Fulguration of Anterior Membrane by Endoscopy (FAME): A modified technique of posterior urethral valve fulguration reduces the incidence of urethral strictures.

BACKGROUND: The standard technique of endoscopic fulguration of posterior urethral valves (PUV) involves fulguration at 5,7 and 12o'clock, with urethral stricture being a major complication. Since the anterior portion of the valve is the point of maximal obstruction, hence we modified the technique by fulgurating only the anterior part of the valve between 10 and 2 o'clock positions. We present the results of the standard and modified techniques of PUV fulguration. We hypothesised that the modified technique might reduce the risk of urethral strictures, while achieving adequate valve ablation.

METHODS: All PUV undergoing cystoscopic fulguration in our unit over a 6-year period were divided into 2 groups (group 1: standard 3-point fulguration; group 2: modified anterior fulguration). For valve fulguration, a 3F bugbee or hook electrode was used with appropriate sized compact cystoscope in all cases (6F in infants and 8/9.8F in older children). The two groups were compared for the adequacy of fulguration and urethral stricture formation during follow-up.

RESULTS: Fifty-nine cases were included (22 group 1, 37 group 2). The mean age at fulguration was comparable between both groups. Follow-up voiding cystourethrogram and check cystoscopy revealed urethral stricture in 3 and residual valves in 4 children. The incidence of urethral stricture was significantly higher (p=0.047) in group 1 (3/22, 13.6 %) compared to group 2 (0/37, 0 %); there was no difference in the incidence of residual valves between both the groups (0/19, 0 % group 1 vs 4/37, 10.8 % group 2, p=0.288).

DISCUSSION: We adopted a modified technique of PUV fulguration limiting diathermy application to the anterior part of PUV. There is no consensus on the best method of PUV ablation; commonly used techniques are cold knife and diathermy ablation. Incision with cold knife may cause bleeding, and may have a higher incidence of residual valves. Diathermy may predispose to more urethral strictures, especially when applied at 3 points circumferentially inside the small urethra, as in the standard technique of fulguration. Several autopsy and videocystoscopic studies, including our own observations, have documented that the valve is, in reality, a membrane with a posterior opening, the anterior part of the membrane being the major obstructing component. The results of the present study seem to be in agreement with this morphology of PUV.

CONCLUSIONS: The modified technique of only anterior PUV fulguration resulted in significantly reduced incidence of urethral strictures with no increase in residual valves compared to the standard technique.