Can urodynamic studies predict bladder behaviour changes after artificial urinary sphincter implantation?

Think Tank 2: How Do We Precisely Define the "High Risk Bladder" and What Are the Interrelationships Between Inflammation, Blood Flow, Fibrosis, and Loss of Bladder Compliance?

INTRODUCTION

Defining "high-risk bladder" or "high-pressure bladder" involves recognizing the potential for an unsafe lower urinary tract, where dysfunction in storage and micturition can threaten upper urinary tract health, leading to unfavorable outcomes like dialysis, recurrent infections, systemic impact, or mortality.

METHODS

ICI-RS was held in Bristol in June 2024, and Think Tank 2 aimed to define research priorities including identifying clinical predictors and developing prevention and monitoring strategies.

RESULTS

Risk factors encompass both congenital and neurogenic lower urinary tract dysfunction, bladder outlet obstruction, vascular diseases, and inflammatory disorders, but a validated stratification risk is lacking. Reduced compliance and detrusor overactivity lead to high filling pressures and raised detrusor leak point pressure, playing urodynamic studies a crucial role in risk assessment, though further research is needed for different neurogenic populations. Congenital conditions such as spina bifida, posterior urethral valves, and bladder exstrophy also contribute to a high-risk bladder through fibrosis and reduced compliance. Inflammation and ischemia are key factors, with inflammation leading to fibrosis and impaired bladder storage and voiding function. Novel treatments, including sGC activators, PDE5 inhibitors, and regenerative therapies like stem cell injections and extracorporeal shock wave treatment, show promise in mitigating fibrosis and improving bladder compliance.

CONCLUSIONS

Identifying and validating clinical risk stratification models, precise biomarkers and therapeutic windows remains essential for effective management and reversal of bladder fibrosis and dysfunction.

Influence in the outcome of neuropathic pediatric patients after early treatment

BACKGROUND

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

AIM

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

PATIENTS AND METHOD

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

RESULTS

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

CONCLUSIONS

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

Need for botulinum toxin injection and bladder augmentation after isolated bladder outlet procedure in pediatric patients with myelomeningocele

INTRODUCTION

In patients with neurogenic bladder outlet incompetence, a bladder outlet procedure (BOP) may be required to achieve urinary continence. However, when performed in isolation, a BOP can be associated with bladder deterioration and upper-tract injury. In the event of bladder deterioration, additional procedures such as bladder augmentation (BA) or botulinum toxin injection (BTI) may be pursued.

OBJECTIVE

The aim of this study was to assess long-term outcomes after isolated BOP in a pediatric myelomeningocele (MMC) population, including the need for additional surgical intervention in the form of BTI or BA.

MATERIALS AND METHODS

A retrospective cohort study was performed for patients with MMC who underwent an isolated BOP between 2004 and 2017. Primary outcomes included the need for postoperative BTI or BA. Secondary outcomes included the association between preoperative urodynamic parameters and need for BTI or BA.

RESULTS

BTI or BA was performed in 18 of 36 (50%) patients at a median of 17.8 months (IQR 11.2-29.3) after an isolated BOP. A median of 1 (IQR 1-3) BTI was performed in 11 (30.6%) patients. BA was performed in 9 (25%) patients, including 2 patients who previously underwent BTI. Patients who did not undergo BTI or BA after BOP had a slightly increased percentage estimated bladder capacity at the end of follow-up (107% versus 95%, p=0.42). By contrast, patients who underwent BTI or BA had a post-BOP percentage estimated bladder capacity that decreased from 112 to 70% (p < 0.001), increased maximum detrusor leak point pressure from 43 to 67 cm H₂O (p = 0.01), and higher rate of de novo upper-tract changes. Unfortunately, no preoperative clinical, radiographic, or urodynamic factors predicted the need for BTI or BA.

DISCUSSION

On time-to-event analysis, the risk of BTI or BA was 53% at 5 years in our cohort. Risk of these procedures was highest in the first two years after BOP. 9 of 11 (82%) patients who underwent BTI had improvement in bladder dynamics and BA was not pursued. These findings suggest that BTI provides a less-morbid alternative to BA in patients with MMC and de novo adverse bladder storage changes after an isolated BOP.

CONCLUSION

The need for BTI or BA after an isolated BOP is significant in patients with MMC. BTI offers a less-invasive alternative to BA in this population.

Mini-invasive collagen sling in the treatment of urinary incontinence due to sphincteric incompetence

OBJECTIVE

To assess the technical feasibility of mini-invasive sling procedure and present preliminary results in the treatment of urinary incontinence due to sphincteric insufficiency.

MATERIALS AND METHODS

Thirteen patients (6 males, 7 females, 8 with myelomeningocele, 1 with tethered spinal cord, 3 with bladder exstrophy, 1 with epispadias) underwent sling procedure with porcine dermis acellular collagen matrix (Pelvilace, Bard medical, UK). The median age was 15.5 (range 8.9-27.5) years. A suprapubic catheter was inserted for the measurement of leak point pressure during the operation. In females vaginal and in males perineal incision was used for sling insertion. The sling was introduced under cystoscopic control. The sling was not fixed with sutures. The outcomes were reviewed at 1, 6 and 12 month after the operation.

RESULTS

The median leak point pressure increased from 21.5 (range 5-25) cm H2O to 85 (range 70-100) cm H2O. At 1 month 8 and at 6 months 3 out of 13 patients were dry. At 12 months, none out of 11 patients was completely dry. However, at 12 months some improvement in incontinence was detected in 9 out of 11 patients. Two patients had primary failures. One patient got sling erosion to urethra after a tightening attempt. In one patient detrusor overactivity increased after the sling procedure.

CONCLUSIONS

Pelvilace sling is safe and easy to introduce in both males and females if pelvic floor anatomy is normal. Although immediate results were promising in neuropathic incontinence, the results seem to deteriorate to unacceptable low level already during the first year. In exstrophy patients the results are generally poor.