Delayed Presentation of Posterior Urethral Valves
Mary Killian, MD, Rajeev Chaudhry, MD, Francis X. Schneck, MD, Glenn M. Cannon, MD, Omar Ayyash, MD, Patrick J. Fox, MD.
Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
Background: Posterior urethral valves (PUV) are the most common cause of congenital lower urinary tract obstruction. Even with early treatment in the newborn period, children experience long-term effects. Historically, approximately 10% of patients have presented with a delayed diagnosis of posterior urethral valves. We reviewed our cohort of patients with a diagnosis of posterior urethral valves to assess patients with a late presentation.
Methods: In accordance with institutional review board approval, we performed a retrospective review of all patients seen in the Pediatric Urology clinic with a diagnosis of posterior urethral valves between the years of 1988 and 2017. Patient charts were then reviewed and classified by the age of diagnosis. Late presentation was defined as an age at diagnosis of six months or greater. The clinical characteristics of these patients were analyzed and compared with patients with an antenatal or immediate postnatal diagnosis of posterior urethral valves.
Results: 32% of the patients were delayed presentation of PUV. When compared with patients diagnosed prior to 6 months, these patients were noted to have a lower peak creatinine (0.5 vs 1.35 [p<0.01]). The delayed presentation patients were also less likely to have a post-operative VCUG or require a vesicostomy. While a higher percentage of delayed presentation patients underwent repeat ablation (12% vs. 6%), this was not statistically significant. The majority of patients in both groups were noted with type 1 PUV but there were more (18 vs 3) Type 3 PUV noted in the early diagnosis group. No patients in the delayed presentation group underwent a transplant within the follow-up period.
Conclusion: Our results demonstrate a larger percentage of patients with delayed presentation of PUV. These patients appear to have a less severe form given their lower peak Cr at time of diagnosis as well as the act that none of the patients has required a renal transplant. Longer-term follow-up will be needed to assess the continued renal function in both groups.
Overall Demographics
| Race (N=150) | White | 111 |
| Black | 23 | |
| Other | 16 | |
| Vesicostomy (N=150) | 11% | |
| Age At Diagnosis (N=136) | 24 (0.03-216) | |
| Age At Ablation (N=133) | 27 (0.03-216) | |
| Follow-up (N=133) | 45 (0-192) | |
| Valve Type (N=150) | Unknown | 51 |
| 1 | 76 | |
| 2 | 2 | |
| 3 | 21 | |
| Post-op VCUG (N=150) | 44% | |
| Peak Cr (N=89) | 1.6 (0.2-5.2) | |
| Nadir Cr (N=95) | 0.5 (0.1-2.5) | |
| Antenatal Intervention (N=150) | 2% | |
| Repeat Ablation (N=150) | 9% |
Late vs Early Diagnosis
| Early (N=82) | Late (N=68) | p-value | ||
| Race | White | 61 | 50 | |
| Black | 13 | 10 | ||
| Other | 8 | 8 | ||
| Vesicostomy | 18% | 3% | <0.01** | |
| Mean Age At Diagnosis (range) | 0.5 (0.03-4) | 61 (6-216) | ||
| Mean Age At Ablation (range) | 4.5 (0.03-144) | 61 (6-216) | ||
| Mean Follow-up | 50 | 38 | ||
| Valve Type | Unknown | 21 | 30 | |
| 1 | 41 | 35 | ||
| 2 | 2 | 0 | ||
| 3 | 18 | 3 | ||
| Post-op VCUG | 55% | 31% | <0.01** | |
| Median Peak Cr | 1.35 | 0.50 | 0.02* | |
| Median Nadir Cr | 0.30 | 0.40 | 0.33* | |
| Antenatal Intervention | 4% | 0% | 0.11* | |
| Repeat Ablation | 6% | 12% | 0.22* |
*p-values calculated using Wilcoxon Rank-Sum Test
**p-values calculated using Fisher’s Exact Test
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