Review: Posterior urethral valves (PUV) … what do we know?

Posterior urethral valves (PUV) remain the most common cause of severe congenital lower urinary tract obstruction in boys and a leading pediatric cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Despite decades of research, management decisions across antenatal counseling, postnatal stabilization, definitive ablation, bladder management, and long-term surveillance remain heterogeneous.

To map the breadth, design, and strength of contemporary evidence informing PUV management across the full clinical pathway, and to identify priority gaps for future research.

PRISMA-ScR scoping review was performed; PubMed was searched on 2026-05-05 combining MeSH and free-text terms for urethral obstruction, PUV, and congenital lower urinary tract obstruction (cLUTO) with management, treatment, and outcome terms in a pediatric population. The 1123 PubMed records were merged with an expert-curated corpus of 120 records assembled by citation snowballing from anchor papers, and 9 duplicates were removed. A single reviewer screened records at title/abstract; after prioritized full-text retrieval, reports were charted by clinical domain and synthesized narratively. EAU levels of evidence (LoE) were applied descriptively to cited claims; no formal risk-of-bias or GRADE certainty assessment was performed.

Of 1243 records identified (1123 via PubMed and 120 via an expert-curated corpus assembled by citation snowballing), 156 reports were included. Strong (LOE 1a-2a) evidence supports: primary endoscopic ablation as the cornerstone of treatment; creatinine-based risk-stratification including nadir creatinine in the first year (and as early as 6 weeks) and the PURK score, circumcision for febrile UTI prevention; anticholinergics and α-blockers for specific bladder phenotypes; nocturnal bladder emptying for valve-bladder syndrome (now supported by a single-centre RCT); aggressive pre-transplant bladder optimization; and standardized multidisciplinary care pathways. As a scoping review without formal risk-of-bias or certainty (GRADE) assessment, these associations are descriptive and hypothesis-generating. Substantial gaps persist regarding antenatal intervention, biomarker validation, surveillance protocols, transition to adult care, and long-term sexual and reproductive outcomes.

Care for PUV appears to be shifting from reactive toward more proactive management, but its evidence base remains dominated by observational data. This prompts further prospective multicenter registry with standardized data collection and stepped-wedge trials of treatment protocols are urgent priorities.