Early clean intermittent catheterization may not prevent dimercaptosuccinic acid renal scan abnormalities in children with spinal dysraphism

Systematic review and meta-analysis to study the outcomes of proactive versus delayed management in children with a congenital neurogenic bladder

PURPOSE

To review the urological outcomes of proactive versus delayed management of children with a neurogenic bladder (NB).

METHODS

We performed a literature search on EMBASE, MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials between January 1, 2000 to August 21, 2023 for studies investigating the management of spina bifida-associated NB in pediatric patients (0-18 years of age). Proactive management was defined as use of clean intermittent catheterization, and/or anticholinergics at presentation, or based on initial high-risk urodynamic findings by 1 year of age. Delayed management was defined as beginning management after 1 year of age or no intervention. Outcomes included incidence or diagnosis of secondary vesicoureteral reflux (VUR), urinary tract infection (UTI), and renal deterioration, which included renal scarring, loss of differential renal function on a nuclear scan, or a decrease in renal function defined by glomerular filtration rate or serum creatinine estimation. Forest plots were synthesized using the Inverse Variance method with random-effect model. The Risk of Bias was assessed using the ROBINS-I tool.

RESULTS

We included 8 observational studies on 652 pediatric patients with spina bifida-associated NB (mean follow-up - 7 years). Proactive management following initial assessment was associated with significantly lower risks of secondary VUR (OR 0.37 [0.19, 0.74], p = 0.004), non-febrile UTI (OR 0.35 [0.19, 0.62], p = 0.0004), and renal deterioration (OR 0.31 [0.20, 0.47], p < 0.00001).

DISCUSSION

Delayed management of NB potentially has 3 times higher risks of secondary VUR, non-febrile UTI, and renal deterioration. However, the evidence is limited by the high risk of bias due to lack of randomization and standardized reporting in observational studies.

CONCLUSION

While further well-defined prospective studies with long-term follow-up should be conducted to confirm this finding, this study supports the EAU/ESPU recommendations for early intervention in children with NB.

Why are pediatric urologists unable to predict renal deterioration using urodynamics? A focused narrative review of the shortcomings of the literature

In this focused narrative review we set out to review the current literature addressing the utilization of UDS in patients with spina bifida (SB). We specifically analyzed 6 urodynamic parameters and their roles as predictors of upper tract deterioration in pediatric SB patients. The material available did not allow a systematic analysis or the usage of metanalysis methodology, due to the predominance of small retrospective cohorts, and high heterogeneity. We identified 10 retrospective chart reviews that met our study criteria. The results of each of these papers, as well as other studies deemed relevant to the discussion, are included in our narrative review of the literature. We summarize the current literature, offer explanations for divergences in opinion, and identify future research directions and emerging solutions with a focus on machine learning.

Management of neuropathic bladder secondary to spina bifida: Twenty years' experience with a conservative approach

INTRODUCTION

Treatment of neuropathic bladder secondary to spina bifida is an ongoing challenge. Although different management strategies and protocols are available in the literature, reliance on expert opinion remains fundamental. A conservative approach can be utilized, but patients must be closely monitored throughout the management process. The objective of this study was to review the management and outcomes of neuropathic bladder in spina bifida by appraising long-term bladder and renal function in patients treated at a medical center utilizing a conservative management style.

METHODS

This is a single-center retrospective review of urology care for all spina bifida patients 5-19 years of age with a neuropathic bladder who attended follow-ups between April 2000 and April 2020. Only patients with more than 5 years of follow-up were included. Renal functions, continence and results of invasive video urodynamics (IUD) and any surgical interventions were recorded.

RESULTS

Seventy-one patients (mean age = 10.5 years) were identified after exclusions. Bladder compliance between first and last IUDs increased significantly (p = 0.0056). Anticholinergic treatment was started at the first outpatient appointment. Intravesical botulinum toxin injection was the second line treatment in ten patients. 94% of patients had an end fill pressure below 40 cm H₂O in their last IUD. 82% were socially continent (dry or occasional damp patches) with or without catheterisations at the age of 11.5 years. One patient in the cohort had bladder augmentation.

CONCLUSION

The optimal management of neuropathic bladder secondary to spina bifida remains controversial. Bladder and renal functional outcomes can be improved with close monitoring and less invasive management.

Influence in the outcome of neuropathic pediatric patients after early treatment

BACKGROUND

Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients.

AIM

To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life.

PATIENTS AND METHOD

Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence.

RESULTS

Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency.

CONCLUSIONS

Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Influence in the outcome of neuropathic pediatric patients after early treatment

BACKGROUND

Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients.

AIM

To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life.

PATIENTS AND METHOD

Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence.

RESULTS

Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency.

CONCLUSIONS

Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Comparison of risk of anticholinergic utilization for treatment of neurogenic bladder between in utero or postnatal myelomeningocele repair

INTRODUCTION

In utero myelomeningocele (MMC) repair has resulted in significant decrease in need for shunt-dependent hydrocephalus, however its impact on bladder function remains less clear. Neurogenic detrusor overactivity (NDO) due to MMC can be addressed with combination of clean intermittent catheterization (CIC) and anticholinergic (AC) therapy to minimize its effect on bladder function and upper urinary tract. The aim of this study was to compare the risk of postnatal AC utilization for in patients that underwent either postnatal or in utero MMC repair related to neurogenic bladder (NGB) management. We hypothesized that postnatal MMC repair would be associated with increased risk of postnatal AC utilization compared to in utero MMC repair.

MATERIAL AND METHODS

All newborns with MMC in our hospital undergo prospective surveillance radiographic and urodynamic testing as part of institutional MMC protocol. Those MMC patients born between 2013 and 2018 at our institution, who underwent in utero or postnatal MMC repair were retrospectively analyzed. We identified postnatal AC utilization from electronic medical records and recorded indications for AC therapy according to the urodynamic, radiographic and clinical findings related to NGB management.

RESULTS

97 patients fulfilled the inclusion criteria. 56 patients underwent a postnatal and 41 an in utero repair. Median follow-up for the in utero and postnatal MMC repair groups was the same at 37 months (p = 0.53). More newborns from the postnatal group were discharged from birth hospital performing CIC (91.1% vs. 58.5%, p < 0.0001), however upon last follow up no difference existed between the groups on use of CIC (83.9% postnatal group % vs. 82.9% in utero group, p = 0.78). At last follow up, postnatal AC utilization was observed in 75% of postnatal MMC group compared to 78.1% of the in utero MMC repair group, p = 0.81 (Figure). The median time to AC utilization was 6.9 months and 8.8 months in the in utero and postnatal groups, respectively (p = 0.28).

DISCUSSION

We observed no reduction in risk of AC utilization with in utero repair which refuted the hypothesis of our study. Indications for AC utilization were urodynamic abnormalities such as NDO (81.3% in utero vs. 81% postnatal) or impaired bladder compliance (53.1% in utero vs. 64.3% postnatal).

CONCLUSIONS

We found no difference in risk of postnatal AC utilization between in utero or postnatal MMC repair. CIC rates were higher at birth hospital discharge in the postnatal repair group, however at last follow up CIC rates did not differ between groups.

Evaluation and Long-term Management of Neurogenic Bladder in Spinal Dysraphism

Spinal dysraphism, which includes conditions such as myelomeningocele and sacral agenesis, is one of the most common causes of congenital lower urinary tract dysfunction. Early evaluation of the neurogenic bladder serves to minimize renal damage, and the main goals of management include preserving renal function, achieving acceptable continence, and optimizing quality of life. The survival of patients with such conditions has improved to greater than 80% reaching adulthood, owing to advances in diagnostic and therapeutic modalities. The result is a real, and unfortunately often unmet, need for successful transitional care in this complex patient population. Clinicians must be able to identify the unique challenges encountered by patients with neurogenic bladder as they shift through different stages of their life.

Long-term urological outcomes of spinal lipoma after prophylactic untethering in infancy: real-world outcomes by lipoma anatomy

STUDY DESIGN

Cohort study.

OBJECTIVES

Long-term urological outcomes in patients with spinal lipoma after prophylactic tethered cord release (TCR) in infancy were investigated.

SETTING

Children's hospital in Yokohama, Japan.

METHODS

Children under one year of age with spinal lipoma who underwent TCR between 1990 and 2010 were investigated. According to Arai's classification, lipomas other than filar lipoma were classified into four types: caudal, dorsal, transitional, and lipomyelomeningocele. The level of the conus medullaris was divided into three categories: L3-5, L5/S1, and sacral. Urological outcomes, including the need for clean intermittent catheterization (CIC), urinary incontinence, presence of renal deterioration, and the need for bladder augmentation, were investigated by both lipoma type and level of the conus medullaris.

RESULTS

Fifty-three patients met the inclusion criteria. The median follow-up period was 14.2 years (interquartile range 9.6-17.6 years). Of the 53 patients, ten (19%) were on CIC, and six (11%) were incontinent. Overall, two patients (4%) had renal deterioration detected by DMSA renal scan, and two (4%) needed augmentation cystoplasty. Of the lipoma types, transitional type showed the worst outcomes with respect to need for CIC (54%) and urinary incontinence (38%). There were no significant differences in renal deterioration and the rate of bladder augmentation by lipoma type. No urological outcomes were significantly associated with conus level.

CONCLUSIONS

Even after prophylactic TCR in infancy in children with spinal lipoma, 19% of patients needed CIC in long-term follow-up. Of the lipoma types, transitional type showed the worst outcomes with respect to need for CIC and urinary incontinence.

Early Vs. Expectant Management of Spina Bifida Patients-Are We All Talking About a Risk Stratified Approach?

PURPOSE OF REVIEW

Advancements in the care of patients affected by myelomeningocele have flourished in recent years especially with respect to renal preservation and continence. Involvement of urologists both prenatally and early in life has driven many developments in preventative care and early intervention. As of yet, however, the ideal management algorithm that offers these patients the least invasive diagnostic testing and interventions while still preserving renal and bladder function remains ill defined.

RECENT FINDINGS

In a shift from prior years where the use of surgical intervention and intermittent catheterization were more liberally employed, some providers have more recently advocated for monitoring patients in a more conservative manner with a variety of diagnostic tests until radiographic or clinical changes are discovered. The criteria used to define the need for catheterization and the timing to initiate CIC or more invasive interventions is disparate across pediatric urology and there is published data to support several approaches. This review presents some of these criteria for use of CIC and some newer evidence to support different approaches along with supporting the trend toward individualized medicine and use of risk stratification in developing clinical treatment algorithms.

Early start of clean intermittent catheterization versus expectant management in children with spina bifida

PURPOSE

We instituted early clean intermittent catheterization (CIC) in 1997 for all newborn infants with spina bifida (SB). We compared this group to a historical group managed expectantly to see if early catheterization was associated with a reduction in renal scar rate as determined by DMSA scanning.

METHODS

Data were studied retrospectively on all infants with SB over a recent 13-year period who were treated with early universal CIC in a regional pediatric urology department. These were compared to our previously published outcomes in a historical group (1985-1994) that was managed expectantly [Brown et al. Chronic pyelonephritis in association with neuropathic bladder. Eur J Pediatr Surg 1999;9 Suppl 1:29-30.] RESULTS: 114 infants were born with SB from 1997 to 2010, of which 13 were excluded from this analysis. Mean follow-up was 11.4 years. In the historical cohort there were 126 infants born from 1985 to 1994, with 26 exclusions; follow-up then ranged from 4 to 13 years. DMSA scan showed renal scarring in 19/101 (18.8%) of the recent cohort versus 39/100 (39%) of the previous group (P = 0.002). Renal scarring at a later age also appeared to be a feature of the recent group, with first detection occuring by 4 years in only 9/19 (47%) in the latest cohort compared to 28/39 (72%) in the historical cohort.

CONCLUSION

Based on these renal protective data, we recommend indwelling and then intermittent catheterization from birth in all patients with SB.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective, cohort comparison study.

Encouraging Results of Bowel and Bladder Management in Spina Bifida Aperta in South India with Quality of Life Scores in a Tertiary Care Institution in South India

Context

It is often a challenge to counsel parents with children operated for spina bifida aperta in developing countries. Data regarding the efficacy of simple measures and preventive are scarce.

Aims

The aim of this study is to study such children for the incidence, prevalence of bowel bladder dysfunction, and the quality of life (QOL) in children who are involved with a multidisciplinary team in India.

Materials and Methods

All children with spina bifida occulta were followed - QOL questionnaires (PIN Q, modified Barthels activities of daily living , and the visual analog score [VAS]) were used. Interventions, such as clean intermittent catheterization (CIC), bowel enemas, and surgical procedures, were studied.

Results

A total of 68 children were assessed. Twenty-nine of these children over five were evaluated with QOL scores. The prevalence of incontinence of bowel and bladder was studied. The primary outcomes included the QOL scores, and the various surgical options help bowel and bladder management. Hydronephrosis in 17.95% of children <5 years and 65.5% of children over 5 years was noted. Nineteen children were socially independent for their bowel management. The Barthel index and PIN-Q showed a poor QOL in 27.6% and the VAS in 34.5% had the same. This translated to an acceptable QOL for over two-thirds of the children.

Conclusions

Simple procedures and training for bowel management translate to a significant number of children being able to independently manage bowel care. About 30% of children develop hydronephrosis by 5 years; the decision to teach CIC must be made by then. We believe that positive counseling is given to the parents of children with spina bifida aperta as the children are capable of a reasonable QOL.

Streamlining risk stratification in infants and young children with spinal dysraphism: Vesicoureteral reflux and/or bladder trabeculations outperforms other urodynamic findings for predicting adverse outcomes

BACKGROUND

Baseline and interval dimercaptosuccinic acid (DMSA) scans and urodynamic (UD) studies are often obtained in infants and young children with spinal dysraphism (SD).

OBJECTIVE

To identify practical UD parameters which accurately stratify urologic risk young children with SD.

STUDY DESIGN

130 expectantly managed infants/young children with SD and initial DMSA and UD before age 2 were reviewed. End fill pressure (EFP), bladder trabeculations, vesicoureteral reflux (VUR), initial volume (IV) drained at UD catheter placement, and detrusor pressure at initial volume (DPIV) were evaluated for association with subsequent febrile urinary tract infection (UTI), DMSA abnormalities, and early clean intermittent catheterization (CIC). A combination of factors to accurately stratify risk was sought. Groups were compared by log-rank test. The association of CIC and febrile UTI incidence was evaluated.

RESULTS

31/130 patients developed DMSA abnormalities, 52/130 started early CIC, and 61/130 developed a febrile UTI with median follow-up of 3.8 years. Trabeculations, VUR, EFP ≥40 cm H₂O, IV ≥50% estimated bladder capacity (EBC), and DPIV >10 cm H₂O were associated with subsequent abnormal DMSA scan (p < 0.001). The best predictor was combination of trabeculation and/or VUR (p < 0.001) (Figure). Among patients who maintained a non-trabeculated bladder without VUR during follow-up, 0/51 developed DMSA abnormalities compared with 31/79 who developed one or both (p < 0.001). Patients with trabeculations and/or VUR were more likely to start early CIC (8/51 vs. 44/79; p < 0.001) and have febrile UTI (11/51 vs. 50/79; p < 0.001). In those with trabeculations, CIC was associated with decreased incidence of febrile UTI (incidence rate ratio (IRR) 0.5, 95% CI 0.3-0.9); in those without trabeculations, CIC was associated with increased incidence of febrile UTI (IRR 1.8, 95% CI 1.1-3.1).

CONCLUSIONS

VUR, bladder trabeculations, EFP ≥40 cm H₂0, IV ≥50% of EBC, and DPIV >10 cm H₂O were associated with subsequent DMSA abnormalities in young children with SD managed expectantly. Many of these parameters were associated with febrile UTI and early CIC. The combination of trabeculations and/or VUR outperformed other UD parameters in identifying those high and low-risk for adverse urologic outcomes. Routine DMSA scan may have limited utility in patients with a non-trabeculated bladder without VUR, as none developed an abnormal DMSA. Most (71%) abnormal DMSAs were in patients with trabeculations and/or VUR following a febrile UTI. Given these findings and that incidence of febrile UTI may be lower in those with trabeculations while on CIC, patients with trabeculations and/or VUR should be managed aggressively to protect kidneys.

Expectant use of CIC in newborns with spinal dysraphism: Report of clinical outcomes

PURPOSE

Report urologic outcomes among newborns with spinal dysraphism managed within an expectant clean intermittent catheterization (CIC) program.

METHODS

Newborns were followed clinically and with serial ultrasound (US). Urodynamics (UD) and dimercaptosuccinic acid (DMSA) renal scan were obtained at 3-6 months, 1 year, 3 years, then as needed. Patients with initial evaluation after 6 months were excluded.

RESULTS

Median follow-up was 3.2 years. 11/102 began catheterization for continence (median 4.0 years) and 47/102 did not start CIC. Of these, 2/58 developed a DMSA abnormality. 44/102 began CIC early, often for elevated storage pressures and febrile urinary tract infection (UTI). Of these, 20/44 developed a DMSA abnormality including 9 who had abnormality detected prior to starting CIC. Being on CIC or starting immediately upon recognition of new hydronephrosis, reflux, elevated filling pressures, or febrile UTI was associated with lower chance of DMSA abnormalities (4/17, 24%) compared to delaying CIC (16/27, 60%) (p= 0.03).

CONCLUSIONS

CIC can be deferred until continence in select infants with a low risk of significant DMSA abnormality. However, immediate initiation of CIC upon recognition of risk factors is recommended as this was associated with fewer DMSA abnormalities than delaying CIC. Recommendations for expectantly-managed patients include close follow-up, serial US and UD, and prompt initiation of CIC upon recognition of new hydronephrosis, reflux, elevated storage pressures, or febrile UTIs.

Can bladder fibrosis in congenital urinary tract obstruction be reversed?

A variety of conditions exists in adults and children in which functional or anatomical urinary tract obstructions cause bladder fibrosis, which reduces the bladder's ability to store and empty urine. Current surgical procedures include removal of the obstructions to facilitate bladder emptying or prompt prenatal or postnatal spinal closure to prevent further neurogenic damage. Bladder fibrosis may occur, and it can get worse if a flow hindrance persists or deteriorates. Anti-fibrotic therapeutic strategies that target a variety of factors have been developed in animal models, but currently there are no anti-fibrotic therapies available for clinical use. This review examines the pathogenesis of bladder fibrosis that is caused by congenital obstructions of the lower urinary tract, and it focuses on the principal signalling factors and potential treatment modalities.

Follow-up urodynamics in patients with neurogenic bladder

INTRODUCTION

Neurogenic bladder patients are at long-term risk of secondary upper urinary tract damage. Symptoms are unreliable and follow-up urodynamics is the only method of ascertaining safety of bladder pressures. This review examines the recommendations, shortcomings and utilization of existing guidelines. The evidence with regard to follow-up urodynamics in different settings relevant to neurogenic bladder is evaluated and an algorithm is proposed.

METHODS

A pubmed search was conducted for studies on follow-up urodynamics in patients with neurogenic bladder. Additional search was made of secondary sources including reviews and guidelines.

RESULTS

The need for follow-up urodynamics should be considered in all patients undergoing an initial assessment and weighed against the risks. Existing guidelines, while unanimous in their recommendation of its utilization, give scant details regarding its incorporation in clinical management. Follow-up urodynamics can document efficacy and identify the need for escalation of therapy in patients on intermittent catheterization and antimuscarinics. Patients with spinal injury, spinal dysraphism and anorectal malformations are at higher risk for upper tract damage. Follow-up urodynamics can help identify patients suitable for intravesical botulinum and mark those destined for failure. Patients undergoing augmentation cystoplasty may be candidates for less aggressive urodynamic follow-up.

CONCLUSIONS

Neurogenic bladder is managed by a broad cross-section of physicians. Clear recommendations and a management algorithm are important for improving patient care. Follow-up urodynamics can identify patients at risk, prevent renal dysfunction and improve the quality of life. There is an urgent need for more evidence on this important subject.

Association between clean intermittent catheterization and urinary tract infection in infants and toddlers with spina bifida

INTRODUCTION

The primary goal of urologic management in children with spina bifida is to reduce the risk of urinary tract infection (UTI) and associated renal injury. While clean intermittent catheterization (CIC) has been the mainstay of treatment, recent studies have suggested that this approach is not without risk. The objective of this study was to examine the association between alternative bladder management strategies and UTI in infants and toddlers with spina bifida.

METHODS

A retrospective cohort study was conducted on spina bifida patients, aged 0-3 years, seen in a multidisciplinary spinal defects clinic between 2008 and 2013. Inclusion criteria included: a primary diagnosis of meningocele, myelomeningocele, or lipomyelomeningocele. Patients were excluded if they had: <1 year of follow-up, urologic surgery prior to initial evaluation, or incomplete data for analysis. Bivariate analyses were performed using Chi-squared or Fisher's exact tests. Multivariate analyses were performed using logistic regression.

RESULTS

A total of 107 patients meeting study criteria were identified. The majority of patients had lumbar lesions (74.8%) and ventriculoperitoneal (VP) shunts (72.9%). Initial bladder management was by CIC in 39.3% of patients and spontaneous voiding in 60.8% of patients. Median age at follow-up was 2.5 years. During the study period, 23.4% of patients switched from spontaneous voiding to CIC. Patients managed with CIC were more likely to have UTIs at final follow-up than those managed with voiding (35.7% vs. 18.5%; P = 0.045). Patients with vesicoureteral reflux (VUR) were also more likely to have UTIs (54.5% vs. 17.9%; P = 0.015). Patients who switched from spontaneous voiding to CIC over the study period were more likely to be evaluated with urodynamics (72.0% vs. 31.8%; P < 0.0001) than those managed with voiding alone. Patients who switched to CIC were also more likely to have VUR (16% vs. 0%; P = 0.09) and UTIs (24% vs. 15%; P = 0.06) than those managed with voiding alone; however, these differences were not statistically significant.

CONCLUSIONS

In the present series, infants and toddlers with spina bifida who were initially managed with spontaneous voiding had a lower risk of UTI than those managed with CIC. Patients who switched to CIC after a period of initial observation with voiding did not have a significantly different risk of UTI compared with those managed with CIC alone. These findings suggest that early initiation of CIC may not be warranted in all infants with spina bifida. Further studies are needed to more clearly define optimal indications for initiation of CIC in these patients.

Study of kidney damage in paediatric patients with neurogenic bladder and its relationship with the pattern of bladder function and treatment received

OBJECTIVES

Kidney failure is the main cause of morbidity and mortality in patients with myelodysplasia. We analysed the presence of renal lesions in these patients using dimercaptosuccinic acid scintigraphy and related their presence with the type of vesical function and the delay in receiving appropriate management.

MATERIAL AND METHODS

We performed a retrospective study of patients with myelodysplasia treated in our hospital since 2004. We analysed the epidemiological and clinical data and the pattern of bladder function according to urodynamic studies. We classified the patients into 4 urodynamic patterns according to detrusor and sphincter behaviour. We linked this behaviour to renal function in the scintigraphy and the care received since birth.

RESULTS

The study included 39 patients with myelodysplasia. The most common bladder pattern was type A (61.5%), with sphincter and detrusor hyperactivity, followed by type D (20.5%), C (7.8%) and B (5.1%). Some 38% of our patients (n=15) had some type of nephropathy. Some 92.9% of the children who were properly treated during the first year of their life had no renal lesions in the scintigraphy. We found some type of nephropathy in 56% of the patients for whom appropriate treatment was delayed for more than a year. The nephropathy was more severe the later the management was started.

CONCLUSIONS

There is a statistically significant relationship between a delay in treatment and impairment in renal scintigraphy in patients with neurogenic bladders. The early study and treatment of patients is essential for decreasing renal impairment, reducing the need for surgery and improving the continence options.