Surgical management of the neurogenic bladder and bowel

Real world treatment patterns in the neurogenic bladder population: a systematic literature review

Myriad treatment modalities are available for neurogenic bladder (NGB) including behavioral therapies, oral pharmacotherapy, catheterization and surgical procedures. Little is known about how NGB patients are managed in the real world, how well patterns relate to clinical guidelines and how strategies may have changed over time. To address this gap, a systematic review (SR) was conducted using MEDLINE and EMBASE [1996–2017]. The inclusion criteria for studies were: (I) published in English; (II) conducted in human subjects; (III) reporting the treatment patterns/use in NGB; (IV) conducted in a real world setting. A narrative synthesis of results was conducted, comparing the results to current treatment guidelines. Percentage of treatment use was summarized using ranges. Eight studies met the inclusion criteria. Although most studies focused on spinal cord injuries (SCI), study designs and settings were heterogeneous. All data was collected before 2007. The most popular form of oral pharmacotherapy was antimuscarinics, used by 12.6–86.7% of patients; 0–100% of patients used catheterization techniques, 2.5–53.1% used reflex voiding (RV), and 0.2–55% underwent surgery. A notable amount of patients switched treatments. This SR revealed that numerous strategies have been used to manage NGB throughout the years and there has been a large variance in their use. Whilst there were some discrepancies, most practices matched recommendations made in current guidelines. Ultimately, this SR showed that there is a large gap of epidemiological studies conducted in the field of NGB and the authors felt that available data was insufficient to build a comprehensive picture of treatment patterns. Epidemiological studies using electronic medical records (EMRs) are necessary to advance our understanding of how treatment patterns have changed, and also build a comprehensive picture of how patients are managed in current practice.

Vesico-cutaneous fistula: a simple method for continent urinary diversion

INTRODUCTION

Patients with lower urinary tract anomalies or neurogenic disorders often suffer from voiding difficulties. Clean intermittent catheterization (CIC) is effective for bladder drainage; however, this is often painful. Transurethral catheterization is also impossible in patients with urethral stricture. A Mitrofanoff conduit may solve some of these problems, but a few disadvantages have been reported, including: difficult surgical techniques and frequent operative complications. A vesicostomy is easy to perform but persistent urine leak over the abdomen and diaper rash can be annoying. A better way to achieve continent urinary diversion is indicated.

METHOD

Between December 01 1998 and December 31 2013, six patients underwent a vesico-cutaneous fistula for CIC. The etiologies included urethral stricture (n=2) and neurogenic bladder (n=4). The fistula was created at the bladder dome with only the muscle layer of the bladder sutured to the skin. A Foley catheter was left in place for at least two weeks to prevent stoma stricture. After removing the Foley catheter, regular CIC from the fistula was performed every 2 h during the daytime with a Fr. 10-12 feeding tube, depending on the patient's age. Further stenting during the night in the first six months was necessary to prevent early closure of the fistula. Patients were followed with periodic renal ultrasonography, blood tests and urinalysis in the outpatient department.

RESULTS

Follow-up ranged from 6 months to 16 years. All patients showed improvements in hydronephrosis. Decreased UTI frequency was seen in five patients. Renal function was normal in five patients, whilst the other suffered from chronic renal failure preoperatively. Only one patient had occasional mild urine leakage from the stoma at night, which was once in two weeks. No patient experienced painful or difficult catheterization and CIC becomes easy, even by young children.

CONCLUSIONS

The vesico-cutaneous fistula is a simple, effective and tolerable method for CIC. It may be a substitute for or a transition to a Mitrofanoff conduit in some patients.

Development, reliability and validation of a neurogenic bowel dysfunction score in pediatric patients with spina bifida

OBJECTIVE

To develop a reliable and valid questionnaire to monitor neurogenic bowel symptoms in children.

PATIENTS

Thirty-four children aged 6-18 with neurogenic bowel and their caregivers. Eighteen control patients.

METHODS

An expert panel generated a domain of observables and formative/reflective content. Response options were scaled following Likert-type items. Key informant interviews revised the measures. A final questionnaire was given to patients twice to calculate intra-rater reliability using Cohen's Kappa Coefficient (k) and paired t-test. Blinded interviews were conducted after physical examination and health assessment and questionnaires completed by a nurse to determine construct validity and inter-rater reliability using k and Spearman's rank-order correlation. Control patients completed the questionnaire once, their results were used to determine discriminate validity and a receiver operating characteristic (ROC) curve.

RESULTS

Intra-rater reliability showed 85% of the questionnaires having k >0.6. Paired t-test results of t(33) = 1.997, P = 0.054, d = 0.53, confirmed there was not a significant difference between the scores of the two completed questionnaires. Inter-rater reliability showed 97% of the questionnaires having k >0.6 between the nurse and the patient/caregiver responses. Scores had a strong positive correlation at rs (32) = 0.943, P < 0.0005. Mean score with neurogenic bowel was 15.18(STD ±  5.77) and control group 4.68(STD ± 2.98). ROC analysis showed an area under the curve of 0.9. A score of 8.5 correlated with presence of neurogenic bowel with sensitivity of 94% and specificity of 87%.

CONCLUSION

The questionnaire shows positive reliability and validity when used for pediatric neurogenic bowel patients. The questionnaire differentiates between normal and neurogenic patients. Larger studies are necessary to conduct further validation.

Feasibility and outcome of clean intermittent catheterization for children with sensate urethra

OBJECTIVE

Clean intermittent catheterization (CIC) is an important asset in managing children with noncompliant bladders. We review the feasibility and late outcomes of patients with normal urethral sensation who began CIC.

MATERIALS AND METHODS

We reviewed all patients with posterior urethral valve (PUV) or non-neuropathic bladder sphincter dysfunction (NNBSD) who began on CIC, and had at least 2 years of follow-up. We considered their age, indication, acceptance and compliance with CIC. Additionally, we examined the late outcome of bladder function and the need for any surgical intervention at follow-up.

RESULTS

Between 1999 and 2006, 52 patients with PUV (38 patients) or NNBSD (14 patients) were started on CIC. Of these 52 patients, 48% were under the age of 4. A total of 44 patients (85%) accepted the recommendation for CIC, and 34 patients (65%) were compliant with the protocol after at least 2 years of follow-up. The age of the patients was the only significant factor related to the success of the protocol (4 years old or younger, p = 0.03). After at least 2 years of follow-up, 28 patients (54%) remained on CIC and have not required urinary diversion or bladder reconstruction.

CONCLUSION

The current study showed that CIC is a feasible option for patients with sensate urethra, which necessitates the introduction of treatment as early as possible. Further, those patients who are compliant with the CIC demonstrated a better chance of avoiding subsequent surgical intervention for the management of a non-compliant bladder.

Patients With Spina Bifida and Bladder Cancer: Atypical Presentation, Advanced Stage and Poor Survival

PURPOSE

Patients with neurogenic bladder dysfunction due to spina bifida have been reported to be at increased risk for bladder cancer. Recent publications suggest that bladder augmentation is also a significant risk factor. We reviewed our experience with treating patients with spina bifida and bladder cancer.

MATERIALS AND METHODS

Patients with spina bifida treated for bladder cancer between 1995 and 2005 were identified. Patient demographics, mode of bladder management, risk factors and presenting symptoms were recorded along with therapy, pathological findings and outcome. This patient cohort was combined with all prior known published studies for analysis.

RESULTS

Eight patients with a median age of 41 years were treated. Only 1 patient (13%) had undergone bladder augmentation. Locally advanced stage (T3 or greater) or lymph node metastases were present in 88% of cases. Median survival was 6 months with only 1 patient alive with no evidence of recurrence at 20 months. A total of 11 prior published cases were identified and combined with this series. Transitional cell carcinoma was present in 58% of patients. Median survival was 6 months. Only 37% of patients had undergone bladder augmentation.

CONCLUSIONS

Patients with spina bifida and bladder cancer present at a young age with variable tumor histology and advanced stage, and they have poor survival. Presenting symptoms are often atypical and bladder cancer should be a consideration in this patient population, even in young adults. Due to poor survival further study is warranted in this population to determine whether screening would be beneficial for earlier detection and improved outcomes.

Myelomeningocele: a review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals

Although the use of folic acid before conception decreases the chance that a fetus will have an open neural tube defect, this condition still affects 0.5-1.0/1000 pregnancies in the United States. Results of a recent survey suggest that there are gaps in obstetrician-gynecologists' knowledge of risk factors for conception, strategies for prenatal diagnosis, and prognosis for affected individuals. To address these gaps this paper reviews the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals, presents current information, and makes suggestions for expanding obstetrician-gynecologists' knowledge of myelomeningocele.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that despite a large amount of professional and public education on the use of folic acid in prevention of open neural tube defects (ONTDs) the incidence still affects 0.5-1.0/1000 pregnancies and recall that a recent survey conducted by the ACOG shows substantial misunderstanding and misinformation on major categories of neural tube birth defects.

Examining the newborn with an open spinal dysraphism

Spinal dysraphism includes a constellation of frequent and potentially complex malformations of the spine and spinal cord. Open spinal dysraphisms, the majority of which are myelomeningoceles, have a number of associated morbidities that require both immediate and lifelong medical care. The role of the neonatal nurse includes the immediate stabilization of the affected infant, systematic examination of the malformation, and implementation of evidence-based protocols to ameliorate the associated medical problems. Coordination of care and communication and support of the family are essential aspects of care. This article reviews the embryology of open spinal dysraphisms and the steps needed to stabilize and evaluate affected infants.