Primary ablation vs. urinary diversion in posterior urethral valve: A meta-analysis
Adree Khondker1, Justin Chan1, Jin Kyu (Justin) Kim1, Michael Chua1, Brittney Henderson2, Priyank Yadav1, Joana Dos Santos1, Gregory Tasian2, Mandy Rickard1, Armando Lorenzo1.
1Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; 2Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
Introduction: The literature regarding the ideal initial surgical management of posterior urethral valves (PUV) patients is conflicted. Here, we aimed to determine long-term kidney and bladder outcomes in boys with PUV undergoing either primary valve ablation or urinary diversion.
Methods: A systematic search was performed in March 2021. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included kidney outcomes (chronic kidney disease stage, kidney function) and bladder outcomes, among others. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analyses were performed and confounders were assessed with subgroup analysis. The review was registered prospectively (PROSPERO CRD42021243967).
Results: Thirty studies describing 1547 boys with PUV were included in this synthesis. Overall effect estimates demonstrate that patients undergoing primary diversion have significantly increased odds of developing kidney insufficiency (OR 0.60, 95% CI 0.44, 0.80, p<0.001). However, in patients with equal or unclear baseline kidney function between interventions, there was no significant difference in followup kidney outcomes (p=0.09–0.35). There was no significant difference in the odds of developing bladder dysfunction on urodynamic study or requiring clean-intermittent catheterization with primary ablation rather than diversion (OR 0.89, 95% CI 0.49, 1.59, p=0.68).
Conclusions: Current low-quality evidence suggests that long-term kidney and bladder outcomes are similar between primary ablation and primary diversion after adjusting for baseline kidney function. As patients managed with a diversion likely represent a more severe form of the disease, it remains possible that these patients derive benefit over primary ablation. Further research with adequate covariate control is warranted to investigate sources of heterogeneity and determine the best individualized approach. Our data also suggests that diversion does not lead to worse bladder function compared to ablation.
