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. 2019 Feb;54(2):313-317.
doi: 10.1016/j.jpedsurg.2018.10.087. Epub 2018 Nov 6.

The postnatal management of boys in a national cohort of bladder outlet obstruction

Ruth Wragg  1 , Ewan Brownlee  1 , Andy Robb  1 , Harish Chandran  1 , Marian Knight  2 , Liam McCarthy  3 ; BAPS-CASS
Affiliations

The postnatal management of boys in a national cohort of bladder outlet obstruction

Ruth Wragg et al. J Pediatr Surg. 2019 Feb.

Abstract

Aim: The most common cause of congenital bladder outlet obstruction (BOO) is posterior urethral valves (PUV). Initial treatment requires decompression, but transurethral incision (TUI) or primary diversion is all described. There is no randomized control trial to guide management. This study aims to describe management, circumcision, and UTI rate in a national cohort of PUV boys.

Methods: Boys diagnosed with BOO were recruited (via BAPS CASS) over 1 year with ethics committee approval (ref: 12/SC/0416). Data were collected via questionnaire, presented as number (%), analyzed by Mann-Whitney/chi-square/Fisher Exact tests, and p < 0.05 was taken as significant.

Results: BOO presented in 121 boys during 2014-2015, and 113 were PUV. Catheter placement in 87/121(72%) was more likely to happen in antenatal vs. postnatal vs. late(>1 y) presentations, p < 0.0001. Polyuria occurred in 23/45(51%), 12/48(25%), 0/28(0%), respectively, p < 0.0001. Initial surgical treatment was TUI in 108/121(89%) and vesicostomy in 2. Two ureterostomies were secondary procedures. Circumcision was performed in 52/121(43%) in antenatal presentation vs. postnatal vs. late 27/45(60%), 20/48(42%), 2/28(7%), respectively, p = 0.01. 69 UTIs occurred in 49 patients. Circumcision was associated with an 86% reduced risk of UTI, p < 0.0001. There was a 66% reduction in UTI risk associated with TUI alone, p < 0.01. There was 1 death due to pulmonary hypoplasia and renal failure, and 2 experienced end-stage renal failure (ESRF).

Conclusion: Standard treatment for BOO and PUV in the current UK cohort is urethral catheterization followed by TUI. Supravesical diversion is a rescue therapy. UTIs are common and reduced by circumcision, with 43% being circumcised. Initial mortality rate was 1%, and 1.6% present in ESRF.

Level of evidence: Prognostic study - Level I - Prospective National Cohort Study.

Keywords: Bladder outlet obstruction; Circumcision; Posterior urethral valves; Postnatal management; Urinary tract infection.

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