Factors affecting outcome in the management of posterior urethral valves

Abstract

Children with posterior urethral valves (PUV) are at high risk for renal failure (RF). The outcome of renal function is significantly influenced by early diagnosis and the choice of primary therapy. We reviewed the outcome of renal function in 58 children with PUV. The choice of therapy in each case primary valve fulguration, vesicostomy, or high ureterostomy--was individually decided on the basis of the response to initial catheter drainage of the bladder. Patient age at diagnosis varied from newborn to 5.5 years, and follow-up ranged from 1.6 to 6 years (mean 3.9 years). The most common procedure was primary endoscopic valve ablation, which was carried out in 56.8% of cases. The other procedures were vesicostomy in 32.75% and high ureterostomy in 10.45%. Most neonates (66.6%) had RF at presentation, but one-half of them had achieved normal serum creatinine values at last follow-up. The recovery of renal function was lowest (33%) in older children where the diagnosis was delayed. A comparison between two groups of neonates and infants who differed on the basis of creatinine concentrations at 1 year of age suggested a statistically significant trend: children with normal or near-normal serum creatinine (0.8 mg/dl or less) by 12 months of age maintained good renal function at the time of final evaluation (1.0 mg/dl or less). Children with higher creatinine values at 1 year of age continued to have progressive RF. Seventy-five percent of the patients who had undergone early high ureterostomy after failure to respond to initial catheter drainage had regained normal renal function. We conclude that: serum creatinine at presentation is not predictive of subsequent renal function, but the values after a period of urinary-tract decompression are prognostically more useful; delay in diagnosis results in a poor outcome of renal function; and for optimal recovery of renal function, the choice of the primary procedure varies from case to case and can be determined by a systematic, stepwise approach (stepladder protocol).

Renal transplantation in children with posterior urethral valves

“…However, the possibility of progressive renal involvement in the child with PUV is not always easy to predict [10][11][12]. Progress in medicosurgical techniques and the earlier age of their application to these patients has enabled greater protection of the renal parenchyma [13][14][15], slowing its progressive deterioration, although without avoiding that a percentage reaches endstage renal disease during childhood.…”

Risk factors for renal insufficiency in children with urethral valves

“…This finding is in agreement with the results of several other studies. Together, these studies and the data presented herein suggest that a creatinine value <70 μmol/l at an age of 12 months [8] or <88 μmol/l 1 year after valve ablation [29] tend to have a more beneficial course. A creatinine nadir at the end of the first year of life of >106 μmol/l indicates a risk for rapid progress into ESRD [30].…”

“…The incidence of ESKD in children with PUV varies between 13 and 38% [6,7]. Results from previous studies imply a variety of prognostic factors for the development of ESKD, including creatinine concentration, bilateral or persistent vesicoureteral reflux (VUR), delayed diagnosis, poor detrusor function, delayed achievement of urinary continence, oligohydramnios, ventilatory support after birth, and breakthrough urinary tract infections [7][8][9][10][11][12][13][14]. In contrast, pathologic corticomedullary differentiation and echogenic renal changes have been described as insensitive prognostic markers [15,16].…”

Prenatal Diagnosis of Severe Fetal Renal Pelvic Dilatation and Treatment with Double Pig Tail Catheter

“…Indication for shunting is to avoid compression of normal tissue by cystic structures, but a high complication rate restricts the application of drainage to selected cases [14]. While some reports reached only 60% benefits from foeto-amniotic shunting, other methods like fetal cystoscopic treatment are to be proved beneficial to prolong the life expectance [15,16].…”