New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

Results of a defined surgical protocol for treating pediatric neurogenic bladder incontinence in a single institution

INTRODUCTION

Incontinent pediatric neurogenic bladder (NB) patients face social ostracization and potential renal deterioration. Reconstructive surgery, after maximal medical therapy, requires a difficult decision-making process. Current literature for NB surgeries is difficult to interpret given definitions of dryness, use of augmentation cystoplasty (AC) and the lack of renal preservation. This study assesses the results of a defined surgical protocol to treat incontinent NB patients, using a new composite outcome measure, which includes upper tracts status and a definition of dryness.

MATERIALS AND METHODS

This is a retrospective cohort study assessing 33 consecutive incontinent NB patients (Spina bifida 31, Sacral agenesis- 2) who underwent one of 2 procedures between 2008 and 2021. AC with a Mitrofanoff procedure (MP) was performed in patients who had a high detrusor leak point pressure (DLPP) and significant bladder trabeculations (N = 21, Group 1). Children with a low DLPP and non-trabeculated bladders, underwent a modified Young-Dees-Leadbetter/Mitchell procedure with a 360° autologous rectus fascial sling (BOP) with concomitant AC and MP (N-12, Group 2). Post-operative success was defined using a composite grading of success assessing dryness, upper tract stability and medication use.

RESULTS

The mean age at surgery was 11.6 years (SD = 6 years), with 21 in Group 1 and 12 in Group 2. Mean follow-up was 3.25 years, with a minimum 24-month follow-up period. Success rate was 90% in Group 1 and 66% in Group 2. No patient had upper tract deterioration following surgery. Redo-surgical intervention, was required in 38% of Group 1 and 50% of Group 2 patients. These include 3 bladder neck injections in Group 1 and 2 bladder neck closure in Group 2, with a final success rate to 95 % in Group 1 and 83 % in Group 2.

DISCUSSION

Achieving dryness and preserving upper tracts is a challenge in incontinent NB patients. Dryness rates achieved in this study is comparable, given complications and redo-surgery. Primary bladder neck closure is a radical intervention, but Group 2 patients, may benefit from an upfront discussion of the pros and cons of a bladder neck closure primarily or as a secondary procedure.

CONCLUSIONS

Isolated AC obtains acceptable results for a selected subset of incontinent NB patients with significant bladder trabeculation. For those requiring a BOP, the success rate is relatively lower with the higher rate of potential complications and need for redo-surgery.

Recent Advances in Urinary Tract Reconstruction for Neuropathic Bladder in Children

Neuropathic bladder usually causes several limitations to patients’ quality of life, including urinary incontinence, recurrent urinary tract infections, and upper urinary tract damage. Its management has significantly changed over the last few years. The aim of our paper is to address some salient features of recent literature dealing with reconstructive procedures in pediatric and adolescent patients with lower urinary tract dysfunction.

Clinical indications for augmentation in children with neurogenic urinary incontinence following bladder outlet procedures: Results of a 14-year observational study

PURPOSE

We report continence, upper tract changes, and augmentation indications and rates in consecutive patients undergoing bladder outlet surgery without augmentation for neurogenic urinary incontinence.

METHODS

From 2000 to 2007, 37 patients underwent bladder neck sling (BNS), and from 2007 to 2013, 45 patients had Leadbetter/Mitchell bladder neck revision plus sling (LMS), all without augmentation. Mitrofanoff channels were created in all cases. Twenty children with persistent outlet insufficiency underwent bladder neck closure (BNC). All patients had pre- and postoperative urodynamic testing (UD).

RESULTS

Mean follow-up was 60 months after BNS, 38 months after LMS, and 29 months after BNC. Continence (dry, no pads) was achieved significantly more often with LMS versus BNS (66% vs. 37%). There were no significant differences between these patients in preoperative UD % capacity, end filling pressure (EFP), or compliance. Those that became dry had a greater % capacity on postoperative UD, but postoperative EFP was similar between dry and wet LMS and BNS patients. BNC resulted in dryness in 65% of patients, with most incontinence occurring from the Mitrofanoff stoma associated with filling pressures > 40 cm. A total of 10 (12%) children had augmentation, seven after BNC. Clinical indications were end filling pressures > 40 cm plus hydronephrosis ≥ grade 3, and/or persistent incontinence. Need for augmentation was not predicted by preoperative urodynamic parameters. Postoperative UD in those who were augmented showed significantly less % capacity and compliance, and significantly greater EFP, than those not augmented.

CONCLUSIONS

Dryness was achieved in only 33% of BNS versus 66% of LMS and BNC patients. Twelve percent of consecutive children undergoing bladder outlet surgery for neurogenic incontinence developed clinical parameters leading to augmentation. These occurred most often after BNC.