Paediatric Urology

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

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S. Tekgül (Chair), H.S. Dogan, P. Hoebeke, R. Kocvara, J.M. Nijman (Vice-chair), C. Radmayr, R. Stein
Guidelines Associates: E. Erdem, A.K. Nambiar, 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 Guidelines document addresses a number of common clinical pathologies in paediatric urological practice, but covering the entire field of paediatric urology in a single guideline document is unattainable.

The majority of urological clinical problems in children are distinct 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 approach is available.

Over time, paediatric urology has informally 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 care-givers into account.

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 Uroweb: http://uroweb.org/guideline/paediatric-urology/.

1.3.Available publications

A quick reference document (Pocket guidelines) is available, in print and in a number of versions for mobile devices. These are abridged versions which may require consultation together with the full text version. Also a number of translated versions, alongside several scientific publications in European Urology, the Associations scientific journal are available [1,2]. 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 with subsequent partial updates in 2005, 2006, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015 and this 2016 publication which 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 2016 publication:

  • Section 3.2 - Undescended testes (former Cryptorchidism chapter): complete update (prior to print publication)
    Two new figures have been inserted: Figure 1: Classification of undescended testes and Figure 2: Treatment of unilateral non-palpable undescended testes
  • Section 3.4 - Acute scrotum in children: The literature has been updated and minor text revisions made
  • Section 3.5 - Hypospadias: The literature has been updated extensively
  • Section 3.7 - Varicocele in children and adolescents: The literature has been updated extensively
  • Section 3.11 - Vesicoureteric reflux literature has been updated
  • Section 3.12 - Urinary stone disease literature has been updated

1.5.1.New and changed recommendations

3.2.7 Recommendation for the management of undescended testes

Recommendation

LE

GR

In case of bilateral undescended testes, endocrine treatment is recommended.

4

C

Section 3.6.5 Congenital penile curvature

Recommendation

LE

GR

Diagnose congenital penile curvature during hypospadias or epispadias repair using an artificial erection.

4

B

Perform surgery to treat congenital penile curvature.

4

B

3.7.5 Summary of evidence and recommendations for the management of varicocele

Recommendations

LE

GR

Examine varicocele in the standing position and classify into three grades.

4

A

Use scrotal US to detect venous reflux without Valsalva manoeuvre in the supine and upright position and to discriminate testicular hypoplasia.

In pre-pubertal boys and in isolated right varicocele perform standard renal US to exlude a retroperitoneal mass.

US=ultrasound.

3.9.5 Recommendation for the management of day-time lower urinary tract conditions

Recommendation

LE

GR

If present, treat BBD bowel dysfunction first, before treating the LUT condition.

2

B

BBD=Bladder Bowel Dysfunction; LUT=lower urinary tract.

3.11.6 Recommendations for the management of neurogenic bladder

Recommendations

LE

GR

In all babies, start intermittent catheterisation soon after birth, except for babies without any clear sign of outlet obstruction. If intermittent catheterisation is delayed, closely monitor babies for urinary tract infections and upper tract changes.

2

B

Use anticholinergic drugs as initial treatment in children with overactive bladders. Clinical improvement is common but usually insufficient.

2

B

Use injection of botulinum toxin into the detrusor muscle as an alternative in children who are refractory to anticholinergics.

2

B

Use a bladder augmentation procedure, using a segment of intestine, in case of therapy-resistant overactivity of the detrusor, or small capacity and poor compliance causing upper tract damage and incontinence.

2

B

Use augmentation with additional bladder outlet procedures when both the bladder and outlet are deficient. Simple augmentation will suffice in most low-capacity, high-pressure bladders.

3

B

Augment with an additional continent stoma after bladder outlet surgery and in patients with urethral catheterisation limitations.

3

B

Follow-up of neurogenic bladder patients will be life-long.

Follow-up includes monitoring of renal and bladder function as well as ensuring that sexuality and fertility issues receive particular care as the child gets older and moves into adulthood.

3

B

3.14.5 Recommendations for the management of urinary stones

Recommendations

LE

GR

Perform a metabolic and anatomical evaluation in any child with urinary stone disease.

2a

B

Any kind of interventional treatment should be supported with medical treatment for the underlying metabolic abnormality, if detected.

2a

B

1.5.2.A summary of evidence has been included in the following sections:

Section 3.2.7 - A summary of evidence has been added to Chapter 3.2 – Undescended testes.

  • Section 3.3.4 – A summary of evidence has been added to Chapter 3.3 – Hydrocele.
  • Section 3.4.4 – A summary of evidence has been added to Chapter 3.4 – Acute scrotum.
  • Section 3.6.4 – A summary of evidence has been added to Chapter 3.6 – Congenital penile curvature.
  • Section 3.7.5– A summary of evidence has been added to Section 3.7 – Varicocele in children and adolescents.
  • Section 3.9.5 – A summary of evidence has been added to Section 3.9 – Day-time lower urinary tract symptoms.
  • Section 3.10.5 – A summary of evidence has been added to Section 3.10 – Monosymptomatic enuresis.
  • Section 3.11.6 – A summary of evidence has been added to Section 3.11 – Neurogenic bladder.
  • Section 3.13.4 – A summary of evidence has been added to Section 3.13 – Vesicoureteric reflux in childhood.
  • Section 3.16.4 – A summary of evidence has been added to Section 3.16 – Disorders of sex development.
  • Section 3.17.7 – A summary of evidence has been added to Section 3.17 – Posterior urethral valves.