O1035: Implementation of a Standardized Clinical Pathway in a Dedicated Posterior Urethral Valves Clinic: Short Term Outcomes

Background: The management of posterior urethral valves (PUV) varies by institution and provider, and long-term outcomes range from mild bladder dysfunction to myogenic failure and different stages of chronic kidney disease (CKD), including end-stage renal disease (ESRD). At our institution we developed a multidisciplinary PUV clinic with standardization of care using a comprehensive clinical pathway from prenatal diagnosis to adolescence. Herein, we investigate if implementing this initiative improves the short-term renal outcomes of infants with PUV.

Methods: From 2016 to 2022, 50 consecutive patients were divided into groups after the implementation of a standardized treatment pathway (APUV, n=29) and before (BPUV, n=21) during a comparable timeframe (~3 years). Assessed data included age at initial postnatal visit, time to catheterization, timing and method of initial management, frequency of follow-up visits, medications, nadir creatinine, and development of CKD/ESRD. Data are shown as median with interquartile range (IQR) and odds ratios (OR) with 95% confidence interval (CI).

Results: APUV provided care for higher rates of prenatal diagnoses (12/29 vs. 1/21; p= 0.0037), earlier initial surgical intervention (8 days; IQR 0, 105 vs. 33 days; IQR 4, 603; p< 0.0001), and higher rates of primary ureterostomies (10/29 vs. 0/21; p=0.0028). Standardized management led to more frequent ultrasound examinations (6.5/year; IQR 1, 32 vs. 3/year; IQR 1, 12; p=0.0002), and earlier initiation of alpha-blockers (326 days; IQR 6, 860 vs. 991; IQR 149, 1634; p= 0.0019) and anticholinergics (57 days; IQR 3, 860 vs. 1283 days; IQR 477, 1718; p< 0.0001). In addition, nadir creatinine was reached at earlier ages in APUV (105 days; IQR 2, 303 vs. 164 days; IQR 21, 447; p=0.0192). At last follow-up, one patient had progressed to CKD 5 in APUV and 3 in BPUV (stages 3a and 5), and one had a transplant at 1 year.

Conclusion: Implementing the PUV clinic with standardized treatment expedited postnatal management and resulted in a higher number of cases detected prenatally, a shift in primary treatment, younger ages at initial treatment, reduced time to nadir creatinine, and timely initiation of supportive medications, potentially leading to preservation of kidney function.