Fetal bladder rupture in posterior urethral valves: a clinically relevant complication or a protective pop-off mechanism.

INTRODUCTION

Posterior urethral valves (PUV) are the most common cause of congenital bladder outlet obstruction in male infants and may result in kidney damage and chronic kidney disease. In severe cases, spontaneous fetal bladder rupture with urinary ascites may occur. This study presents a rare case of fetal bladder rupture secondary to PUV requiring complex bladder reconstruction and systematically reviews similar cases.

METHODS

We report a male patient with prenatal bladder rupture due to PUV. A systematic review was conducted according to PRISMA guidelines using PubMed, Embase, Scopus, Web of Science, and the Cochrane Library up to March 2026. Pediatric cases of bladder rupture associated with PUV were included.

RESULTS

Prenatal imaging showed bladder rupture with urinary ascites at 23 weeks' gestation. Postnatal treatment included endoscopic valve ablation, vesicostomy, and subsequent ileocystoplasty with a continent catheterizable channel using the Macedo technique. Kidney function remained stable, but severe bladder dysfunction required reconstruction. The review identified 15 patients with PUV-associated bladder rupture. Prenatal diagnosis was reported in 33% of cases, most often in the third trimester. Fetal ascites, hydronephrosis, and oligohydramnios were the main prenatal findings. Management usually involved urgent postnatal urinary decompression followed by valve ablation. Follow-up was limited, but available reports suggested relatively preserved kidney function and frequent bladder dysfunction.

DISCUSSION: Fetal bladder rupture in PUV is a rare and severe manifestation of lower urinary tract obstruction. Although proposed as a potential pressure-relieving "pop-off" mechanism, this hypothesis remains speculative and unsupported by robust evidence. Available data are limited to heterogeneous case reports. Multidisciplinary follow-up is essential to assess kidney and bladder outcomes in this group of patients.

SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration: CRD420261367565.