OXYBUTYNIN FOR POSTERIOR URETHRAL VALVES IN NEWBORNS1520

ment in bladder capacity and compliance when pa-tients are followed without intervention after initialablation.11,12 Thus, we acknowledge it is not clearfrom this pilot study whether the improvements wenoted in bladder function would have occurred inde-pendent of anticholinergic treatment. However, re-view of the past literature and comparison to histor-ical controls suggest these improvements are greaterthan those achieved without anticholinergics. Never-theless, this perceived positive effect needs validationin larger controlled trials. Therefore, based on theseencouraging observations, we propose a randomizedprospective trial evaluating the early use of anticho-linergic therapy in patients with PUVs. Additionally,

recent studies have demonstrated that the persistent

REFERENCES

EDITORIAL COMMENT

ingly, the study also demonstrated the paradoxical

bladder neck obstruction from muscle hypertrophymay contribute to persistent bladder dysfunction inpatients with PUVs.13 Thus, we propose adding atreatment arm for empiric alpha-antagonist therapyin this prospective trial.

CONCLUSIONS

This pilot study demonstrates that the early use ofanticholinergic therapy in infants with high voidingpressures and/or small bladder capacity after pri-mary PUV ablation has beneficial effects on bladderfunction. Prospective randomized studies are neededto better define the role of anticholinergics in this

patient population.

1. Ansari MS, Gulia A, Srivastava A et al: Riskfactors for progression to end-stage renal dis-ease in children with posterior urethral valves.J Pediatr Urol 2010; 6: 261.

2. Peters CA, Bolkier M, Bauer SB et al: The uro-dynamic consequences of posterior urethralvalves. J Urol 1990; 144: 122.

3. Holmdahl G, Sillén U, Hanson E et al: Bladderdysfunction in boys with posterior urethral valvesbefore and after puberty. J Urol 1996; 155: 694.

4. Franco I, Horowitz M, Grady R et al: Efficacy andsafety of oxybutynin in children with detrusorhyperreflexia secondary to neurogenic bladderdysfuntion. J Urol 2005; 173: 221.

5. Glassberg KI: The valve bladder syndrome: 20

6. Ichino M, Igawa Y, Seki S et al: The nature ofhigh-pressure voiding in small boys and its rela-tion with the influence of a transurethral cathe-ter. Neurourol Urodyn 2008; 27: 319.

7. Yeung CK, Godley ML, Ho CK et al: Some newinsights into bladder function in infancy. Br J Urol1995; 76: 235.

8. Kim YH, Horowitz M, Combs AJ et al: Manage-ment of posterior urethral valves on the basis ofurodynamic findings. J Urol 1997; 158: 1011.

9. Puri A, Bhatnagar V, Grover VP et al: Urodynam-ics-based evidence for the beneficial effect ofimipramine on valve bladders in children. Eur

10. Misseri R, Combs AJ, Horowitz M et al: Myo-genic failure in posterior urethral valve disease:real or imagined? J Urol 2002; 168: 1844.

11. De Gennaro M, Mosiello G, Capitanucci ML et al:Early detection of bladder dysfunction followingposterior urethral valves ablation. Eur J PediatrSurg 1996; 6: 163.

12. Youssif M, Dawood W, Shabaan S et al: Earlyvalve ablation can decrease the incidence ofbladder dysfunction in boys with posterior ure-thral valves. J Urol 2009; 182: 1765.

13. Androulakakis PA, Karamanolakis DK, TsahouridisG et al: Myogenic bladder decompensation inboys with a history of posterior urethral valves iscaused by secondary bladder neck obstruction?

years later. J Urol 2001; 166: 1406. J Pediatr Surg 2005; 15: 347. BJU Int 2005; 96: 140.

As with far too many aspects of contemporary clin-ical practice, pediatric urologists have long admin-istered oxybutynin to infants and children with pos-terior urethral valves, ostensibly to restore normalcyin the function of these bladders affected by outletobstruction. And while previous studies have demon-strated safety and tolerability (reference 4 in article),the authors should be lauded for this pilot study inrigorously following a cohort of infants measuring theurodynamic consequence of oxybutynin.

The present study lacks a control group and val-idated parameters of normal bladder compliance,voiding pressures and residual volume in small in-fants with which to compare outcomes after anti-cholinergic therapy. Nevertheless, the study demon-strates unequivocally that initially high voidingpressures and poor bladder compliance were amelio-rated after the initiation of oxybutynin. Interest-

finding that for 5 of 9 patients with initially highresidual volumes, anticholinergics actually led todecreases in those volumes.

Bladders affected by congenital outlet obstructiondemonstrate abnormal genotypic and myofilamentchanges that clinically endanger the upper tracts,increase the risk of urinary tract infection and con-demn many children to prolonged incontinence. Thepresent study will rightly encourage further con-trolled studies examining the role of medications,gene therapy and clinical interventions such as over-night bladder drainage in reaching the elusive goalof restoring normal bladder phenotype and functionin children with posterior urethral valves.

Aseem R. Shukla

Departments of Urologic Surgery and PediatricsUniversity of Minnesota

Minneapolis, Minnesota