Treatment Approach for Pediatric Patients with Posterior Urethral Valves
The recommended treatment approach for pediatric patients with posterior urethral valves (PUV) is primary endoscopic valve ablation, which is no longer considered an emergency procedure and should be performed after clinical stabilization of the patient. 1
Initial Management
- Prenatal diagnosis allows for early planning of treatment in specialized centers with a multidisciplinary approach 1
- Upon diagnosis, immediate urinary drainage should be established to prevent further damage to the urinary tract 2
- Primary valve ablation is the gold standard treatment but should be performed after clinical stabilization rather than as an emergency procedure 1, 3
- Suprapubic cystostomy is specifically recommended for pediatric patients with bladder injuries or as part of PUV management 2, 4
Surgical Options
- Endoscopic ablation of the valve is the first-line treatment and gold standard for PUV 3
- In settings where endoscopic facilities are limited, alternative approaches such as Mohan's valvotome may be utilized 3
- Proximal urinary diversion (high diversion) should be reserved for specific cases:
Post-Treatment Management
- Urethrography should be performed every two weeks until complete healing following surgical intervention 4
- All children with PUV require long-term follow-up, at minimum until puberty, and in many cases lifelong 1
- Voiding cystourethrography (VCUG) is the gold standard for diagnosis and follow-up of vesicoureteral reflux, which is common in PUV patients 4
- Contrast-enhanced voiding urosonography (ceVUS) can be used as an alternative to VCUG for follow-up to reduce radiation exposure 4
Management of Associated Conditions
- For persistent vesicoureteral reflux or obstruction with recurrent infections despite adequate valve ablation, ureteroneocystostomy may be indicated 5
- When performing ureteroneocystostomy, a psoas hitch technique significantly reduces the risk of postoperative reflux (10% vs 100% without hitch) 5
- For patients diagnosed within the first year of life, continuous antibiotic prophylaxis is recommended regardless of the grade of reflux 4
- Immediate parenteral antibiotic treatment should be provided for febrile breakthrough infections 4
Bladder Management
- Bladder dysfunction is common in PUV patients (associated with urinary incontinence in approximately 55% of cases) 1
- Urodynamic patterns may change over time from detrusor overactivity to decreased compliance/small capacity bladder, to myogenic failure ("valve bladder") 1
- Management should include a multidisciplinary approach with pediatric urologist, nephrologist, and urotherapist 1
- Advanced urotherapy programs with medical treatments and regular urodynamic evaluations are recommended to improve bladder function and toilet training 1
Long-term Follow-up
- Follow-up imaging should be driven by the patient's clinical condition 2, 4
- Despite successful valve ablation, approximately 50% of children with PUV may develop renal failure 6
- Patients with normal serum creatinine have better growth outcomes (73% achieve normal stature) compared to those with renal failure (20% achieve normal stature) 6
- Proteinuria and hypertension during teenage years may indicate progression to renal failure and require close monitoring 7
Pitfalls to Avoid
- Performing high urinary diversion as first-line treatment when primary valve ablation is possible may lead to poor bladder compliance 3
- Reimplanting ureters immediately after valve ablation should be avoided as patients often have hypertonic bladders during this period 7
- Focusing solely on valve ablation without addressing bladder dysfunction may lead to deterioration of the upper urinary tract 1
- Inadequate follow-up can miss complications such as progressive renal failure, which may develop years after successful initial treatment 7