The impact of standardized postnatal treatment and implementation of the PUV-clinic on postnatal outcome: a retrospective single-center cohort study
Juliane Richter, MD1, Natasha Brownrigg, NP1, Joana Dos Santos, MD1, Justin Kim, MD2, Michael Chua, MD1, Armando J. Lorenzo, MD1, Mandy Rickard, NP1.
1Division of Urology, The Hospital for Sick Children (SickKids), Toronto, ON, Canada, 2Division of Urology, University of Toronto, Toronto, ON, Canada.
Background: Posterior urethral valves (PUV) are associated with high morbidity and mortality and management strategies vary by provider. We developed a dedicated PUV clinic with standardization of care following a comprehensive clinical pathway. Herein, we investigate if the implementation of the PUV-clinic improves the immediate postnatal management of infants with PUV. Methods: A chart review of confirmed PUV cases between 2017 and 2022 was performed. Based on the first newborn managed with the standardized treatment regimen, patients were divided into two groups (Before [BF PUV-C: 03/2017 - 10/2019] and after [AF PUV-C: 10/2019 - 04/2022]). The BF group was chosen to ensure similar observation periods (929 days). Assessed measures included age at index postnatal visit, index catheterization, primary treatment and kidney function. Mean values and standard deviations as well as Odds ratios (OR) and mean difference with 95% confidence interval (CI) were calculated from the obtained data. Results: A total of 47 patients were included in the analysis. The mean age at initial treatment was significantly lower in the AF PUV-C group compared to the BF PUV-C group [14.5 + 20.5 vs. 94.6 + 173.0 days; p = 0.0007]. Furthermore, patients reached nadir creatinine at significantly earlier ages since start of the PUV-clinic compared to before [131.2 + 122.7 vs. 376.9 + 314.8 days; p = 0.0004] and significantly shorter after initial treatment [116.7 + 124.5 vs. 309.1 + 225.0 days; p = 0.0014]. After implementation of the PUV-clinic overall effect estimates demonstrated significantly reduced odds of primary valve ablation [OR 0.141, 95% CI 0.04 - 0.54; p = 0.006] and significantly increased odds of primary ureterostomy [OR ∞, 95% CI 2.25 to ∞; p = 0.006]. Conclusion: The implementation of the PUV-clinic with standardized treatment expedited postnatal management as patients are younger at initial treatment and reach nadir creatinine earlier. Furthermore, there is a shift of initial management from valve ablation to urinary diversion.
| TABLE 1 Characteristics of the 47 PUV cases | ||||
| Before PUV-Clinic (n=20) | After PUV-Clinic (n=27) | Odds Ratio (95% CI) | p-value | |
| Prenatal data | ||||
| GA diagnosis (weeks) | 26.17 + 6.65 | 28.05 + 7.55 | 0.439 | |
| HN (%) | 14/20 (70.00) | 23/27 (85.19) | 0.406 (0.12 to 1.49) | 0.286 |
| Oligo-/Anhydramnios (%) | 2/19 (10.53) | 9/25 (36.00) | 0.209 (0.04 to 1.12) | 0.080 |
| Suspected LUTO (%) | 2/20 (10.00) | 10/27 (37.04) | 0.189 (0.04 to 0.95) | 0.047* |
| No prenatal diagnosis (%) | 6/20 (30.00) | 4/27 (14.81) | 2.464 (0.67 to 8.66) | 0.286 |
| Postnatal data | ||||
| Birth weight (kg) | 3.093 + 0.58 | 3.199 + 0.54 | 0.574 | |
| Birth length (cm) | 48.13 + 4.65 | 48.59 + 4.50 | 0.959 | |
| GA delivery (weeks) | 37.37 + 2.49 | 37.43 + 2.03 | 0.831 | |
| Ventilation | 2/12 (16.67) | 5/25 (20.00) | 0.800 (0.14 to 5.36) | > 0.999 |
| Data are shown as mean + standard deviation (SD) or n (%). GA= gestational age; HN= hydronephrosis; LUTO= lower urinary tract obstruction. *: statistically significant at p ≤ 0.05. |
| TABLE 2 Postnatal outcome of the 47 PUV cases | ||||
| BF PUV-Clinic (n=20) | After PUV-Clinic (n=27) | Odds Ratio (95% CI) | p-value | |
| Initial management | ||||
| Valve ablation | 17/20 (85.00) | 12/27 (44.44) | 0.141 (0.04 to 0.54) | 0.006** |
| Vesicostomy | 3/20 (15.00) | 6/27 (22.22) | 1.619 (0.39 to 6.53) | 0.713 |
| Ureterostomy | 0/20 (0.00) | 9/27 (33.33) | ∞ (2.25 to ∞) | 0.006** |
| Reason for Presentation | ||||
| Asymptomatic presentation | 2/20 (10.00) | 4/27 (14.81) | 1.565 (0.33 to 8.86) | > 0.999 |
| Abnormal ultrasound | 16/20 (80.00) | 19/27 (70.37) | 0.594 (0.18 to 2.34) | 0.517 |
| UTI | 3/20 (15.00) | 0/27 (0.00) | 0.00 (0.00 to 0.81) | 0.070 |
| Sepsis | 3/20 (15.00) | 2/27 (7.41) | 0.453 (0.08 to 2.45) | 0.638 |
| Abdominal distension | 5/20 (25.00) | 7/27 (25.93) | 1.050 (0.26 to 3.80) | > 0.999 |
| > 1 presenting symptom | 9/20 (45.00) | 16/27 (59.26) | 1.778 (0.52 to 5.36) | 0.386 |
| Kidney function | ||||
| Creatinine DOL 4-8 (𝜇;;mol/L) | 147.9 + 163.2 | 122.4 + 106.0 | 0.940 | |
| Creatinine MOL 4-7 (𝜇;;mol/L) | 60.33 + 110.3 | 58.67 + 141.2 | 0.794 | |
| Nadir creatinine (𝜇;;mol/L) | 29.42 + 20.78 | 29.81 + 36.68 | 0.670 | |
| Time to nadir creatinine (days) | 309.1 + 225.0 | 116.7 + 124.5 | 0.001** | |
| Postnatal ultrasound | ||||
| Ultrasounds (6 months) | 5.8 + 4.4 | 4.5 + 1.7 | 0.516 | |
| Length right kidney (mm) | 57.40 + 11.44 | 55.19 + 10.68 | 0.642 | |
| Length left kidney (mm) | 55.50 + 15.72 | 56.63 + 11.34 | 0.903 | |
| High-grade HN (SFU 3-4) | 23/29 (79.31) | 48/54 (88.89) | 2.087 (0.55 to 7.26) | 0.327 |
| Additional Procedures | ||||
| VCUGs (6 months) | 1.2 + 0.6 | 1.2 + 0.5 | > 0.999 | |
| Nuclear studies (6 months) | 0.1 + 0.2 | 0.0 + 0.0 | 0.386 | |
| Uroflowmetries (6 months) | 0.1 + 0.2 | 0.0 + 0.0 | 0.400 | |
| Number of UTIs (6 months) | 1.2 + 1.7 | 0.7 + 1.2 | 0.339 | |
| Medications | ||||
| Antibiotic prophylaxis | 16/20 (80.00) | 25/27 (92.59) | 0.320 (0.06 to 1.55) | 0.379 |
| Tamsulosin | 10/19 (52.63) | 11/27 (40.74) | 1.616 (0.51 to 4.98) | 0.550 |
| Oxybutynin | 6/20 (30.00) | 16/27 (59.26) | 0.295 (0.09 to 1.05) | 0.076 |
| Data are shown as mean + standard deviation (SD) or n (%). GA= gestational age; HN= hydronephrosis; LUTO= lower urinary tract obstruction; UTI= urinary tract infection; DOL= day of life; MOL= month of life. *: statistically significant at p ≤ 0.05. **: statistically significant at p< 0.01. |
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