Renal deterioration in myelodysplastic children: urodynamic evaluation and clinical correlates

Risk determination for upper urinary tract damage in children with neuropathic bladder

AIM

Neuropathic bladder dysfunction (NBD) or neurogenic lower urinary tract dysfunction occurs as a result of a lesion at any level of central nervous system. The most common aetiology of NBD in children is abnormal development of spinal column. These defects cause neurogenic detrusor overactivity which contributes to detrusor-sphincter dysfunction and results in lower urinary tract symptoms such as incontinence. One of the more progressive and insidious, at the same time preventable result of neuropathic bladder is upper urinary tract deterioration. It is vital to aim reduction in bladder pressures and the minimisation of urine stasis in order to prevent or at least attenuate renal disease. Despite world-wide strategies for prevention of neural tube defects currently, we will still be involved in the care of spina bifida patients born every year with a neuropathic bladder and at risk of long-term renal damage. This study was planned for evaluation of results and detection of possible risk factors for upper urinary tract deterioration during routine visits of neuropathic bladder population.

METHODS

The electronic medical records of the patients who were followed up for at least 1 year with the diagnosis of neuropathic bladder in Pediatric Urology and Nephrology units of Adana City Training and Research Hospital were reviewed retrospectively. A total of 117 patients, whose blood, urine, imaging and urodynamic study required for the evaluation of nephrological and urological status were completed and included in the study. Patients under the age of one were excluded from the study. Demographic characteristics, medical history, laboratory and imaging results were recorded. All statistical analyses were analysed by SPSS version 21 software package and analysed by descriptive statistical.

RESULTS

Of the 117 patients who participated in the study, 73 (62.4%) were female and 44 (37.6%) were male. Mean age of the patients was 6.7 ± 4.9 years. The leading cause of neuropathic bladder was neuro-spinal dysraphism with 103 (88.1%) patients. Urinary tract ultrasound imaging revealed hydronephrosis in 44 patients (35.9%), parenchymal thinning in 20 patients (17.1%), increased parenchymal echo in 20 patients (17.1%) and trabeculation or increase in wall thickness of the bladder in 51 patients (43.6%). Voiding cystogram revealed the presence of vesicoureteral reflux in a total of 37 patients (31.6%), with 28 patients being unilateral and 9 patients bilateral. More than half of the patients had abnormal bladder findings (52.1%). In the Tc 99 m DMSA scan of the patients, 24 patients (20.5%) had unilateral renal scars and 15 (12.8%) had bilateral. Loss of renal function was detected in 27 (23.1%) of the patients. Urodynamic study revealed decreased bladder capacity in 65 patients (55.6%) and increased detrusor leakage pressure was found in 60 patients (51.3%). The mean leak point pressure of the patients was 36 ± 26 cm H2 O, and the mean leakage volume was determined as 157 ± 118 mL.

CONCLUSION

Findings obtained from imaging and urodynamic studies during routine investigation of neuropathic bladder patients can be a guide for the upper urinary tract. According to our results, age, bladder changes in ultrasound and voiding cystogram, high leak point pressure obtained during urodynamic studies are thought to have strong correlation with upper urinary tract damage. The prevalence of progressive chronic kidney disease in children and adults with spina bifida is remarkable and completely preventable. The strategies for prevention of renal disease in this patient population should be planned by coordinated work of urologist with nephrologist and requires family cooperation.

The Utility of Urodynamic Studies in Neuro-Urological Patients

INTRODUCTION

The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review.

METHODS

For this narrative review, a PubMed^® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used.

ANALYSIS

Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities.

CONCLUSION

Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

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.

Urodynamics findings pre- and post-untethering surgery in children with filum lipoma: A single-institution experience

OBJECTIVES

We aimed to investigate the changes in urodynamics and voiding cystourethrogram parameters on pre- and post-untethering surgery in patients aged under 2 years with filum lipoma.

METHODS

Sixty-two patients were enrolled in this study. The changes in urodynamics and voiding cystourethrogram parameters were compared before untethering surgery and 6 months after untethering surgery. These parameters were bladder volume, bladder deformity, vesicoureteral reflux during voiding cystourethrogram, detrusor overactivity, bladder compliance, and post-void residual volume in urodynamics.

RESULTS

Bladder volume during voiding cystourethrogram and bladder compliance increased significantly from 89.8 ± 49.5 mL to 114.5 ± 50.5 mL (P = 0.0069) and 10.2 ± 6.2 mL/mmH₂ O to 17.0 ± 13.3 mL/mmH₂ O (P = 0.0008), respectively, at 6-month follow-up. Six patients required combination management with clean intermittent catheterization at 25.1 ± 8.2 months (14.3 ± 6.5-months follow-up) because of elevated post-void residual volumes.

CONCLUSIONS

According to voiding cystourethrogram results, bladder function and urodynamics in patients with filum lipoma significantly improved after untethering surgery. Non-invasive assessment based on measurements of post-void residual should be considered as a postoperative follow-up method.

Autologous regeneration of blood vessels in urinary bladder matrices provides early perfusion after transplant to the bladder

Large animal testing and clinical trials using bioengineered bladder for augmentation have revealed that large grafts fail due to insufficient blood supply. To address this critical issue, an in vivo staged implant strategy was developed and evaluated to create autologous, vascularized bioengineered bladder tissue with potential for clinical translation. Pig bladders were used to create acellular urinary bladder matrices (UBMs), which were implanted on the rectus abdominus muscles of rats and pigs to generate cellular and vascular grafts. Rectus-regenerated bladder grafts (rrBGs) were highly cellularized and contained an abundance of CD31-positive blood vessels, which were shown to be functional by perfusion studies. Muscle patterns within grafts showed increased smooth muscle formation over time and specifically within the detrusor compartment, with no evidence of striated muscle. Large, autologous rrBGs were transplanted to the pig bladder after partial cystectomy and compared to transplantation of control UBMs at 2 weeks and 3 months post-transplant. Functional, ink-perfused blood vessels were found in the central portion of all rrBGs at 2 weeks, while UBM grafts were significantly deteriorated, contracted and lacked central cellularization and vascularization. By 3 months, rrBGs had mature smooth muscle bundles and were morphologically similar to native bladder. This staged implantation technique allows for regeneration and harvest of large bladder grafts that are morphologically similar to native tissue with functional vessels capable of inosculating with host bladder vessels to provide quick perfusion to the central area of the large graft, thereby preventing early ischemia and contraction.

A Study of Urodynamic Parameters at Different Bladder Filling Stages for Predicting Upper Urinary Tract Dilatation

Purpose

To identify more accurate predictors of upper urinary tract dilatation (UUTD) in neurogenic bladder (NB) children, we studied the relationship among urodynamic parameters at different bladder filling stages, detrusor leak point pressure (DLPP) and UUTD.

Methods

A total of 158 children (3–16 years) with NB were included and then divided into 2 groups according to whether their NB diagnosis was complicated with UUTD: the UUTD group (39 patients) and those without UUTD group (control group, 119 patients). The bladder filling phase was divided into 3 equal parts: the early, middle, and end filling stages. The bladder compliance (BC) and detrusor pressure (△P_det) at each phase and DLPP at the end filling stage were recorded.

Results

A BC<8 mL/cm H₂O both in the middle and end stages is more specific than a BC<9 mL/cm H₂O in the end stage (72%, 73%, vs. 66%), and △P_det >8 cm H₂O in the early stage, 20 cm H₂O in the middle stage and 25 cm H₂O in the end stage are more sensitive than △P_det >40 cm H₂O in the end stage (82%, 85%, 85%, vs. 49%). A DLPP cutoff value of 20 cm H₂O showed higher sensitivity for predicting UUTD than 40 cm H₂O.

Conclusions

Low BC and a high △P_det in the middle and end filling stages are more accurate factors than classic indicators for predicting UUTD. In addition, a DLPP value of >20 cm H₂O in the end bladder filling stage shows high sensitivity.

Renal Outcomes in Children with Operated Spina Bifida in Uganda

Background

To describe the extent of renal disease in Ugandan children surviving at least ten years after spina bifida repair and to investigate risk factors for renal deterioration in this cohort.

Patients and Methods

Children who had undergone spina bifida repair at CURE Children's Hospital of Uganda between 2000 and 2004 were invited to attend interview, physical examination, renal tract ultrasound, and a blood test (creatinine). Medical records were retrospectively reviewed. The following were considered evidence of renal damage: elevated creatinine, hypertension, and ultrasound findings of hydronephrosis, scarring, and discrepancy in renal size >1cm. Female sex, previous UTI, neurological level, mobility, detrusor leak point pressure, and adherence with clean intermittent catheterisation (CIC) were investigated for association with evidence of renal damage.

Results

65 of 68 children aged 10-14 completed the assessment. The majority (83%) reported incontinence. 17 children (26%) were performing CIC. One child had elevated creatinine. 25 children (38%) were hypertensive. There was a high prevalence of ultrasound abnormalities: hydronephrosis in 10 children (15%), scarring in 42 (64%), and >1cm size discrepancy in 28 (43%). No children with lesions at S1 or below had hydronephrosis (p = 0.025), but this group had comparable prevalence of renal size discrepancy, scarring, and hypertension to those children with higher lesions.

Conclusions

Incontinence, ultrasound abnormalities, and hypertension are highly prevalent in a cohort of Ugandan children with spina bifida, including those with low neurological lesions. These findings support the early and universal initiation of CIC with anticholinergic therapy in a low-income setting.

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.

Clinical outcomes of non-surgical management of detrusor leak point pressures above 40 cm water in adults with congenital neurogenic bladder

AIMS

Neurogenic bladders (NGB) with detrusor leak point pressures >40 cm H₂ O (dLPP > 40) have been associated with deterioration of renal function in children with myelomeningocele. For these children, careful pressure management preserves renal function. However, similar evidence is lacking in adult congenital urology (ACU) patients with NGB. We describe renal functional outcomes of non-surgical management of adults with dLPP > 40 or premicturition detrusor pressure (PMDP) >40 cm H₂ O, consisting of close follow-up with urodynamic studies (UDS) and renal ultrasound (RUS), paired with adjustments to clean intermittent catheterization (CIC) frequency, anticholinergics, and addition of onabotulinumtoxinA toxin (BTX) injection.

METHODS

We retrospectively reviewed the UDS of all patients at an ACU clinic from 2011 to 2016. Patients with dLPP/PMDP > 40 cm who elected for non-surgical management were included. We describe their management and renal functional outcomes.

RESULTS

A total of 33/42 patients with dLPP/PMDP > 40 elected for non-surgical management. 28/33 (85%) were successfully managed without bladder augmentation or urinary diversion at follow-up of nearly 3 years. The median index dLPP/PMDP was 49 cm H₂ O (IQR 44, 63) and final dLPP/PMDP was 28 (IQR 18, 43). There was a significant decrease in dLPP/PMDP and increase in bladder compliance between index and final UDS (P < 0.001). No patients advanced their CKD stage and 6/10 with baseline hydronephrosis had improvement or resolution of hydronephrosis with non-surgical management.

CONCLUSIONS

A non-surgical protocol for ACU patients with NGB and dLPP/PMDP > 40, utilizing CIC, anticholinergics, and BTX is safe and effective when coupled with coordinated care and close follow-up.

Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: A systematic review

AIM

The main goals of neurogenic lower urinary tract dysfunction (NLUTD) management are preventing upper urinary tract damage (UUTD), improving continence, and quality of life. Here, we aimed to systematically assess all available evidence on urodynamics predicting UUTD in patients with NLUTD.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in March 2017. Only neuro-urological patients assessed by urodynamics were included. Any outcome of upper urinary tract function were evaluated.

RESULTS

Forty-nine studies (1 randomized controlled trial, 9 prospective, and 39 retrospective case series) reported urodynamic data on 4930 neuro-urological patients. Of those, 2828 (98%) were spina bifida (SB) children. The total number of adults was 2044, mainly having spinal cord injury (SCI) (60%). A low bladder compliance was found in 568 (46.3%) and 341 (29.3%) of the paediatric and adult population, respectively. Hydronephrosis (HDN) was detected in 557 children (27.8%) in 19/28 studies and 178 adults (14.6%), mainly SCI, in 14/21 studies. Nine out of 30 multiple sclerosis (MS) patients affected by HDN (16.8%) showed low compliance in 4/14 studies.

CONCLUSIONS

Patients with SB and SCI have a higher risk of developing UUTD (mainly reported as HDN) compared to those with MS. Reduced compliance and high DLPP were major risk factors for UUTD. Although our findings clarify the mandatory role of urodynamics in the management of NLUTD, standardization and better implementation of assessments in daily practice may further improve outcomes of neuro-urological patients based on objective measurements, that is, urodynamics.

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.

Predictors of upper tract damage in pediatric neurogenic bladder

INTRODUCTION

Upper tract damage (UTD) is a life-threatening complication of neurogenic bladder (NB). Early identification of risk factors for UTD and institution of remedial measures may probably prevent UTD. The aim was to study the predictors of UTD in children 2 years or older with NB.

METHOD

This cross-sectional, observational study over 2 years included 30 children. UTD was defined as serum creatinine of >1 mg/dL or society of fetal urology grade III-IV hydronephrosis or hydroureteronephrosis on ultrasonography or renal scars on ^99mtechnetium dimercaptosuccinic scan or subnormal glomerular filtration rate (GFR) for age. The evaluated clinical variables were age at presentation, gender, palpable bladder lump, and recurrent urinary tract infection (UTI). Bladder wall thickness (BWT), grade and laterality of vesicoureteric reflux (VUR), status of the bladder neck, post-void residue (PVR), and level and type of intraspinal lesions were also noted. Urodynamic studies were performed for functional bladder assessment. A p-value <0.05 identified the risk factors.

RESULTS

UTD was detected in 15 (50%) with serum creatinine >1 mg% (2, 6%), SFU III-IV (11, 36%), renal scars (12, 40%), and subnormal GFR in (2, 6%) patients. Clinical risk factors for UTD were delayed presentation (p = 0.034), palpable bladder lump (p ≤ 0.001; OR 38.5; CI 5.6-262.5), and recurrent UTI (p = 0.033, OR 4.125, CI 0.913-18.630). The presence of significant PVR, trabeculated bladder, spin-top urethra, and bilateral VUR were identified as radiological risk factors for UTD. Mean BWT in patients with and without UTD was 4.69 ± 1.78 mm and 2.91 ± 1.08 mm respectively. BWT predictive of UTD was 3.05 mm (Figure). The mean detrusor leak point pressure (DLPP) did not vary significantly in those with and without UTD (36.82 ± 14.74 and 29.09 ± 10.44 cmH₂O, respectively), yet 75% patients with DLPP > 40 cmH₂O had UTD (p = 0.038, OR 5.4, CI 0.84-34.84). DLPP <40 cmH₂O was associated with UTD in 35% patients.

DISCUSSION

The incidence of UTD in this series is in accordance with that reported with expectant management (40%) and is much higher than the 17% stated with proactive management. A limitation of this study is the small number of patients and heterogeneous clinical diagnosis.

CONCLUSION

Delayed presentation with palpable bladder lump, recurrent UTI, increased BWT, bilateral VUR, increased PVR, and DLPP > 40 cm H₂O were identified as potential risk factors for UTD. This study highlights the significance of BWT as a predictor of UTD in NB.

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.

Application of data mining techniques to explore predictors of upper urinary tract damage in patients with neurogenic bladder

This study proposed a decision tree model to screen upper urinary tract damage (UUTD) for patients with neurogenic bladder (NGB). Thirty-four NGB patients with UUTD were recruited in the case group, while 78 without UUTD were included in the control group. A decision tree method, classification and regression tree (CART), was then applied to develop the model in which UUTD was used as a dependent variable and history of urinary tract infections, bladder management, conservative treatment, and urodynamic findings were used as independent variables. The urethra function factor was found to be the primary screening information of patients and treated as the root node of the tree; Pabd max (maximum abdominal pressure, >14 cmH₂O), Pves max (maximum intravesical pressure, ≤89 cmH₂O), and gender (female) were also variables associated with UUTD. The accuracy of the proposed model was 84.8%, and the area under curve was 0.901 (95%CI=0.844-0.958), suggesting that the decision tree model might provide a new and convenient way to screen UUTD for NGB patients in both undeveloped and developing areas.

How botulinum toxin in neurogenic detrusor overactivity can reduce upper urinary tract damage?

Intradetrusor injections of botulinum toxin are the cornerstone of medical treatment of neurogenic detrusor overactivity. The primary aim of this treatment is to ensure a low pressure regimen in the urinary bladder, but the mechanisms leading to long-term protection of the urinary tract remain poorly understood. In this paper, we highlight the potential benefits of intradetrusor injections of botulinum toxin regarding local effects on the bladder structures, urinary tract infections, stone disease, vesico ureteral reflux, hydronephrosis, renal function based on a comprehensive literature review.

Inosculation of blood vessels allows early perfusion and vitality of bladder grafts--implications for bioengineered bladder wall

Bioengineered bladder tissue is needed for patients with neurogenic bladder disease as well as for cancer. Current technologies in bladder tissue engineering have been hampered by an inability to efficiently initiate blood supply to the graft, ultimately leading to complications that include graft contraction, ischemia, and perforation. To date, the biological mechanisms of vascularization on transplant have not been suitably investigated for urologic tissues. To better understand the mechanisms of neovascularization on bladder wall transplant, a chimeric mouse model was generated such that angiogenesis and vasculogenesis could be independently assessed in vivo. Green fluorescence protein (GFP) transgenic mice received bone marrow transplants from β-galactosidase (LacZ) transgenic animals and then subsequent bladder wall transplants from wild-type donor mice. Before euthanization, the aorta was infused with fluorescent microbeads (fluorospheres) to identify perfused vessels. The contributions of GFP (angiogenesis) and LacZ (vasculogenesis) to the formation of CD31-expressing blood vessels within the wild-type graft were evaluated by immunohistochemistry at different time points and locations within the graft (proximal, middle, and distal) to provide a spatiotemporal analysis of neovascularization. The GFP index, a measure of angiogenic host ingrowth, was significantly higher at proximal versus mid or distal regions in animals 2-16 weeks post-transplant. However, GFP index did not increase over time in any area. Within 7 days post-transplant, perfusion of primarily wild-type, donor blood vessels in the most distal areas of the graft was observed by intraluminal fluorospheres. In addition, chimeric host-donor (GFP-wild type) blood vessels were evident in proximal areas. The contribution of vasculogenesis to vascularization of the graft was limited, as LacZ cells were not specifically associated with the endothelial cells of blood vessels, but rather found primarily in areas of inflammation. The data suggest that angiogenesis of host blood vessels into the proximal region leads to inosculation between host and donor vessels and subsequent perfusion of the graft via pre-existing graft vessels within the first week after transplant. As such, the engineering of graft blood vessels and the promotion of inosculation might prevent graft contraction, thereby potentiating the use of bioengineered bladder tissue for transplantation.

Upper tract changes in patients with neurogenic bladder and sustained pressures >40 cm following bladder neck surgery without augmentation

OBJECTIVE

We report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence.

MATERIALS

Consecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥ 1 year were included as participants in the study.

RESULTS

Of 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection.

CONCLUSIONS

Despite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation.

Vesico-ureteral reflux in women with idiopathic high-pressure detrusor overactivity: prevalence, bladder function, and effect on the upper urinary tract

INTRODUCTION AND HYPOTHESIS

To assess the prevalence of vesico-ureteral reflux (VUR) and upper urinary tract damage in women with idiopathic high-pressure detrusor overactivity (IHPDO) and to characterize their bladder function.

METHODS

A retrospective chart review of women diagnosed with IHPDO (detrusor pressures > 40 cm H2O during involuntary bladder contractions) from 2007 to 2010 was conducted. Women were assessed for VUR by X-ray voiding cysto-urethrogram. Renal ultrasound or CT urogram, serum BUN/creatinine, and urinalyses were performed if reflux reached the renal pelvices. Cystometric and voiding pressure study data were reviewed for detrusor overactivity pressure and volume, voiding dysfunction, urethral relaxation, compliance, and bladder outlet obstruction.

RESULTS

Sixty-five women were diagnosed with IHPDO, and 50 completed an X-ray voiding cysto-urethrogram. The median (range) detrusor overactivity pressure was 65 (41-251) cm H2O. Four (8.0%) women had IHPDO; none had upper urinary tract deterioration. The majority of women exhibited urethral relaxation with voiding, impaired compliance, and bladder outlet obstruction.

CONCLUSIONS

Women with IHPDO are at risk of low-grade vesico-ureteral reflux. However, most women with IHPDO are likely protected from reflux by intermittent exposure to high detrusor pressures and the ability to decompress the bladder by urethral relaxation.

Spontaneous improvement in urological dysfunction in children with congenital spinal lipomas of the conus medullaris

Congenital spinal lipomas of the conus (SLCs) are among the most common closed neural tube defects. The treatment of SLC is an area of controversy because the true natural history of this condition is unknown. Here, the authors present two cases of SLC presenting in infancy with compromised lower urinary tract function, which was objectively confirmed by abnormal urodynamic studies. In both cases, there was spontaneous improvement in urodynamic parameters, with stable normal urinary function at the long-term follow-up. Although cases of spontaneous radiological regression of SLC have very infrequently been reported, they have not been associated with the reversal of already present neurological deficits. This report reinforces the need for further delineation of the true natural history of SLC and highlights the dynamic nature of associated neurological compromise over time.

Urinary tract infections in children with myelodysplasia in whom clean intermittent catheterization was administered

AIM

In this study, it was aimed to evaluate the frequency of significant bacteriuria and antibiotic resistance characteristics in children with myelodysplasia in whom clean intermittent catheterization was administered.

MATERIAL AND METHODS

The study group was composed of 71 patients with myelodysplasia who were found to have significant bacteriuria (age: 8.20±4.57 years; 39 girls) and the control groups was composed of 49 children who were diagnosed with community-acquired urinary tract infection (age: 7.94±4.17 years; 29 girls). The patient and control groups were evaluated in terms of the microorganisms grown in urinary cultures and antibiotic resistance characteristics. The study approved by the ethics committe (14/02/2012-19/E).

RESULTS

Growth of Escherichia coli (E. coli) was found with the highest rate in myelodysplasic patients. However, when compared with the control group in terms of microorganism types, an increase in the growth rates of the microorganisms excluding E. coli was observed in the patients with myelodysplasia which was close to the significance limit (p=0.055). When antibiotic resistance properties were examined, a significantly increased resistance against cotrimaxazole was found in the patient group compared to the control group (p=0.001). 84.5% of the patients were using prophylactic antibiotic including mainly co-trimoxazole. A significantly increased co-trimoxazole resistance was also found in the patients who were using prophylactic antibiotic compared to the patients who were not using prophylactic antibiotic (p=0.025). The rate of symptomatic UTI was found to be 21% in the patients with myelodysplasia and a significant increase was found in the complaints of abdominal/side pain and nausea/vomiting as well as fever in these patients compared to the patients with asymptomatic bacteriuria (p=0.029 and p=0.032, respectively).

CONCLUSION

Our results show that UTI is still a significant problem in patients with myelodysplasia. In addition, they show that use of prophylactic antibiotic may increase the frequency of development of resistance and co-trimoxazole used for this objective is not a good option..

Urodynamic parameters development and complications of clean intermittent self-catheterization in Chinese schoolchildren with neurogenic underactive bladder

OBJECTIVE

To evaluate the urodynamic parameters, development of bladder function and complications of clean intermittent self-catheterization (CIC) in Chinese schoolchildren with neurogenic underactive bladder.

METHODS

Ninety-three children with neurogenic underactive bladder were successfully treated with CIC or combined with oxybutynin for two years follow-up. According to bladder compliance before CIC, they were subdivided into a normal bladder compliance (NBC) group and a low bladder compliance (LBC) group. Urodynamic parameters and complications were recorded.

RESULTS

At follow-up, the incidence of neurogenic detrusor overactivity was found to have significantly decreased in both groups. Moreover, maximum cystometric capacity (CC) and relatively safe CC in the NBC group was significantly higher than those before CIC. However, relatively safe CC was significantly lower than that before CIC, and detrusor leakage point pressure was significantly higher than that before CIC in the LBC group. The incidences of bacteriuria, vesicureteral reflux (VUR), febrile urinary tract infections (UTI) and macroscopic hematuria were, respectively, 62, 13, 25 and 15%, and those of VUR and febrile UTI in the LBC group were significantly higher than those in the NBC group.

CONCLUSION

For these cases, the complications of CIC are rare, and bladder compliance seems to be correlated with the development of bladder function and complications during CIC.

Risk factors for renal function impairment in a series of 502 patients born with spinal dysraphisms

OBJECTIVE

To evaluate the risk of renal damage in a large series of patients affected by spinal dysraphism.

METHODS

Renal function was studied in 502 spinal dysraphisms treated over the last 25 years in a single center: 283 meningomyelocele (MMC), 90 caudal regression syndrome (CRS) and 129 spinal lipoma (SL) cases. In patients with normal and impaired renal function, we compared congenital renal anomalies, vesicoureteric reflux, bladder voiding pattern and upper tract dilatation, analyzing the results with the Fisher test.

RESULTS

Neuropathic bladder was observed in 97% of MMC, 60% of CRS, and 39% of SL cases. There was some degree of renal function impairment in 19 MMC (6.7%), 11 CRS (12%, increased to 20% if considering only neuropathic bladder patients), and two SL (1.5%) cases. Renal agenesis was more frequent in CRS (13%), but was not associated with decreased renal function. Overall, vesicoureteric reflux and upper tract dilatation were more frequent in patients with renal damage. Insufficient bladder voiding was statistically associated with renal damage only in the CRS population. Intermittent catheterization did not represent a protective factor against renal damage in patients able to void without significant residual urine.

CONCLUSION

This study has increased our understanding of the prognostic risk factors for renal deterioration. More prospective studies are necessary to confirm these results and correlate treatment with renal outcome.

Urodynamic Study of Bladder Function for Patients with Lumbar Spinal Stenosis Treated by Surgical Decompression

Lumbar spinal stenosis usually leads to different degrees of nerve damage, presenting with back and leg pain, and/or neurogenic bladder symptoms. To determine whether lumbar decompression improved urological function, bladder dysfunction was evaluated in this retrospective study of 26 patients with lumbar spinal stenosis who had undergone lumbar decompression surgery. Urodynamic study procedures were performed pre-operatively and 6 months post-operatively. The Japanese Orthopaedic Association score rating system and Oswestry Disability Index were employed for clinical evaluation. Following surgery, post-voiding residual urine, maximum cystometric capacity and maximum flow rate improved significantly. There was no statistically significant improvement in voided volume, bladder compliance, maximum detrusor pressure or upper urinary tract damage. Urodynamic study was important in the diagnosis of neurogenic bladder dysfunction, prevention of renal deterioration and assessment of post-operative effects after surgical decompression for patients with lumbar spinal stenosis.

Intravesical oxybutynin in the pediatric neurogenic bladder

Pediatric neuropathic bladder dysfunction can cause irreversible renal damage and urinary incontinence. Etiologically, it is usually the consequence of a congenital neural tube defect. The majority of affected children can be successfully managed with the standard medical treatment of clean intermittent catheterization and anticholinergic (typically oxybutynin) medication. A subset of patients experience severe side effects or insufficient suppression of detrusor overactivity on oral oxybutynin. Intravesical instillations offer an effective alternative; this Review considers their indications, administration, safety and efficacy.

The significance of 99mtechnetium dimercapto-succinic acid renal scan in children with spina bifida during long-term followup

PURPOSE

(99m)Technetium dimercapto-succinic acid renal scans are ideal for demonstrating renal scarring in children with spina bifida. However, doubt persists about the need for routine application. We assessed the associations among abnormal (99m)technetium dimercapto-succinic acid renal scans, vesicoureteral reflux and urodynamic findings in patients with spina bifida during long-term followup.

MATERIALS AND METHODS

We retrospectively reviewed the records of 64 patients with spina bifida followed at our center. All patients were older than 10 years (mean 15.8, range 10 to 23). Dimercapto-succinic acid renal scans were considered abnormal with differential function of less than 40% or focal defects. Patient age, gender, previous febrile urinary tract infections, positive vesicoureteral reflux history, timing of clean intermittent catheterization initiation and the latest urodynamic findings were noted. Patients were grouped based on normal/abnormal scan results. Statistical analysis included univariate and multivariate regression analyses and chi-square tests.

RESULTS

A total of 16 patients (25%) had abnormal scans. Mean patient age, male-to-female ratio, leak point pressure, bladder compliance and timing of clean intermittent catheterization initiation did not differ between groups. Rates of previous febrile urinary tract infections differed significantly (11 of 16 in the abnormal group vs 9 of 48 in the normal group, p <0.01), as did positive reflux history (100% vs 31%, p <0.01). No patient with a negative reflux history had an abnormal dimercapto-succinic acid renal scan. Multivariate analysis identified previous febrile urinary tract infections as a significant risk factor for an abnormal scan.

CONCLUSIONS

A positive vesicoureteral reflux history and febrile urinary tract infections were associated with abnormal dimercapto-succinic acid renal scan in followup of patients older than 10 years with spina bifida. Thus, these factors are indicators of proactive evaluation of renal function using dimercapto-succinic acid renal scanning.

Neurophysiology in neurourology

The bladder has only two essential functions. It stores and periodically empties liquid waste. Yet it is unique as a visceral organ, allowing integrated volitional and autonomous control of continence and voiding. Normal function tests the integrity of the nervous system at all levels, extending from the neuroepithelium of the bladder wall to the frontal cortex of the brain. Thus, dysfunction is common with impairment of either the central or peripheral nervous system. This monograph presents an overview of the neural control of the bladder as it is currently understood. A description of pertinent peripheral anatomy and neuroanatomy is provided, followed by an explanation of common neurophysiological tests of the lower urinary tract and associated structures, including both urodynamic and electrodiagnostic approaches. Clinical applications are included to illustrate the impact of nervous system dysfunction on the bladder and to provide indications for testing.

Evaluation of clinico-urodynamic outcome of bladder dysfunction after surgery in children with spinal dysraphism - a prospective study

BACKGROUND

The aim was to asses the clinical profile and urodynamic findings and the outcome of surgery in children with spinal dysraphism.

METHOD

Twenty five children with spinal dysraphism who were treated at our institute between January 2005 and June 2006 were studied prospectively. There were 10 with an open spina bifida and 15 closed. The clinical profile of bladder dysfunction was assessed and urodynamic evaluation done pre-operatively in each child. An ultrasound study of the kidneys was also done to assess for hydro-uretero-nephrois. All underwent surgery for their primary and associated malformations. Post-operatively, re-evaluation of bladder dysfunction and urodynamic parameters was performed at 6-8 months.

RESULTS

Before operation there was a history indicating that the bladder was involved in 14 of the 25 children. Six of the 10 cases with an open spina bifida showed clinical involvement of the bladder as compared to 8 of 15 with a closed pattern. Urodynamic studies showed evidence of bladder dysfunction in 19 children. Of 10 with a meningomyelocele, there were abnormal urodynamics in 9 as compared to 10 of 15 with closed dysraphism. Follow up urodynamic studies showed improvement in 9 of 20 children 3 of 7 with a meningomyelocele and 6 of 13 with closed dysraphism.

CONCLUSION

Children with open spina bifida, as compared to closed dysraphism, tend to have more bladder dysfunction as exemplified on clinical history and urodynamic assessment. A pre-operative urodynamic study helps to identify severity of bladder dysfunction which is clinically overt cases and also identifies subtle bladder dysfunction in clinically silent cases. Evaluation after operation tends to shows better outcome in children with closed dysraphism. The study also identifies deterioration in some patients with seemingly clinical improvement.

The neurogenic bladder: medical treatment

Neurogenic bladder sphincter dysfunction (NBSD) can cause severe and irreversible renal damage and bladder-wall destruction years before incontinence becomes an issue. Therefore, the first step in adequate management is to recognize early the bladder at risk for upper- and lower-tract deterioration and to start adequate medical treatment proactively. Clean intermittent catheterization combined with anticholinergics (oral or intravesical) is the standard therapy for NBSD. Early institution of such treatment can prevent both renal damage and secondary bladder-wall changes, thereby potentially improving long-term outcomes. In children with severe side effects or with insufficient suppression of detrusor overactivity despite maximal dosage of oral oxybutynin, intravesical instillation is an effective alternative. Intravesical instillation eliminates systemic side effects by reducing the first-pass metabolism and, compared with oral oxybutynin, intravesical oxybutynin is a more potent and long-acting detrusor suppressor. There is growing evidence that with early adequate treatment, kidneys are saved and normal bladder growth can be achieved in children so they will no longer need surgical bladder augmentation to achieve safe urinary continence in adolescence and adulthood.

Factors affecting renal scar development in children with spina bifida

BACKGROUND/AIMS

Prevention of renal scarring is the main therapeutic goal in children with spina bifida. We aimed to determine factors affecting renal scar development in these patients.

MATERIALS AND METHODS

Records of 312 children admitted between 1994 and 2005 with spina bifida were reviewed. Age on admission, gender, presence of previous febrile urinary tract infections (UTIs), vesicoureteral reflux (VUR), and initial urodynamic findings were noted. Patients were grouped regarding presence/absence of renal scars on DMSA scans. Chi2 and Student's t tests were used for statistical evaluation.

RESULTS

Seventy-two patients had renal scars on admission. Mean age was 4.62 +/- 4.59 years for patients without renal scars and 6.35 +/- 4.9 years for patients with scars. Male/female ratio was 1:1 in the scarless group and 1:2 in the group with scars. Previous febrile UTI was present in 11 of 240 scarless patients in contrast to 7 out of 72 patients in the scar group (p > 0.05). VUR was present in only 16.3% of cases without scars, whereas 36.1% of patients in the scar group had VUR. Detrusor overactivity and detrusor sphincter dyssynergia were observed in 67.1% of scarred patients, whereas this figure was 42.4% in the scarless group. The comparison of age on admission, gender, detrusor overactivity, and detrusor sphincter dyssynergia revealed significant differences between patients with and without renal scars.

CONCLUSIONS

Late referral, female gender, overactive detrusor, and detrusor sphincter dyssynergia have detrimental effects on renal parenchymal function in spina bifida patients. Patient selection for aggressive treatment using these features may prevent renal parenchymal deterioration.

Chapitre A - Troubles vésico-sphinctériens et traumatismes médullaires

The life expectancy of spinal cord injury patients has increased considerably over recent years due to improved management based on a better understanding of the pathophysiology of the abnormalities induced by spinal cord injury. The objective of treatment of spinal cord injury patients is to prevent the various complications, but also allow patients to regain maximum independence in order to facilitate their social rehabilitation. This result can only be obtained and maintained by multidisciplinary management in a network including urologists, as, although urinary complications have considerably decreased (they no longer represent the leading cause of mortality), they still constitute a frequent presenting complaint or reason for rehospitalization in this population.

Renal cortical deterioration in children with spinal dysraphism: analysis of risk factors

BACKGROUND/OBJECTIVE

Because hydronephrosis and reflux are reversible, we believe cortical loss represents true renal deterioration in children with spinal dysraphism. Our goal was to better define risk factors for cortical loss.

METHODS

After institutional review board approval, we reviewed the medical records of 272 children with spinal dysraphism. The following factors were evaluated: age, sex, renal and bladder imaging, urodynamic parameters, medications, catheterization program, continence, infections, and surgical history. Renal cortical loss was defined by scarring or a differential function greater than 15% using a nuclear scan. Univariate and multivariate logistic regression models were fitted to test the associations of specific variables with cortical loss.

RESULTS

Renal cortical loss was found in 41% of children with high-grade reflux vs. 2% of children without reflux. Univariate analysis showed only high-grade reflux and female sex to be independent risk factors. Controlling for age and sex, reflux and initiation of catheterization after 1 year of age are significant risk factors. High bladder pressure and hydronephrosis in the absence of reflux were not associated with cortical loss. Multivariate analysis showed that girls with reflux have a 55-fold increased risk of cortical loss.

CONCLUSION

By limiting the definition of renal deterioration to cortical loss, we identified relevant risk factors: reflux, female sex, and delayed initiation of clean intermittent catheterization. We have also discounted other suspected risk factors: hydronephrosis and elevated bladder pressure. Rather than continuing our focus on hydronephrosis and urodynamics, we believe more research and management debate should be afforded to females with reflux.

Is it possible to use urodynamic variables to predict upper urinary tract dilatation in children with neurogenic bladder-sphincter dysfunction?

OBJECTIVE

To investigate the possibility of using urodynamic variables to predict upper urinary tract dilatation (UUTD) in children with neurogenic bladder-sphincter dysfunction (NBSD).

PATIENTS AND METHODS

The study included 200 children with NBSD, of whom 103 had UUTD and 97 did not; they were examined using routine urological, neurological and urodynamic methods. The group with UUTD was divided into three subgroups (group 1-3, from mild to severe hydronephrosis). A urodynamic risk score (URS) was calculated, including a detrusor leak-point pressure (DLPP) of >40 cmH2O, a bladder compliance (BC) of <9 mL/cmH2O and evidence of acontractile detrusor (ACD).

RESULTS

The postvoid residual urine volume (PVR), DLPP, incidences of ACD and DLPP of >40 cmH2O were greater and the BC significantly less in groups 1-3 than in the control group. Moreover, the BC decreased, while the PVR, DLPP and the incidence of DLPP of >40 cmH2O were significantly higher in group 3 than in group 2. The relative safe cystometric capacity of groups 2 and 3 were lower, respectively, than that of the control and group 1, and the relative unsafe cystometric capacity (RUCC) and relative risk rate of cystometric capacity (RRRCC) were significantly greater with the severity of UUTD. The maximum detrusor pressure on voiding or at maximum flow rate, and the Abrams-Griffiths number for voluntary contractile bladders, of the UUTD group were significantly higher than those of the control group. There was a positive correlation between URS and UUTD.

CONCLUSIONS

The selective use of urodynamic variables might be valuable for predicting the risk of UUTD in children with NBSD. Decreased BC, and increased DLPP and ACD are the main urodynamic risk factors, and they reciprocally increase the occurrence and grades of UUTD. The grades of UUTD are compatible with increases in RUCC, RRRCC and URS.

Predictive value of initial urodynamic pattern on urinary continence in patients with myelomeningocele

AIMS

To investigate whether the initial urodynamic pattern may predict urinary continence and the need for adjunctive incontinence surgery in patients with myelomeningocele.

PATIENTS AND METHODS

One hundred and twenty-three patients with myelomeningocele were included in our retrospective study. The patients were divided based on the urodynamic pattern at initial evaluation into four categories: overactive detrusor with overactive (spastic) sphincter (group 1, n = 43), overactive detrusor with underactive/acontractile sphincter (group 2, n = 37), underactive/acontractile detrusor with overactive (spastic) sphincter (group 3, n = 8), and underactive/acontractile detrusor with underactive/acontractile sphincter (group 4, n = 35). Urinary continence status at the last follow-up and the need for adjunctive incontinence surgery were compared between the four groups.

RESULTS

Mean follow-up was 10 years and mean age at the last follow-up 17 years. A socially acceptable continence status (continent or socially dry) was achieved in 74% and was significantly different among the four groups (P = 0.023): 86% and 87% of the patients in group 1 and 3 became continent or socially dry, but only 57% and 74% of those in group 2 and 4, respectively. Although none of the patients in group 3 underwent adjunctive incontinence surgery compared to about 25% in the other groups, statistically the difference was not significant (P = 0.48).

CONCLUSIONS

The initial urodynamic pattern is very useful in counseling families by predicting urinary continence in patients with myelomeningocele. The chances of becoming continent or at least socially dry are best for patients with overactive (spastic) sphincter.

Early proactive management improves upper urinary tract function and reduces the need for surgery in patients with myelomeningocele

AIMS

To investigate whether upper urinary tract function and the need for surgery in patients with myelomeningocele depends on the timing of initiating neurourological management.

PATIENTS AND METHODS

One hundred thirty-three patients with myelomeningocele were included in our retrospective study. The patients were divided based on age at the initial evaluation into three categories: from day of birth to age 2 (group 1, n = 67), from age 3 to age 10 (group 2, n = 44), and after age 10 (group 3, n = 22). Upper urinary tract function and the need for surgery with the intention to preserve or normalize the upper urinary tract function were compared between the three groups.

RESULTS

Mean follow-up was 11, 10, and 9 years in group 1, 2, and 3, respectively. The upper urinary tract function was normal in 91%, 80%, and 82% at the initial evaluation (P = 0.194) and in 99%, 86%, and 86% at the last follow-up (P = 0.012) in group 1, 2, and 3, respectively. Following failure of conservative therapy only, the proportions of patients undergoing surgical interventions with the intention to preserve or normalize the upper urinary tract function was significantly (P = 0.0002) different among the three groups: 15%, 34%, and 59%, respectively.

CONCLUSIONS

Early proactive management improves upper urinary tract function and reduces the need for surgery in patients with myelomeningocele in the long-term. Therefore, initiation of proactive neurourological management as early as possible, ideally from the day of birth, is strongly recommended.

Management of de novo nonneurogenic detrusor-sphincter dyscoordination in a bladder-drained pancreas and kidney transplantation case

Pancreas transplantation is associated with significant urological complications. Urological complications can jeopardize the graft survival. We present a de novo nonneurogenic detrusor-sphincter dyscoordination in a pancreas and kidney transplanted case. We also report follow-up under conservative treatment.

SPINAL CORD INJURY IN CHILDREN: LONG-TERM URODYNAMIC AND UROLOGICAL OUTCOMES

PURPOSE

Urological complications in adults with spinal cord injuries (SCIs) are well documented. We sought to determine the effect of SCI on the developing bladder and kidneys in the child.

MATERIALS AND METHODS

We retrospectively reviewed cases of SCI with 1-year minimum followup. We identified 42 children with an average age at injury of 5.3 years (range 1 day to 14 years). Mean followup was 5.5 years (range 1 to 15.5). Videourodynamics, sonograms, infection, medications and continence were reviewed. Safe bladder capacity was defined as the pressure specific volume at 40 cm water or less. Patients were divided into 3 groups based on level of injury-cervical (10), thoracic (26) and lumbar (6).

RESULTS

Bladder management included clean intermittent catheterization in 40 of 42 patients and antispasmodics in 37. No patient had reflux, hydronephrosis or renal scarring. In the cervical group safe bladder capacity was less than the expected capacity in 80% of patients but all patients undergoing multiple urodynamics had increasing capacity with time. In the thoracic group 58% of patients had a safe bladder capacity less than expected and 76% of those undergoing multiple urodynamics had increasing capacity. In the lumbar group 50% of patients had a safe bladder capacity less than expected and 67% of those undergoing multiple urodynamics had increasing capacity.

CONCLUSIONS

To our knowledge this is the largest and longest urological study of young children with SCI. Early clean intermittent catheterization and use of anticholinergics appear to prevent upper tract deterioration, improve continence and decrease infections. Serial urodynamics confirm increasing safe capacity with growth in most children. Close followup is necessary as bladder characteristics may change with time.

Relationship between febrile urinary tract infection and urodynamics in myelodysplastic children with vesicoureteral reflux

OBJECTIVE

We conducted a retrospective study in order to identify factors that may predict the incidence of febrile urinary tract infection (UTI) in myelodysplastic children with vesicoureteral reflux (VUR).

METHODS

A total of 23 myelodysplastic children with persistent VUR who were managed by clean intermittent catheterization (CIC) were eligible for this study. Any factors, including urodynamic parameters and urinary tract abnormalities, that may have been associated with the incidence of febrile UTI were evaluated using both univariate analysis and multiple logistic regression analysis.

RESULTS

Of 23 patients, 10 (43%) had had one or more episodes of febrile UTI. Both univariate and multivariate analyses showed a statistically significant relationship between low bladder compliance (<10 ml/cm H(2)O) and episodes of febrile UTI.

CONCLUSION

These results demonstrated that the urodynamics linked to bladder function disorder in the filling phase appear to be correlated with the incidence of febrile UTI in myelodysplastic children with VUR who are managed by CIC.

Ureterocystoplasty (bladder augmentation) with a solitary kidney

Children who develop end-stage renal disease (ESRD) as a result of obstructive uropathies require evaluation and treatment of associated bladder dysfunction to ensure a good outcome following renal transplantation. Bladder dynamics can often be optimized medically, although surgical intervention is occasionally necessary. For those patients who require bladder augmentation, the use of a dilated native ureter (ureterocystoplasty) is preferred to the more commonly used intestine or stomach (enterocystoplasty), which carry a higher risk of complications. Unfortunately, most patients do not have a suitable anatomy for ureterocystoplasty and, by necessity, intestine or stomach has to be utilized. Herein, we describe the successful application of ureterocystoplasty in the presence of ESRD and a solitary kidney prior to renal transplantation. We believe that owing to the many advantages of native urothelium, every effort should be made to use ureter and avoid the use of intestine.

An analysis of risk factors for upper urinary tract deterioration in patients with myelodysplasia

OBJECTIVE

To identify the risk factors for upper urinary tract deterioration in a retrospective study of patients with myelodysplasia.

PATIENTS AND METHODS

The medical history, radiographic studies and urodynamic results from 39 children with myelodysplasia who were treated at our hospital were reviewed retrospectively to obtain more accurate data in the prognosis of such patients. The upper urinary tracts were assessed by cysto-urethrography and excretory urography to determine the incidence of vesico-ureteric reflux (VUR) and hydronephrosis. The relationships between the urodynamic variables, including vesical compliance, detrusor hyper-reflexia, detrusor-sphincter dyssynergia (DSD) and the maximum urethral closing pressure (MUCP) to such upper tract deterioration were evaluated using both univariate and multiple logistic regression analysis.

RESULTS

The univariate analysis showed low vesical compliance, a high level of MUCP and the presence of DSD to be significant factors for the incidence of VUR. Low vesical compliance and a high level of MUCP also correlated with the incidence of hydronephrosis. The multivariate analysis showed a significant relationship between urodynamic values and upper urinary tract deterioration. The incidence of VUR was strongly correlated with a high MUCP and the presence of DSD. A high MUCP was also a significant factor in the incidence of hydronephrosis.

CONCLUSION

Urodynamic results associated directly with the abnormal function of urethral control are significantly correlated with the cause of upper tract deterioration in patients with myelodysplasia.

Neurogenic bladder dysfunction

Urodynamics are still essential for diagnosis and prognosis of neurogenic lower urinary tract-dysfunction and can not be replaced by other means of investigation so far, neither by a thorough clinical investigation nor by sophisticated means like magnetic resonance imaging. The findings with clinical investigations are specific, but not sensitive enough, and the spinal cord lesions may sometimes be beyond the resolution of magnetic resonance-scanning. Pharmacotherapy is still the corner stone in the management of detrusor hyperreflexia. Further studies with tolterodine, oxybutynin, trospiumchloride and propiverine have increased our knowledge about these substances. Capsaicin was proved to be the effective substance and not the alcoholic solution, which serves as a carrier. Intrathecal clonidine may represent a new conservative reversible alternative treatment for detrusor hyperreflexia. Experiments with detrusor strips from end-stage MMC-patients may explain the relative resistance of the low compliant bladder to the common anticholinergic/spasmolytic therapy. The differential indication for bladder augmentation, either using segments of the gastrointestinal-tract or performing a partial detrusor myectomy is ongoing, favourable results are reported for both techniques. Sacral posterior root rhizotomy is able to abolish detrusor hyperreflexia and therefore recommended for tetra- and paraplegics, however autonomic dysreflexia, if present, can not be totally abolished. Collagen injections for neuropathic sphincter incompetence can not be recommended as demonstrated in children with congenital neuropathy, a new design of an artificial sphincter must stand the test of time.