Tuesday, November 18, 2014

Historical Contribution: 1929, Young, Posterior Urethral Valves

Posterior urethral valves: Congenital valve obstruction of the prostatic urethra. Young HH, McKay RW. Surg Gynecol Obstret 1929; 48:509.


Within this manuscript is the "classic" description of posterior urethral valves (PUV) and the first classification system taught to urologists to define the disease. PUV, or congenital valvular obstruction of the prostatic urethra, was described as a medical entity in the late-1700's and was first described in the medical literature by Dr. Conrad Johann Martin Langenbeck in 1802. In the first portion of this manuscript, Young and McKay detail the history of PUV from Langenbeck to their description including thoughtful descriptions of autopsy series, case reports and clinical outcomes from around the world. Common among all these reports was that all cases were found at autopsy or incidental discoveries during other genitourinary operations.

From Tolmatschew in 1870.

The etiology of PUV was unknown with a number of hypotheses put forward including: persistence of the urogenital membrane, or anomalous development of the Wolffian and Muellerian ducts. Young recognized that PUV was a clinical heterogeneous entity, with patients having a variety of clinical presentations and outcomes. Part of the objectives of this manuscript was to present a unifying theory of PUV – a challenging feat that Young recognized, "Apparently no single theory, as stated previously, will explain satisfactorily the formation of [PUV]."


The History of PUV at Johns Hopkins

The first cystoscopic diagnosis of PUV was at Johns Hopkins in 1912. The first curative, transurethral surgery was performed one year later, in 1913, by HH Young. By 1915, with a combination of cystoscopic evaluation and cystogram, Young and colleagues were able to demonstrate the clinical association between PUV and significant vesicoureteral reflux (VUR) often seen in the disease. In 1916, Young modified his famous "punch" operation for the prostate to the treatment of PUV in two patients. By 1919, Young, Frontz and Baldwin from Johns Hopkins reported 12 cases of PUV, of which 8 were treated transurethrally. The four patients who did not undergo treatment died of complications of urinary obstruction and renal failure.

Description of Cases and Clinical Outcomes from Hopkins

In this manuscript from 1929, Young added 21 cases from the Brady Urological Institute to the world's literature of 41 treated cases of PUV. This can be considered a very early, systematic review of PUV before that concept existed. In typical HH Young fashion, the clinical circumstances and outcomes of each case are recorded and reported with meticulous detail. Young reviews the "Symptomatology" or clinical presentation of patients, the diagnostic algorithm including differential diagnosis, treatment strategies including the prepatory treatment, and prognosis.
Importantly, incorporating all these concepts with careful attention to detail, Young was able to classify PUV into three main types (figure below):
  • Type I: valves of the distal verumontanum, classified into (a) two separate valves, (b) two fused valves, and (c) and unilateral single valve.
  • Type II: a bifurcated valve from the distal verumontanum to the more proximal prostatic urethra.
  • Type III: an "iris-like" valve above the verumontanum.


When describing the clinical outcomes the first nine patients treated with the modified "punch procedure," HH Young demonstrated: six curative treatments, one curative treatment with resulting incontinence and two deaths (one due to sepsis following treatment, one death due to sepsis prior to treatment). Young was extremely selective in choosing patients for an operation, as he recognized many patients had end-stage renal disease – a terminal condition at the time. According to Young, "These results show conclusively that the punch operation was the method of choice but should always be preceded by thorough prepatory drainage until functional tests show sufficient improvement in renal function to warrant an operation."

The "punch procedure" modified for posterior urethral valves (PUV).


In summation, Young stressed the following points in the work-up and treatment of PUV – much of which are still relevant today!
  • Initial evaluation should involve:
    • Anatomic investigation of the upper tracts
    • Investigation of renal function
  • Initial management can involve insertion of small catheters to gain adequate drainage of the bladder and evaluate subsequent renal function.
  • Cystoscopic evaluation and possible treatment (punch procedure) is the second step in management of these children and can be very effective in carefully selected patients.


To read the entire manuscript: follow the link above, visit the Centennial Website or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy!