Short- and Long-Term Renal Outcomes in Clinically Matched Cohorts of Newborns With Posterior Urethral Valve (PUV) Managed by Primary Vesicostomy Versus Primary Valve Ablation.

OBJECTIVE: To understand optimal primary management for posterior urethral valve (PUV) by comparing renal outcomes of a uniquely matched cohort of primary valve ablation (PVA) versus vesicostomy, whereby progressive urethral dilation (PUD) was performed to achieve PVA for previously ineligible infants. While PVA is often the preferred treatment, smaller, sicker neonates have historically undergone primary vesicostomy, limiting true comparisons between treatment cohorts. The advent of PUD has made PVA feasible in a broader population, including neonates previously deemed too small for PVA.

METHODS: We conducted a retrospective cohort study of neonates treated with either PVA (with or without PUD) or primary vesicostomy at two institutions between 1995 and 2021. Match criteria were creatinine at intervention, gestational age, and age/weight at intervention. The primary outcome was progression to renal replacement therapy (RRT). Secondary outcomes included trends in nadir serum creatinine.

RESULTS: Twenty-four neonates met inclusion criteria (12 PVA, 12 vesicostomy). Groups were matched across clinical variables. There was no significant difference in serum creatinine at 6 weeks (P = .74) or 1 year (P = .89). Kaplan-Meier analysis showed no significant difference in time to RRT between groups (HR (95% CI): 1.32 (0.32, 5.45); P = .70). These findings persisted after adjustment for clinical covariates (OR (95% CI): 1.24 (0.10, 15.9); P = .87).

CONCLUSION: This study represents a uniquely matched comparison of PVA and vesicostomy following the introduction of PUD, addressing a longstanding treatment selection bias. While renal outcomes were comparable, vesicostomy may impose greater surgical burden and disrupt bladder cycling.