Paediatric Urology

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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C. Radmayr (Chair), G. Bogaert, H.S. Dogan, R. Kočvara, J.M. Nijman (Vice-chair), R. Stein, S. Tekgül
Guidelines Associates: L.A. 't Hoen, J. Quaedackers, M.S. Silay, S. Undre

1.INTRODUCTION

1.1.Aim

A collaborative working group consisting of members representing the European Society for Paediatric Urology (ESPU) and the European Association of Urology (EAU) has prepared these Guidelines with the aim of increasing the quality of care for children with urological conditions. This Guideline document is limited to a number of common clinical pathologies in paediatric urological practice, as covering the entire field of paediatric urology in a single guideline document is unattainable.

The majority of urological clinical problems in children are specialised and in many ways differ to those in adults. This publication intends to outline a practical and preliminary approach to paediatric urological conditions. Complex and rare conditions that require special care with experienced doctors should be referred to designated centres where paediatric urology practice has been fully established and a multidisciplinary team is available.

Over time, paediatric urology has developed and matured, establishing its diverse body of knowledge and expertise and may now be ready to distinguish itself from its parent specialties. Thus, paediatric urology has recently emerged in many European countries as a distinct subspecialty of both urology and paediatric surgery and presents a unique challenge in the sense that it covers a large area with many different schools of thought and a huge diversity in management.

Knowledge gained by increasing experience, new technological advances and non-invasive diagnostic screening modalities has had a profound influence on treatment modalities in paediatric urology, a trend that is likely to continue in the years to come.

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of children and their caregivers into account. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The EAU-ESPU Paediatric Urology Guidelines Panel consists of an international group of clinicians with particular expertise in this area. All experts involved in the production of this document have submitted potential conflict of interest statements, which can be viewed on the EAU Website: http://uroweb.org/guideline/paediatric-urology/.

1.3.Available publications

A quick reference document (Pocket guidelines) is available, both in print and as a App for IOS and Android devices. These are abridged versions which may require consultation together with the full text version. A number of translated versions, alongside several scientific publications in European Urology, the Associations scientific journal are also available [1-3]. All documents can be viewed through the EAU website: http://uroweb.org/guideline/paediatric-urology/.

1.4.Publication history

The Paediatric Urology Guidelines were first published in 2001 [4]. This 2018 publication includes a number of updated chapters and sections as detailed below.

1.5.Summary of changes

The literature for the complete document has been assessed and updated, wherever relevant. Key changes in the 2018 publication:

  • Section 3.9 - Day-time lower urinary tract conditions: Both the literature and the text have been revised extensively;
  • Section 3.10 - Monosymptomatic enuresis - bedwetting: the literature and the text have been revised extensively;
  • Section 3.11 - Management of neurogenic bladder: Both the literature and the text have been revised extensively;
  • Section 3.15 - Obstructive pathology of renal duplication: ureterocele and ectopic ureter: The literature has been updated resulting in minor amendments to the text.

1.5.1.New and changed recommendations


3.9.5 Recommendations for the management of day-time urinary tract conditions

Recommendations

LE

Strength rating

Use two day voiding diaries and/or structured questionnaires for objective evaluation of symptoms, voiding drinking habits and response to treatment

2

Strong

Use a stepwise approach, starting with the least invasive treatment in managing day-time lower urinary tract dysfunction (LUTD) in children.

4

Weak

Initially offer urotherapy involving bladder rehabilitation and bowel management.

2

Weak

If bladder bowel dysfunction is present, treat bowel dysfunction first, before treating the lower urinary tract condition.

2

Weak

Use pharmacotherapy (mainly antispasmodics and anticholinergics) as second line therapy in OAB.

1

Strong

Use antibiotic prophylaxis if there are recurrent infections.

2

Weak

Re-evaluate in case of treatment failure; this may consist of (video) urodynamics magnetic resonance imaging of lumbosacral spine and other diagnostic modalities, guiding off-label treatment which should only be offered in highly experienced centres.

3

Weak

3.10.5 Recommendations for the management of monosymptomatic nocturnal enuresis – bedwetting

Recommendations

LE

Strength rating

Do not treat children less than five years of age in whom spontaneous cure is likely, but inform the family about the involuntary nature, the high incidence of spontaneous resolution and the fact that punishment will not help to improve the condition.

2

Strong

Use voiding diaries or questionnaires to exclude day-time symptoms.

2

Strong

Perform a urine test to exclude the presence of infection or potential causes such as diabetes insipidus.

2

Strong

Offer supportive measures in conjunction with other treatment modalities, of which pharmacological and alarm treatment are the two most important.

1

Strong

Offer desmopressin in proven night-time polyuria.

1

Strong

Offer alarm treatment in motivated and compliant families.

1

Strong

3.11.6 Recommendations for the management of neurogenic bladder

Recommendations

LE

Strength rating

Urodynamic studies should be performed in every patient with spina bifida as well as in every child with high suspicion of a neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter.

2

Strong

In all newborns, intermittent catheterisation (IC) should be started soon after birth. In those with a clear underactive sphincter and no overactivity starting IC may be delayed. If IC is delayed, closely monitor babies for urinary tract infections, upper tract changes (US) and lower tract (UD).

3

Strong

Start early anticholinergic medication in the new-borns with suspicion of an overactive detrusor.

2

Strong

The use of suburothelial or intradetrusoral injection of onabotulinum toxin A is an alternative and a less invasive option in children who are refractory to anticholinergics in contrast to bladder augmentation.

2

Strong

Treatment of faecal incontinence is important to gain continence and independence. Treatment should be started with mild laxatives, rectal suppositories as well as digital. If not sufficient transanal irrigation is recommended, if not practicable or feasible, a Malone antegrade colonic enema (MACE)/Antegrade continence enema (ACE) stoma should be discussed.

3

Strong

Ileal or colonic bladder augmentation is recommended in patients with therapy-resistant overactivity of the detrusor, small capacity and poor compliance, which may cause upper tract damage and incontinence. The risk of surgical and non-surgical complications and consequences outweigh the risk for permanent damage of the upper urinary tract +/- incontinence due to the detrusor.

2

Strong

In patients with a neurogenic bladder and a weak sphincter, a bladder outlet procedure should be offered. It should be done in most patients together with a bladder augmentation.

3

Weak

Creation of a continent cutaneous catheterisable channel should be offered to patients who have difficulties in performing a IC through the urethra.

3

Weak

A life-long follow-up of renal and reservoir function should be available and offered to every patient. Addressing sexuality and fertility starting before/during puberty should be offered.

3

Weak

Urinary tract infections are common in children with neurogenic bladders, however, only symptomatic UTIs should be treated.

3

Weak

3.15.5 Recommendations for the management of obstructive pathology of renal duplication± ureterocele and ectopic ureter

Recommendations

LE

Strength rating

Ureterocele

Diagnosis

Use ultrasound (US), radionuclide studies (mercaptoacetyltriglycine (MAG3)/dimercaptosuccinic acid (DMSA)), voiding cystourethrography (VCUG), magnetic resonance urography, high-resolution magnetic resonance imaging (MRI), and cystoscopy to assess function, to detect reflux and rule out ipsilateral compression of the lower pole and urethral obstruction.

3

Weak

Treatment

Select treatment based on symptoms, function and reflux as well on surgical and parenteral choices: observation, endoscopic decompression, ureteral re-implantation, partial ephroureterectomy, complete primary reconstruction.

3

Weak

Offer, early endoscopic decompression to patients with an obstructing ureterocele.

Ectopic ureter

Diagnosis

Use US, DMSA scan, VCUG or MRI for a definitive diagnosis.

3

Weak

Treatment

In non-functioning moieties with recurrent infections, heminephro-ureterectomy is a definitive solution. Ureteral reconstruction (ureteral re-implantation/ureteroureterostomy/ ureteropyelostomy and upper-pole ureterectomy) are other therapeutic options, especially in cases in which the upper pole has function worth preserving.

3

Weak