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Macedo A, Campelo TR, Aragon RG, Macedo EL, Garrone G, Ottoni SL, Leal da Cruz M. Prospective trial of a uniform protocol for managing infants with neurogenic bladder. J Pediatr Urol 2024:S1477-5131(24)00287-0. [PMID: 39232867 DOI: 10.1016/j.jpurol.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 09/06/2024]
Abstract
INTRODUCTION Since the Management of Myelomeningocele Study (MOMS) publication in 2011 we have designed a prospective protocol for surveillance of neurogenic bladder according to the Leal da Cruz categorization system (J Urol, 2015) that guides us on treatment. Our institution was the precursor of in-utero myelomeningocele (MMC) in Latin America, so our database was biased mostly for patients that underwent fetal surgery for MMC closure. We have demonstrated that in-utero MMC closure does not improve bladder function in opposition to the data from the urological branch of the MOMS study (10), but our control group was based on a historical cohort, before the onset of in-utero MMC repair in our division (15) Since 2018, we have identified an increasing number of referrals of postnatal operated MMC patients to our group just for urological follow up. We decided then to start this prospective protocol for all neurogenic patients and provide a contemporary database to record differences in early bladder function, presence of hydronephrosis and vesicoureteral reflux, treatment, initial outcome and indication of surgery among three mains groups (in-utero MMC repair, post-natal repair and miscellaneous other cases of neurogenic bladder). We want to present preliminary data of this cohort in the period of time 2018 to 2023 (5 years). There was not an exclusion criteria, all patients with neuropathic bladder were included in this study. MATERIALS AND METHODS We evaluated our database of all neurogenic bladder (NB) patients aged <1 year who started urological treatment in our institution from 2018. We evaluated diagnosis, age at first visit, clinical data, prevalence of hydronephrosis and (vesicoureteral reflux) VUR, bladder pattern according to the Leal da Cruz categorization system (1), treatment, time of follow-up, number of clinical visits and (urodynamic evaluation) UE performed, final bladder status and surgeries performed. RESULTS We identified 43 were aged <1 year with a mean age of 4.5 months (median 3.5) at first urological appointment. Diagnosis was myelomeningocele in 33 patients and miscellaneous in 10. From the MMC group, 24 were operated in-utero and 9 post-natal. The initial bladder pattern in the whole group showed 23 (53.5%) high risk, 11 normal (25.6%), 5 underactive bladder (11.6%) and 4 incontinent (9.3%). Mean follow-up was 24 months, mean age at last UE (cases with minimum of 2): 37 months, mean UE per patient: 2. At present, 28 patients perform clean intermittent catheterization (CIC), 23 with anticholinergics and 15 are only under surveillance. VUR was seen in 11/43 cases: 25.6%. Urological surgery has been performed in 4 patients: bladder augmentation in 3 and vesicostomy in 1. Bladder categorization for high-risk and normal patterns were respectively 62.5% and 25% for in utero and 44.4% and 22.2% for postnatal repair and detailed statistical analysis did not present statistical significance of in utero and postnatal groups. CONCLUSION Our study can conclude in a contemporary prospective study the findings of elevated incidence of high-risk patterns irrespectively of in-utero or post-natal repair (62.5% and 44.4%). We acknowledge that even though this is not new information and besides the still limited follow up, this cohort is one of the very few that follow and compare in one single institution with comparable UE for in-utero and post-natal MMC repair population, having also a miscellaneous group of NB as a pictorial report of also a similar initial distribution of bladder patterns. We plan to report in the future in a larger cohort the continuation of this study.
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Affiliation(s)
- Antonio Macedo
- Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil; Department of Urology, CACAU-NUPEP, São Paulo, Brazil
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Kamran H, Tafazoli N, Eftekharzadeh S, Samaei M, Kajbafzadeh AM. Application of urethral injection of calcium hydroxyapatite as a natural bulking agent for improvement of urinary incontinence in children with spinal dysraphism. Int Urol Nephrol 2023; 55:1403-1411. [PMID: 37085677 DOI: 10.1007/s11255-023-03596-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE The aim of this report is to evaluate the efficacy of endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck and posterior urethra in children with refractory urinary incontinence due to spinal dysraphism. METHODS A retrospective study was performed on patients with neuropathic bladder due to spinal dysraphism who had undergone submucosal urethral injections of CaHA from 2010 until 2019. All patients were totally incontinent without voiding per urethra and did not respond to 1-year standard pharmacotherapy with anticholinergic drugs. All children underwent a precise physical exam and urodynamic studies. Patients underwent urethrocystoscopy and injection of pure soluble CaHA into the bladder neck and posterior urethra except for the verumontanum. The outcomes were determined as no change, improvement (social continent), or cure (total continent). RESULTS Fifteen children (ten boys, five girls, mean age of 7.6 years) with a history of spinal dysraphism and refractory urinary incontinence were included. Endoscopic injections of CaHA were performed one or two times for each patient. At the median follow-up of 2 years (interquartile range = 6), seven (46.7%), three (20.0%), and five (33.3%) of the patients were total continent, social continent, and total incontinent, respectively. In four patients, intradetrusor botulinum toxin injection was performed simultaneously with CaHA injection. Also, one patient experienced a febrile urinary tract infection between two CaHA injections. Among 15 patients, 9 had atonic/hypotonic bladders both before and after CaHA injections; at the last follow-up, 4 of these children (44.4%) were totally continent. No injection-related or other complications were observed in the patients. CONCLUSION Injection of CaHA into the bladder neck is relatively safe, reproducible, and effective for total dribbling urinary incontinence in children with spinal dysraphism. The bladder neck reconstruction with or without a urethral sling or other surgical procedures could be postponed until puberty in selected cases. However, further multicenter clinical trials are highly recommended.
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Affiliation(s)
- Hooman Kamran
- Pediatric Urology and Regenerative Medicine Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box: 1419733151, Tehran, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nooshin Tafazoli
- Pediatric Urology and Regenerative Medicine Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box: 1419733151, Tehran, Iran
| | - Sahar Eftekharzadeh
- Department of Urology, Einstein Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mehrnoosh Samaei
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Gene, Cell and Tissue Research Institute, Children's Medical Center, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box: 1419733151, Tehran, Iran.
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Hannallah A, Baker ZG, Cowan A, Bajakian T, Vasquez E, Ko JS. Imaging characteristics predicting elevated detrusor pressures in patients with spina bifida. J Pediatr Urol 2023; 19:65.e1-65.e7. [PMID: 36333199 DOI: 10.1016/j.jpurol.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/04/2022] [Accepted: 10/14/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE Patients with spina bifida require urologic follow up with assessments of bladder and renal function. The ideal screening protocol for bladder compliance remains controversial. This study assessed associations between bladder end filling pressure (EFP) and detrusor leak point pressure (DLPP) on urodynamic studies (UDS) and findings from renal bladder ultrasounds (RBUS) and voiding cystourethrograms (VCUG). METHODS Pediatric spina bifida patients who underwent RBUS and/or VCUG within six months of UDS at a single institution from 2015 to 2021 were retrospectively reviewed. Demographics, VCUG and RBUS results, and UDS EFP and DLPP were recorded. Multiple linear regression analyses and Pearson chi-square tests were conducted to correlate RBUS and VCUG findings with DLPP/EFP. RESULTS 129 patients were included. In adjusted analyses, moderate to severe hydronephrosis on RBUS was significantly associated with elevations in mean DLPP/EFP (p = 0.006). Patients with round bladders had significantly lower mean DLPP/EFP than patients with elongated or conical bladders (p < 0.0001). The presence of trabeculations was associated with increased mean DLPP/EFP (p < 0.0001) and increases in severity of trabeculations were associated with higher DLPP/EFP (p < 0.0001). The presence of vesicoureteral reflux (VUR) on VCUG was not associated with significant differences in mean DLPP/EFP (p = 0.20). CONCLUSIONS Abnormal bladder shape and trabeculations on VCUGs in spina bifida patients had significant associations with increased mean bladder pressures on UDS. Assessment of bladder shape and contour by VCUG may be a valuable screening tool in conjunction with routine RBUS in determining the need for further assessment of bladder pressures in patients with spina bifida.
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Affiliation(s)
- Arthi Hannallah
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA USA.
| | - Zoë G Baker
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA USA.
| | - Andrew Cowan
- Keck School of Medicine, University of Southern California, Los Angeles, CA USA.
| | - Thalia Bajakian
- Department of Urology, University of Southern California, Los Angeles, CA USA.
| | - Evalynn Vasquez
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA USA.
| | - Joan S Ko
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA USA.
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Macedo A, Ottoni SL, Moron A, Cavalheiro S, da Cruz ML. In utero myelomeningocele repair and high-risk bladder pattern. a prospective study. Int Braz J Urol 2022; 48:672-678. [PMID: 35373958 PMCID: PMC9306372 DOI: 10.1590/s1677-5538.ibju.2022.0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives High-risk bladder pattern can be defined by Urodynamic Evaluation (UE) as overactive bladder with detrusor leak point pressure higher than 40 cmH2O and/or higher filling pressures also above 40 cmH2O. We wanted to evaluate response to treatment in myelomeningocele patients operated in utero in this subgroup. Patients and Methods From our prospective cohort of in utero MMC we have identified patients in the high-risk group. Treatment consisted of anticholinergics (Oxybutynin 0.2 mg/Kg) 2 or 3 times daily in association with CIC. At every UE, patients were reclassified in high-risk or low-risk patterns. Patients not responding were proposed bladder reconstruction or diversion according to age. Results Between 2011 to 2020, we have been following 121 patients and 60 (49.6%) of them were initially categorized as high-risk. The initial UE was performed at a mean age of 7.9 months and detrusor overactivity was found in 83.3% (mean maximum pressure of 76.5cmH20). When evaluating patients with 2 or more UE, we identified 44 patients (follow-up: 36.8months). It was observed in the group of patients who underwent 2 to 5 UE, that response to treatment was validated by the finding of 40% of low-risk bladder patterns in the second UE and between 62% to 64% in the third to the fifth UE. The incidence of surgery was 13.3%. Conclusions Early urological treatment of high-risk bladder pattern was effective in approximately 60%. We reinforce the need to correctly treat every patient with myelomeningocele, in accordance with UE, whether undergoing in utero or postnatal treatment.
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Affiliation(s)
- Antonio Macedo
- Departamento de Pediatria, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil.,Departamento de Urologia, CACAU-NUPEP, São Paulo, Brasil
| | | | - Antonio Moron
- Departamento de Obstetrícia-Medicina Fetal, Universidade Federal de São Paulo - Unifesp, São Paulo, Brasil.,Hospital Maternidade Santa Joana, São Paulo, Brasil
| | - Sergio Cavalheiro
- Hospital Maternidade Santa Joana, São Paulo, Brasil.,Departamento de Neurocirurgia, Universidade Federal de São Paulo - Unifesp, São Paulo, SP, Brasil
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Macedo A, Ottoni SL, Garrone G, Moron A, Cavalheiro S, Leal da Cruz M. In utero myelomeningocele repair and incidence of lower urinary tract surgery. Results of a prospective study. J Pediatr Urol 2021; 17:769-774. [PMID: 34452829 DOI: 10.1016/j.jpurol.2021.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The purpose of this study was to determine the incidence of lower urinary tract surgery in patients with myelomeningocele (MMC) operated in utero as well as in the subgroup of patients with a minimum age of 5 years. METHODS We use a previously published protocol to categorize bladder patterns and propose the treatment: high risk pattern-anticholinergics and clean intermittent catheterization (CIC); incontinent and normal patterns-clinical surveillance and underactivity pattern- CIC. Non-response to clinical treatment with maintenance of detrusor pressure higher than 40 cmH20 with worsening of hydronephrosis or recurrent urinary infection were imperative indications for surgery and urinary incontinence due to sphincter deficiency and leakage pressure below 40 cmH20 in patients aged 5 years and older were possible indications too. We identified the prevalence of urinary tract surgery and concomitant treatment of constipation and refractory fecal incontinence by convenience, the technique performed and surgery outcomes. RESULTS A total of 122 patients are part of the prospective protocol. The first UE was performed in 119 patients (median age of 4 months). The categorization of the bladder pattern was high risk in 52.1%, incontinent in 25.2%, hypocontractile 4.2% and normal in 18.5%. Current follow-up was 29.9 months (1-99 months). Surgery was performed on 10 patients (8.4%): 3 vesicostomies, 2 surgeries to treat vesicoureteral reflux, 6 bladder augmentations, 3 ACE and a sling surgery. Considering only patients older than 5 years, we identified 65 patients and seven surgeries performed (10.8%). DISCUSSION Most bladder reconstruction studies are case series of single institutions or cooperative services, most of which are retrospective. The prospective clinical interpretation and imaging and urodynamic exams over time allowed us prospectively to define the risk of surgery in patients with myelomeningocele operated in utero. It must be considered that the response to the initial urological treatment and even the failure that leads to the need for surgery have to be evaluated in a context of follow-up time. For this reason we have studied separately patients over 5 years-old and also the group considered to be at greatest risk for surgery, the high-risk group of the categorization already described. CONCLUSION We found an incidence of 10.8% of surgeries in patients over 5 years-old and 12.9% for the high-risk group. This information may be useful to educate parents when stating urological treatment.
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Affiliation(s)
- Antonio Macedo
- Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil; Department of Urology, CACAU-NUPEP, São Paulo, Brazil
| | | | | | - Antonio Moron
- Departament of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil; Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Sergio Cavalheiro
- Departament of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil; Santa Joana Maternity Hospital, São Paulo, Brazil
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Macedo A, Leal da Cruz M. Re: Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:958-959. [PMID: 34855296 DOI: 10.1002/uog.24801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Affiliation(s)
- A Macedo
- Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
- Department of Urology, CACAU-NUPEP, São Paulo, Brazil
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Paslaru FG, Panaitescu AM, Iancu G, Veduta A, Gica N, Paslaru AC, Gheorghiu A, Peltecu G, Gorgan RM. Myelomeningocele Surgery over the 10 Years Following the MOMS Trial: A Systematic Review of Outcomes in Prenatal versus Postnatal Surgical Repair. ACTA ACUST UNITED AC 2021; 57:medicina57070707. [PMID: 34356988 PMCID: PMC8307221 DOI: 10.3390/medicina57070707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/04/2022]
Abstract
Background and Objectives: Myelomeningocele is the most severe form of spina bifida, a congenital neural tube defect arising from an incomplete neural tube closure during early development with damage worsening with advancing gestational age. The Management of Myelomeningocele Study (MOMS) Trial proved that surgery performed before 26 weeks of gestation significantly improved the prognosis, significantly changing treatment paradigms. This article aims to provide a review of the changes and updates in spina bifida repair over the 10-year period following the MOMS Trial. Material and methods: We performed a systematic review in the PubMed and Cochrane databases as well as a hand-search of high-impact journals using the reference list of all identified articles, searching for randomized controlled trials and observational studies. Results: We identified 27 articles published between 2011 and 2021 that fulfilled the inclusion criteria and review them in the present study. Conclusions: With growing experience and with the improvement of prenatal open and fetoscopic techniques, the outcome of SB-associated conditions could be improved and the risks to both the mother and the fetus reduced. A continuous follow-up of the treated infants and further randomized trials are essential to study the complications and advantages or disadvantages of any given treatment strategy.
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Affiliation(s)
- Francesca Gabriela Paslaru
- Neurosurgical Department, “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania; (F.G.P.); (A.G.); (R.M.G.)
- Neurosurgery Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Anca Maria Panaitescu
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence: ; Tel.: +40-23188930
| | - George Iancu
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alina Veduta
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
| | - Nicolae Gica
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandru Catalin Paslaru
- Physiology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Anamaria Gheorghiu
- Neurosurgical Department, “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania; (F.G.P.); (A.G.); (R.M.G.)
| | - Gheorghe Peltecu
- Filantropia Clinical Hospital, 11171 Bucharest, Romania; (G.I.); (A.V.); (N.G.); (G.P.)
- Obstetrics and Gynecology Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Radu Mircea Gorgan
- Neurosurgical Department, “Bagdasar-Arseni” Clinical Emergency Hospital, 041915 Bucharest, Romania; (F.G.P.); (A.G.); (R.M.G.)
- Neurosurgery Department, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Mazzone L, Hölscher AC, Moehrlen U, Gobet R, Meuli M, Horst M. Urological Outcome after Fetal Spina Bifida Repair: Data from the Zurich Cohort. Fetal Diagn Ther 2020; 47:882-888. [PMID: 32894833 DOI: 10.1159/000509392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) represents a severe burden for patients with open spina bifida (OSB). The effect of fetal OSB repair on the urological outcome remains unclear, as controversial data exist. The aim of this study was to further increment existing outcome data and to demonstrate that our earlier published positive preliminary results are not erratic. METHODS Data from standardized urological follow-up appointments of patients with fetal OSB repair operated at our center were analyzed. Data were obtained from urodynamic studies (UDSs) and radiologic exams performed in the newborn (gestational age 37-39 weeks), at ages of 6, 12, 18, and 24 months, and then at yearly intervals. RESULTS Of 82 patients (mean age 2.6 years, range 6 months to 7 years), 26 (32%) had a normal bladder function as demonstrated by UDSs. Of the 56 (68%) patients with NLUTD, 29 (51%) patients showed initially a normal UDS, but developed NLUTD in the follow-up, 19 (66%) of them spontaneously and another 10 (34%) in association with growth and development, or surgery of inclusion cysts. Radiologic abnormalities (upper tract dilatation and vesico-uretero-renal reflux) were seen in 15%, mainly patients with NLUTD. CONCLUSION Our results add an important set of information to the existing body of evidence. The data reconfirm our earlier published favorable preliminary results and support other studies that show a possible benefit of prenatal OSB repair on the urological outcome, but they also demonstrate that the positive effect remains limited.
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Affiliation(s)
- Luca Mazzone
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland, .,Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland, .,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland,
| | - Alice Catherine Hölscher
- Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Rita Gobet
- Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Maya Horst
- Division of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
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Blount JP, Bowman R, Dias MS, Hopson B, Partington MD, Rocque BG. Neurosurgery guidelines for the care of people with spina bifida. J Pediatr Rehabil Med 2020; 13:467-477. [PMID: 33325414 PMCID: PMC7838965 DOI: 10.3233/prm-200782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Myelomeningocele (MMC) arises from an early neural developmental anomaly and results in a variety of structural abnormalities and associated functional neurologic deficits. As such, neurologic issues are central to virtually all clinical problems. Neurosurgical intervention strives to correct or improve these defects and prevent secondary complications. These interventions include closure of the open myelomeningocele and management (across the life span) of hydrocephalus, the Chiari II malformation (C2M) and tethered spinal cord (TSC). The development of pre-natal closure techniques and reports of improved outcome with in-utero closure (IUMC) have revolutionized the neurosurgical approach to myelomeningocele. Controversies remain surrounding patient selection, maternal risks, technique of IUMC (endoscopic vs. open) and long-term outcomes. However, real gains include reduced rates of hydrocephalus, modestly improved motor capabilities and reduction in C2M morbidity. For many decades, the cornerstone of treatment of hydrocephalus for many decades has been the placement and support of ventricular shunts. Endoscopic third ventriculostomy (ETV) with or without choroid plexus coagulation (ETV/CPC) is an appealing alternate strategy that avoids the morbidity and complications associated with shunts. The exact criteria for ETV-CPC candidacy and best metrics for outcome analysis remain active areas of debate and controversy. Similarly, neurosurgical management C2M, has centered upon the indications and clinical thresholds for performing posterior fossa surgical decompression. Tethered spinal cord management incorporates the diagnosis and surgical management of adhesions formed at the initial closure site, the consequent longitudinal traction related stress on the cord and the resulting neurologic signs and symptoms.
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Affiliation(s)
- Jeffrey P Blount
- Department of Neurosurgery, Alabama Children's Hospital and University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robin Bowman
- Department of Neurosurgery, Lurie Children's Hospital of Chicago and Northwestern University College of Medicine, Chicago, IL, USA
| | - Mark S Dias
- Department of Neurosurgery, Penn State Hershey Children's Hospital and Penn State College of Medicine, Hershey, PA, USA
| | - Betsy Hopson
- Department of Neurosurgery, Alabama Children's Hospital and University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael D Partington
- Department of Neurosurgery, Children's Mercy Hospital and University of Kansas School of Medicine, Kansas City, KA, USA
| | - Brandon G Rocque
- Department of Neurosurgery, Alabama Children's Hospital and University of Alabama at Birmingham, Birmingham, AL, USA
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Stein R, Bogaert G, Dogan HS, Hoen L, Kocvara R, Nijman RJM, Quadackers JSLT, Rawashdeh YF, Silay MS, Tekgul S, Radmayr C. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment. Neurourol Urodyn 2019; 39:45-57. [PMID: 31724222 DOI: 10.1002/nau.24211] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND In childhood, the most common reason for a neurogenic bladder is related to spinal dysraphism, mostly myelodysplasia. AIMS Herein, we present the EAU/ESPU guidelines in respect to the diagnostics, timetable for investigations and conservative management including clean intermittent catheterization (CIC). MATERIAL AND METHODS After a systematic literature review covering the period 2000 to 2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS The EAU/ESPU guideline panel advocates a proactive approach. In newborns with spina bifida, CIC should be started as soon as possible after birth. In those with intrauterine closure of the defect, urodynamic studies are recommended be performed before the patient leaves the hospital. In those with closure after birth urodynamics should be done within the next 3 months. Anticholinergic medication (oxybutynin is the only well-investigated drug in this age group-dosage 0.2-0.4 mg/kg weight per day) should be applied, if the urodynamic study confirmed detrusor overactivity. Close follow-up including ultrasound, bladder diary, urinalysis, and urodynamics are necessary within the first 6 years and after that the time intervals can be prolonged, depending on the individual risk and clinical course. In all other children with the suspicion of a neurogenic bladder due to various reasons as tethered cord, inflammation, tumors, trauma, or other reasons as well as those with anorectal malformations, urodynamics-preferable video-urodynamics, should be carried out as soon as there is a suspicion of a neurogenic bladder and conservative treatment should be started soon after confirmation of the diagnosis of neurogenic bladder. With conservative treatment the upper urinary tract is preserved in up to 90%, urinary tract infections are common, but not severe, complications of CIC are quite rare and continence can be achieved at adolescence in up to 80% without further treatment. DISCUSSION AND CONCLUSIONS The transition into adulthood is a complicated time for both patients, their caregivers and doctors, as the patient wants to become independent from caregivers and treatment compliance is reduced. Also, transition to adult clinics for patients with neurogenic bladders is often not well-established.
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Affiliation(s)
- Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Guy Bogaert
- Department of Urology, University of Leuven, Belgium
| | - Hasan S Dogan
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
| | - Lisette Hoen
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Radim Kocvara
- Department of Urology, 1st Faculty of Medicine in Praha, General Teaching Hospital, Charles University, Prague, Czech Republic
| | - Rien J M Nijman
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Rijks Universiteit Groningen, Groningen, The Netherlands
| | - Josine S L T Quadackers
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Rijks Universiteit Groningen, Groningen, The Netherlands
| | | | - Mesrur S Silay
- Division of Pediatric Urology, Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Serdar Tekgul
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
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11
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Weiss DA, Lee AS, Flanders TM, Long CJ, van Batavia JP, Zderic SA, Heuer GG. Neurological dysfunction of the bladder from myelomeningocele. Neurosurg Focus 2019. [DOI: 10.3171/2019.7.focus19468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Myelomeningocele (MMC) affects approximately 2000 infants in the US yearly and causes long-term damage to the genitourinary system. There is a wide spectrum of effects on the bladder and urethral sphincter that do not correlate with the level of the spinal cord defect. The bladder changes can provide a safe storage pressure, often at the expense of continence, or can create a hostile environment leading to increased pressure on the kidneys and eventually to chronic kidney disease. The ultimate goals in management are to maintain a safe system that prevents renal deterioration, while providing social continence and independence in the long term. This review intends to provide an overview of the effects of MMC on the genitourinary system, regardless of intervention, in order to understand the pathophysiology of the disease.
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Affiliation(s)
- Dana A. Weiss
- Division of Urology, Children’s Hospital of Philadelphia
| | - Albert S. Lee
- Department of Urology, Einstein Medical Center, Philadelphia
| | - Tracy M. Flanders
- Department of Neurosurgery, University of Pennsylvania, Philadelphia; and
| | | | | | | | - Gregory G. Heuer
- Division of Neurosurgery, Children’s Hospital of Philadelphia, Pennsylvania
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12
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Beuriat PA, Poirot I, Hameury F, Demede D, Sweeney KJ, Szathmari A, Di Rocco F, Mottolese C. Low level myelomeningoceles: do they need prenatal surgery? Childs Nerv Syst 2019; 35:957-963. [PMID: 30915531 DOI: 10.1007/s00381-019-04123-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/08/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postnatal closure of a myelomeningocele remains the standard of care in many countries. The prenatal closure has given hope for decreasing the damage to the neural placode and has challenged classic management. However, this technique presents potential sources of complications. Patients with MMC with an anatomical level of L4 and below have a better functional prognosis than higher level malformations. Are they still candidates for prenatal surgery? OBJECTIVE To evaluate outcome of MMC with an anatomical level of L4 and below and discuss, with support of the literature, the indications to perform prenatal closure in this particular group of patients. MATERIALS AND METHODS Twenty-nine children were included in this observational study. The level of the vertebral malformation was sacral in 12 cases (41.4%) or lumbar (level ≤ L4) in 17 cases (58.6%). All the patients was operated postnatally for closure of the MMC with microsurgical technique as soon as possible after clinical evaluation (range 0-97 days). RESULTS Only 11 out of 29 patients (37.9%) needed of a CSF diversion. A Chiari II malformation was present before MMC closure in 17 patients (58.6%) and only in 5 (17%) after. Twenty-six patients (89.7%) were able to walk. Seven (23%) and 16 (55%) of our patients have a normal bladder and bowel control, respectively. All school-aged children attend school. CONCLUSIONS The functional outcome for low-level MMC is good when managed with modern microneurosurgical techniques with a low risk for the patient and the mother. Therefore, we do not suggest prenatal surgery for subgroup of infant with MM.
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Affiliation(s)
- Pierre-Aurelien Beuriat
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Isabelle Poirot
- Department of Pediatric Rehabilitation l'ESCALE, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Frederic Hameury
- Department of Urologic Surgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Delphine Demede
- Department of Urologic Surgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Kieron J Sweeney
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Alexandru Szathmari
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Federico Di Rocco
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Carmine Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France.
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13
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Macedo A, Cavalheiro S, Moron A, Lobountchenko T, Dini FS, Ottoni SL, Garrone G, Ligori R, Leal da Cruz M. Urinary and Fecal Continence in 5-Year-Old Patients Who Underwent in utero Myelomeningocele Repair: A Prospective Study. Fetal Diagn Ther 2019; 46:319-322. [PMID: 30884481 DOI: 10.1159/000496791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 01/09/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION After the successful results of in utero myelomeningocele (MMC) repair presented by the Management of Myelomeningocele Study, the concept of fetal surgery was introduced in our institution in 2011. Since then, we have been able to follow prospectively a group of patients with attention to urological care. In the present study, we were interested in estimating urinary and fecal continence in this new subset of patients. MATERIAL AND METHODS We selected from our database patients aged 5 years or older for evaluation of urinary and fecal continence. We reviewed all charts and completed a questionnaire to study aspects of urinary and fecal continence. RESULTS We identified 14 patients, i.e., 4 (28.6%) males and 10 (71.4%) females. The mean age at MMC surgery was 25.6 gestational weeks. The uro-dynamic class was high-risk in 6 (42.9%), incontinent in 4 (28.6%), hypocontractile in 1 (7.1%), and normal in 3 (21.4%) patients. Three patients had undergone surgery (2 augmentations, i.e., 1 in association with a left colon ACE Macedo-Malone procedure and 1 mini-sling urethroplasty). Twelve patients underwent clean intermittent catheterization (CIC) (85.7%). Only 3 (21.4%) patients had no urinary leakage. Eleven patients (78.6%) used diapers. Eight patients (57.2%) underwent retrograde rectal irrigation and 11 (78.6%) complained of fecal loss. Eleven patients (78.6%) did not report an impact on their self-esteem. CONCLUSION Despite the use of CIC in 85.7% of the cases, the continence rate in MMC patients operated on in utero was low and 78.6% of the patients used diapers. This data can be used to educate parents about future conditions of their 5-year-old children and may stimulate the debate regarding further attempts (surgical or not) to improve fecal and urinary continence.
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Affiliation(s)
- Antonio Macedo
- Department of Urology, CACAU-NUPEP, São Paulo, Brazil.,Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | - Sérgio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Antonio Moron
- Department of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, Brazil
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14
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Macedo A, Ottoni SL, Garrone G, Liguori R, Cavalheiro S, Moron A, Leal Da Cruz M. In utero myelomeningocoele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function? BJU Int 2019; 123:676-681. [PMID: 30548158 DOI: 10.1111/bju.14639] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the first 100 cases of in utero myelomeningocoele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function. PATIENTS AND METHODS We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak-point pressure >40 cm H2 O and high filling pressures also >40 cm H2 O), incontinent, and underactivity (underactive bladder with post-void residual urine), and patients were treated accordingly. RESULTS We evaluated 100 patients, at a mean age of 5.8 months (median 4 months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico-ureteric reflux. CONCLUSION The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.
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Affiliation(s)
- Antonio Macedo
- Department of Urology, CACAU-NUPEP, São Paulo, Brazil.,Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil.,Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Antonio Moron
- Santa Joana Maternity Hospital, São Paulo, Brazil.,Department of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil
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15
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Pastuszka A, Bohosiewicz J, Koszutski T. Prenatal myelomeningocele repair improves urinary continence and reduces the risk of constipation. Neurourol Urodyn 2018; 37:2792-2798. [PMID: 30058735 DOI: 10.1002/nau.23771] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/01/2018] [Indexed: 11/07/2022]
Abstract
AIMS The aim of the study was to evaluate the lower urinary tract function, frequency UTI, the degree of social urine continence, and the occurrence of constipation in children who underwent prenatal or postnatal surgery for MMC. MATERIALS AND METHODS Seventy-two patients with MMC were assessed and divided into the prenatal group (36 patients) and the postnatal one (36 patients). All children, regardless the time of operation, received the same treatment after birth. The urodynamic tests, USG, cystourethrography were performed in all patients along with evaluation of the UTI's, social urine continence, and presence of constipation. RESULTS Urodynamic and imaging studies showed no differences between the test groups. Children from the prenatally operated group showed statistically significant lower number of urinary tract infections, better urine continence, and less frequent constipation. CONCLUSIONS Prenatal MMC repair ensures statistically significant improvement of the degree of social urinary continence, reducing the risk of urinary infections and constipation. Time of MMC repair does not statistically influence the urodynamic tests results and the urodynamic parameters are not the prognostic elements to assess the social urinary continence possibility in patients with the neurogenic bladder.
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Affiliation(s)
- Agnieszka Pastuszka
- Chair and Department of Descriptive and Topographic Anatomy, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Zabrze, Poland
| | - Janusz Bohosiewicz
- Higher School of Strategic Planning in Dąbrowa Górnicza, Śląski Uniwersytet Medyczny w Katowicach, Klinika Chirurgii i Urologii Dziecięcej, Katowice, Poland
| | - Tomasz Koszutski
- Clinical Department of Children's Surgery, Department of Children's Surgery and Urology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Katowice, Poland
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16
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Huang GO, Belfort MA, Whitehead WE, Olutoye OO, Castillo J, Castillo H, Ostermaier KK, Koh CJ, Tu DD. Early postnatal bladder function in fetoscopic myelomeningocele repair patients. J Pediatr Rehabil Med 2017; 10:327-333. [PMID: 29125525 DOI: 10.3233/prm-170465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Prenatal repair of myelomeningocele (MMC) via hysterotomy has demonstrated neurosurgical and motor benefits, when compared to postnatal repairs. Urologic benefits, however, remain to be seen. The purpose of this study was to review early postnatal bladder function in patients undergoing a novel endoscopic approach for MMC repair using an exteriorized uterus. METHODS A prospective urologic assessment of patients undergoing fetoscopic MMC repair and receiving subsequent care at our facility, was performed. Patients were managed and urodynamic studies risk-stratified according to the Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida. RESULTS Fetoscopic MMC repair was performed in 14 patients. No patients had hydronephrosis or bladder thickening at birth. Detrusor overactivity was observed in nine (64.3%) patients. Impaired compliance was seen in eight (57.1%) patients. No patients had a detrusor leak point pressure of > 40 cm H2O or evidence of detrusor sphincter dyssynergia. Three (21.4%) patients had vesicoureteral reflux, seven (50.0%) had an open bladder neck, and none had trabeculated bladders. CONCLUSION In this early experience with fetoscopic MMC repair, postnatal bladder function does not appear to be any worse than that of previously reported prenatal or postnatal closures.
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Affiliation(s)
- Gene O Huang
- Division of Urology, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - William E Whitehead
- Department of Neurosurgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Jonathan Castillo
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Heidi Castillo
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Kathryn K Ostermaier
- Division of Developmental Pediatrics, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Chester J Koh
- Division of Urology, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Duong D Tu
- Division of Urology, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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17
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Tang L, Zhong H, Chen H, Shen J, Bi Y, Xiao X. In utero repair of fetal rat myelomeningocele affects neuromuscular development in the bladder. Exp Ther Med 2017; 14:3681-3687. [PMID: 29042964 PMCID: PMC5639334 DOI: 10.3892/etm.2017.4978] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 06/05/2017] [Indexed: 11/23/2022] Open
Abstract
Fetal repair of myelomeningocele (MMC) has been proven to be beneficial for the central nervous system development; however, the effect of fetal MMC repair on bladder function remains controversial. The objective of the present study was to establish an early timepoint for in utero MMC repair using a rat model, and to investigate the changes in bladder development subsequent to that intervention. Sprague Dawley rats were divided into the MMC, MMC repair and control groups. MMC rat fetus models were created by treating pregnant rats with all-trans retinoic acid. The MMC defect was then repaired in utero at embryonic day 17 (E17) using a chitosan-gelatin membrane patch. Fetal rat bladders were removed at E19 and E21 in each group, as well as at stage E17 in the MMC and control groups. Differential expression of β-III-tubulin, α-smooth muscle actin (α-SMA), nerve growth factor (NGF) and acetylcholinesterase (AChE) mRNA, and β-III-tubulin and α-SMA protein in the bladder following fetal repair was measured and compared among the three groups. In addition, the expression of NGF mRNA was significantly elevated at E21 in the MMC group compared with that of the control group, however, the level decreased in the repair group at stage E21. The expression of α-SMA mRNA significantly increased at E19 and then decreased at E21 in the repair group compared with that of the MMC group; however, there were no significant changes in α-SMA protein following the repair. Furthermore, the repair enhanced β-III-tubulin mRNA expression at E19, but ameliorated the decrease of β-III-tubulin protein at E21. The expression of AChE mRNA increased in the MMC group at E19 and E21 compared with that of the control group, although it was not significantly altered following repair as compared with that of the MMC group. In conclusion, in the current study, abnormal neuromuscular development was observed in the MMC bladder, which enabled a certain degree of improvement in the in utero MMC repair.
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Affiliation(s)
- Liangfeng Tang
- Department of Urology, Children's Hospital, Fudan University, Shanghai 201102, P.R. China
| | - Haijun Zhong
- Department of Urology, Children's Hospital, Fudan University, Shanghai 201102, P.R. China
| | - Hong Chen
- Department of Urology, Children's Hospital, Fudan University, Shanghai 201102, P.R. China
| | - Jian Shen
- Department of Urology, Children's Hospital, Fudan University, Shanghai 201102, P.R. China
| | - Yunli Bi
- Department of Urology, Children's Hospital, Fudan University, Shanghai 201102, P.R. China
| | - Xianmin Xiao
- Department of Surgery, Children's Hospital, Fudan University, Shanghai 201102, P.R. China
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18
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Abstract
Therapeutic fetal surgical procedures are predicated upon the ability to make an accurate fetal diagnosis. The earliest open fetal surgical procedures were introduced in the 1960s to treat Rh isoimmunisation. They were introduced when it became possible to predict impending fetal demise. Open procedures were abandoned when percutaneous approaches proved superior. The introduction of fetal ultrasound allowed the diagnosis of other congenital anomalies, some being amenable to fetal interventions. Open fetal surgical procedures were initially utilised, with significant maternal morbidity. For some anomalies, percutaneous approaches became favoured. In general, all of these procedures involved significant risks to the mother, to save a baby that was likely to die before or shortly after birth without fetal intervention. Fetal repair for myelomeningocele was a "sea change" in approach. The same maternal risks were taken to improve the quality of life of the affected fetus, not save its life. The completion of the "MOMs Trial" has occasioned a "tsunami" of centres in North America applying this approach. Others are attempting percutaneous repairs, with mixed results. This paper reviews the history of fetal surgery, focusing on the themes of the tension between accurate diagnosis and prognosis and open versus "minimally invasive" approaches.
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Affiliation(s)
- H Kitagawa
- Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - K C Pringle
- Paediatric Surgery, Department of Obstetrics and Gynaecology, University of Otago, Wellington, P.O. Box 7343, Wellington South, 6242, Wellington, New Zealand
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19
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Abstract
PURPOSE OF REVIEW Spina bifida is caused by incomplete neural tube closure during the first trimester. This condition may lead to bowel and bladder dysfunction as well as truncal weakness and motor anomalies. Presentations vary between myelomeningoceles and lipomeningoceles and may result in different outcomes. This review seeks to explore our current understanding of the variations in outcomes between individuals with myelomeningocele and lipomeningocele. RECENT FINDINGS Prenatal intervention has become a standard of care for prenatal diagnoses of myelomeningocele and has been shown to reduce shunt placement and improve motor skills. However, urological benefit from early intervention remains to be seen. Early surgical repair, however, may be beneficial for patients with lipomeningocele. Literature on the urological outcomes of patients with myelomeningocele and lipomeningocele is lacking. Further research is needed to better elucidate differences in long-term urological outcomes between these two pathologies.
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Affiliation(s)
- Yvonne Y Chan
- Department of Urology, University of California Davis Children's Hospital, Sacramento, CA, 95817, USA
| | - Samantha K Sandlin
- Department of Urology, University of California Davis Children's Hospital, Sacramento, CA, 95817, USA.,Stem Cell Program, Institute for Regenerative Cures, University of California, Davis Medical Center, 4860 Y Street, Suite 3500, Sacramento, CA, 95817, USA
| | - Eric A Kurzrock
- Department of Urology, University of California Davis Children's Hospital, Sacramento, CA, 95817, USA. .,Stem Cell Program, Institute for Regenerative Cures, University of California, Davis Medical Center, 4860 Y Street, Suite 3500, Sacramento, CA, 95817, USA.
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20
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Leal da Cruz M, Liguori R, Garrone G, Ottoni SL, Cavalheiro S, Moron AF, Macedo A. A 4-Year Prospective Urological Assessment of In Utero Myelomeningocele Repair-Does Gestational Age at Birth Have a Role in Later Neurogenic Bladder Pattern? J Urol 2016; 197:1550-1554. [PMID: 27988193 DOI: 10.1016/j.juro.2016.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Premature delivery is a major complication of in utero myelomeningocele repair. The prematurity rate in MOMS (Management of Myelomeningocele Study) was 79%, with a mean gestational age at birth of 34 weeks. We speculated that prematurity could also influence urological outcome in patients operated on prenatally for myelomeningocele. MATERIALS AND METHODS Beginning in November 2011, we prospectively followed a population of patients with myelomeningocele who had undergone in utero repair. RESULTS We compared patients based on gestational age at birth, ie younger than 34 weeks (group 1, 42 patients) and 34 weeks or older (group 2, 37 patients). Mean gestational age at birth was 28.3 weeks (range 25 to 33) in group 1 and 35.2 weeks (34 to 38) in group 2. Of the cases 47.5% in group 1 were classified as high risk, 35% as incontinent, 10% as hypocontractile and 7.5% as normal. By comparison, 54.5% of cases in group 2 were classified as high risk, 33.3% as incontinent and 12.1% as normal. Differences between the groups were not statistically significant. Mean followup was 27.9 months in group 1 and 24.3 months in group 2. CONCLUSIONS Our results show that gestational age at birth has little impact on bladder pattern. These data reinforce the need to follow this population closely.
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Affiliation(s)
- Marcela Leal da Cruz
- Department of Urology, Division of Pediatric Urology-Center for Supporting Children with Urological Anomalies, São Paulo, Brazil.
| | - Riberto Liguori
- Department of Urology, Division of Pediatric Urology-Center for Supporting Children with Urological Anomalies, São Paulo, Brazil
| | - Gilmar Garrone
- Department of Urology, Division of Pediatric Urology-Center for Supporting Children with Urological Anomalies, São Paulo, Brazil
| | - Sérgio Leite Ottoni
- Department of Urology, Division of Pediatric Urology-Center for Supporting Children with Urological Anomalies, São Paulo, Brazil
| | - Sérgio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Antonio Fernandes Moron
- Department of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil; Santa Joana Maternity Hospital, São Paulo, Brazil
| | - Antonio Macedo
- Department of Urology, Division of Pediatric Urology-Center for Supporting Children with Urological Anomalies, São Paulo, Brazil; Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
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21
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Horst M, Mazzone L, Schraner T, Bodmer C, Möhrlen U, Meuli M, Gobet R. Prenatal myelomeningocele repair: Do bladders better? Neurourol Urodyn 2016; 36:1651-1658. [DOI: 10.1002/nau.23174] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/14/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Maya Horst
- Division of Pediatric Urology; University Children's Hospital; Zurich Switzerland
| | - Luca Mazzone
- Department of Pediatric Surgery; University Children's Hospital; Zurich Switzerland
| | - Thomas Schraner
- Diagnostic Imaging; University Children's Hospital; Zurich Switzerland
| | - Christine Bodmer
- Division of Pediatric Urology; University Children's Hospital; Zurich Switzerland
| | - Ueli Möhrlen
- The Zurich Center for Fetal Diagnosis and Therapy; University of Zurich; Zurich Switzerland
| | - Martin Meuli
- The Zurich Center for Fetal Diagnosis and Therapy; University of Zurich; Zurich Switzerland
| | - Rita Gobet
- Division of Pediatric Urology; University Children's Hospital; Zurich Switzerland
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Brock JW, Carr MC, Adzick NS, Burrows PK, Thomas JC, Thom EA, Howell LJ, Farrell JA, Dabrowiak ME, Farmer DL, Cheng EY, Kropp BP, Caldamone AA, Bulas DI, Tolivaisa S, Baskin LS. Bladder Function After Fetal Surgery for Myelomeningocele. Pediatrics 2015; 136:e906-13. [PMID: 26416930 PMCID: PMC4586733 DOI: 10.1542/peds.2015-2114] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A substudy of the Management of Myelomeningocele Study evaluating urological outcomes was conducted. METHODS Pregnant women diagnosed with fetal myelomeningocele were randomly assigned to either prenatal or standard postnatal surgical repair. The substudy included patients randomly assigned after April 18, 2005. The primary outcome was defined in their children as death or the need for clean intermittent catheterization (CIC) by 30 months of age characterized by prespecified criteria. Secondary outcomes included bladder and kidney abnormalities observed by urodynamics and renal/bladder ultrasound at 12 and 30 months, which were analyzed as repeated measures. RESULTS Of the 115 women enrolled in the substudy, the primary outcome occurred in 52% of children in the prenatal surgery group and 66% in the postnatal surgery group (relative risk [RR]: 0.78; 95% confidence interval [CI]: 0.57-1.07). Actual rates of CIC use were 38% and 51% in the prenatal and postnatal surgery groups, respectively (RR: 0.74; 95% CI: 0.48-1.12). Prenatal surgery resulted in less trabeculation (RR: 0.39; 95% CI: 0.19-0.79) and fewer cases of open bladder neck on urodynamics (RR: 0.61; 95% CI: 0.40-0.92) after adjustment by child's gender and lesion level. The difference in trabeculation was confirmed by ultrasound. CONCLUSIONS Prenatal surgery did not significantly reduce the need for CIC by 30 months of age but was associated with less bladder trabeculation and open bladder neck. The implications of these findings are unclear now, but support the need for long-term urologic follow-up of patients with myelomeningocele regardless of type of surgical repair.
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Affiliation(s)
| | - Michael C. Carr
- Division of Pediatric Urology, and,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - N. Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela K. Burrows
- The Biostatistics Center, George Washington University, Washington, District of Columbia
| | | | - Elizabeth A. Thom
- The Biostatistics Center, George Washington University, Washington, District of Columbia
| | - Lori J. Howell
- Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Mary E. Dabrowiak
- Pediatric Surgery/Fetal Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Earl Y. Cheng
- Lurie Children’s Hospital and Northwestern University, Chicago, Illinois
| | - Bradley P. Kropp
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Anthony A. Caldamone
- Division of Urology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dorothy I. Bulas
- Department of Diagnostic Imaging and Radiology, Children’s National Medical Center, Washington, District of Columbia; and
| | - Susan Tolivaisa
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Laurence S. Baskin
- Department of Urology, University of California, San Francisco, San Francisco, California
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Categorization of Bladder Dynamics and Treatment after Fetal Myelomeningocele Repair: First 50 Cases Prospectively Assessed. J Urol 2015; 193:1808-11. [DOI: 10.1016/j.juro.2014.10.118] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/18/2022]
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Faas BH, Ghidini A, Van Mieghem T, Chitty LS, Deprest J, Bianchi DW. In case you missed it: thePrenatal Diagnosiseditors bring you the most significant advances of 2014. Prenat Diagn 2015; 35:29-34. [DOI: 10.1002/pd.4551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Brigitte H. Faas
- Department of Human Genetics; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Alessandro Ghidini
- Obstetrics and Gynecology; Georgetown University Hospital; Washington DC USA
| | - Tim Van Mieghem
- Obstetrics and Gynaecology; University Hospitals Leuven; Leuven Belgium
- Academic Department Development and Regeneration; Biomedical Sciences; KU Leuven Leuven Belgium
| | - Lyn S. Chitty
- UCL Institute of Child Health; Great Ormond Street Hospital for Children and UCLH NHS Foundation Trusts; London England UK
| | - Jan Deprest
- Obstetrics and Gynaecology; University Hospitals Leuven; Leuven Belgium
- Academic Department Development and Regeneration; Biomedical Sciences; KU Leuven Leuven Belgium
| | - Diana W. Bianchi
- Mother Infant Research Institute; Tufts Medical Center; Boston MA USA
- Floating Hospital for Children; Boston MA USA
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Meuli M, Moehrlen U. Fetal surgery for myelomeningocele is effective: a critical look at the whys. Pediatr Surg Int 2014; 30:689-97. [PMID: 24908159 DOI: 10.1007/s00383-014-3524-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
Formerly, the disastrous cluster of neurologic deficits and associated neurogenic problems in patients with myelomeningocele (MMC) was generally thought to solely result from the primary malformation, i.e., failure of neurulation. Today, however, there is no doubt that a dimensional additional pathogenic mechanism exists. Most likely, it contributes much more to loss of neurologic function than non-neurulation does. Today, there is a large body of compelling experimental and clinical evidence confirming that the exposed part of the non-neurulated spinal cord is progressively destroyed during gestation, particularly so in the third trimester. These considerations gave rise to the two-hit-pathogenesis of MMC with non-neurulation being the first and consecutive in utero acquired neural tissue destruction being the second hit. This novel pathophysiologic understanding has obviously triggered the question whether the serious and irreversible functional loss caused by the second hit could not be prevented or, at least, significantly alleviated by timely protecting the exposed spinal cord segments, i.e., by early in utero repair of the MMC lesion. Based on this intriguing hypothesis and the above-mentioned data, human fetal surgery for MMC was born in the late nineties of the last century and has made its way to become a novel standard of care, particularly after the so-called "MOMS Trial". This trial, published in the New England Journal of Medicine, has indisputably shown that overall, open prenatal repair is distinctly better than postnatal care alone. Finally, a number of important other topics deserve being mentioned, including the necessity to work on the up till now immature endoscopic fetal repair technique and the need for concentration of these extremely challenging cases to a small number of really qualified fetal surgery centers worldwide. In conclusion, despite the fact that in utero repair of MMC is not a complete cure and not free of risk for both mother and fetus, current data clearly demonstrate that open fetal-maternal surgery is to be recommended as novel standard of care when pregnancy is to be continued and when respective criteria for the intervention before birth are met. Undoubtedly, it is imperative to inform expecting mothers about the option of prenatal surgery once their fetus is diagnosed with open spina bifida.
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Affiliation(s)
- Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland,
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