Inter-Hospital Management and Outcome Variation in Posterior Urethral Valves; A Call for Care Standardization
Daryl McLeod, MD1, Brian VanderBrink, MD2, Konrad Szymanski, MD MPH3, Molly Fuchs, MD MPH1, Patricio Gargollo, MD4, Candace Granberg, MD4, Benjamin Whittam, MD5, Pramod Reddy, MD2, Edward M. Gong, MD5.
1Nationwide Children's, Columbus, OH, USA, 2Cincinnati Children's, Cincinnati, OH, USA, 3Riley Children's Hospital, Indianapolis, IN, USA, 4Mayo Clinic, Rochester, MN, USA, 5Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
BACKGROUND: Posterior Urethral Valves (PUV) is a common cause of pediatric renal transplantation and is associated with significant morbidity. While early management of PUV with transurethral ablation is well agreed upon, longitudinal management is less defined. We reviewed patient factors, management, and outcomes between 5 pediatric urology institutions in the Pediatric Urology Midwest Alliance (P.U.M.A).
METHODS: P.U.M.A. was initiated in 2017 with the goal of improving patient care for rare urologic diseases. A retrospective cohort study of patients from P.U.M.A. hospitals identified 274 patients with a diagnosis of PUV confirmed by voiding cystourethrogram (VCUG) or cystoscopy that underwent surgical management of PUV prior to 90 days of life. Patients were evaluated according to demographic data, management techniques, and outcomes metrics. Management variation between institutions was evaluated using chi-square or Kruskal-Wallis analysis. RESULTS: Patient demographic data varied significantly between centers in regard to race (p<0.001) and insurance status (p=0.009). Patient age and gestational age at time of birth was similar. However, patient factors such as birth weight (p=0.014), severity of VUR at diagnosis (p<0.001), and antenatal detection of PUV (p<0.001) were significantly different. Variation in management was also seen between centers with differences in utilization of post-valve ablation urodynamics (46-94%, p<0.001), renal nuclear scan (43-79%, p<0.001), anticholinergic medications (21-71%, p<0.001), and alpha-blockers (0-29%, p<0.001). Outcome measures such as the rate of CIC (5-54%, p<0.001), dialysis (4-20%, p=0.021), and renal transplantation (4-22%, p = 0.002) also differed between centers.
Significant variation was identified between institutions regarding the management and renal outcomes of PUV. Management variation included the utilization of urodynamic/renal nuclear scan studies, anticholinergic/ alpha-blocker medications and CIC. Interestingly, we also found a significant difference in the rate of renal replacement therapy between institutions. However, patient factors, specifically disease severity was not controlled for and likely contributed to the differences in renal outcomes between institutions, making it difficult to interpret the effects of management strategies. We conclude that developing a standardized protocol across institutions is necessary to determine optimal management strategies and ultimately improve patient outcomes.
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