright: © 2024 Urology Annals
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Objectives:

The objectives of this study were to detect whether the use of alpha-blockers in posterior urethral valve (PUV) pediatric patients after valve ablation will improve the persistent obstructive symptoms despite the absence of obstruction and if there are associated side effects of its use.

Patients and

Methods: A prospective, single-blinded randomized study was conducted at the urology department of two hospitals on 50 male children between September 2019 and June 2021 with PUV. All children were treated by endoscopic ablation of PUV using the cold knife and were followed clinically for voiding symptoms and with ultrasonography and laboratory tests. All patients underwent second-look cystoscopy 1 month after primary valve ablation to see residual valves as a routine procedure confirming no remnant of the valve and still complaining of obstructive symptoms. They were divided into two equal groups 25 patients each. Group A was given alpha-blockers and Group B placebo for 1 month.

Results:

Marked improvement of obstructive symptoms in Group A reaching about 90% (21 patients), whereas no mentioned improvement in Group B was noticed with no side effects of both medication the alpha-blocker and the placebo during its use.

Conclusion:

The use of alpha-blockers improves the obstructive symptoms in pediatric patients with PUV after valve ablation and in the absence of any further urethral obstruction with no side effects noticed during the period of its use.

Alpha-blocker
obstructive symptoms
posterior urethral valve
residual urine
ultrasound
==== Body
pmcINTRODUCTION

Posterior urethral valves (PUV) are life-threatening congenital anomalies causing lower urinary tract obstruction in male neonates.[1] The incidence is 1 in 1250 in a population undergoing fetal US screening.[2] Clinical presentation varies according to the degree of outlet obstruction which depends on the severity and configuration of the valves if not early managed.[3] It can cause renal failure in 25%–30% of cases before adolescence, in addition to other morbidities such as urinary tract infection, vesicoureteral reflux, voiding dysfunction, and even death.[4]

Management of PUVs remains a real challenge, requiring long-term management through childhood to avoid progressive structural and functional deterioration of both upper and lower urinary tracts.[5]

The main and gold standard therapy is endoscopic ablation of the valve as early as it can be. If there are residual valve remnants after ablation, it may result in progressive dysfunction of the urinary bladder and the upper tract.[6] Second-look cystoscopy 1 month after primary cystoscopy and valve ablation for detection of residual valve remnants and to assess pre- and postablation prognostic factors is important. If no obstruction is found, then the cause is functional either due to high bladder neck or affected detrusor contractility.[7]

Our aim of the study was in cases with no anatomical infravesical obstruction, to detect whether the use of alpha-blockers in PUV pediatric patients after valve ablation will improve the persistent obstructive symptoms with monitoring of the possibility of associated side effects of the use of alpha-blockers in pediatric age group by close monitoring of the patients.

PATIENTS AND METHODS

A prospective, double-blinded randomized study was conducted at the urology departments of two hospitals on 50 male children between September 2019 and June 2021 with PUV. All children were treated by endoscopic ablation of PUV using the cold knife and were followed clinically for voiding symptoms and with ultrasonography for residual urine and laboratory tests, especially creatinine. Our assessment was divided into subjective methods by monitoring the urine flow and objective methods by doing ultrasonography for residual urine and laboratory tests, especially creatinine. All patients underwent 2nd look cystoscopy one month after primary valve ablation to see residual valves as a routine procedure confirming no remnant of valve. They are still complaining of obstructive symptoms which is proved to us by taking a video of the child during micturition which is a subjective method and by measuring residual urine after micturition which is considered objective method. we considered significant residual urine if more than 50 cc in children less than 1 year and more than 100 cc in children more than 1 year old. Also by laboratory tests especially creatinine if there rise of creatinine from the baseline before starting the study.

They were divided into two equal groups 25 patients each. Group A was given alpha-blockers and Group B placebo for 1 month. It was a randomized double-blinded controlled study where 50 closed envelopes 25 of them containing tamsulosin 0.4 mg tablet as an alpha-blocker and the other 25 containing a placebo which we choose to be paracetamol 150 mg syrup. Both drugs were instructed to be given as a single dose per day at night and in the case of tamsulosin tablet, put the tablet in a small amount of water and stirring well till it dissolves in the water and then the children drink the water.

We asked the parents to monitor their children for the improvement of obstructive symptoms for 1 month and to provide us with a video of their child during micturition taken before they come to us in the clinic for assessment and also to monitor the measurement of blood pressure at least one time daily for their children during the uptake of treatment. Recording any new symptoms that may appear during this month, especially in the general condition of their infants example fatigue, drowsiness, and headache. We supplied them with a questionnaire paper to answer and provide it to us at the time of the visit to the clinic for assessment [Table 1]. We reviewed all patients after 1 month and record their comments, analyzed them, and do abdominopelvic ultrasound for residual urine.

Table 1 Questionnaire given to the parents of the children

Question		Yes		No		Blood pressure value daily	
Is there improvement in urine flow?							
Is there any noticed new symptoms during treatment?							
Is there any missing doses of the treatment?							
Was the drug taken at night?							

The data were statistically described in terms of standard deviation, mean, median, range or frequencies (number of cases), and percentage when appropriate. All statistical calculations were done using the computer program SPSS (the Statistical Package for the Social Sciences Inc., Chicago, IL., USA) version 15 for Microsoft Windows, and the graphs were done using Microsoft Excel 2007.

Comparisons between variables of two groups were done by Mann–Whitney rank sum test for nonparametric data. Comparing categorical variables was done by the Chi-square test or Fischer’s exact test for a small sample size.

RESULTS

Marked improvement of obstructive symptoms in Group A reaching about 90% (21 patients), whereas no mentioned improvement in Group B was noticed (P < 0.005). The improvement is detected in both the subjective method by comparing the video taken by the parents before treatment and that taken by them before visiting our clinic after 1 month of treatment and by reviewing the questionnaire paper given to them. And also by doing ultrasound for residual urine after 1 month and compare it with the pretreatment value of residual urine and doing serum creatinine after 1 month and compare it with the pretreatment basal creatinine. No side effects of both the alpha-blocker and the placebo during their use by reviewing the questionnaire paper given and reading the values of blood pressure measured which was considered normal if not <90/60. The age in all patients was <5 years old, ranged at presentation from 0 to 53 months, with a mean age of 8.3 ± 12.6 months. In most of the cases, 43 (86%) patients were ≤1 year, whereas only 7 (14%) patients were >1 year [Table 2].

Table 2 Summary of our results

Drug		Alpha-blocker		Placebo	
Number of patients		25		25	
Improvement of obstructive symptoms		21 (90%)		0	
No improvement in obstructive symptoms		4 (10%)		25	
Blood pressure measurement		Normal in 25 patients		Normal in 25 patients	
Appearance of other symptoms		0		0	
Residual urine		Improvement of residual urine in 21 patients		No improvement in residual urine in 25 patients	
Creatinine		No change		No change	

DISCUSSION

To the best of our knowledge, this is the first prospective randomized double-blinded controlled study to assess the role of alpha-blockers in the improvement of obstructive symptoms in pediatric patients with PUV after ablation and in the absence of any further anatomical obstruction.

Abraham et al. in a study on 64 patients concluded that there was a reduction of 85% in the pretreatment postvoiding residual (PVR) volume.[8] Kareem and Hassan showed that with the use of doxazosin, 83% of patients showed improvement in their symptoms where the mean postvoid residual volume decreased by 72.7% of the pretreatment mean PVR and the increment in the maximum flow rate was 68.4%.[9] Bajpai et al. showed that the mean pretreatment PVR in the interventional group decreased from 110 ± 22.62 ml to 15 ± 8.21 ml as compared to the control group. Similarly, there was a significant increase in the mean flow rate of the interventional group from 8.50 ± 2.71 ml/s to 14.3 ± 21 ml/s as compared to the control group (7.1 ± 1.9–8.7 ± 2.3 ml/s) in a retrospective study done on 113 patients in India.[10] In our study, marked improvement of obstructive symptoms in Group A reaching about 90% (21 patients) who took alpha-blocker, whereas no mentioned improvement in Group B was noticed who took the placebo. Furthermore, improvement of posttreatment PVR in Group A, whereas no improvement in PVR in Group B. No side effects of both the alpha-blocker and the placebo during their use.

The drawback of our study is the small number of patients included in the study and the short-term follow-up of the patients for only 1 month. Our recommendations are to do more prospective studies with a large number of patients and to follow-up the patient for at least 6 months to detect any possible side effects of the treatment on the pediatric population.

CONCLUSION

The use of alpha-blockers improves the obstructive symptoms in pediatric patients with PUV after valve ablation and in the absence of any further urethral obstruction with no side effects noticed during the period of its use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
==== Refs
REFERENCES

1 Heikkilä J Holmberg C Kyllönen L Rintala R Taskinen S Long-term risk of end stage renal disease in patients with posterior urethral valves J Urol 2011 186 2392 6 22014822
2 Thomas DF Gordon AC Management of prenatally diagnosed uropathies Arch Dis Child 1989 64 58 63 2647045
3 Nasir AA Ameh EA Abdur-Rahman LO Adeniran JO Abraham MK Posterior urethral valve World J Pediatr 2011 7 205 16 21822988
4 Hutton KA Management of posterior urethral valves Curr Paediatr 2004 14 568 75
5 Sarhan O El-Ghoneimi A Hafez A Dawaba M Ghali A Ibrahiem el-H Surgical complications of posterior urethral valve ablation: 20 years experience J Pediatr Surg 2010 45 2222 6 21034948
6 Burmeister D AbouShwareb T D’Agostino R Jr. Andersson KE Christ GJ Impact of partial urethral obstruction on bladder function: Time-dependent changes and functional correlates of altered expression of Ca²⁺ signaling regulators Am J Physiol Renal Physiol 2012 302 F1517 28 22442207
7 Mirone V Imbimbo C Longo N Fusco F The detrusor muscle: An innocent victim of bladder outlet obstruction Eur Urol 2007 51 57 66 16979287
8 Abraham MK Nasir AR Sudarsanan B Puzhankara R Kedari PM Unnithan GR Role of alpha adrenergic blocker in the management of posterior urethral valves Pediatr Surg Int 2009 25 1113 5 19727771
9 Kareem DA Hassan OA The role of alpha blockers in the treatment of children with voiding dysfunction Iraqi Postgrad Med J 2016 15 459 64
10 Bajpai M Baba A Singh AK Postablation and α-1 blocker therapy in children with congenital obstructing posterior urethral membrane Formos J Surg 2021 9 [doi: 10.4103/fjs.fjs_97_20]
