Early Administration of Oxybutynin Improves Bladder Function and Clinical Outcomes in Newborns with Posterior Urethral Valves

Clinical considerations in adults with history of posterior urethral valves

INTRODUCTION

Management of patients with posterior urethral valves (PUV) is commonplace for many pediatric urologists, however adult providers may be far less familiar with this diagnosis, its management and long-term ramifications. As urologic management of these patients has evolved, clinical outcomes have substantially improved with many more patients now surviving into adulthood. These patients remain at increased risk of morbidity due to their condition and therefore are likely to benefit from long term follow-up with adult providers.

OBJECTIVE

In this review we analyze the psychosocial impacts of PUV on adults, evaluate long term transplant outcomes in PUV patients and discuss effective clinical management strategies of bladder dysfunction in adult PUV patients.

STUDY DESIGN

A retrospective literature review was performed using the MEDLINE (Pubmed) electronic database using key words such as "posterior urethral valve", "quality of life", "sexual function", "transplant outcomes", "bladder dysfunction", "mitrofanoff" etc. to identify relevant studies.

RESULTS

Generally, the quality of life of PUV patients is good, those suffering from renal insufficiency or lower urinary tract symptoms, specifically incontinence, appear to be a group that may benefit from more intensive follow-up. Good long-term kidney transplant (KT) function and survival can be achieved in patients with PUV. Rigorous management to optimize bladder function and close follow-up, are key for long term graft survival after KT.

DISCUSSION

The chronicity of PUV warrants adult providers to be not only well versed in the pathophysiology of the disease, but well prepared to care for these patients as they transition into adulthood.

CONCLUSION

Additional studies addressing psychosocial, clinical and transplant outcomes of adults with PUV are necessary to develop optimal long-term follow-up regimens for these patients.

Prospective evaluation of a pediatric urodynamics protocol before and after limiting urine cultures

PURPOSE

While our institution has historically obtained a urine culture (UCx) from every child at the time of urodynamics (UDS), no consensus exists on UDS UCx utility, and practice varies widely. This study aims to prospectively study our symptomatic post-UDS UTI rate before and after implementing a targeted UCx protocol.

MATERIALS AND METHODS

A 2-part prospective study of patients undergoing UDS at one pediatric hospital was undertaken, divided into Phase 1 (7/2016-6/2017) with routine UCx at the time of UDS and Phase 2 (7/2019-6/2020) after implementation of a protocol limiting UCx at the time of UDS to only a targeted subset of patients. The primary outcome was symptomatic post-UDS UTI, defined as positive UCx ≥10ˆ4 CFU/mL and fever ≥38.5 °C or new urinary symptoms within seven days of UDS.

RESULTS

A total of 1,154 UDS were included: 553 in 483 unique patients during Phase 1 and 601 in 533 unique patients during Phase 2. Age, sex, race, ethnicity, and bladder management did not differ significantly between phases. All 553 UDS in Phase 1 had UCx at the time of UDS, compared to 34% (204/601) in Phase 2. The rate of positive UCx decreased from 39% in Phase 1-35% in Phase 2. Three patients developed symptomatic post-UDS UTI in each study period, resulting in a stable post-UDS UTI rate of 0.5% (3/553) in Phase 1 and 0.5% (3/601) in Phase 2. These patients varied in age, sex, UDS indication, and bladder management. Four of the six (67%) patients had positive UCx at the time of UDS, one had a negative UCx, and one had no UCx under the targeted UCx protocol. Predictors of symptomatic post-UDS UTI could not be evaluated.

DISCUSSION

In the largest prospective study to date, we found that symptomatic post-UDS UTI was <1% and that UCx at the time of UDS can safely be limited at our hospital. This reduction has important implications for cost containment and antibiotic stewardship. We will continue iterative modifications to our protocol, which may eventually include the elimination of UCx at the time of UDS in all groups.

CONCLUSIONS

This 2-part prospective evaluation at one pediatric hospital determined that the symptomatic post-UDS UTI rate remained <1% with no identifiable predictors after limiting previously universal UCx at the time of UDS to only a targeted subset of patients.

Bladder height width ratio on voiding cystourethrogram as a predictor of future valve bladder in children with posterior urethral valve

BACKGROUND/AIMS

Prompt and early treatment of valve bladder is known to improve renal outcome in patients with PUV. We hypothesized that bladder height width ratio (HWR) measurement on voiding cystourethrogram (VCUG) could predict development of valve bladder.

METHODS

All patients who underwent primary PUV ablation and evaluated later with urodynamics were included. Valve bladder was suspected when there were daytime wetting, persistent hydroureteronephrosis, and elevated detrusor pressures on urodynamics. VCUGs were analysed for HWR: maximum height/width of bladder. ROC curve analysis was performed to identify HWR that could predict development of urodynamic abnormality.

RESULTS

Between 2012 and 2017, 102 patients were studied: median age at valve ablation 25 days (3-125 days); follow-up 5 years (3-7 years). The ROC curve comparing post-ablation HWR with occurrence of valve bladder showed a cut-off of 1.45 (AUC 0.93). HWR cut-off of 1.45 had a sensitivity of 89% and specificity of 84% in predicting future valve bladder. Detrusor overactivity was noticed on urodynamics in 41/55 (74%) of those with HWR > 1.45 compared 5/47 (11%) in those with HWR < 1.45 (p = 0.001).

CONCLUSION

Bladder height width ratio on VCUG is a useful parameter to predict development of future valve bladder in children with PUV.

Safety and short-term efficacy of mirabegron in children with valve bladder: a pilot study

AIMS

This pilot study aims to assess the short-term efficacy and safety of mirabegron in valve bladder, an important cause of persistent hydronephrosis after successful treatment of posterior urethral valves (PUV).

METHODS

Twenty-two patients with early valve bladder (no residual PUV; persistent hydronephrosis, wetting and urodynamic evidence of detrusor overactivity) were included. Three subjective parameters: frequency, wetting episodes; patient perception of bladder condition score (PPBC) and four objective parameters: uroflow index (UI = Qave/Qmax), voided volume (VV = voided volume/ expected bladder capacity), maximum filling pressure (P det-max) and society of fetal urology (SFU) hydronephrosis grading were analysed pre- and post-3-month treatment with mirabegron (0.5-1 mg/kg/day). All patients were observed for heart rate, BP, ECG changes during therapy.

RESULTS

There was significant reduction (p = 0.001) in mean frequency (pre 15; post 10), wetting episodes (pre 5; post 2) and PPBC (pre 4; post 3). There was significant improvement (p = 0.01) in mean UI (pre 0.3; post 0.5), VV (pre 0.54; post 0.72), Pdet-max (pre 42; post 25) and hydronephrosis grade (pre 3.5; post 2.2). There were no significant side effects.

CONCLUSION

This pilot study establishes short-term efficacy and safety of mirabegron in valve bladder with overactivity. Further larger long-term studies are warranted.

Effects of oxybutynin in children with posterior urethral valves post fulguration: Report in a select cohort of children

Objectives:

Posterior urethral valves (PUV) is the commonest obstructive uropathy with varied consequences. Though valve fulguration is the treatment of choice, appropriate bladder management modifies outcome and includes rational use of anticholinergics. Here, we aim to evaluate the effects of oxybutynin on the bladder and urinary tract morphology and function. Concurrently, we document adverse effects encountered, patient compliance, and medication adherence.

Methods:

A retrospective study of children below 5 years of age (2012–2017) post fulguration and on oxybutynin for at least 6 months. Patient demographics, clinical features, renal ultrasound, micturating cystourethrogram, dimercaptosuccinic acid scan, adverse effects, and pill count for medication adherence were collated.

Results:

48 children below the age of 5 years were included, and 12 were excluded either due to the presence of concomitant problems or were not on oxybutynin. Of the 36, four were lost to follow-up and one had died due to an unrelated condition. Thus, a total of 31 children were analyzed. At follow-up, 28/31 patients were asymptomatic, two had daytime incontinence, and one had recurrent urinary tract infection. All patients except one have preserved renal function tests. On ultrasonography, hydroureteronephrosis worsened in only 1/25 children and two showed significant post void residues. The resolution of vesicoureteral reflux was noted in almost 50%. 4/31 renal units had progressive scars. Only two parents defaulted medication. Urodynamic study done in half of these children showed stable bladder pressures except in two.

Conclusion:

Oxybutynin therapy following adequate valve fulguration aids upper tracts preservation by stabilizing deranged bladder dynamics. The medication is well tolerated with minimal or no side effects.

Antenatal and postnatal management of posterior urethral valves: where do we stand?

Introduction

Posterior urethral valve (PUV) is the leading etiology of lower urinary tract obstruction (LUTO) in boys and is an important cause of end-stage renal disease (ESRD) in children. The aim of this article is to review the current status on antenatal intervention for PUV as well as postnatal medical and surgical management.

Main body

MEDLINE, EMBASE, Pubmed and Google Scholar search was conducted throughout December 2020 using the keywords: posterior urethral valves, congenital urinary obstruction, antenatal, valve bladder syndrome, medical, anticholinergics, alpha blocker, antibiotics, biofeedback, diversion, augmentation cystoplasty and renal transplantation. Only papers written in English were included. The relevant literature was summarized. Despite advances in antenatal intervention for fetal LUTO, it remains associated with considerable fetal and maternal morbidity. Patient selection criteria for antenatal intervention are greatly debated. Fetal intervention has resulted in improved perinatal survival in properly selected cases, with a questionable benefit to postnatal renal function. There is decent evidence supporting the use of anticholinergics in infants and young children following valve ablation, with less robust evidence advocating alpha blockers, overnight catheter drainage and biofeedback. The role of urinary diversion remains contentious. Optimizing bladder dynamics is crucial for successful renal transplantation outcomes.

Conclusion

While antenatal intervention has failed to improve renal function outcomes of PUV, patient-centered medical and sometimes surgical interventions can help delay the progression of chronic kidney disease. Lifelong monitoring and management of the associated bladder dysfunction is indispensable even after successful renal transplantation.

Are pressure pop-offs beneficial to the bladder in boys with posterior urethral valves?

BACKGROUND

Pressure pop-offs, such as high-grade vesicoureteral reflux with renal dysplasia, have historically been considered beneficial for renal and bladder outcomes in boys with posterior urethral valves (PUV). Recent longer-term studies have called into question the beneficial effects of pop-offs on renal function.

OBJECTIVE

To evaluate how pop-offs affect bladder outcomes in boys with PUV.

STUDY DESIGN

At a single-center, the electronic medical records of boys with PUV who underwent valve ablation from 2000 to 2014 were retrospectively reviewed for bladder and continence outcomes. Patients were excluded due to presentation after one year of age, age at last follow-up <1 year, lack of urodynamic study (UDS), lack of voiding cystourethrogram, or concomitant prune belly syndrome. Between patients with and without pop-offs, the following outcomes were compared: prevalence of significant hydronephrosis (Society for Fetal Urology grade 3 or 4) prior to valve ablation and at last follow-up, nadir creatinine level, classification of initial UDS, type of medical and/or surgical interventions, dryness during the day and toilet-training status at last follow-up (among patients ≥4 years), and age at toilet-training. For patients with multiple UDS, initial and latest UDS were compared.

RESULTS

48 patients met inclusion criteria, of whom 31 (65%) had pop-offs and 17 (35%) did not. Median age at last follow-up was 5.9 years (range: 1.0-12.2 years). Patients with pop-offs were more likely to have unsafe initial UDS (26% vs. 12%, p = 0.15) but less likely to have high voiding pressures at their latest UDS (15% vs. 50%, p = 0.03). Patients with pop-offs were more likely to have used clean intermittent catheterization (26% vs. 0%, p = 0.04) and were less likely to be toilet-trained by age 4 (76% vs. 100%, p = 0.15) or dry during the day at last follow-up (56% vs. 92%, p = 0.06). Toilet-trained patients with pop-offs were toilet-trained by an earlier age than patients without pop-offs (3 vs 4 years, p = 0.04).

DISCUSSION

The results of the present retrospective study show that patients with pop-offs required more extensive interventions to achieve continence, and achieved continence and toilet-training less frequently than patients without pop-offs. Additionally, our results demonstrated that patients with pop-offs had worse bladder dynamics initially, which may suggest that pop-offs are a manifestation of more excessive pressure build-up prior to valve ablation.

CONCLUSIONS

Among boys with posterior urethral valves who present in the first year of life, pop-offs do not appear to impart significant benefit to bladder outcomes and may indicate more severe bladder dysfunction.

Intravesical Oxybutynin for Urgent Bladder Rescue in a Newborn with Posterior Urethral Valves

Posterior urethral valves are the most common cause of bladder outlet obstruction in male newborns. Initial catheter drainage alleviates the urethral obstruction before definitive management by valve ablation. Newborns with posterior urethral valves often present with hypercontractile bladders that may inhibit upper tract drainage despite bladder catheterization. Anticholinergic agents are commonly used to treat detrusor hyperactivity, with oxybutynin being the most commonly used. We report the first case of a newborn with posterior urethral valves and ureterovesical junction obstruction caused by detrusor hypertrophy who underwent urgent intravesical instillation of oxybutynin at high doses in an attempt to avoid a diversion procedure.

Correlation between the estimated GFR and SWRD score in patients with posterior urethral valves at King Abdul-Aziz University Hospital

Objective

The aim was to establish the reliability of the SWRD score as a predictor of both renal and bladder outcomes in posterior urethral valves. This retrospective study included 67 patients with PUVs at King Abdul-Aziz University Hospital. The score was calculated from voiding cystourethrogram before and after the relief of obstruction, and estimated glomerular filtration rates (eGFRs) were calculated as well.

Results

Based on Spearman correlations, both baseline eGFRs and SWRD scores can be possible predictors of long-term renal outcomes, as a significant positive correlation between the baseline eGFRs and the last eGFRs was found (p = 0.005). A significant negative correlation was also found between the SWRD score calculated before the intervention and the last eGFRs (p = 0.02). Additionally, the baseline SWRD scores can be possible predictors of short-term bladder outcomes, as the correlation analysis showed a positive relationship between the baseline SWRD scores and the SWRD scores calculated within 2 months after the intervention (p < 0.0001). A significant decrease in SWRD scores and eGFRs was found from before to after the intervention, regardless of the type of intervention. In conclusion, the SWRD scoring system proved to be a potentially promising tool in the anticipation of the clinical outcomes of PUVs.

Current strategies to predict and manage sequelae of posterior urethral valves in children

Posterior urethral valves (PUV) constitute a significant urological cause of chronic kidney disease (CKD) in children. The condition is characterised by the unique pathophysiology of the evolution of bladder dysfunction after relief of obstruction, which contributes to CKD. Improvements in prenatal diagnosis followed by selective foetal intervention have not yet produced improvement in long-term renal outcomes, although better patient selection may alter this in the future. Proactive management with surveillance, pharmacotherapy, timed voiding, double voiding, and/or assisted bladder-emptying, is being increasingly offered to those with severe bladder dysfunction and has the potential of reducing the burden of renal disease. Clinicians are currently able to counsel regarding the prognosis using serum creatinine and other emerging markers. However, much of this work remains to be validated. Satisfactory graft survival rates are now reported with aggressive management of bladder dysfunction in children who are candidates for renal transplantation. Knowledge gaps exist in identifying early markers of renal injury, risk stratification, and in understanding patient and carer perspectives in PUV.

Predicting and Modifying Risk for Development of Renal Failure in Boys with Posterior Urethral Valves

PURPOSE OF REVIEW

The purpose of this review is to bring the reader up to date on the current risk factors for the development of renal deterioration in the boys with posterior urethral valves (PUV) and approaches to modify this risk.

RECENT FINDINGS

Renal bladder ultrasound (RBUS) is routinely performed in boys with PUV and recent advancements allow imaging processing that can more accurately quantify renal parenchyma and correlate this with risk for renal loss. Refinement of urine studies may improve our ability to stratify patients into renal loss categories. Use of videourodynamics (VUDS) allows refined assessment of the valve bladder to identify those who might benefit from secondary procedures and/or the addition of targeted pharmacotherapy to improve bladder emptying or dangerous storage pressures. All boys with a history of PUV are at a significant long-term risk of renal deterioration. The literature suggests that several technical advances have improved our ability to predict this risk, although there needs to be further refinement and validation before widespread use. Utilization of close follow-up, VUDS, pharmacotherapy, and bladder drainage provide the best methods to improve care to this group of patients and if more studies confirm their utility, adoption of these as part of standard of care protocols may be warranted.

All grown up: A transitional care perspective on the patient with posterior urethral valves

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Reassessing the utility of routine urine culture with urodynamics: UTI incidence and risk factors

INTRODUCTION

There is no consensus regarding use of periprocedural antibiotics or routine urine cultures during urodynamics study (UDS) in children. At our hospital, we historically have obtained urine cultures during UDS. However, even with positive cultures, few patients require treatment. Most are successfully managed with increased hydration and frequent bladder emptying.

PURPOSE

To evaluate clinical characteristics, antibiotic treatment, and outcomes in patients undergoing UDS to identify (1) risk factors for urinary tract infection (UTI) after UDS, and (2) patients who may benefit from routine urine culture.

STUDY DESIGN

Retrospective review of 769 patients who underwent 1057 UDS between January 2013 and January 2015. Positive urine culture was defined as ≥10⁴ colony forming units/ml. Afebrile UTI was defined as new symptoms within 7 days. Febrile UTI was new symptoms with fever (≥38.5 °C). Fisher's exact test was used for comparative analyses.

RESULTS

Nearly all patients had a urine culture taken immediately prior to UDS (94%, 993/1057). Patients on clean intermittent catheterization (CIC) were more likely to be on pre-UDS antibiotics, 22.8% (106/464) vs. 17.9% of those not on CIC (106/593) (p = 0.04). Of patients who had a urine culture, it was positive in 40% (402/993) with more positive cultures in patients on CIC vs. not (72.0%, 316/439 vs. 15.5%, 86/554, p < 0.0001). Factors significantly associated with clinical/possible post-UDS UTI included clinical UTI within 30 days before UDS, immunosuppression, overnight Foley catheter use, febrile UTI as indication, and symptoms on day of procedure (Table). Fifteen patients (1.4%, 95% confidence interval 0.7-2.1%) developed a clinical/possible post-UDS UTI, of which 40% (6/15) were febrile, with one requiring hospitalization. Of patients with post-UDS UTIs, 33% (5/15) had negative cultures at the time of UDS.

DISCUSSION

If urine cultures were obtained selectively based on our study findings, 78% of pre-UDS urine cultures could be eliminated, while "missing" clinically relevant cultures in only 0.4% (4/1057). Study limitations include the retrospective design. However, prospective data collection will now be possible by using standardized, templated UDS and post-UDS follow-up notes with extractable data elements that automatically populate a database.

CONCLUSION

Post-UDS UTI is uncommon (1.4%), even in the setting of bacteriuria. This finding calls into question the utility of routine pre-UDS urine culture. Data from this study and a future prospective study will be used to refine a new working protocol, with the goal of targeting future urine cultures to a high-risk subset of patients.

Best practice in the assessment of bladder function in infants

The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be 'reflexive' or 'uninhibited', with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic 'detrusor sphincter dyssynergy' seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of 'early prophylactic treatment (clean intermittent catheterization and anticholinergics)' versus initial 'watchful waiting and treatment as needed' is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.