Posterior Urethral Valves In Children: Achieving Renal Preservation Through Integrated Multidisciplinary Care In A...

Posterior urethral valves (PUV) remain the leading cause of congenital obstructive uropathy and chronic kidney disease (CKD) in male children. Outcomes vary widely across healthcare systems, with end-stage renal disease (ESRD) rates of 10-25% reported in international series. We present a single-centre PUV cohort, examining renal preservation, surgical outcomes, and the prognostic impact of detection timing.

A retrospective review of 120 consecutive patients with PUV managed between 2018 and 2024 was conducted. Patients were stratified by antenatal versus postnatal detection. The primary outcome was renal functional status at last follow-up, classified according to CKD stage. Secondary outcomes included procedural burden, urinary diversion requirement, and predictors of poor renal outcome.

Overall renal function was preserved (normal or mild impairment) in 84 of 120 patients (70.0%; 95% CI 61.0-77.9), with 77 patients (64.2%; 95% CI 55.3-72.3) achieving normal renal function. Mild impairment (CKD stage 1-2) was present in 7 patients (5.8%), moderate impairment (CKD stage 3) in 29 (24.2%), and severe impairment/ESRD in 7 (5.8%). ESRD occurred in 7 patients (5.8%; 95% CI 2.4-11.6). Antenatal detection was achieved in 58 patients (48.3%). Despite earlier diagnosis and intervention, the antenatal group demonstrated lower rates of normal renal function (53.4% vs 74.2%; absolute difference 20.8%; OR 0.40, 95% CI 0.19-0.84; p=0.008), lower rates of preserved renal function (58.6% vs 80.6%; OR 0.34, 95% CI 0.15-0.78; p=0.009), higher procedural burden (mean 3.29 vs 2.13 procedures; p<0.001), and greater requirement for urinary diversion (24.1% vs 4.8%; p<0.001). On multivariable analysis, severe oligohydramnios (OR 4.2, 95% CI 1.8-9.7), dense occluding valves (OR 3.1, 95% CI 1.4-6.8), Grade V VUR (OR 2.8, 95% CI 1.2-6.5), and urinary diversion requirement (OR 2.4, 95% CI 1.1-5.3) were independent predictors of poor renal outcome. A total of 323 procedures were performed.

This cohort demonstrates that systematic, multidisciplinary PUV management is associated with favorable renal outcomes even in a resource-limited setting. The paradox of antenatal detection, where earlier identification is associated with worse outcomes, reflects inherent disease severity rather than treatment inadequacy. These findings highlight the importance of disease-severity stratification and early aggressive surgical intervention.