Long-Term Bladder and Renal Outcomes In Boys with Posterior Urethral Valves

    Purpose: In 1996, a short-term study at our institution showed patients treated with early valve ablation had better bladder outcomes than those treated with urinary diversion. In the same cohort, we examined whether these bladder outcomes endure with long-term follow-up.  Methods: This is a retrospective cohort study of patients who underwent valve ablation (PVA, n=19) or urinary diversion (UD, n=6) during the first year of life from 1986 to 1995. Pre-operative renal and bladder characteristics were not significantly different. Clinical bladder outcomes measured were continence at most recent follow-up, age at toilet training, age at nocturnal control, rate of nocturnal enuresis and febrile UTIs, and resolution of hydronephrosis. Urodynamic data during follow-up were reviewed for patterns of voiding dysfunction classified as hypertonic, hyperreflexic, or myogenic failure. Renal outcomes were defined as end stage renal disease (ESRD) (GFR < 15 mL/min per 1.73 m²). To normalize the comparison groups, a subset analysis of bladder outcomes amongst patients with ESRD was conducted. Results: Long-term follow-up a median of 13 years (range 5-21 years) was available for 81% (25/31) of the original valve cohort of which 74% (14/19) of PVA patients and 100% (6/6) of UD patients had follow-up since 1996. PVA patients had significantly higher rates of continence, underwent toilet training, and gained nocturnal urinary control at an earlier age compared to UD patients (Table 1). At the time of follow-up, 5 of 19 (23%) PVA patients and 6 of 6 (100%) UD patients had developed ESRD (p<0.05). A subset analysis of these patients with ESRD revealed more PVA patients were continent (4/5, 80% versus 2/6, 33% of UD patients) and had resolution of hydronephrosis (5/5, 100% versus 2/6, 33% of UD patients). Nocturnal enuresis and febrile UTIS were less frequent in the PVA group (0/5, 0% and 0/5, 0% versus 3/6, 50% and 2/6, 33% of UD patients, respectively). Urodynamic evaluation was performed for 21 of 25 patients; on follow-up, 3 UD patients and 0 PVA patients demonstrated late myogenic failure.  Conclusions: PUV patients treated with early valve ablation before the age of 1 year have clinically durable, improved bladder outcomes compared to patients treated with urinary diversion even if they develop end stage renal disease. Long term follow-up is imperative in this population of patients to monitor for delayed bladder and renal dysfunction.

Table 1. Summary of bladder function at followup

	Ablation	Diversion
Continence*	16/18 (86%)	2/6 (33%)
Age at toilet training*	5 years	9 years
Age at nocturnal control*	6 years	12 years
Nocturnal Enuresis	3/17 (18%)	3/6 (50%)
Recurrent UTIs*	2/19 (11%)	4/6 (66%)
Bladder Augmentation	1/19 (5%)	2/6 (33%)

*p<0.05