A Mini-Invasive Approach to Severe Neurogenic Bladder as an Alternative to Diversion and Augmentation with Reimplantation in Selected Children

Abstract

Purpose In the past years we demonstrated as combined endoscopic injection of botulinum toxin type A (BTXA) and dextranomer/hyaluronic acid (DHA) could be effective in the management of vesicoureteral reflux (VUR) in neurogenic bladder dysfunction (NBD) not responding to clean intermittent catheterization (CIC) and anticholinergics. When patients or caregivers are unable to catheterize native urethra other options must be considered. We present our preliminary experience in the treatment of VUR and NBD in children, unabled to perform CIC, using a new combined mini-invasive approach. Material and Methods 3 patients with NBD and VUR enabled to perform CIC, aged from 5 to13 yrs (mean 8.5) were treated, after ethical and scientific committee approval, and written consent obtained. All patients presented severe urinary tract infections (UTI) and VUR was present in all renal units. VUR and NBD were evaluated with videourodynamics, pre and post-op. First suburetheral injection of DHA (0.5-1 ml/side) and bladder BTXA injections (10 IU/Kg, max 300 IU) were performed and then percutaneous cistostomy (Mic-Key gastrostomy) button was inserted according to original Subramaniam's technique, under endoscopic control. Results The mean operative time was 40 minutes.No complications were reported either intraoperative either at the follow-up (mean 5.5 months).UTI was solved in all, as well as VUR, but in one unit, where VUR decreased only (5° to 3°).All buttons are functioning and in situ. Buttons were changed every 3 months,and bladder drainage was found easy to perform in all.Urodynamics data (capacity, leak point pressure)improved in all. Conclusions Today the management of NBD is mainly conservative, but in selected cases surgery is required. However surgical procedure is not always related to an improvement of quality of life. For this reason button cistostomy endoscopic insertion associated to endoscopic treatment of VUR and NBD could be a valid alternative to derivation, augmentation and reimplantation in the short and medium- term period, in selected children.