What is the effect of circumcision on risk of urinary tract infection in boys with posterior urethral valves?

The role of circumcision in preventing urinary tract infections in children with antenatal hydronephrosis: Systematic review and meta-analysis

INTRODUCTION

Circumcision has been reported to reduce the risk of urinary tract infections (UTIs) in boys with antenatal hydronephrosis (HN). Our aim was to compare the incidence of UTIs in circumcised vs. uncircumcised boys with antenatal HN by conducting a systematic review and meta-analysis.

STUDY DESIGN

A comprehensive search was performed until December 2022. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included: UTIs, continuous antibiotic prophylaxis (CAP) use, renal outcomes, and circumcision complications. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analysis were performed.

RESULTS

Twenty-three studies describing 9093 boys with antenatal HN were identified, including 4677 uncircumcised and 4416 circumcised boys. Overall effect estimates demonstrate that circumcised boys have significantly reduced odds of developing any UTI [OR 0.26, 95%CI 0.21, 0.32; p < 0.001]]. In addition, there a significantly reduced odds of developing UTI when circumcised and on CAP [OR 0.19, 95% CI 0.13, 0.30; p < 0.001]. When stratifying by etiology, circumcision reduced the odds of UTI in boys with isolated HN [OR 0.33, 95% CI 0.16, 0.68; p = 0.003], vesicoureteral reflux [OR 0.23, 95% CI 0.13, 0.42; P < 0.00001], or with posterior urethral valves [OR 0.29, 95% CI 0.13, 0.64; p = 0.002].

DISCUSSION

Circumcision reduces the incidence of UTIs in boys with antenatal HN. This review is limited by the varied definitions of UTIs and inconsistent reporting on HN etiology, renal outcomes, and circumcision complications.

CONCLUSIONS

Circumcision should be considered in boys with antenatal HN to prevent the risk of developing UTI. Further research is warranted to individualize the prophylactic role of circumcision for patients with HN.

Circumcision reduces urinary tract infection in children with antenatal hydronephrosis: Systematic review and meta-analysis

INTRODUCTION

Urinary tract infection (UTI) is more prevalent in boys with antenatal hydronephrosis (ANH). Circumcision is known to lessen the risk of UTI. This study was performed to examine the associations between circumcision and UTI among patients with ANH.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed for conducting this systematic review and meta-analysis. PubMed, ScienceDirect, EMBASE, and Cochrane Library databases were searched through August 4th, 2022 to identify eligible studies. The risk of bias was measured using the Newcastle-Ottawa Scale (NOS). Review manager 5.4 was used for all analysis.

RESULTS

A total of 21 studies involving 8,968 patients with ANH were included in the meta-analysis. The incidences of UTI were 18.1% in the uncircumcised group and 4.9% in the circumcised group. From analysis, circumcision had significant protective effect against UTI with pooled OR of 0.28 (95% CI 0.23-0.32). The significant protective effects were also found in subgroup analysis of hydronephrosis etiology, including vesicoureteral reflux (pooled OR of 0.24; 95% CI 0.17-0.32), obstructive hydronephrosis (pooled OR of 0.34; 95% CI 0.21-0.53), and posterior urethral valve (pooled OR of 0.28; 95% CI 0.16-0.52).

CONCLUSION

Our meta-analysis showed that circumcision was associated with a decreased incidence of UTI in children with ANH. This benefit was consistent irrespective of the underlying cause of hydronephrosis.

Posterior urethral valves: Role of prenatal diagnosis and long-term management of bladder function; a single center point of view and review of literature

Posterior Urethral Valves (PUV) are the most common cause of lower urinary tract obstruction. More severe forms are detected early in pregnancy (mainly type I), while other forms are usually discovered later in childhood when investigating lower urinary tract symptoms. Bladder dysfunction is common and is associated with urinary incontinence in about 55% (0%-72%). Despite the removal of the obstruction by urethral valve ablation, pathological changes of the urinary tract can occur with progressive bladder dysfunction, which can cause deterioration of the upper urinary tract as well. For this reason, all children with PUV require long-term follow-up, always until puberty, and in many cases life-long. Therefore, management of PUV is not only limited to obstruction relief, but prevention and treatment of bladder dysfunction, based on urodynamic observations, is paramount. During time, urodynamic patterns may change from detrusor overactivity to decreased compliance/small capacity bladder, to myogenic failure (valve bladder). In the past, an aggressive surgical approach was performed in all patients, and valve resection was considered an emergency procedure. With the development of fetal surgery, vesico-amniotic shunting has been performed as well. Due to improvements of prenatal ultrasound, the presence of PUV is usually already suspected during pregnancy, and subsequent treatment should be performed in high-volume centers, with a multidisciplinary, more conservative approach. This is considered to be more effective and safer. Primary valve ablation is performed after clinical stability and is no longer considered an emergency procedure after birth. During childhood, a multidisciplinary approach (pediatric urologist, nephrologist, urotherapist) is recommended as well in all patients, to improve toilet training, using an advanced urotherapy program with medical treatments and urodynamic evaluations. The aim of this paper is to present our single center experience over 30 years.

Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial

BACKGROUND

Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this.

OBJECTIVE

To determine the effect of circumcision on the risk of fUTIs in boys with PUVs.

DESIGN, SETTING, AND PARTICIPANTS

A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1-28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision.

INTERVENTION

Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method.

RESULTS AND LIMITATIONS

In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3-82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age.

CONCLUSIONS

Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs.

PATIENT SUMMARY

In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.

Cost-Effectiveness of Screening Ultrasound after a First, Febrile Urinary Tract Infection in Children Age 2-24 Months

OBJECTIVE

To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics.

STUDY DESIGN

We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY).

RESULTS

Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group.

CONCLUSIONS

Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

The postnatal management of boys in a national cohort of bladder outlet obstruction

AIM

The most common cause of congenital bladder outlet obstruction (BOO) is posterior urethral valves (PUV). Initial treatment requires decompression, but transurethral incision (TUI) or primary diversion is all described. There is no randomized control trial to guide management. This study aims to describe management, circumcision, and UTI rate in a national cohort of PUV boys.

METHODS

Boys diagnosed with BOO were recruited (via BAPS CASS) over 1 year with ethics committee approval (ref: 12/SC/0416). Data were collected via questionnaire, presented as number (%), analyzed by Mann-Whitney/chi-square/Fisher Exact tests, and p < 0.05 was taken as significant.

RESULTS

BOO presented in 121 boys during 2014-2015, and 113 were PUV. Catheter placement in 87/121(72%) was more likely to happen in antenatal vs. postnatal vs. late(>1 y) presentations, p < 0.0001. Polyuria occurred in 23/45(51%), 12/48(25%), 0/28(0%), respectively, p < 0.0001. Initial surgical treatment was TUI in 108/121(89%) and vesicostomy in 2. Two ureterostomies were secondary procedures. Circumcision was performed in 52/121(43%) in antenatal presentation vs. postnatal vs. late 27/45(60%), 20/48(42%), 2/28(7%), respectively, p = 0.01. 69 UTIs occurred in 49 patients. Circumcision was associated with an 86% reduced risk of UTI, p < 0.0001. There was a 66% reduction in UTI risk associated with TUI alone, p < 0.01. There was 1 death due to pulmonary hypoplasia and renal failure, and 2 experienced end-stage renal failure (ESRF).

CONCLUSION

Standard treatment for BOO and PUV in the current UK cohort is urethral catheterization followed by TUI. Supravesical diversion is a rescue therapy. UTIs are common and reduced by circumcision, with 43% being circumcised. Initial mortality rate was 1%, and 1.6% present in ESRF.

LEVEL OF EVIDENCE

Prognostic study - Level I - Prospective National Cohort Study.

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

N/A

Prediction of need for intervention in posterior urethral valves: Use of urine osmolality

AIM

Renal tubular dysfunction (RTD) causing obligate production of hypoosmolar urine in boys with posterior urethral valves (PUVs) has been described. It is not known how clinically significant this is. We hypothesize that a feedback loop is present in many PUV boys who suffer deterioration of their lower urinary tract (LUT). RTD results in hypoosmolar urine, obligate polyuria, and bladder stretch-injury. The increasing back-pressure worsens RTD, thus exacerbating the injury. Coexisting renal dysplasia and acquired renal scarring exacerbate this. We compared the concentrating ability (random clinic urine osmolality) of PUV boys who had no LUT deterioration to those who required intervention, examining the confounding effect of renal impairment with a subgroup analysis comparing those with plasma creatinine ≤80μmol/l.

METHODS

A retrospective review of our PUV database was performed. Age, intervention, and highest recorded random clinic urine osmolality (>1year) with concurrent plasma creatinine were recorded (normal urine osmolality 500-850 mOsm/kg). Data are given as median values, analyzed by Mann-Whitney u-test, with P<0.05 deemed significant.

MAIN RESULTS

Urine osmolality was available in 77 boys with PUV out of 125 in our series. Of these, 34 required subsequent intervention (e.g., Mitrofanoff procedure, bladder augmentation). Age at testing trended towards being higher in the intervention group [7.9 (4.3-10.9) years vs. nonintervention 6.3 (4-8.4); P=0.06]. Urine osmolality was significantly reduced in the intervention group [411(293-547) vs. 631 (441-805) mOsm/kg; P<0.001]. Subgroup analysis comparing only those with creatinine ≤80μmol/l was respectively 451 (322-567) mOsm/kg (n=22) vs. 645 (469-810) mOsm/kg (n=40), P<0.01.

CONCLUSION

This study confirms that hypoosmolar urine is highly associated with progression of LUT dysfunction, requiring intervention. Even boys with normal creatinine values have a greater risk of LUT deterioration if they have a RTD and produce hypoosmolar urine.

LEVEL OF EVIDENCE

IV (retrospective service development project).

Urinary Tract Infection in Children: Management in the Era of Antibiotic Resistance-A Pediatric Urologist's View

CONTEXT

Antibiotic resistance to uropathogens has grown significantly worldwide. Today, pediatric urologist experience a situation that needs appropriate action because urinary tract infections are one of the most common bacterial infections in children.

OBJECTIVE

In this overview we aimed at presenting the clinical aspects of antibiotic usage in pediatric urology. Our intention was to take part of the important debate regarding future management of bacterial resistance against antibiotics.

EVIDENCE ACQUISITION

We searched PubMed for the terms: [UTI in children], [Recurrent UTI in children], and [Antibiotic resistance in UTI]. When using these terms, we found a numerous amount (3875) of published clinical articles related to the topic. By means of an overview, we chose not to focus on a specific condition but to an overall understanding of the problems related to pediatric urology in general.

EVIDENCE SYNTHESIS

We found that usage of antibiotics has had an unquestionable benefit to reduce the morbidity and mortality related to urinary tract infections in childhood. However, recent studies suggest that early exposure to antibiotics in childhood might have negative systemic effects related to neurocognitive function, body metabolism, and fat distribution. In addition to increased resistance to common antimicrobial agents, it has resulted in increased costs and inadequate effect in severe infections. This calls for changes in the clinical management of urinary pathogens in pediatric urology.

CONCLUSIONS

As the prevalence of antibiotic resistance grows, pediatric urologists have a key role in managing its consequences and its prevention.

PATIENT SUMMARY

In this overview we looked at the consequences of antibiotic usage treating urinary tract infections in childhood. We found that the prevalence of antibiotic resistance has grown. We concluded that decision-makers must know about the short- and long-term effects of antibiotic usage in children. When we understand the development of antibiotic resistance better, we can build up prevention strategies.

Phimosis in a 10-yr-old Boy Without Urinary Infection-How to Inform Parents: Against Circumcision

In a 10-yr-old boy with no abnormalities or symptoms other than nonretractability of the foreskin, the foreskin should be preserved. If treatment is needed, local corticoid application should be used as first-line therapy, as it gives excellent results in up to 90% of cases, before removing this sensitive part of the body.

Cystometrogram appearance in PUV is reliably quantified by the shape,wall, reflux and diverticuli (SWRD) score, and presages the need for intervention

OBJECTIVE

Radiological bladder abnormalities in boys with posterior urethral valves (PUV) are well recognised; however, the assessment is subjective. The shape, wall, reflux and diverticuli (SWRD) score objectively assesses shape, wall, reflux and diverticuli in a simple way. This study was undertaken to demonstrate that the SWRD score is reliable, reproducible and correlates with bladder outcome and videourodynamic (VUD) assessment in boys with PUV.

MATERIALS AND METHODS

Three blinded assessors determined the SWRD scores of PUV bladders from cystometrograms taken during VUD from September 2012 to October 2013. The scores were correlated with clinical outcome and VUD pressure measurements. Data were given as median (interquartile range), non-parametric tests used as appropriate (Mann-Whitney U test, or Kruskall-Wallis) and P < 0.05 was taken as significant.

RESULTS

A total of 55 boys with PUV underwent VUD assessment, for which 52 cystometrograms were available. The SWRD score for non-operative management was 1.0 (0.1-1.9) vs 2.0 (1.0-3.3) for operative intervention, P = 0.018 (Summary Figure). The SWRD score for compliant bladders was 1.1 (0.6-2.0) vs hypercompliant 1.7 (0.5-2.8) vs non-compliant 3.3 (2.8-5.0), Kruskall-Wallis P = 0.011. The hostile detrusor overactivity (DO) bladders (Pdet >40 cmH₂O) had a SWRD score of 2.0 (1.3-3.7) vs 1.0 (0.5-2.5) for low-pressure DO bladders, P < 0.05.

DISCUSSION

In this series of patients, increasingly distorted bladder shape was seen to be associated with poor bladder dynamics on VUD. Patients with poorly compliant bladders had a significantly higher SWRD score than normal or megacystis patients. Severe DO was also significantly associated with a high SWRD score. Therefore, the radiological appearance of a hostile bladder represented a marker for high intravesical pressure. VUR and bladder diverticuli may lead to spurious pressure measurements during VUD; however, the SWRD score provided an independent mechanism with which to objectively assess these patients, even in the presence of gross VUR.

CONCLUSIONS

The SWRD score is a simple and objective scoring system for the radiological abnormalities of PUV bladders. It correlates with clinical outcome and VUD assessment of compliance and DO, but is independent of pressure measurements and so not confounded by VUR acting as a 'pop-off' mechanism.

Work-up of Pediatric Urinary Tract Infection

Pediatric urinary tract infection (UTI) costs the health care system more than $180 million annually, and accounts for more than 1.5 million clinician visits per year. Accurate and timely diagnosis of these infections is important for determining appropriate treatment and preventing long-term complications such as renal scarring, hypertension, and end-stage renal disease. After the first 12 months, girls are more likely to be diagnosed with a UTI. About half of boys with UTI are diagnosed within the first 12 months of life. Diagnosis of UTI is made based on history and examination findings and confirmed by urine testing.

Long-term, low-dose prophylaxis against urinary tract infections in young children

Urinary tract infection (UTI) affects about 2 % of boys and 8 % of girls during the first 6 years of life with Escherichia coli as the predominant pathogen. Symptomatic UTI causes discomfort and distress, and carries a risk of inducing renal damage. The strong correlation between febrile UTI, dilating vesicoureteral reflux (VUR), and renal scarring led to the introduction of antibiotic prophylaxis for children with VUR to reduce the rate of UTI recurrence. It became common practice to use prophylaxis for children with VUR and other urinary tract abnormalities. This policy has been challenged because of a lack of scientific support. Now, randomized controlled studies are available that compare prophylaxis to no treatment or placebo. They show that children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. Dilating VUR may still be an indication for prophylaxis in young children. After the first year of life, boys have very few recurrences and do not benefit from prophylaxis. Girls with dilating VUR, on the other hand, are more prone to recurrences and benefit from prophylaxis. There has been a decline in the use of prophylaxis due to questioning of its efficacy, increasing bacterial resistance, and a propensity to low adherence to medication. Alternative measures to reduce UTI recurrences should be emphasized. However, in selected patients carefully followed, prophylaxis can protect from recurrent UTI and long-term sequelae. 1. There is a strong correlation between UTI, VUR, and renal scarring. 2. Children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. 3. Young children, mainly girls, with dilating VUR are at risk of recurrent UTI and acquired renal scarring and seem to gain from antibiotic prophylaxis. 4. Increasing bacterial resistance and low adherence with prescribed medication is a major obstacle to successful antibiotic prophylaxis.

Vesicoureteric reflux in children

Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25-40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.

Lower urinary tract obstruction in the fetus and neonate

This article summarizes the most recent literature regarding congenital lower urinary tract obstruction in the fetus and newborn. Lower urinary tract obstruction is a heterogeneous group of rare diagnoses that have significant potential for in utero mortality and long-term morbidity in survivors. The diagnosis and management of the most common causes are reviewed. In addition, the current state of prenatal intervention for congenital lower urinary tract obstruction is discussed.

What is the efficacy of circumcision in boys with complex urinary tract abnormalities?

The risk of urinary tract infection (UTI) in normal boys is 1%. This risk is significantly increased in boys with congenital abnormalities of the urinary tract, which includes such abnormalities as vesico-ureteric reflux, obstructive megaureter (VUJO) and posterior urethral valves. UTI in these boys can lead to urosepsis, a potentially life-threatening complication, and in the longer term renal scarring complicating pyelonephritis can lead to chronic renal impairment or even end-stage renal disease. Circumcision has been shown in normal boys to reduce the risk of UTI by 90%, and potentially could be a simple intervention to reduce the risk of urosepsis and renal scarring. In order to make this decision a clinician really needs to have the answers to two questions: 1) What is the risk of UTI in this particular boy? 2) What is the evidence of efficacy of circumcision in this particular condition? This article reviews what evidence exists to make a calculation of the risk/benefit ratio for circumcision in boys with abnormalities of the urinary tract.

Reduced bacterial colonisation of the glans penis after male circumcision in children--a prospective study

OBJECTIVE

The aim of this prospective study was to evaluate the effect of male circumcision on the bacterial colonisation of the glans penis in children.

PATIENTS AND METHODS

244 males were included in this study. The study group consisted of 143 boys admitted for circumcision between August 2009 and July 2010. Periurethral swabs were taken preoperatively and one week postoperatively. The control group included 101 boys without phimosis, in which only one swab was taken. Patients were subgrouped according to age below and above five years. Bacterial cultures were analysed, results were categorized by non-uropathogenic and uropathogenic bacteria, and compared within and between groups.

RESULTS

Patients in both control group and study group before circumcision showed significant bacterial colonisation (>98%), involving known uropathogenic bacteria in over 86%. After circumcision, bacterial colonisation dropped from 100% to 86.3% (p < 0.005) in boys younger than five years and from 98.57% to 77.14% (p < 0.001) in those aged five or above, respectively. Moreover, the fraction of uropathogenic bacteria decreased significantly.

CONCLUSION

Male circumcision significantly reduces the bacterial colonisation of the glans penis with regard to both non-uropathogenic and uropathogenic bacteria.

The effect of circumcision on the frequency of urinary tract infection, growth and nutrition status in infants with antenatal hydronephrosis

The objective of this study was to determine the effect of circumcision on the frequency of urinary tract infection (UTI), growth development, and the nutrition status in infants with antenatal hydronephrosis (AH). The data were collected prospectively between 1998 and 2010. Infants with a fetal pelvis diameter of >5 mm identified with antenatal ultrasound were followed-up. Body height and weight were expressed as HZ scores (observed height - median height/standard deviation) and WZ scores (observed weight - median weight/Standard deviation). The nutritional status was evaluated and the body weight was transformed to a weight-for-height index (WHI = weight/median weight for the height age × 100). The HZ and WZ scores or WHI were calculated for each patient at the first and last visits. The chi-square and Student's t tests were used for statistical analysis. A p value <0.05 was considered significant. The study included 178 (134 males, 44 females) patients. Of these, 29 were diagnosed by vesicoureteral reflux (VUR), 87 by obstructive uropathy, and 54 by normal. Of 134 males, 111 infants were circumcised. The mean monitoring time was 45±24.9 months and the mean age of circumcision was 14 ± 16.06 months. The pre-circumcision UTI frequency (2.97 ± 1.14/y) was significantly higher than post-circumcision period (0.25 ± 0.67/y) (p < 0.05). Also, pre-circumcision UTI frequency (2.97 ± 1.14/y) was significantly higher than the UTI frequency observed in female cases (0.85 ± 0.91/y) and in the overall study group (0.73 ± 0.79/y) (p < 0.05). In all patients, the HZ of the circumcised subjects (0.18 ± 1.01) was statistically higher than uncircumcised subjects (-0.26 ± 0.92) (p < 0.05). Although statistically insignificant, the HZ of the circumcised males (0.13 ± 1.24) with VUR was higher than the uncircumcised patients (0.03 ± 0.55) (p > 0.05). In obstructive uropathy groups, the HZ of the circumcised males (-0.13 ± 0.54) was also found to be higher than uncircumcised males (-0.49 ± 0.66) (p < 0.05). Although nutrition scores were found to be better in circumcised males, no statistically significant effect of circumcision on the nutrition status was detected. In conclusion, postnatal early circumcision of infants with AH seems to prevent frequent UTIs and nutritional disturbances enabling normal growth.

Antenatally diagnosed hydronephrosis: current postnatal management

The issue of antenatal hydronephrosis has become a routine component for the care of a pregnant woman despite limited evidence of a clinical benefit. The genitourinary tract represents the most commonly detected organ system with identified abnormalities, with antenatal hydronephrosis (ANH), being the most notable and common finding. ANH represents a spectrum, with most cases being a trivial and inconsequential finding on maternal fetal ultrasound. However, there is a correlation with increased grades of ANH being associated with increased severity of urinary tract pathology. Most patients can be managed expectantly with appropriate evaluation commenced postnatally based on severity of ANH and proper parental counseling and education. The purpose of this review was to assess current literature and guidelines pertaining to ANH and incorporate our practical interpretations of their significance.

Urinomas protect renal function in posterior urethral valves--a population based study

BACKGROUND/PURPOSE

Urinomas have been thought to protect renal function in boys with posterior urethral valves (PUVs), although recent reports have disputed this. This study tested the hypothesis that urinomas protect global renal function in boys with PUV.

METHODS

A retrospective analysis of all boys with PUV presenting to a tertiary unit derived from a region with an estimated population of 5.5 million was performed. Comparisons of the initial nadir creatinine, current creatinine, and renal status score (RSS) were made between those with and without urinomas. The RSS was derived from nephrology assessment of current renal status (0 = normal to 4 = end-stage renal failure or transplantation). Results were given as median (range), except for RSS, which was given as mean +/- SEM. P < or = .05 was regarded as significant.

RESULTS

During 1989-2009, 9 of 89 PUV boys were diagnosed with urinomas. Initial nadir creatinine was statistically lower in boys with urinomas (31 [18-44] vs 45 [20-574] mumol/L, P < .01). Length of follow-up was similar (5.1 [2.2-17.3] vs 5.9 [1.8-19.7] years, P = .59). Follow-up creatinine was significantly lower in urinoma boys (44 [25-77] vs 61 [29-1227] micromol/L, P < .05), as was the RSS (0.14 +/- 0.14 vs 0.91 +/- 0.14, P < .01). No urinoma boys progressed to end-stage renal failure or required transplant.

CONCLUSION

This population-based study of PUV boys demonstrates that urinomas reduce nadir creatinine and significantly protect long-term global renal function.

CONGENITAL URINARY BLADDER OUTLET OBSTRUCTION

The term congenital ‘bladder outlet obstruction (BOO)’ describes the collection of conditions in which the normal, urethral egress of urine from the fetal bladder is impaired. The term is interchangeable with fetal ‘lower urinary tract obstruction’, as used by other authors. After considering normal urinary tract embryology, we describe the epidemiology of congenital BOO and the primary anatomical disorders associated with it. We then proceed to describe its fetal and postnatal clinical manifestations and then consider therapies and interventions which have been used to manage the condition. We not only focus on urethral and bladder disease with constitutes BOO itself, but also describe associated kidney disorders which, via chronic renal excretory failure, are important causes of morbidity. Rather than provide an exhaustive review, we emphasise studies published in the last decade, and therefore readers are referred to other reviews citing numerous earlier references.