Neurogenic bladder: etiology and assessment

Causes and management of urinary system problems in children on long-term home invasive mechanical ventilation

Many ventilator-dependent children have comorbid conditions including urinary tract disorders. We aimed to present a focused review of the literature describing the causes and management of urinary system problems in children with long-term home mechanical ventilation. We performed a literature search in PubMed/MEDLINE, Scopus, and Web of Science with keywords "children," "home mechanical ventilation," "urinary system," "urinary tract," "neurogenic bladder," "clean intermittent catheterization," "urinary tract infection," "urolithiasis," and "acute kidney injury." We included original articles, reviews, guidelines, and case reports published in English. Ventilator-dependent children may have neurogenic bladder/bowel dysfunction which renders them prone to urinary tract infection, high bladder pressure, vesicoureteral reflux, hydronephrosis, and renal dysfunction. These children require bladder catheterization, medications affecting parasympathetic/sympathetic nervous systems, or surgical procedures to prevent urinary infections, and to maintain continence and renal functions. However, bladder catheterization or surgical procedures like augmentation cystoplasty may also be complicated with urinary infections, urolithiasis, or urethral strictures. Urolithiasis frequency is also increased due to immobilization-related hypercalciuria, hypocitraturia caused by antiepileptic drugs, urinary stasis, and urinary infections. On the other hand, mechanical ventilation can impair renal function by reduction of cardiac output, redistribution of intrarenal blood flow and stimulation of sympathetic and hormonal pathways. Children requiring long-term invasive home mechanical ventilation may have other comorbid conditions, including urinary system diseases, which become manifest as these patients are being kept alive due to the advances in ventilation strategies. These children must be carefully observed for urological complications and managed accordingly to prevent kidney injury.

Proteomic profiling of regenerated urinary bladder tissue in a non-human primate augmentation model

Urinary bladder dysfunction can be caused by environmental, genetic, and developmental insults. Depending upon insult severity, the bladder may lose its ability to maintain volumetric capacity and intravesical pressure resulting in renal deterioration. Bladder augmentation enterocystoplasty (BAE) is utilized to increase bladder capacity to preserve renal function using autologous bowel tissue as a "patch." To avoid the clinical complications associated with this procedure, we have engineered composite grafts comprised of autologous bone marrow mesenchymal stem cells (MSCs) co-seeded with CD34+ hematopoietic stem/progenitor cells (HSPCs) onto a pliable synthetic scaffold [poly(1,8-octamethylene-citrate-co-octanol)(POCO)] or a biological scaffold (SIS; small intestinal submucosa) to regenerate bladder tissue in our baboon bladder augmentation model. We set out to determine the global protein expression profile of bladder tissue that has undergone regeneration with the aforementioned stem cell seeded scaffolds along with baboons that underwent BAE. Data demonstrate that POCO and SIS grafted animals share high protein homogeneity between native and regenerated tissues while BAE animals displayed heterogeneous protein expression between the tissues following long-term engraftment. We posit that stem cell-seeded scaffolds can recapitulate tissue that is nearly indistinguishable from native tissue at the protein level and may be used in lieu of procedures such as BAE.

The urological evaluation and management of neurogenic bladder in children and adolescents-what every pediatric nephrologist needs to know

Neurogenic bladder (NGB) is an encompassing term that includes multiple causes of bladder dysfunction linked to a congenital or acquired neurological condition that adversely impacts the innervation of the lower urinary tract. Multiple static or progressive conditions can be associated with NGB in pediatric and adolescent patients. Currently, spinal dysraphism (i.e., spina bifida) is one of the most common etiologies, which occurs in 3-4 per 10,000 live births in developed nations. Abnormal bladder dynamics can lead to kidney damage secondary to high pressures or recurrent infections, as well as urinary incontinence. The current management paradigm centers on a proactive approach to preserving kidney function and achieving continence through behavioral, pharmacological, and surgical means. This educational review highlights the key components of urological management to maximize collaboration with pediatric nephrologists.

Substantial incidence of bladder dysfunction in patients with VACTERL association: Implications for surveillance

VACTERL association is defined as the nonrandom co-occurrence of a minimum of three of the following six key components: Vertebral anomalies, Anal atresia, Cardiac malformations, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities. Patients presenting with two components may also belong in the same spectrum. Additional components have been associated with VACTERL defects, including single umbilical artery, tethered spinal cord (TSC), and genital malformations. We observed a significant proportion of patients with bladder dysfunction (often called neurogenic bladder in the medical record) when reviewing a cohort of patients with VACTERL defects at our clinical center. Our finding calls attention to bladder dysfunction as an additional VACTERL phenotypic component. The prevalence of bladder dysfunction is greatest in those with genital anomalies, anorectal malformations, sacral dysplasia, renal anomalies, and TSC. We propose that patients with two or more VACTERL malformations be monitored for symptoms of bladder dysfunction if one or more of the identified risk factors are present until the achievement of urinary continence.

Follow-up for the upper urinary tract in patients with high-risk neurogenic lower urinary tract dysfunction

PURPOSE

Patients with neurogenic lower urinary tract dysfunction (nLUTD) can be at risk of preventable damage to the upper urinary tract (UUT), a risk that varies with the underlying diagnosis. Existing literature fails to document precisely which domains of UUT must be followed. This review focusses on surveillance of UUT with special emphasis on high-risk nLUTD.

METHODS

Narrative review of available evidence and current global guidelines to identify patients of nLUTD at higher risk of UUT damage and to define each domain that needs to be followed.

RESULTS

Patients with open spina bifida, spinal cord injury, and anorectal malformation, as well as those with unsafe features on clinical evaluation or urodynamics should be considered at high risk. Structured program should include evaluation of (1) glomerular filtration rate (GFR) which can be estimated ± measured, (2) renal growth (in pre-pubertal children) by ultrasonography, (3) renal scarring by baseline nuclear renogram, (4) hydronephrosis and stones by ultrasonography, (5) vesicoureteral reflux by baseline video-urodynamics, (6) non-GFR measures of renal function (somatic growth, hypertension, proteinuria, anemia and metabolic acidemia). Serum creatinine-based estimations of GFR are more likely to be confounded in select patients with high-risk nLUTD than cystatin-based estimations and measured-GFR. Urological guidelines do not always describe details of UUT surveillance and appear to lack cognizance of nephrology guidelines for evaluation of kidneys.

CONCLUSION

A structured surveillance protocol that includes clear documentation of each domain of the UUT is important in ensuring optimum care for patients with high-risk nLUTD.

Proteomic profiling of regenerated urinary bladder tissue with stem cell seeded scaffold composites in a non-human primate bladder augmentation model

Urinary bladder insult can be caused by environmental, genetic, and developmental factors. Depending upon insult severity, the bladder may lose its ability to maintain capacity and intravesical pressures resulting in renal deterioration. Bladder augmentation enterocystoplasty (BAE) is employed to increase bladder capacity to preserve renal function using autologous bowel tissue as a "patch." To avoid the clinical complications associated with this procedure, we have engineered composite grafts comprised of autologous bone marrow mesenchymal stem cells (MSCs) with CD34+ hematopoietic stem/progenitor cells (HSPCs) co-seeded onto a pliable synthetic scaffold [POCO; poly(1,8-octamethylene-citrate-co-octanol)] or a biological scaffold (SIS; small intestinal submucosa) to regenerate bladder tissue in a baboon bladder augmentation model. We set out to determine the protein expression profile of bladder tissue that has undergone regeneration with the aforementioned stem cell seeded scaffolds along with baboons that underwent BAE. Data demonstrate that POCO and SIS grafted animals share high protein homogeneity between native and regenerated tissues while BAE animals displayed heterogenous protein expression between the tissues following long-term engraftment. We posit that stem cell seeded scaffolds can recapitulate tissue that is almost indistinguishable from native tissue at the protein level and may be used in lieu of procedures such as BAE.

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.

An evaluation of onobotulinumtoxinA as a therapeutic option for pediatric neurogenic detrusor overactivity

INTRODUCTION

Neurogenic detrusor overactivity (NDO) results in involuntary detrusor contractions during bladder filling or storage risking transmission of pressure to the upper urinary tracts and/or significant incontinence. The goals of bladder management in children with NDO prioritize the preservation of renal function, prevention of UTIs, and optimizing quality of life. First-line measures include intermittent catheterization and anticholinergic medication. However, when conservative measures fail, surgical intervention may be indicated. Historically, the next step was major reconstructive surgery to create a low-pressure urinary reservoir. The introduction of intravesical botulinum neurotoxin A (BoNT/A) for use in children in 2002 offered a less invasive option for management. However, its exact role is still evolving.

AREAS COVERED

This article summarizes the mechanism of action of BoNT/A for management of NDO and evaluates the current literature defining common practice and clinical efficacy in children with NDO. The findings of the recently completed phase III trial for intravesical onabotulinumtoxinA in children are discussed in detail.

EXPERT OPINION

As the first BoNT/A approved for use in children with NDO, onabotulinumtoxinA appears to be a safe and less invasive alternative to major reconstructive surgery. However, data defining appropriate patient selection and its role as a long-term treatment option continue to develop.

Ultrasound-Estimated Bladder Weight Correlates With Videourodynamic Studies in Neurogenic Bladder Dysfunction

PURPOSE

This retrospective study was designed to evaluate which lower urinary tract ultrasound parameter(s) could predict the results of invasive urodynamic testing which are the current reference standard in the evaluation of bladder dysfunction in children with spina bifida.

MATERIALS AND METHODS

Fifty eight children with spina bifida undergoing video urodynamic evaluation and a renal bladder ultrasound as their standard of care were evaluated. Quantitative and qualitative ultrasound parameters were then correlated with the videourodynamic study results which served as the reference standard.

RESULTS

For bladders with ending storage pressures above 15 cm H₂ O, there were increases in these ultrasound measured parameters: 1) bladder mass (P = .00019), 2) bladder/body mass ratio (P = .0059), and 3) wall thickness (P = .01). We defined the storage cost as the final storage pressure divided by the percentage of expected bladder capacity attained. These data were analyzed to compute receiver operating curves with assuming end storage pressures cutoff points of 15, 20, 30, and 40 cm H₂ O. The optimal area under the curve was found for a bladder weight of 65 g and a pressure cutoff of 30 cm H₂ O with a sensitivity of 75% with a specificity of 84%.

CONCLUSION

Bladder weight is independent of luminal volume, can be normalized to body weight, and may serve as a clinically valuable tool for noninvasive screening to define a subset of patients with neurogenic bladder with a higher likelihood of having abnormal videourodynamic results.

The role of spinal cord tractography in detecting lesions following selective bladder afferent and efferent fibers: A novel method for induction of neurogenic lower urinary tract dysfunction in rabbit

OBJECTIVE

Neurogenic lower urinary tract dysfunction (NLUTD), a challenging disorder, is defined by lack of bladder control due to the abnormalities in neural pathways and can be classified based on the location of lesions within the nervous system, thus investigating the neural pathways can help us to know the site of the lesion and specify the class of the NLUTD. Diffusion Tensor Imaging (DTI) tractography, a noninvasive advanced imaging method, is capable of detecting central nervous system pathologies, even if routine magnetic resonance imaging shows no abnormality. Accordingly, tractography is an ideal technique to evaluate patients with NLUTD and visualize the pathology site within the spine. This study aimed to introduce a novel method of spinal cord injury (SCI) to establish NLUTD in the rabbit and to investigate the potential of tractography in tracing neural tracts of the spinal cord in an induced NLUTD animal model.

MATERIALS AND METHODS

An animal model of NLUTD was induced through cauterization of the spinal cord at the level T12-L1 in 12 rabbits. Then rabbits were assessed via DTI, urodynamic studies (UDS), voiding cystourethrogram (VCUG), and pathology assessments using antineurofilament 200 (NF200) antibody, anti-S100, anti-Smooth Muscle Actin, anti-Myogenin, and anti-MyoD1.

RESULTS

The tractography visualized lesions within spinal cord fibers. DTI parameters including fractional anisotropy (FA) value and tract density were significantly decreased (FA: p-value = 0.01, Tract density: p-value = 0.05) after injury. The mean diffusivity (MD) was insignificantly increased compared to before the injury. Also, the results of UDS and pathology assessments corroborated that applying SCI and the establishment of the NLUTD model was completely successful.

CONCLUSION

In the present study, we investigated the auxiliary role of tractography in detecting the spinal cord lesions in the novel established rabbit model of NLUTD. The introduced method of NLUTD induction was without the leg's neurological deficit, easily applicable, low-cost, and was accompanied by minimal surgical preparation and a satisfactory survival rate in comparison with other SCI animal models.

Nephro-urological outcomes of a proactive management of children with spina bifida in their first 5 Years of life

INTRODUCTION

The proactive management of spina bifida (SB), especially of its severe form, myelomeningocele (MMC), has contributed to decreasing chronic kidney disease (CKD). The objective of this study is to present the evolution of 5-year-old patient with MMC followed from birth with a proactive approach.

MATERIAL AND METHODS

This retrospective study included 55 cases with MMC of up to 5 years of age. All of them were admitted at birth and followed by a multidisciplinary group, with a proactive approach: CIC and anticholinergics. In the same group, the variables were compared within the first year and the within the fifth year of life. Chronic kidney disease (CKD) was defined by: alterations on renal DMSA scintigraphy; alterations in microalbuminuria/creatininuria ratio, proteinuria 24 hs and decrease in glomerular filtration rate (GFR) calculated with Schwartz bedside equation.

RESULTS

Although overactivity, UTI and VUR decreased throughout the first 5 years (49, 9 and 12%), reduced cystometric capacity, DLPP >40 cm of water and end-filling pressure (Pdet) >20 cm of water increased (41, 27 and 61%). All patients at 5 years of age required CIC. Reduced cystometric capacity and VUR were more significant with abnormal DMSA (36%) at 5 years old ( p: 0.03). Proteinuria and CKD increased to 25% and 49%. Similarly, the need for enalapril increased from 10% to 27%. The microalbuminuria/creatininuria ratio was pathological in 27.3%. 48 patients (87%) remained unchanged on DMSA scan and the other 7 underwent modifications (4 new cases with altered DMSA) over time. Of the 32 normal DMSA cases without changes, 81% did not present proteinuria and 88% continued to respond favorably to oxybutynin. GFR <90 ml/min/1.72m 2 was found in only 3 cases with abnormal DMSA. There was a RR 1.91 (IC95% 1.15-3.16) greater of renal compromise in cases that were anticholinergic-resistant compared to non-refractory cases.

DISCUSSION

Over time, some patients suffered loss of bladder wall compliance, despite the proactive approach. There is an association between abnormal renal DMSA, reduced bladder capacity, and VUR at 5 years of age. Although proteinuria, CKD and enalapril requirement increased over 5 years, almost 90% did not show changes in renal DMSA status.

CONCLUSIONS

Over time, some patients suffered loss of bladder wall compliance. Hence, even if a proactive approach is followed since birth, it is essential to continue with the ongoing monitoring of the renal status and thus avoid greater renal deterioration.

Onabotulinumtoxin A (Botox): A reasonable alternative for refractory neurogenic bladder dysfunction in children and young adults

AIMS

We aimed to describe the effectiveness of Onabotulinumtoxin A (Botox) in children with neurogenic bladder (NGB) unresponsive to medical therapy to determine urodynamic parameters predictive of success.

METHODS

Children receiving Botox for refractory NGB, between 2008 and 2019, from a single academic center, were included in this study. Botox success was defined as improvement of incontinence and/or urodynamic parameters.

RESULTS

Of 34 patients who received Botox, 13 (38.2%) had a positive response from their first injection, with improvement in capacity by a median of 35% of expected capacity for age compared to only a 9% increase in those who did not respond clinically. When patients were divided into groups by baseline urodynamic parameters, high-pressure (Pdetmax > 20 cm H₂ O) patients had significantly greater improvement in compliance compared with low-pressure patients (p = 0.017). Low compliance patients (<10 ml/cm H₂ O) had a dramatic improvement of 3.08 ml/cm H₂ O in their compliance compared with minimal change in the high compliance group (p = 0.003). Finally, low-capacity (<50% of expected CC) patients had significant improvement in capacity and compliance when compared with high-capacity patients (p = 0.004 and p = 0.036, respectively). Improvement in detrusor overactivity (DO) was noted in both the clinical responders and non-responders.

CONCLUSION

In our series, 38% had clinical success with intradetrusor Botox injections for refractory neurogenic bladder. When successful, improvement in capacity and compliance, DO, and/or incontinence was consistent with prior literature. While we could not determine which parameters predicted success, subdividing patients into categories based on baseline urodynamic parameters identified who would benefit from Botox treatment based on differential improvements in capacity and compliance. At least 1 injection of Botox should be considered for a subset of children with refractory NGB, before undertaking more invasive treatments.

Lower urinary tract dysfunction in pediatrics progress to kidney disease in adolescents: Toward precision medicine in treatment

Newborn infants who had neurogenic bladder dysfunction (NBD) have a normal upper urinary tract at birth. Most of them will develop deterioration of renal function and chronic kidney disease if they do not receive proper management. Children with NBD can develop renal damage at adolescence or earlier, which is due to high detrusor pressures resulted from poor compliance of the bladder, detrusor overactivity against a closed sphincter or detrusor sphincter dyssynergia. To preserve renal function and prevent deterioration of the kidneys, NBD must be treated immediately after being diagnosed. Over the last few years there was great progress in the treatment of children with the NBD. We searched PubMed and the Cochrane Library for peer-reviewed articles published in any language up to March 10, 2021, using the search term “neurogenic bladder children.” Our search excluded diagnosis, pathophysiology, surgical treatment of spinal cord injury and spina bifida. The research identified the effectiveness of treatment regimens targeting prevention of chronic kidney disease and the indications of kidney transplantation. The results of the research showed that NBD in children should be diagnosed early in life, and the child should receive the proper management. The literature search concluded that the management of NBD in children would be personalized for every case and could be changed according to response to treatment, side effects, child compliance, availability of treatment modality and costs of treatment. The objectives of the study are to present the different options of management of NBD in children and the selection of the proper method in a personalized manner.

Efficacy and safety of mirabegron in children and adolescents with neurogenic detrusor overactivity: An open-label, phase 3, dose-titration study

Aims

To evaluate the efficacy and safety of mirabegron in children and adolescents (aged 3 to <18 years) with neurogenic detrusor overactivity (NDO) using clean intermittent catheterization.

Methods

In this open‐label, multicenter, baseline‐controlled, Phase III study (NCT02751931), participants received once‐daily mirabegron at an adult dose equivalent of 25 mg. Dose was increased to 50 mg equivalent unless there were safety/tolerability concerns. The primary efficacy endpoint was change from baseline to Week 24 in maximum cystometric capacity (MCC). Secondary urodynamic assessments, Pediatric Incontinence Questionnaire (PIN‐Q), Patient Global Impression of Severity (PGI‐S), Clinician Global Impression of Change (CGI‐C), and Acceptability questionnaires were included.

Results

Overall, 86 participants (55 aged 3 to <12 years, 31 aged 12 to <18 years) received treatment; 68 were included in efficacy assessments. A statistically significant increase in MCC from baseline to Week 24 was observed (87.20 ml, 95% confidence interval: 66.07, 108.33; p < .001); this increase was apparent from Week 4. Significant increases in bladder compliance, bladder volume until first detrusor contraction, average volume per catheterization, maximum daytime catheterized volume and number of dry days per week. Significant decreases in detrusor pressure and number of leakage episodes per day were also observed. Significant improvement in PGI‐S but not PIN‐Q was observed. Most participants reported their condition had either much or very much improved using the CGI‐C. Mirabegron was well tolerated in this population with a profile aligned with that in adults.

Conclusions

Mirabegron was effective and well‐tolerated in the treatment of pediatric patients with NDO.

Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment

INTRODUCTION

Defective closure of the neural tube affects different systems and generates sequelae, such as neurogenic bladder (NB). Myelomeningocele (MMC) represents the most frequent and most severe cause of NB in children. Damage of the renal parenchyma in children with NB acquired in postnatal stages is preventable given adequate evaluation, follow-up and proactive management. The aim of this document is to update issues on medical management of neurogenic bladder in children.

MATERIALS AND METHODS

Five Pediatric Urologists joined a group of experts and reviewed all important issues on "Spina Bifida, Neurogenic Bladder in Children" and elaborated a draft of the document. All the members of the group focused on the same system of classification of the levels of evidence (GRADE system) in order to assess the literature and the recommendations. During the year 2020 the panel of experts has met virtually to review, discuss and write a consensus document.

RESULTS AND DISCUSSION

The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies. Clean intermittent catheterization (CIC) should be implemented during the first days of life, and antimuscarinic drugs should be indicated upon results of urodynamic studies. When the patient becomes refractory to first-line therapy, receptor-selective pharmacotherapy is available nowadays, which leads to a reduction in reconstructive procedures, such as augmentation cystoplasty.

Recurrent Febrile Urinary Tract Infections in a Five-Year-Old Girl

Urinary tract infections (UTIs) are one of the most common bacterial infections of childhood and in pediatric urology. Medical history, examination findings, and clinical course usually vary with the patient's age. Hence, there are no specific clinical features that are strictly associated with UTI in infants or children. This report presents a five-year-old female patient with spina bifida occulta and recurrent history of febrile UTIs diagnosed with detrusor sphincter dyssynergia over the last year. Urodynamic study confirmed an overactive uroflow pattern with bladder outlet obstruction (BOO) and high flow obstruction with long voiding time and terminal dribbling. The aim of this report is to showcase a typical presentation of secondary detrusor overactivity to bladder outlet obstruction in a patient with a coincidental finding of spina bifida occulta and to emphasize the importance of early treatment intervention in decreasing the risk of future complications such as UTIs.

Role of urodynamics in male patients of high-anorectal malformations: a prospective study

PURPOSE

Association of spinal or vertebral anomalies and the iatrogenic denervation during surgical correction of anorectal malformation patients especially in boys can lead to neurogenic bladder inthese subset of patients. The paucity of literature with regard to urodynamic studies focusing exclusively in male children with high-anorectal malformations (HARM) lead us to analyze the urodynamic changes. The objective was to study urodynamic profile in male patients who have undergone surgery for anorectal malformation.

METHODS

Male high-anorectal malformation patients who had completed all the stages of repair were prospective studied. Following the basic work up, all patients based on the urodynamics were categorized into 2 groups as safe or unsafe bladders. Unsafe bladder was defined as detrusor pressure > 40 cm (high detrusor pressure) or pressure variability of 15 cm of water (detrusor overactivity) or significant post-void residue. MRI was limited to patients with only abnormal urodynamics to rule out spinal causes of neurogenic bladder and due to financial constraints, it could not be offered to all patients.

RESULTS

41 HARM meet the exclusion criteria. All patients were asymptomatic with none having history of urinary tract infections. Ultrasound showed bladder wall thickening in 31.7% patients. UDS revealed reduction in bladder capacity and compliance was noted in 31.7% and 30% patients, respectively. Elevated detrusor pressures (> 40 cm of water) were noted in 10% (4/41), detrusor overactivity with concomitant elevated detrusor pressures in 19.5% (8/41) and normal UDS in 70% (29/41). 13 patients (31.7%) had abnormal cystometric parameters with 12(30%) having unsafe bladders. MRI confirmed sacral agenesis in 1 patient with unsafe bladder.

CONCLUSION

Urodynamics can demonstrate occult neurovesical dysfunction in patients with HARM. This would help in early renal protective therapy and prevent the burden of long-term sequelae of neurovesical dysfunction in HARM patients.

Electrospinning: Application and Prospects for Urologic Tissue Engineering

Functional disorders and injuries of urinary bladder, urethra, and ureter may necessitate the application of urologic reconstructive surgeries to recover normal urine passage, prevent progressive damages of these organs and upstream structures, and improve the quality of life of patients. Reconstructive surgeries are generally very invasive procedures that utilize autologous tissues. In addition to imperfect functional outcomes, these procedures are associated with significant complications owing to long-term contact of urine with unspecific tissues, donor site morbidity, and lack of sufficient tissue for vast reconstructions. Thanks to the extensive advancements in tissue engineering strategies, reconstruction of the diseased urologic organs through tissue engineering have provided promising vistas during the last two decades. Several biomaterials and fabrication methods have been utilized for reconstruction of the urinary tract in animal models and human subjects; however, limited success has been reported, which inspires the application of new methods and biomaterials. Electrospinning is the primary method for the production of nanofibers from a broad array of natural and synthetic biomaterials. The biomimetic structure of electrospun scaffolds provides an ECM-like matrix that can modulate cells' function. In addition, electrospinning is a versatile technique for the incorporation of drugs, biomolecules, and living cells into the constructed scaffolds. This method can also be integrated with other fabrication procedures to achieve hybrid smart constructs with improved performance. Herein, we reviewed the application and outcomes of electrospun scaffolds in tissue engineering of bladder, urethra, and ureter. First, we presented the current status of tissue engineering in each organ, then reviewed electrospun scaffolds from the simplest to the most intricate designs, and summarized the outcomes of preclinical (animal) studies in this area.

The role of bladder function in the pathogenesis and treatment of urinary tract infections in toilet-trained children

Urinary tract infections (UTIs) are a common reason for referral to pediatric specialists and the risk profile of these children is influenced by age, sex, and underlying urinary tract abnormalities. UTIs in toilet-trained children represent a different entity than confirmed, febrile UTIs that occur in infants, impacted by suboptimal bladder habits, bladder dysfunction, constipation, or a combination of these factors. A comprehensive literature search was conducted using PubMed and MEDLINE and search terms included recurrent UTI, VUR, bladder and bowel dysfunction (BBD), constipation, lower urinary tract symptoms, and voiding dysfunction. Common presenting symptoms of UTI in children include fever (> 38 °C) with or without "traditional" lower urinary tract symptoms (LUTS) such as dysuria, malodorous urine, frequency, urgency, and incontinence. However, many infections in older children are afebrile episodes-consisting primarily of LUTS-which may or may not be confirmed with biochemical and/or microbiological evidence. Therefore, when evaluating toilet-trained children with recurrent UTIs, it is paramount to consider dysfunctional elimination as an underlying cause, diagnose, and treat it prior to indicating surgical options, even in the presence of VUR or other anatomical abnormalities. Although the impact of bladder function on the risk of infections is important, so is the accurate diagnosis and initial evaluation. This review article will focus on an often overlooked yet critical factor: the impact of bladder function, particularly for toilet-trained children, as well as the importance of implementing bladder training strategies, aggressive management of constipation, and pharmacological management as necessary.

Let's Talk About Sex: Special Considerations in Reproductive Care and Sexual Education in Young Women With Spina Bifida

Medical advances in the last several decades have allowed an increasing number of children with spina bifida to reach adolescence and adulthood. As they reach puberty, girls with spina bifida face unique social and health challenges to their sexuality, such as orthopedic restrictions, continence, and pelvic floor disorders. Recent research efforts have focused on better understanding female sexual desires, dysfunctions, and activity and the role of the physician in educating this vulnerable population. This article aims to summarize current literature on sexual function, knowledge gaps, and the importance of tailored sexual education from providers in women with spina bifida.

Study of serum and urinary markers of the renin-angiotensin-aldosterone system in myelomeningocele patients with renal injury detected by DMSA

Introduction:

The Renin-Angiotensin-Aldosterone System (RAAS) has been suggested as a possible marker of renal injury in chronic diseases. This study proposes to analyze the serum and urinary markers of the RAAS in myelomeningocele patients with renal function abnormalities detected on DMSA.

Material and Methods:

Seventeen patients followed in our institution that presented with renal injury on DMSA. We review nephrologic and urologic clinical aspects and evaluated ultrassonagraphy, voiding urethrocystography and urodynamics. Urinary and serum samples were collected to evaluate possible correlations of renal lesions with RAAS. Control group urine and serum samples were also sent for analysis.

Results:

Serum ACE 2 activity means in relation to urodynamic findings were the only values that had a statistically significant difference (p = 0.040). Patients with normal bladder pattern presented higher ACE 2 levels than the high risk group. Statistical analysis showed that the study group (SG) had a significantly higher mean serum ACE than the CG. The means of ACE 2 and urinary ACE of the SG and CG were not statistically different. The ROC curve for serum ACE values had a statistically significant area for case and non-case differentiation, with 100% sensitivity and 53% specificity for values above 60.2 mg/dL. No statistically significant areas were observed in relation to ACE 2 and urinary ACE values between SG and CG.

Conclusion:

The analysis of serum ACE, ACE 2 and urinary ACE were not significant in patients with myelomeningocele and neurogenic bladder with renal injury previously detected by renal DMSA.

Routine Screening and Treatment of Urinary Tract Infection May Be Justified in Children and Adolescents with Cerebral Palsy: A Systematic Review

Context: Children and adolescents with cerebral palsy may present with lower urinary tract dysfunction which increases their risk for urinary tract infection (UTI). Whereas few studies reported low prevalence rates of UTI in these patients, several studies documented high prevalence rates. Thus, it appears there is no unanimity about the burden of UTI in affected children and adolescents to justify routine screening and treatment of the infection. This systematic review aims to determine the risk and pooled prevalence rate of UTI in children and adolescents with cerebral palsy. Evidence Acquisition: Using appropriate descriptors, we searched the PubMed and Google Scholar databases. Eligible papers were primary studies published in English language: reporting an association between cerebral palsy and UTI or UTI prevalence in children and adolescents with cerebral palsy and healthy comparators, with a clear definition of UTI and cerebral palsy. We assessed the quality of included studies with the Newcastle-Ottawa Scale (NOS) and resolved inter-rater discrepancies by consensus. We independently retrieved relevant data from these studies using a preconceived data-extraction form. We analyzed the aggregate data on UTI prevalence in these pediatric patients, using the log odds ratio (OR) at 95% confidence interval as the summary estimate. Results: Of the seven included studies, only two (28.6%) were case-control studies, while five (71.4%) were cross-sectional studies. There was no uniform definition of UTI in these studies. Prevalence rates varied widely from as low as 2.2% to as high as 56.7%. The mean UTI prevalence rate estimated for six of the included studies was 31.8%. The log OR at 95% CI computed for the case-control studies was 10.9 (95% CI: 9.0, 12.9). Conclusions: The prevalence and risk of UTI in children and adolescents with cerebral palsy are significantly high. Routine screening and treatment for UTI may be justified in these pediatric patients. We however recommend more prospective case-control studies to strengthen the current evidence of the high UTI burden in these patients.

Challenges in pediatric urologic practice: a lifelong view

The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.

Long-term efficacy and safety of solifenacin in pediatric patients aged 6 months to 18 years with neurogenic detrusor overactivity: results from two phase 3 prospective open-label studies

INTRODUCTION

The standard recommended treatment for neurogenic detrusor overactivity (NDO) is clean intermittent catheterization combined with an antimuscarinic agent. However, the adverse systemic side-effects of oxybutynin, the most widely used agent, are of concern.

OBJECTIVE

To evaluate the efficacy and safety of solifenacin in pediatric patients with NDO, aged 6 months-<5 years and 5-<18 years.

STUDY DESIGN

Two open-label, baseline-controlled, phase 3 studies were conducted in pediatric patients with NDO. Patients were treated with sequential doses of solifenacin oral suspension (pediatric equivalent doses 2.5-10 mg) for 12 weeks to determine each patient's optimal dose, followed by a fixed dose ≥40-week treatment period. Primary efficacy endpoint was change from baseline in maximum cystometric capacity (MCC) after 24 weeks. Secondary endpoints included bladder compliance, bladder volume until first detrusor contraction (>15 cmH₂O), number of overactive detrusor contractions (>15 cmH₂O), maximum catheterized volume (MCV)/24 h, and incontinence episodes/24 h. Safety parameters were treatment-emergent adverse events (TEAEs), serious adverse events, laboratory variables, vital signs, electrocardiograms, and ocular accommodation and cognitive function assessments.

RESULTS

After 24 weeks, MCC had significantly increased compared with baseline in patients aged 6 months -<5 years and 5-<18 years (37.0 ml and 57.2 ml, respectively; P < 0.001; Fig.). Improvement was also observed after 52 weeks' treatment. Significant changes were observed from baseline to week 24 in all secondary endpoints in both age groups: increase in bladder compliance, increase in bladder volume to first detrusor contraction as a percentage of expected bladder capacity, reduction in the number of overactive detrusor contractions, increase in MCV, and decreased incontinence episodes. TEAEs were mostly mild or moderate, and there were no new drug-related TEAEs compared with adult studies. Age-related improvements were noted in ocular accommodation and cognitive function.

DISCUSSION

These long-term multicenter investigations demonstrated the efficacy and safety of solifenacin in pediatric patients with NDO. The observed increases in MCC were clinically relevant and demonstrated that an increase in fluid volume can be accommodated in the bladder prior to reaching intravesical pressures that endanger kidney function and/or are associated with leakage or discomfort. Solifenacin was well tolerated with low incidences of constipation and dry mouth (typically associated with antimuscarinics), central nervous system-related side-effects, and facial flushing.

CONCLUSION

Solifenacin was effective and well tolerated in pediatric patients with NDO, aged 6 months-<18 years, suggesting that it is a viable alternative to oxybutynin, the current standard of care. STUDIES ARE REGISTERED AT CLINICALTRIALS.GOV: NCT01981954 and NCT01565694.

Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers?

CONTEXT

Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families.

OBJECTIVE

To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction.

EVIDENCE ACQUISITION

We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management.

EVIDENCE SYNTHESIS

Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories.

CONCLUSIONS

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children's Continence Society.

PATIENT SUMMARY

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.

The Effects of Intradetrusor BoNT-A Injections on Vesicoureteral Reflux in Children With Myelodysplasia

PURPOSE

We retrospectively evaluated the efficacy of botulinum neurotoxin A (BoNT-A) on vesicoureteral reflux (VUR), continence status, and urodynamic parameters in children with myelodysplasia who were not responsive to standard conservative therapy.

METHODS

The study included 31 children (13 boys, 18 girls) with a mean age of 9.2±2.3 years (range, 5-14 years) with myelodysplasia, retrospectively. All children were fully compatible with clean intermittent catheterization (CIC) and did not respond to the maximum tolerable anticholinergic dose. All children received an intradetrusor injection of 10 U/kg (maximum, 300 U) of BoNT-A into an infection-free bladder. All patients had VUR (22 unilateral, 9 bilateral) preoperatively. The grade of reflux was mild (grades 1, 2), intermediate (grade 3), and severe (grades 4, 5) in 25, 7, and 8 ureters, respectively.

RESULTS

The mean maximum bladder capacity increased from 152.9±76.9 mL to 243.7±103 mL (P<0.001), and the maximum detrusor pressure decreased from 57±29.4 cm H2O to 29.6±13.9 cm H2O (P<0.001). After BoNT-A treatment, 16 refluxing ureters (40%) completely resolved, 17 (42.5%) improved, 5 (12.5%) remained unchanged, and 2 (5%) became worse. Of the 31 children with urinary leakage between CICs, 22 (71%) became completely dry, 6 (19%) improved, and 3 (10%) experienced partial improvement.

CONCLUSION

In children with myelodysplasia, we were able to increase bladder capacity, enhance continence, and prevent VUR by using intradetrusor BoNT-A injections. Although our results are promising, a larger group of long-term prospective studies are warranted to investigate this method of treatment.

An Unusual Case of Syringohydromyelia Presenting with Neurogenic Bladder

We report the case of a 4-year-old boy who first presented with acute pyelonephritis at the age of 6 months. Diagnostic workup revealed high-grade bilateral vesicourethral reflux (VUR). At the age of 18 months, a bulking agent was used to treat bilateral VUR. Since the VUR persisted, an open bilateral Lich-Gregoir procedure was done at the age of 3 years. Immediately after surgery, he developed acute urinary retention with hydronephrosis that resolved with the placement of dwelling urinary catheter. After removal of the catheter urinary retention relapsed so placement of suprapubic urinary catheter was indicated since he did not have sensory loss. He was started with tamsulosin (α − 1-blocker) and prophylactic antibiotics. Urodynamics were performed and suggested bladder outlet obstruction. On the basis of previous urethroscopy and the absence of neurological sequelae, the differential diagnosis of Hinman syndrome was made. After removal of the suprapubic catheter, clean intermittent catheterization was started and α-blocker continued. However, magnetic resonance imaging of the brain and the spinal cord revealed syringohydromyelia extending from thoracic spine (Th5) to conus medullaris with 6 to 7 mm in diameter. Electromyoneurogram was normal. After a follow-up of 3 years, the hydronephrosis has resolved. The patient is on clean intermittent catherization and has no urinary tract infections.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment

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.

Prospective evaluation of the management of bowel dysfunction in children with neuropathic lower urinary tract dysfunction and its effect on bladder dynamics

INTRODUCTION AND AIM

Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics.

PATIENTS AND METHODS

In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart.

RESULTS

Mean age was 8.3 ± 3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ± 1.54 to 10.17 ± 1.76, p = 0.00), rectal diameter (decreased from 34.83 ± 5.91 to 27.90 ± 5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ± 24.95 to 30 ± 17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ± 45.69 to 155.17 ± 39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively).

CONCLUSION

Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.

Can sacral development as a marker for caudal regression help identify associated urologic anomalies in patients with anorectal malformation?

BACKGROUND AND AIM

The sacral ratio (SR) is a well-established tool to quantify sacral development in patients with anorectal malformations (ARM) and can be used as a predictor of fecal continence. We hypothesized that a lower SR correlated with the presence of urologic and renal malformations.

METHODS

We retrospectively reviewed the medical records of patients with ARM treated at our center from 2014 to 2016. We measured the lateral SR as a marker for sacral development and assessed the spine for the presence of tethered cord (TC). Urological and renal anomalies, including single kidney, hydronephrosis, hypospadias, vesicoureteral reflux (VUR), ectopic ureter, and penoscrotal transposition were assessed. Analysis of variance (ANOVA), t-tests, and multivariable linear regression were used to test for differences in SR with consideration of associated urologic malformations and tethered cord.

RESULTS

283 patients with ARM were included for analysis (156 females). The median age was 39months (10-90). Among these, 178 (55.6%) had 1 or more urologic malformations, and 81 (25.3%) had a TC. Hydronephrosis, high-grade VUR (3-5), solitary kidney, and tethered cord were significantly associated with lower SR (p<0.01). In multivariable regression models, the presence of urologic abnormalities remained significantly associated with lower a SR despite the presence or absence of TC (p<0.001).

CONCLUSION

SR is a potentially useful indicator of certain urologic anomalies including hydronephrosis, high grade VUR, and solitary kidney in patients with ARM. This association is independent of the presence of TC. A sacral ratio as a part of the VACTERL screening can help the surgeon identify which patients need closer urologic follow up.

LEVEL OF EVIDENCE

IV.

Neuropathic Bladder and Augmentation Cystoplasty

Surgical indications for individuals with neuropathic bladder include unsafe urinary storage pressures, progressive upper tract deterioration, and continued urinary incontinence that is recalcitrant to oral pharmacologic or intradetrusor injection therapy and intermittent catheterization. Bladder augmentation is currently the gold standard surgical procedure used to increase bladder capacity and reduce storage pressures but has significant long-term risks. The medical and surgical management of neuropathic bladder, as well as long-term consequences of bladder augmentation, are reviewed.

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.

A geriatric patient with spinal cord injury without radiographic abnormality: outcomes and causes

Introduction

Although the prognosis of spinal cord injury without radiographic evidence of abnormality (SCIWORA) depends on the severity of the initial neurological damage, most patients with American Spinal Injury Association impairment scale grade D are expected to recover fully.

Case presentation

An 85-year-old patient with SCIWORA and urinary incontinence, who did not produce the expected response to rehabilitation, displayed the central, peripheral, and autonomic nervous system findings together. Conventional radiography, computed tomography, and even magnetic resonance imaging were unable to explain this complicated neurological condition thoroughly. More in-depth research into the patient's history revealed some sequelae left by urinary surgery and chemotherapy.

Discussion

Comorbidities in geriatric SCIWORA have severe effects on both etiology and prognosis. Furthermore, incontinence in SCIWORA is an essential condition that has not been addressed until now and may play a role in prognosis.

Longitudinal Study of Bladder Continence in Patients with Spina Bifida in the National Spina Bifida Patient Registry

PURPOSE

Achieving bladder continence in individuals with spina bifida is a lifetime management goal. We investigated bladder continence status through time and factors associated with this status in patients with spina bifida.

MATERIALS AND METHODS

We used National Spina Bifida Patient Registry data collected from 2009 through 2015 and applied generalized estimating equation models to analyze factors associated with bladder continence status.

RESULTS

This analysis included 5,250 participants with spina bifida in a large, multi-institutional patient registry who accounted for 12,740 annual clinic visit records during the study period. At last followup mean age was 16.6 years, 22.4% of participants had undergone bladder continence surgery, 92.6% used some form of bladder management and 45.8% reported bladder continence. In a multivariable regression model the likelihood of bladder continence was significantly greater in those who were older, were female, were nonHispanic white, had a nonmyelomeningocele diagnosis, had a lower level of lesion, had a higher mobility level and had private insurance. Continence surgery history and current management were also associated with continence independent of all other factors (adjusted OR and 95% CI 1.9, 1.7-2.1 and 3.8, 3.2-4.6, respectively). The association between bladder management and continence was stronger for those with a myelomeningocele diagnosis (adjusted OR 4.6) than with nonmyelomeningocele (adjusted OR 2.8).

CONCLUSIONS

In addition to demographic, social and clinical factors, surgical intervention and bladder management are significantly and independently associated with bladder continence status in individuals with spina bifida. The association between bladder management and continence is stronger in those with myelomeningocele.

Impact of posterior urethral diameter/external urethral sphincter diameter as a new tool to predict detrusor pressure in the voiding phase

PURPOSES

We measured posterior urethra diameter (PUD) and external urethral sphincter diameter (EUSD), which can also be measured by voiding cystourethrography (VCUG) and investigated the relationship between PUD/EUSD and detrusor pressure (Pdet) during voiding by videourodynamics (VUDS).

METHODS

Sixty-three children, who were 3 years old or less and underwent VUDS, were enrolled in the present study. We measured PUD and EUSD in addition to detrusor pressure at the time of the widest EUS during voiding (Pdet-voiding) by VUDS, and PUD/EUSD was investigated compared to Pdet-voiding.

RESULTS

Seventy-eight VUDS were performed in 63 patients, and the median age at VUDS was 10.2 months. These studies revealed a significant correlation between PUD/EUSD and Pdet-voiding (r = 0.641, p < 0.001). However, a significant correlation was not observed between PUD/EUSD and age (r = 0.180). We defined Pdet-voiding of more than 80 cmH₂O as a high voiding pressure, and a PUD/EUSD of 2.4 was a good predictor for the cutoff value for high voiding pressure. Pdet-voiding was significantly higher in children with a PUD/EUSD of ≥ 2.4 (p < 0.001). In 19 children who had neurological diseases, a significant correlation was found between PUD/EUSD and Pdet-voiding (r = 0.842, p < 0.001), and a PUD/EUSD of 2.4 was a useful cutoff value for high voiding pressure.

CONCLUSIONS

PUD/EUSD is a valuable tool to predict high voiding pressure in pediatric patients. A PUD/EUSD of ≥ 2.4 in VCUG indicates the need to perform more invasive tests, such as VUDS, in pediatric patients aged 3 and under with neuropathic diseases.

Urinary Diversion in Renal Transplantation

Renal transplantation involving anatomically or functionally altered recipient urinary reservoirs is a challenging procedure. Initial reports discouraged kidney transplantation in patients with urinary diversion due to inferior outcomes. However, more recent studies have shown that although there are more infectious complications, patients with urinary diversions have comparable long-term graft survival with those with native anatomy. Careful preoperative assessment of these candidates is mandatory. Unique technical and surgical concepts must be considered before embarking on transplanting this specific cohort of kidney transplantation candidates.

Pre-operative risk factors for stomal stenosis with Malone antegrade continence enema procedures

INTRODUCTION

The Malone antegrade continence enema (MACE) procedure remains an effective tool in providing independence to patients with refractory constipation. Appendiceal, ileal and colonic segments are all used depending upon the patient's individual anatomy and surgeon's preference. Unfortunately, MACE stomal stenosis (SS) remains a frustrating complication. It was hypothesized that SS is associated with the type of efferent limb used for MACE construction.

OBJECTIVE

To perform a retrospective risk analysis of the pre-operative factors that correlated with postoperative stomal stenosis.

MATERIALS AND METHODS

The study reviewed 39 consecutive patients treated with MACE by a single surgeon at the present institution. Collected data included: the type of channel construction, stoma site, pre-operative body mass index (BMI) z-score, pre-operative diagnosis, and development of SS. Stomal stenosis was defined as a documented inability to catheterize, requirement of a Chait tube, or a subsequent stomal revision. An odds ratio (OR) analysis was performed to evaluate the association with the development of SS.

RESULTS

Stomal stenosis developed in 19 patients (49%) with an average follow-up of 4.7 years. The majority of patients had a diagnosis of myelomeningocele (90%), and there was no significant difference in gender distribution (54% males, 46% females). The distribution types of MACE efferent limbs consisted of appendicocecostomy in 20 (51%), cecal-wall flap in 16 (41%) and ileocecostomy in three patients (8%). Neither type of efferent limb, nor stomal location were significant predictors of postoperative SS. Pre-operative obesity (BMI ≥95%), however, demonstrated a significant risk of SS compared to non-obese patients (OR 4.44, 95% CI 1.08-18.4, P = 0.04).

DISCUSSION

This was a single-institution study of a relatively small number of patients. However, examining consecutive patients with a common surgeon can minimize technique variability. Also, the rates of stenosis in this cohort were higher than most. This may have been due to a more broad definition (unable to catheterize). These findings complement recent literature showing an increased complication rate for the obese pediatric patient.

CONCLUSION

Stomal stenosis remains a frustrating complication following creation of the MACE stoma. In the present series, neither a cecal wall flap, nor the stomal site location contributed to SS. Obesity was the only identified statistically significant risk factor that led to SS.

Is urodynamic evaluation a must in all operated cases of open neural tube defects

BACKGROUND

Spina bifida is a common cause of pediatric neurogenic bladder. It causes renal failure in almost 100% of patients if the associated detrusor sphincter dyssynergia (DSD) is inadequately managed. Detrusor instability and high detrusor pressures (Figure) have been implicated as the major factors predictive of renal damage in these patients. Urodynamic studies provide early identification of "at risk" kidneys so that appropriate intervention can be made. However, the role in post-operative patients of spina bifida who have no clinical manifestations remains unclear.

OBJECTIVE

To study the bladder dynamics in asymptomatic post-operative patients of spina bifida and to determine whether routine urodynamic study is justifiable.

MATERIAL AND METHODS

Urodynamics was performed on 15 operated patients of spina bifida who did not have any neurological deficit and were asymptomatic.

RESULTS

The mean age of the patients was 4.97 years. None of the patients had any urological complaints with their ultrasonography being normal. None had scars on nuclear scan. Of the 15 patients, 12 (80%) had abnormal findings on urodynamic assessment. Three patients (20%) had detrusor pressures greater than 40 cm of H₂O. One patient had significant residual urine and detrusor instability.

DISCUSSION

The use of urodynamic studies in asymptomatic patients of spina bifida remains controversial, with one school of thought advocating early invasive urodynamic testing. In contrast, some favor noninvasive sonological monitoring, reserving invasive tests only for patients with renal tract dilatation. In our subset of patients none had renal tract dilatation but three patients (20%) had "at risk" bladders. These patients would benefit from early intervention aimed at renal preservation. The study is limited by a small sample size because of the relative rarity of the patient profile included. A further multicenter study with a case-control design could conclusively indicate the role of urodynamic testing in these patients.

CONCLUSION

Patients of spina bifida, even when asymptomatic, have a high incidence of unsafe bladders. Early identification and appropriate measures can protect kidneys from long-term damage, hence urodynamic profiling is mandatory for identification of potentially high-risk bladders.

Comparing a novel hand held device (Peritron+) to standard urodynamics in measuring intravesical pressure

AIMS

Peritron+ is a new handheld device, which can be attached to a urethral catheter to measure intravesical pressures (Pves). The goal of this study was to assess if Pves recorded by standard urodynamics (UDs) are comparable to those recorded by the Peritron+.

METHODS

Patients with voiding dysfunction and an indication for UD underwent measurement of Pves with nonvideo UD and Peritron+. Pves were recorded at volumes of 50, 100, and 200 mL for the supine and sitting positions. A failure of the Peritron+ was considered to be a discrepancy of Pves values >3 cmH₂ O between Peritron+ and UD recordings. Two-way ANOVA was used to assess for statistical significance. P-values < 0.05 were considered significant.

RESULTS

Ten female patients, mean age 51 years old, were enrolled in the study. The difference in Pves measurements between Peritron+ and UD were ≤3 cmH₂ O at all bladder volumes measured in a supine and sitting positions. There were no adverse events and there were no malfunctions of the Peritron+ device during the study.

CONCLUSIONS

Peritron+ handheld device accurately assessed Pves at different intravesical volumes when compared to UD measurements. The Peritron+ is a simple and safe device, which can be used in the office by a clinician and at home by a patient to monitor Pves and help to select patients who may require standard UD re-evaluation. This will be a valuable tool in managing patients with neurogenic and nonneurogenic bladders who are at a risk of upper urinary tract deterioration.

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.

Pharmacotherapy for Pediatric Neurogenic Bladder

Neurogenic bladder (NB) is a nonspecific term that may describe conditions ranging from areflectic noncontractile bladder to detrusor overactivity. The most common cause of NB in children is the presence of dysraphic malformations. Urodynamic evaluations make it possible to describe bladder dysfunctions and to plan a therapeutic strategy for each patient. In a child with NB there are two major dangerous functional problems seen in urodynamic investigations: high intravesical pressure in the storage phase and high pressure during urination. The basic goals of urologic treatment for a child with NB are the protection of the urinary tract from complications and improvement of continence. Treatment for a child with NB is usually conservative, and focuses on achieving safe bladder pressures during storage with reliable emptying, via voiding or catheterization. The two most important forms of conservative treatment are clean intermittent catheterization and pharmacological treatment of functional disorders. Some drugs are used in the treatment of functional disorders in children with NB, but none of the drugs are officially approved for small children and babies.

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.

Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society

AIMS

As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Children's Continence Society (ICCS) recommendations for diagnosis and treatment of OSD.

METHODS

Guidelines were formulated based on analysis of pertinent literature and consensus among authors. This document was vetted by the multidisciplinary members of the ICCS via its website before submission for peer review publication.

RESULTS

The more frequent diagnosis of OSD is associated with increased operative intervention. Spinal cord untethering (SCU) has a highly variable risk profile, largely dependent on the specific form of OSD. Progressive neurological deterioration attributed to "tethered cord" may occur, with or without surgery, in selected forms of OSD whereas other cohorts do well.

CONCLUSION

Infants with classic cutaneous markers of OSD, with progressive neurologic, skeletal, and/or urologic findings, present no diagnostic or therapeutic dilemma: they routinely undergo MRI and SCU. Conversely, in asymptomatic patients or those with fixed, minor abnormalities, the risk profile of these OSD cohorts should be carefully considered before SCU is performed. Irrespective of whether or not SCU is performed, patients at risk for progression should be followed carefully throughout childhood and adolescence by a multidisciplinary team.

Management of Neurogenic Bladder

This article provides a comprehensive summary of the clinical approach, investigative modalities and management of a child with neurogenic bladder disease due to myelodysplasia. It is aimed at pediatric physicians and surgeons working in developing nations. The methodologies suggested are simple and can be practised even in resource poor regions. The goal of management is avoidance of Chronic kidney disease and for this, meticulous bladder management is the key.

Early treatment improves urodynamic prognosis in neurogenic voiding dysfunction: 20 years of experience

OBJECTIVE

To evaluate the association between early treatment and urodynamic improvement in pediatric and adolescent patients with neurogenic bladder.

METHODOLOGY

Retrospective longitudinal and observational study (between 1990 and 2013) including patients with neurogenic bladder and myelomeningocele treated based on urodynamic results. The authors evaluated the urodynamic follow-up (bladder compliance and maximum bladder capacity and pressure) considering the first urodynamic improvement in two years as the outcome variable and early referral as the exposure variable, using a descriptive and multivariate analysis with logistic regression model.

RESULTS

Among 230 patients included, 52% had an early referral. The majority were diagnosed as overactive bladder with high bladder pressure (≥40cm H₂O) and low bladder compliance (3mL/cmH₂O) and were treated with oxybutynin and intermittent catheterization. Urodynamic follow-up results showed 68% of improvement at the second urodynamic examination decreasing bladder pressure and increasing bladder capacity and compliance. The percentage of incontinence and urinary tract infections decreased over treatment. Early referral (one-year old or less) increased by 3.5 the probability of urodynamic improvement in two years (95% CI: 1.81-6.77).

CONCLUSION

Treatment onset within the first year of life improves urodynamic prognosis in patients with neurogenic bladder and triplicates the probability of urodynamic improvement in two years. The role of neonatologists and pediatricians in early referral is extremely important.

Management of vesicoureteral reflux in neurogenic bladder

Vesicoureteral reflux (VUR) is a significant risk factor for pyelonephritis and renal scarring. VUR can occur through a defective ureterovesical junction (UVJ) or an overwhelmed normal UVJ mechanism such as in bladder dysfunction of congenital, acquired, or behavioral etiology. There are numerous causes for the development of a neurogenic bladder from spinal dysraphisms to spinal cord trauma and even centrally based abnormalities in children with apparently normal motor function (inappropriately termed nonneurogenic neurogenic bladder). The foundation of managing reflux in these neurogenic bladders is to maintain low bladder pressures which will commonly mean that compliance will be normal as well. There have been several publications that have shown that if bladder pressures are lowered simply with clean intermittent catheterization and medications that the reflux can resolve spontaneously. Alternatively, the patients that are in need of bladder augmentation can have spontaneous resolution of their reflux with the resulting increase in capacity. Surgical intervention is called for when bladder capacity is adequate and the reflux persists or if it is part of a larger operation to increase capacity and to manage outlet resistance. In some instances, reimplantation is necessary because the ureters interfere with the bladder neck procedure. Aside from open and robotic surgical intervention the use of endoscopic injectable agents is beginning to become more popular especially when combined with intravesical botulinum toxin A injections. Great strides are being made in the management of patients with neurogenic bladders and we are seeing more choices for the urologist to be able to manage these patients.