Paediatric Urology

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


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

1.INTRODUCTION

1.1.Aim

The European Association of Urology (EAU) Paediatric Urology Guidelines Panel 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 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 an 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 are also available [1-7]. 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 [8]. This 2021 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 2021 publication:

  • Section 3.2 - Management of undescended testes: Both the literature and the text have been updated;
  • Section 3.3 - Testicular Tumours in prepubertal boys: This is a new section in the Guideline;
  • Section 3.5 - Acute Scrotum: Both the literature and the text have been updated;
  • Section 3.6 - Hypospadias: Both the literature and the text have been updated;
  • Section 3.7 - Congenital penile curvature: Both the literature and the text have been updated;
  • Section 3.9 - Urinary Tract Infections: Both the literature and the text have been extensively updated;
  • Section 3.10 - Day-time lower urinary tract conditions: The literature has been updated resulting in minor amendments to the text;
  • Section 3.13 - Dilatation of the upper urinary tract (UPJ and UVJ obstruction): The literature has been updated resulting in minor amendments to the text:
  • Section 3.15 - Urinary stone disease: The literature has been updated resulting in minor amendments to the text;
  • Section 3.18 - Congenital lower urinary tract obstruction (CLUTO): Both the literature and the text have been updated;
  • Section 3.19 – Rare Conditions - This is a new section in the Guideline comprising of urachal remnants, papillary tumours of the bladder and penile rare conditions.

1.5.1.New recommendations

3.3 Recommendations for testicular tumours in prepubertal boys

Recommendations

LE

Strength rating

High-resolution ultrasound (7.5 – 12.5 MHz), preferably a doppler ultrasound, should be performed to confirm the diagnosis.

3

Strong

Alpha-fetoprotein (AFP) should be determined in prepubertal boys with a testicular tumour before surgery.

2b

Strong

Surgical exploration should be done with the option for frozen section, but not as an emergency operation.

3

Strong

Organ-preserving surgery should be performed in all benign tumours.

3

Strong

Staging (MRI abdomen /CT chest) should only be performed in patients with a malignant tumour to exclude metastases.

3

Strong

MRI should only be performed in patients with the potential malignant Leydig or Sertoli-cell-tumours to rule out lymph node enlargement.

4

Weak

Patients with a non-organ confined tumour should be referred to paediatric oncologists post-operatively.

4

Weak

3.19 Recommendations for rare conditions in children

3.19.1 Urachal remnants

Recommendations

Strength rating

Urachal remnants with no epithelial tissue carry little risk of malignant transformation.

Strong

Asymptomatic and non-specific atretic urachal remnants can safely be managed non-operatively.

Strong

Urachal remnants (UR) incidentally identified during diagnostic imaging for non-specific
symptoms should also be observed non-operatively since they tend to resolve spontaneously.

Strong

A small urachal remnant, especially at birth, may be viewed as physiological.

Strong

Urachal remnants in patients younger than 6 months are likely to resolve with non-operative management.

Strong

Follow-up is necessary only when symptomatic for 6 to 12 months.

Strong

Surgical excision of urachal remnants solely as a preventive measure against later malignancy appears to have minimal support in the literature.

Strong

Only symptomatic URs should be safely removed by open or laparoscopic approach.

Strong

A voiding cystourethrogram is only recommended when presenting with febrile UTIs.

Strong

3.19.2 Papillary tumours of the bladder

Recommendations

LE

Strength rating

Ultrasound is the first investigation of choice for the diagnosis of paediatric bladder tumours.

3

Strong

Cystoscopy should be reserved if a bladder tumour is suspected on imaging for diagnosis and treatment.

3

Strong

After histological confirmation, inflammatory myofibroblastic bladder tumours should be resected locally.

4

Weak

Follow-up should be every 3-6 months in the first year, and thereafter at least annually with urinanalysis and an ultrasound for at least 5 years.

4

Weak

3.19.3 Penile conditions

Recommendations

LE

Strength rating

Treatment of penile cystic lesions is by total surgical excision, it is mainly indicated for cosmetic or symptomatic (e.g. infection) reasons.

4

Weak

Propranolol is currently first line treatment for infantile haemangiomas.

2b

Strong

Conservative management is the first-line treatment for penile lymphedema.

4

Weak

In symptomatic cases or in patients with functional impairment, surgical intervention may become necessary for penile lymphedema.

4

Weak