Natural Fill Urodynamics and Conventional Cystometrogram in Infants With Neurogenic Bladder

A Y-shape connection device for pediatric patients with an indwelling catheter (Dia = 8Fr) during urodynamic studies, especially for filling phase measurements: a single-center prospective study for safety and effectiveness

Introduction

This prospective study aimed to assess the effectiveness of a Y-shape connection device in reducing pain and bleeding in pediatric patients with indwelling catheters during urodynamic studies (UDS), while also obtaining effective results in the filling phase.

Methods

A total of 45 pediatric patients with a mean age of 13 years were included, all of whom underwent both a UDS with the Y-shape connection device (Method A) and a standard UDS procedure (Method B).

Results

The Y-shape connection device demonstrated similar overall urodynamic parameters compared to the standard procedure, while also resulting in significantly less bleeding (P = 0.006) and lower VAS scores during (1.12 ± 0.58 vs. 3.88 ± 1.01, P = 0.001) and after (0.12 ± 0.08 vs 2.91 ± 0.89, P = 0.001) the procedure. No adverse events were reported at the 1-month follow-up.

Discussion

These findings suggest that the Y-shape connection device can effectively reduce pain and bleeding during and after UDS in pediatric patients with indwelling catheters (Dia = 8Fr), while also obtaining effective results in the filling phase. Therefore, this Y-shape connection device has a more significant value for children who require urodynamic studies and place more emphasis on filling phase parameters.

Clinical trial registration

ChiCTR2300068280.

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.

What is the utility of urodynamics, including ambulatory, and 24 h monitoring, in predicting upper urinary tract damage in neuro-urological patients and other lower urinary tract dysfunction? ICI-RS 2017

AIMS

This article focuses on how, and if, urodynamics can help to identify which kidneys are in danger of deteriorating in function and also gives recommendations for future research.

METHODS

At the International Consultation on Incontinence-Research Society (ICI-RS) in 2017, a multi-disciplinary group presented a literature search of what is known about the utility of Urodynamics, including ambulatory, and 24 h monitoring, in predicting upper urinary tract damage in neuro-urological patients and other lower urinary tract dysfunctions. Wider discussions regarding knowledge gaps, and ideas for future research ensued and are presented in this paper along with a review of the evidence.

RESULTS

The current treatment strategy both in congenital and acquired neurogenic bladder is rather aggressive and successful when addressing hazards to kidney function. This article has highlighted uncertainties concerning the use of 40 cmH2O DLPP and even the lower value of 20. The current literature suggests that patients with spina bifida and those with spinal cord injury have a higher risk of developing upper urinary tract damage and kidney function impairment than those with multiple sclerosis.

CONCLUSIONS

Future research should focus on less invasive methods to assess the risk to the upper and lower urinary tract such as urine and serum measurements of cytokines that are involved in the pathophysiology of urinary tract impairment.

Urodynamic studies in spinal cord tethering

INTRODUCTION

Tethered cord syndrome (TCS) is of particular interest to urologists through its effects on the function of the lower urinary tract. Tethering of the spinal cord can result in bladder dysfunction with multiple manifestations, clinically raging from urinary retention and detrusor under-activity to urinary incontinence, over-activity of the detrusor, and sphincter dysfunction. Goals of management include protecting renal function and preserving patient quality of life.

METHODS

Evaluation of a TCS patient with urinary complaints begins with a thorough history and physical examination. Further characterization of urinary symptoms with a voiding diary provides vital information that helps to direct treatment while engaging the patient and family in the treatment plan. Urodynamic studies then provide key diagnostic data regarding bladder function, bladder outlet resistance, and urinary sphincter function. In the pediatric population, particular care must be paid to counseling patients and their families prior to the procedure to alleviate the often-considerable anxiety associated with an invasive procedure.

CONCLUSION

The armamentarium for management of neurogenic bladder associated with TCS includes behavioral training, biofeedback therapy, medications, patient-performed procedures, and surgical intervention. The choice of intervention depends on the patient's symptoms, urodynamic findings, and patient and family preferences. The primary problem of TCS should be addressed first through detethering, and then the urological team can use progressively more aggressive therapies as necessary. Interpretation and treatment by a dedicated, specialized, multidisciplinary team that includes the pediatric urologist, pediatric neurosurgeon and dedicated nurse practitioner, is critical for successful treatment.

Availability of a newly devised ambulatory urodynamics monitoring system based on personal device assistance in patients with spinal cord injury

Conventional urodynamics systems have been widely used for the assessment of bladder functions. However, they have some drawbacks due to the unfamiliar circumstances for the patient, restrictive position during the test, expense and immovability of the instrument as well as the unphysiological filling of the bladder. To mitigate these problems, we developed a fully ambulatory urodynamics monitoring system, which enables the abdominal pressure to be measured in a non-invasive manner, as well as the manual recording of various events such as the bladder sensations or leakage of urine. Conventional (CMG) and furosemide-stimulated filling cystometry (FCMG) were performed for 28 patients with neurogenic bladders caused by spinal cord injury (24 males and 4 females, age: 49.4 ± 13.9 years, BMI: 23.5 ± 2.4). There were high correlation coefficients (r=0.97 ± 0.02) between the clinical parameters measured by the conventional rectal catheter and those measured by our non-invasive algorithm in the FCMG studies. Also, 10 of the patients (36%) were diagnosed as having different reflexibility of the bladder between conventional CMG and FCMG (p<0.05). In the patients with detrusor overactivity, the average volume and detrusor pressure at bladder sensation in FCMG were lower than those in CMG, while the average compliance was higher (p<0.05). In the patients with areflexic bladders, the number of patients with detrusor overactivity was higher in FCMG and leakage was observed more frequently. These results showed that our system could be a useful additional tool in the clinical assessment of patients in which conventional cystometry failed to explain their symptoms.