Elsevier

The Lancet

Volume 390, Issue 10099, 9–15 September 2017, Pages 1061-1071
The Lancet

Series
Advances in paediatric urology

https://doi.org/10.1016/S0140-6736(17)32282-1Get rights and content

Summary

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes. A variety of surgical techniques have been developed for hypospadias, with excellent outcomes for distal but not proximal hypospadias. Pelvi-ureteric junction obstruction is mostly detected prenatally; indications for surgery have been refined with evidence, and minimally invasive pyeloplasty is now standard. The outlook for patients with neurogenic bladder has been transformed by a combination of clean intermittent catheterisation, algorithms of diagnostic investigations, and innovative medical and surgical therapies. Posterior urethral valves are associated with considerable mortality; fetal diagnosis allows stratification of candidates for intervention, but ongoing bladder dysfunction in patients after valve ablation remains a cause of long-term morbidity.

Introduction

A substantial portion of paediatric urology entails surgical correction of congenital and acquired disorders of the genitourinary system. With rapid developments in clinical and basic research, from prenatal diagnosis and minimally invasive surgery to evidence-based clinical guidelines, paediatric urology has become a major subspecialty. In this Series paper, we describe the exciting advances and innovations in the surgical management of six important paediatric urological disorders. Although minimally invasive surgery and innovative surgical techniques have improved early outcomes of common, non-lethal disorders such as vesicoureteral reflux, undescended testes, and the mild forms of hypospadias and pelvi-ureteric junction obstruction, most paediatric urological disorders, especially the severe anomalies, are associated with long-term morbidity. Treatment of neurogenic bladder exemplifies the advantages of a multidisciplinary approach with medical and innovative surgical therapies. Although fetal and neonatal diagnosis and treatment have improved survival in children with rare, complex, and life-threatening diseases such as posterior urethral valve, the management of long-term sequelae remain challenging.

Section snippets

Vesicoureteral reflux

Vesicoureteral reflux is the retrograde flow of urine from the bladder to the ureter (or ureters), affecting 1–25% of children and predisposing them to urinary tract infection and renal scarring. A comprehensive review is available elsewhere;1 here we focus on recent research findings.

Although vesicoureteral reflux resolves in many cases, the ability to predict resolution in a given patient is limited. Vesicoureteral reflux grade is important. Multivariable models incorporating a range of

Undescended testes

Undescended testes is considered the most common genital anomaly in boys, with a reported incidence that varies between 0·5% and 9% (1–5% in most reports). This variation reflects the clinical nature of the diagnosis, the patient population studied, and the inclusion or otherwise of acquired undescended testes.19 The apparent increase in incidence suggested in some reports probably reflects a combination of enhanced screening, improved survival of premature infants, and strengthened recognition

Hypospadias

The incidence of hypospadias (1/300 newborn boys) was once thought to be increasing, with a doubling of incidence in the USA in the 1970s and 1980s. However, European and Australian data have indicated a more stable incidence in the past 10 years.34, 35 The data reported worldwide remain conflicting, and reported incidence ranges from 0·6 to 34·2 per 10 000 live births.36 Increasing awareness of the disease, putative effects from environmental endocrine disruptors, and differing study

Pelvi-ureteric junction obstruction

Antenatal hydronephrosis is found in up to 4·5% of all pregnancies, making it one of the most common urological abnormalities. Non-operative management will fail in about a third of patients with high-grade hydronephrosis (Society for Fetal Urology grade 3–4) due to pelvi-ureteric or ureteropelvic junction obstruction, and the anterior–posterior diameter of the renal pelvis appears to be the strongest predictor of the need for intervention postnatally.47 Various cutoffs have been proposed,

Neurogenic bladder

Neurogenic bladder affects 1·5–2 babies per 10 000 live-births. The challenge for the paediatric surgical specialist is to protect renal function and achieve urinary continence. The most common cause of paediatric neurogenic bladder is spina bifida. Other congenital causes include caudal regression and anorectal malformations. Acquired causes include spinal cord injury (trauma, infection, or tumour), extensive pelvic surgery, or CNS insults.64 Renal failure was once the most common cause of

Posterior urethral valves

With an incidence of about 1/5000 newborn boys, posterior urethral valves are the most common cause of congenital lower urinary tract obstruction (LUTO). Posterior urethral valves are associated with high fetal and neonatal mortality (30%) and considerable lifelong morbidity. In severe cases, the disorder can lead to anhydramnios and pulmonary dysplasia during the canalicular phase of lung development. Abnormal renal development persists into childhood and adolescence: 30–42% of patients

Discussion

Advances in paediatric urology have been remarkable, especially because innovations and randomised controlled trials are difficult to implement in the paediatric population and because diseases are heterogeneous. In the coming years, refinements in fetal diagnosis and interventions and the introduction of regenerative medicine and tissue engineering for bladder reconstruction can be anticipated. The benefits of minimally invasive surgery and robot-assisted surgery compared with conventional

Search strategy and selection criteria

We searched Web of Science and PubMed for reports in English published from Jan 1, 2007, to July 1, 2017, using the terms “paediatric urology”, “paediatric genito-urinary disorders”, “undescended testes”, “cryptorchidism”, “hypospadias”, “posterior urethral valves”, “neurogenic bladder”, “neuropathic bladder”, “vescicoureteral reflux”, “vescicoureteric reflux”, “pelvi-ureteric junction obstruction”, “ureteropelvic junction obstruction”, and “congenital hydronephrosis”. We largely selected

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