Pre‐versus postnatal presentation of posterior urethral valves: a multi‐institutional experience

Abstract

To compare the outcomes of pre-vs postnatally diagnosed posterior urethral valves (PUV) at two large paediatric centres in North America to ascertain if the prenatal diagnosis of PUV is associated with better outcomes. Patients and MethodsAll boys with PUV were identified at two large paediatric institutions in North America between 2000 and 2020 (The Hospital for Sick Children [SickKids, SK] and Children's Hospital of Philadelphia [CHOP]). Baseline characteristics and outcome measures were compared between those diagnosed pre-vs postnatally. Main outcomes of interest included progression of chronic kidney disease (CKD), the need for renal replacement therapy (RRT), and bladder function compromise, as determined by need for clean intermittent catheterisation (CIC). Time-to-event analyses were completed when possible. ResultsDuring the study period, 152 boys with PUV were treated at the SK (39% prenatal) and 216 were treated at the CHOP (71% prenatal). At the SK, there was no difference between the pre-and postnatal groups in the proportion of boys who required RRT, progressed to CKD Stage ≥3, or who were managed with CIC when comparing the timing of diagnosis. The time to event for RRT and CIC was significantly younger for prenatally detected PUV. At the CHOP, significantly more prenatal boys required RRT; however, there was no significant difference in the age this outcome was reached. The proportion of boys managed with CIC was not different but the time to event was significantly earlier in the prenatal group. ConclusionThis study represents the largest multi-institutional series of boys with PUV and failed to identify any difference in the outcomes of pre-vs postnatal detection of PUV. A multidisciplinary approach with standardisation of the treatment pathways will help in understanding the true impact of prenatal/early detection on outcomes of PUV.

The Toronto nomogram: A Bayesian meta‐regression derived prenatal ultrasound index to predict lower urinary tract obstruction and prune belly syndrome

“…In a recent study, Yadav et al . performed a multicenter review of boys with PUV comparing outcomes between those with a prenatal diagnosis versus a postnatal presentation, with the rate of prenatal detection ranging from 40% to 70% 6 . Surprisingly, they found no significant differences in outcomes between pre and postnatal presentation.…”

“…Nevertheless, approximately 10% of patients will require renal replacement therapy during childhood, over 30% will develop chronic kidney disease, and up to 40% will require clean intermittent catheterization to help with bladder emptying secondary to detrusor myogenic failure. [6][7][8] It is believed that earlier diagnosis and interventions may ameliorate long-term outcomes. Thus, prenatal diagnosis may be the key to improving outcomes.…”

“…The long‐term outcomes of LUTO are wide‐ranging due to the spectrum presented by the degree of renal dysplasia, bladder dysfunction and post‐natal additive insults. Nevertheless, approximately 10% of patients will require renal replacement therapy during childhood, over 30% will develop chronic kidney disease, and up to 40% will require clean intermittent catheterization to help with bladder emptying secondary to detrusor myogenic failure 6–8 . It is believed that earlier diagnosis and interventions may ameliorate long‐term outcomes.…”

Fetal urinary tract dilation: What to tell the parents

“…LUTO is a spectrum condition with a range of long‐term outcomes. Some children may experience mild bladder dysfunction; others may require medications and catheters to facilitate bladder dynamics, 50 up to 30% will develop chronic kidney disease and 10%–15% end‐stage renal disease during childhood or adolescence 51 …”

Chronic Kidney Disease in Boys with Posterior Urethral Valves–Pathogenesis, Prognosis and Management

“…Sarhan et al provided evidence for the latter through a large multicenter study, in which renal function was found to be better and upper urinary tract dilation milder in 315 boys with prenatal diagnoses [ 32 ]. However, two large recent studies that included 541 patients showed that there were no differences in renal outcomes between antenatal and postnatal diagnoses [ 33 , 34 ].…”