Urological manifestations of sacral agenesis

Determination of voiding pressure in infants with normal lower urinary tracts: Exploring the possible effect of sacral development

OBJECTIVE

To investigate the association between sacral underdevelopment, as defined by subnormal sacral ratio (SR) measurements, with increased maximum detrusor voiding pressure (P det. Max) in infants.

METHODS

In this 2007-2015 retrospective cohort study, the medical records of all infants who underwent a pyeloplasty due to congenital ureteropelvic junction obstruction were added. Their P det. Max was evaluated through the suprapubic catheter utilized for urinary drainage intraoperatively, without imposing any additional risk of urethral catheterization on the infant. SR was calculated via the plain kidney, ureter, and bladder (KUB) radiography film obtained during the voiding cystourethrogram (VCUG) evaluation before the surgery. Participants were categorized into SR < 0.74 or SR ≥ 0.74. P det. Max was subsequently compared between these two groups.

RESULTS

A total of 45 patients were included in our analysis. Twenty-eight (62.2%) patients had a (SR < 0.74), while 17 (37.8%) had a (SR ≥ 0.74). P det. Max was shown to be significantly higher in the SR < 0.74 compared to the SR ≥ 0.74 group (167.5 ± 60.8 vs. 55.7 ± 17.9 cmH2O, p < 0.001). After adjusting for age and sex, SR remained a significant contributor to P det. Max (p < 0.001). Physiologic detrusor sphincter dyscoordination (PDSD) rate was significantly higher in the SR < 0.74 versus SR ≥ 0.74 group (100.0% vs. 70.6%, respectively; p = 0.005).

CONCLUSION

Lumbosacral underdevelopment, as indicated by subnormal sacral ratios, is associated with sphincter-detrusor dyscoordination, which causes PDSD and can ultimately result in higher P det. Max in infants.

Long-term outcomes in sacral agenesis

INTRODUCTION

Sacral agenesis (SA) includes a range of clinical presentations of varying severity, with implications for function and quality of life (QoL). Diagnosis is often made perinatally, and prognostic discussions become an important aspect of parental counselling. This study engaged SA sufferers and their caregivers to obtain objective, long-term patient reported outcome data.

METHOD

Patients with radiologically confirmed SA from a single tertiary spinal unit underwent retrospective medical record review. Patients were then contacted by telephone to complete QoL questionnaires including EQ-ED-5L for adults and EQ-ED-Y for < 16-year-olds. Additional information including Renshaw grade, employment, living situation and bladder function was also collected.

RESULTS

Twenty-six patients with SA were identified. Mean age is 23.35 years (range 0.92-63.53), 13 M:17F. Renshaw grade ranged from 1 to 4. Sixty-eight percent had associated kyphoscoliotic deformities. The majority (70%) had either impaired or absent bladder control, and 80% need walking aids to mobilise. Twenty patients completed the questionnaire (10 adults and 10 < 16-year-olds). Mean EQ-ED-5L index for adults was +0.474 (range -0.1 to +0.089, 1 = best), with a lower mean value of +0.287 (range -0.54 to +1) for the < 16-year cohort. Those undergoing spinal fusion procedures had significantly lower scores (-0.08 v +0.44, p = 0.022).

CONCLUSION

This study provides an objective record of the QoL of individuals with SA, illustrating a wide variety of outcomes, with differences between younger and older individuals which may reflect the results of a long-term adaptive process. The implications for individuals should be carefully tailored to the specific deformity and the likely underlying neurological deficits.

A Case Report of a Colorectal and Caudal Duplication Syndrome Associated with Caudal Regression Syndrome

We describe an uncommon clinical presentation of caudal duplication syndrome and features of caudal regression syndrome in a female infant with complex urogenital and colorectal duplication associated with lipomyleomeningocele and left lower limb hypoplasia. A staged surgical treatment plan was carried out to maintain fecal and urine continence, potential fertility, and cosmetic appearance.

Descriptive and risk factor analysis of nonsyndromic sacral agenesis: National Birth Defects Prevention Study, 1997-2011

Sacral agenesis is a rare birth defect characterized by partial or complete absence of the sacrum. We sought to (a) describe case characteristics, (b) estimate birth prevalence, and (c) identify risk factors for nonsyndromic sacral agenesis using data from the National Birth Defects Prevention Study (NBDPS). The NBDPS was a population-based, case-control study involving pregnancies with estimated dates of delivery from October 1997 through December 2011. We estimated birth prevalence using all NBDPS eligible cases. Using self-reported maternal exposure information, we conducted multivariable logistic regression analysis to identify potential risk factors overall and among women without diabetes. The birth prevalence of sacral agenesis was 2.6/100,000 live births. In the multivariable analysis, multifetal pregnancy, pre-existing Type 1 diabetes, and pre-existing Type 2 diabetes were positively and significantly associated with sacral agenesis, albeit estimates were imprecise. Preexisting Type 1 diabetes was the strongest risk factor (adjusted odds ratio = 96.6, 95% confidence interval = 43.5-214.7). Among women without diabetes, periconceptional smoking was positively and significantly associated with sacral agenesis. Our findings underscore the importance of smoking cessation programs among women planning pregnancy and the importance of better understanding the role of glycemic control before and during pregnancy when designing interventions for primary prevention of sacral agenesis.

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.

Sacral agenesis combined with spinopelvic dissociation: A case report and literature review

INTRODUCTION

Sacral agenesis is a rare congenital disease with radiologic manifestation of sacrum deformity. Its clinical manifestations include spinopelvic instability due to sacroiliac joint deformity, spinal rotation, scoliosis, difficulties in walking, and claudication. Surgical intervention aims to prevent further deformity progression and to improve the patients' walking function. It is challenging to achieve solid arthrodesis for this congenital disease, and fusion failure could aggravate deformity.

CASE PRESENTATION

We retrospectively studied one case of a 12-year-old girl with sacral agenesis combined with spinopelvic dissociation and spinal scoliosis. She was presented with intermittent lumbosacral pain and worsening walking instability. We reconstructed the posterior pelvic ring through 1 iliac screw implanted in the bilateral posterior superior iliac spine, and the preflexed connecting rod was tightly locked with bilateral screws through the opening at the right spinal process of S2. With this method, bilateral ilia and sacrum were integrated and hemipelvic floating could be corrected. Bone fusion was achieved between the bilateral ilia and the sacrum.

CONCLUSION

Ilium-sacrum-ilium internal fixation and fusion for treating sacral agenesis combined with spinopelvic dissociation could achieve sacroiliac joint fusion. It is easy to perform and could cause little trauma while preserving the lumbar motion segment, which will provide new insight for treating sacral agenesis.

How to Explore Fetal Sacral Agenesis Without Open Dysraphism: Key Prenatal Imaging and Clinical Implications

The estimated prevalence of fetal caudal dysgenesis is 1 per 100,000 births. The functional prognosis of sacral agenesis is dominated by the large spectrum of associated caudal malformations. Except for cases associated with hydrocephalus secondary to open spinal dysraphism or chromosomal anomalies, association with mental deficiency is rare. We propose a systematic prenatal approach to cases of fetal sacral agenesis based on 9 etiologic items: clinical context, type of sacral dysgenesis, associated spinal cord malformations, mobility of lower limbs, investigation of the presacral region, analysis of the gastrointestinal tract, analysis of the genitourinary tract, associated vertebral defects, and cytogenetic analysis.

Symptomatic lower urinary tract dysfunction in sacral agenesis: Potentially high risk?

Introduction

Sacral agenesis (SA) is a caudal regression anomaly that can cause neurogenic bladder but is not generally recognized as high risk. We studied the clinical presentation, upper urinary tract, bone and spine abnormalities, and urodynamic findings in patients with SA and compared them with related high-risk conditions, anorectal malformation (ARM), and cloacal malformation.

Materials and Methods

Patient records between May 2011 and December 2015 were identified and grouped into isolated SA without an overt anomaly (Group I), SA with overt caudal regression anomalies (Group II), and ARM or cloacal malformation without the SA (Group III). Distribution of clinical and urodynamic findings and factors associated with reduced eGFR were tested with rank sum test, t-test, and unadjusted odds (P < 0.05 significant) using R statistical program (version 3.1.3).

Results

Of 605 neurogenic bladder patients treated in the study period, 39 fulfilled the inclusion criteria. 12 were Group I, 5 Group II, and 22 Group III. Long-standing lower urinary symptoms were noted in all SA patients. Group I patients were older (14.5 years vs. 6 years and 5 years for II and III). Patients with SA (Group I and II) had poor compliance (6.7 ml/cmH₂O, interquartile range [IQR] 4-13.6 ml/cmH₂O), reduced age-adjusted bladder capacity (59%, IQR 22-85%), elevated end-fill pressure (22 cmH₂O, IQR 11-28 cmH₂O), hydronephrosis (88%), and reduction in eGFR (29%), all comparable to Group III. Most had Renshaw type II SA and tethered spinal cord rather than wedge-shaped termination. Limitations include small numbers and significant selection bias.

Conclusions

Symptomatic neurogenic bladder due to SA may cause renal damage similar to ARM but often eludes diagnosis.

Congenital talipes equinovarus and congenital vertical talus secondary to sacral agenesis

Sacral agenesis is a rare congenital defect which is associated with foot deformities such as congenital talipes equinovarus (CTEV) and less commonly congenital vertical talus (CVT). We report a 3-year-old Caucasian girl who was born with right CTEV and left CVT secondary to sacral agenesis. Her right foot was managed with a Ponseti casting method at 2 weeks, followed by an Achilles tenotomy at 4 months. The left foot was initially managed with a nocturnal dorsi-flexion splint. Both feet remained resistant and received open foot surgery at 10 months producing plantigrade feet with neutral hindfeet. At 19 months, she failed to achieve developmental milestones and examinations revealed abnormal lower limb reflexes. A full body MRI was performed which identified the sacral agenesis. We advocate early MRI of the spine to screen for spinal defects when presented with resistant foot deformities, especially when bilateral.

Bilateral vascularized rib grafts to promote spinopelvic fixation in patients with sacral agenesis and spinopelvic dissociation: a new surgical technique

BACKGROUND CONTEXT

Sacral agenesis is a rare congenital disorder that may have spinopelvic instability due to sacroiliac joint malformation. Surgical indication in patients with sacral agenesis is to improve their sitting balance and protect the visceral organs. Achieving solid arthrodesis across this congenital malformation is challenging and prone to non-union.

PURPOSE

The purpose of this study was to describe a novel surgical technique with vascularized ribs for management of sacral agenesis and complex spinopelvic dissociation.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Six patients with sacral agenesis were reviewed and followed for a mean of 8.5 years after spinopelvic fusion augmented with vascularized rib graft spanning the lumbo-pelvic junction.

OUTCOME MEASURES

The primary outcome measure was the presence or absence of a stable spinopelvic junction and fusion across the spine-vascular rib grafts-pelvis interface. The secondary outcome measures were maintenance of pelvic obliquity, lumbosacral kyphosis, and overall sagittal balance.

METHODS

The surgical procedure consisted of two-stage surgeries performed 6-12 weeks apart. The first stage consisted of spinal instrumentation and correction of the deformity via a posterior approach and impaction of one of the vascularized ribs from the spine to the iliac crest. The second stage consisted of an anterior thoraco-lumbar approach for spinal fusion and the second vascularized rib spanning the spine to the iliac crest.

RESULTS

All six patients eventually achieved a solid spinal and spinopelvic fusion. All vascularized ribs increased in diameter over time. A high complication rate consisted mainly of spinal infections and prominent hardware requiring revision surgeries (a total of seven procedures in four patients). Two patients had decreased mobility secondary to spinopelvic surgery at last follow-up.

CONCLUSIONS

Spinopelvic fusion can be successfully achieved with this novel surgical technique using vascularized rib grafts. This technique allows for biological long-term maintenance of the sagittal deformity correction. Fusion across the lumbosacral junction in patients with sacral agenesis may place them at risk of losing the ability to mobilize independently. Recent lower profile implants have prevented implant-related complications.

Correlation between sacral ratio and primary enuresis

BACKGROUND

Enuresis is defined as the repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 yr of age and has a high prevalence in school aged children. In primary enuresis (PE) children have never gained control over urination or has been dry for<6months. While in secondary enuresis children have developed incontinence after a period of at least 6 months of urinary control.

OBJECTIVES

The aim of this study was to investigate a possible relation between PE and sacral ratio (SR) in 5-9 aged children.

PATIENTS AND METHODS

118 children with aged 5-9 year were enrolled in this case-control study. All them were divided into two aliquots groups of 59 patients. The case study (children with PE) and the control (children without PE) groups were matched in age and sex. SR based on antero-posterior plain radiograms of pelvis was calculated. Results were then analyzed using Chi square and student t-test as appropriate.

RESULTS

There were no significant differences between the two groups regarding age and gender. Mean SR in case and control group was 0.89 and 0.90, respectively. Moreover, there was no significant difference between the two groups (p=0.82). Only 1 child (1.6%) in case group showed abnormal SR while this was 7 children (11.9%) in the control group.

CONCLUSIONS

This study showed that, there was no significant difference between children with PE and those without PE in terms of SR. However, multicenter and larger sample size is recommended for definite decision of this finding.