Research Article| Volume 19, ISSUE 1, P90.e1-90.e8, February 2023

Technical details and long-term outcomes of P.A.D.U.A. for congenital urethral narrowing; a case series and review of the literature

Published:November 01, 2022DOI:



      The P.A.D.U.A. technique is a method of addressing congenital urethral narrowing. It involves passive dilation with a series of progressively larger indwelling catheters. Utilization is limited by scant literature, particularly regarding technical details and long-term durability. Tools for achieving safe and reliable urinary drainage are critical in these patients, who require careful stewardship of their kidney and bladder function.


      To describe long-term urethral patency and urinary function following P.A.D.U.A., and to provide sufficient technical detail to reproduce the technique.

      Study design

      Patients with congenital urethral narrowing managed with P.A.D.U.A. were identified and chart review was performed. Details of catheter exchange sequences were compiled and described. The primary outcome was the attainment of adequate urethral caliber by successful completion of P.A.D.U.A., and the secondary outcome was voiding per urethra at most recent follow-up.


      P.A.D.U.A. achieved adequate urethral caliber in 9/11 (82%) of patients. This included seven patients with Prune Belly Syndrome, one with isolated urethral atresia, and one with a cloacal anomaly. P.A.D.U.A. failed to achieve urethral patency in one patient with urethral duplication, who was unable to progress through the catheter sequence, and one patient with Prune Belly Syndrome, who completed P.A.D.U.A. but developed recurrent narrowing one week later. There were no delayed failures of urethral patency. Patients who achieved patency underwent a median of seven catheter placements over 92 days. Median (range) initial and final catheter sizes were 3.5F (1.9–8F) and 14F (8–16F). While 82% achieved patency, only 3/11 (27%) were voiding spontaneously per native urethra at most recent follow-up.


      This series of patients undergoing P.A.D.U.A. for primary treatment of congenital urethral narrowing is the largest to date and provides granular technical details. It aligns with prior reports suggesting that P.A.D.U.A. achieves urethral patency in most patients with Prune Belly Syndrome or isolated urethral atresia, but has limited application in the hypoplastic duplicated urethra. Despite high rates of urethral patency in this select population, many patients will not achieve and maintain spontaneous voiding without catheterization. This is likely due to ongoing deterioration of bladder function caused by the prenatal developmental insult, paralleling the phenomenon seen in posterior urethral valves.


      Summary Figure
      Graphical AbstractCurrent urinary status. Voiding status as of most recent follow-up for all patients in the cohort.



      PBS (Prune Belly Syndrome), P.A.D.U.A. (progressive dilation of the urethra anterior), PUV (posterior urethral valve), UTI (urinary tract infection), CIC (clean intermittent catheterization)
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        • Clayton D.B.
        • Brock J.W.
        Current state of fetal intervention for lower urinary tract obstruction.
        Curr Urol Rep. 2018; 19: 12
        • Partin A.W.
        • Dmochowski R.R.
        • Kavoussi L.R.
        • Peters C.
        Campbell-Walsh-Wein urology.
        12th ed. 3. Elsevier, Philadelphia, PA2021: 3706 (illustrations (chiefly color) p)
        • Berdon W.E.
        • Baker D.H.
        • Wigger H.J.
        • Blanc W.A.
        The radiologic and pathologic spectrum of the prune belly syndrome. The importance of urethral obstruction in prognosis.
        Radiol Clin North Am. 1977; 15: 83-92
        • Rogers L.W.
        • Ostrow P.T.
        The prune belly syndrome. Report of 20 cases and description of a lethal variant.
        J Pediatr. 1973; 83: 786-793
        • Kroovand R.L.
        • Al-Ansari R.M.
        • Perlmutter A.D.
        Urethral and genital malformations in prune belly syndrome.
        J Urol. 1982; 127: 94-96
        • Reinberg Y.
        • Chelimsky G.
        • Gonzalez R.
        Urethral atresia and the prune belly syndrome. Report of 6 cases.
        Br J Urol. 1993; 72: 112-114
        • Sarhan O.M.
        • Al-Ghanbar M.S.
        • Nakshabandi Z.M.
        Prune belly syndrome with urethral hypoplasia and vesico-cutaneous fistula: a case report and review of literature.
        Urol Ann. 2013; 5: 296-298
        • Teramoto R.
        • Opas L.M.
        • Andrassy R.
        Splenic torsion with prune belly syndrome.
        J Pediatr. 1981; 98: 91-92
        • Woodhouse C.R.
        • Ransley P.G.
        • Innes-Williams D.
        Prune belly syndrome--report of 47 cases.
        Arch Dis Child. 1982; 57: 856-859
        • Snyder H.M.
        • Harrison N.W.
        • Whitfield H.N.
        • Williams I.
        Urodynamics in the prune belly syndrome.
        Br J Urol. 1976; 48: 663-670
        • Passerini-Glazel G.
        • Araguna F.
        • Chiozza L.
        • Artibani W.
        • Rabinowitz R.
        • Firlit C.F.
        • et al.
        (progressive augmentation by dilating the urethra anterior) procedure for the treatment of severe urethral hypoplasia.
        J Urol. 1988; 140: 1247-1249
        • Ortolano V.
        • Nasrallah P.F.
        Urethral duplication.
        J Urol. 1986; 136: 909-912
        • Stalberg K.
        • Gonzalez R.
        Urethral atresia and anhydramnios at 18 weeks of gestation can result in normal development.
        J Pediatr Urol. 2012; 8: e33-e35
        • Gobbi D.
        • Fascetti Leon F.
        • Gnech M.
        • Midrio P.
        • Gamba P.
        • Castagnetti M.
        Management of congenital urethral strictures in infants. Case series.
        Urol J. 2019; 16: 67-71
        • Lima M.
        • Destro F.
        • Di Salvo N.
        • Gargano T.
        • Ruggeri G.
        Fate of males with urethral "Y-duplication": 40-year long follow-up in 8 patients.
        J Pediatr Surg. 2017; 52: 1335-1339
        • Haleblian G.
        • Kraklau D.
        • Wilcox D.
        • Duffy P.
        • Ransley P.
        • Mushtaq I.
        Y-type urethral duplication in the male.
        BJU Int. 2006; 97: 597-602
        • Al-Bassam A.
        • Sheikh M.A.
        • Al-Smayer S.
        • Al-Boukai A.
        • Al-Damegh S.
        Congenital H-type anourethral fistula with severe urethral hypoplasia: case report and review of the literature.
        J Pediatr Surg. 1998; 33: 1550-1553
        • Wu C.Q.
        • Traore E.J.
        • Patil D.
        • Blum E.
        • Cerwinka W.
        • Elmore J.
        • et al.
        Role of a preoperative catheter regimen in achieving early primary endoscopic valve ablation in neonates with posterior urethral valves.
        J Urol. 2021; 205: 1792-1797
        • Kinahan T.J.
        • Churchill B.M.
        • McLorie G.A.
        • Gilmour R.F.
        • Khoury A.E.
        The efficiency of bladder emptying in the prune belly syndrome.
        J Urol. 1992; 148: 600-603
        • Seidel N.E.
        • Arlen A.M.
        • Smith E.A.
        • Kirsch A.J.
        Clinical manifestations and management of prune-belly syndrome in a large contemporary pediatric population.
        Urology. 2015; 85: 211-215
        • Julio Junior H.R.
        • Costa S.F.
        • Costa W.S.
        • Barcellos Sampaio F.J.
        • Favorito L.A.
        Structural study of the bladder in fetuses with prune belly syndrome.
        Neurourol Urodyn. 2018; 37: 148-152
        • Workman S.J.
        • Kogan B.A.
        Fetal bladder histology in posterior urethral valves and the prune belly syndrome.
        J Urol. 1990; 144: 337-339
        • Hennus P.M.
        • van der Heijden G.J.
        • Bosch J.L.
        • de Jong T.P.
        • de Kort L.M.
        A systematic review on renal and bladder dysfunction after endoscopic treatment of infravesical obstruction in boys.
        PLoS One. 2012; 7e44663
        • Holmdahl G.
        • Sillen U.
        • Hanson E.
        • Hermansson G.
        • Hjalmas K.
        Bladder dysfunction in boys with posterior urethral valves before and after puberty.
        J Urol. 1996; 155: 694-698
        • De Gennaro M.
        • Capitanucci M.L.
        • Silveri M.
        • Morini F.A.
        • Mosiello G.
        Detrusor hypocontractility evolution in boys with posterior urethral valves detected by pressure flow analysis.
        J Urol. 2001; 165: 2248-2252
        • De Gennaro M.
        • Capitanucci M.L.
        • Mosiello G.
        • Caione P.
        • Silveri M.
        The changing urodynamic pattern from infancy to adolescence in boys with posterior urethral valves.
        BJU Int. 2000; 85: 1104-1108
        • Sheth K.R.
        • White J.T.
        • Bilgutay A.N.
        • Seth A.
        • Mittal A.G.
        Anterior urethral valves - a rare but challenging congenital pathology.
        J Pediatr Urol. 2020; 16: 585 e1-e7
        • McLeod D.J.
        • Szymanski K.M.
        • Gong E.
        • Granberg C.
        • Reddy P.
        • Sebastiao Y.
        • et al.
        Renal replacement therapy and intermittent catheterization risk in posterior urethral valves.
        Pediatrics. 2019; 143
        • Sarhan O.
        • Zaccaria I.
        • Macher M.A.
        • Muller F.
        • Vuillard E.
        • Delezoide A.L.
        • et al.
        Long-term outcome of prenatally detected posterior urethral valves: single center study of 65 cases managed by primary valve ablation.
        J Urol. 2008; 179 (discussion 12-3): 307-312
        • Biard J.M.
        • Johnson M.P.
        • Carr M.C.
        • Wilson R.D.
        • Hedrick H.L.
        • Pavlock C.
        • et al.
        Long-term outcomes in children treated by prenatal vesicoamniotic shunting for lower urinary tract obstruction.
        Obstet Gynecol. 2005; 106: 503-508