Delay of Secondary Diversion After Failed Ablation May Commit Patients With Posterior Urethral Valves to Worse Renal Short-term Outcomes

To compare the effects of secondary versus primary diversion on kidney and bladder function in infants with posterior urethral valves (PUV). Although primary valve ablation is considered the gold standard, it is controversial and typically reserved for severe cases with valve ablation being the gold standard. In cases that fail to improve, secondary diversion may be offered-after a delay that likely had a detrimental impact on renal reserve.

A retrospective review of our institutional database between 2000 and 2024 identified 81 patients with diversion. After exclusion of patients ≥1 year at initial presentation (n = 8), other LUTO diagnoses (n = 11), and deceased patients (n = 1), 61 patients were included. Data were summarized as mean ± standard deviation (SD) for continuous variables.

A total of 45 patients underwent primary and 16 secondary diversions. Mean follow-up was 4.9 ± 4.7 years for primary and 8.9 ± 5.9 years for secondary diversion, respectively. There was no difference in creatinine levels at presentation (P = .7609), at 30 days (P = .3748), 1 year postoperatively (P = .4487), at 1 year of age (P = .6158), time to nadir (P = .2109), and nadir creatinine levels (P = .8708). Secondary diversion was associated with higher likelihood of persistent high-grade hydronephrosis (P = .0146) and transplantation (P = .0252). While secondary diversion had an impact on CIC rates (P = .0028) and creatinine levels at last follow-up (P = .0064), risk of progression to ESKD (P = .1159) and UTI rates (P = .3207) were not impacted.

There was no impairment in short-term renal function; however, children with marginal baseline function deteriorated early (elevated creatinine levels, progression to transplantation). In carefully selected patients, primary diversion appears advantageous over salvage diversion after failed ablation and should be favored to protect long-term kidney function.