Congenital Neuropathic Bladder Research Articles

Artificial urinary sphincter in congenital neuropathic bladder: Very long-term outcomes.

Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter. A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected. An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra. The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients.

Complications of Pediatric Bladder Reconstruction in the Adult Patient

Bladder augmentation and associated reconstructive procedures are a surgical option for patients with urologic congenital anomalies and neuropathic bladder with the goal of improving continence and reducing the risk of upper tract deterioration. Despite these benefits, augmentation also portends several short- and long-term potential complications. The goal of this chapter is to discuss these complications and review the current literature on this topic. Metabolic abnormalities, including acid-base disorders and their sequelae, occur in 5–15% of patients with bladder augmentation and are typically seen within 5–10 years from intervention. Chronic bacteriuria and recurrent urinary tract infections often play a role in renal dysfunction and contribute to 70% of urinary tract stone disease. Bladder perforation is reported at rates between 3 and 13%, with associated mortality rates ranging from 1% to as high as 25%. Other more common surgical complications include catheterizable channel issues: stricture, false passage, stenosis, stomal prolapse, channel redundancy, and channel incontinence. Channel complications should be thought of as suprafascial vs. subfascial in order to help guide treatment options. Following augmentation cystoplasty, incidence of bladder cancer ranges from 0 to 5.5%; unfortunately, the vast majority present with locally advanced or node-positive disease. Therefore, yearly screening with cytology and cystoscopy is not recommended and symptom-based screening protocols have been proposed. Given the complexity and wide variety of complications possible after bladder augmentation, it is critical that these patients are closely followed into adulthood by a urologist, but also receive tailored multi-disciplinary care based on their specific medical and surgical needs.

PD11-06 DURABILITY OF REVISION SURGERY FOR STENOSIS OF CATHETERIZABLE CHANNELS IN ADULTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion II1 Apr 2015PD11-06 DURABILITY OF REVISION SURGERY FOR STENOSIS OF CATHETERIZABLE CHANNELS IN ADULTS Travis Pagliara, Daniel Liberman, Jeremy Myers, John Stoffel, and Sean Elliott Travis PagliaraTravis Pagliara More articles by this author , Daniel LibermanDaniel Liberman More articles by this author , Jeremy MyersJeremy Myers More articles by this author , John StoffelJohn Stoffel More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1095AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The incidence of stenosis of continent catheterizable channels varies by channel type (e.g. Mitrofanoff vs. Monti vs. tapered ileal limb) and patient factors. Up to 55% of channels will require intervention for stenosis; intervention is usually a dilation but for recurrent stenosis revision surgery may be required. We sought to describe the strategies of surgical revision for catheterizable channel stenosis and their outcomes. METHODS We retrospectively reviewed the charts of 74 adult patients who underwent catheterizable channel revision or replacement from 2000 to 2014 for stomal stenosis or difficult catheterization. The primary outcome was continued ability to catheterize the channel post-operatively without surgical dilation or revision. Secondary outcomes included channel continence and post-operative complications. Revisions were classified into the following strategies: revision above the rectus fascia, below the fascia, or channel replacement. RESULTS Revision approaches included 42% above the fascia, 30% below the fascia, and 28% channel replacement. Patients with congenital etiology of neurogenic bladder were more likely than other patients to undergo more complicated revisions (p=0.012). Channel patency was achieved in 65% at a median 34 months post-revision procedure; there was no difference by revision strategy (p=0.104). Severe stomal incontinence occurred in 3.2% after above the fascia repairs, 22.7% after below the fascia repairs and 14.3% after channel replacement (p=0.111). Surgical complications occurred in 28.4%; almost all were Clavien 1-2 and there was no difference by revision strategy (p=0.293). CONCLUSIONS Surgical revision for continent channel stenosis can be performed with good rates of durable patency. Patency rates are similar across surgical strategies of revision. Those with congenital neuropathic bladder require more complex revisions. Severe post-operative channel incontinence is not uncommon. We present our management algorithm based on length of stenosis, the amount of redundant channel available for reconstruction, and the presence or lack of a continence mechanism prior to intervention (Figure 1). © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e253 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Travis Pagliara More articles by this author Daniel Liberman More articles by this author Jeremy Myers More articles by this author John Stoffel More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cystatin C as a Marker of Early Renal Insufficiency in Children with Congenital Neuropathic Bladder

Due to decreased muscle mass in children with congenital neuropathic bladder there may be significant inaccuracy when using the creatinine based estimated glomerular filtration rate. Cystatin C is highly sensitive and specific for measuring changes in the glomerular filtration rate in children and in patients with muscle wasting conditions. We hypothesized that a cystatin C calculated glomerular filtration rate would be more sensitive than the standard creatinine based modified Schwartz equation to detect renal insufficiency in children with congenital neuropathic bladder. We prospectively identified children with congenital neuropathic bladder at a multidisciplinary spina bifida clinic who underwent serum creatinine and serum cystatin C testing. Clinical history and anthropomorphic variables at the time of laboratory testing were catalogued. The creatinine based glomerular filtration rate was estimated using the modified (bedside) Schwartz formula and the cystatin C based rate was calculated using the Zappitelli cystatin C formula. Dual estimated glomerular filtration rate calculation was done in 69 children at a total of 74 patient encounters. Absolute creatinine was within age range normal limits in each patient, including 1 with chronic kidney disease stage 3A. The median creatinine based estimated glomerular filtration rate was 123 ml per minute/1.73 m(2) (range 58 to 229). The median cystatin C based estimated rate was 103 ml per minute/1.73 m(2) (range 47 to 144) for an absolute median rate reduction of 15.4%. Using cystatin C estimates chronic kidney disease stage was upgraded from stage 1 to 2 in 13 patients (18.8%). In children with neuropathic bladder the cystatin C estimated glomerular filtration rate is a better screening test for early renal insufficiency that is not detected by creatinine based rate calculations. To our knowledge it remains to be determined whether the cystatin C estimated glomerular filtration rate can ultimately improve the clinical outcome in this population.

Single-center experience with botulinum toxin endoscopic detrusor injection for the treatment of congenital neuropathic bladder in children: Effect of dose adjustment, multiple injections, and avoidance of reconstructive procedures

ObjectiveSince 2007, intra-detrusor OnabotulinumtoxinA (OnabotA) injections have been selectively offered at our institution for cases in which maximal anticholinergic therapy failed or was not tolerated. Herein we present our experience with this approach. Materials and methodsWe prospectively obtained data on 17 patients who underwent OnabotA injections over a 4-year period. Demographic information, number of injections, and dose delivered were captured. Children were monitored with baseline and post-injection renal ultrasound, urodynamics, and assessed for side effects, satisfaction, and symptom improvement. ResultsForty-three sessions were performed with injections given every ∼6 months. Mean patient age was 10.7 years (range, 3–17). Compared with baseline, after the first injection, mean bladder capacity adjusted for age and compliance improved by 27% (p = 0.039) and 45.2% (p = 0.041), respectively. After subsequent injections, these values increased to 35.7% (p = 0.043) and 55.1% (p = 0.091), respectively. Out of 13 symptomatic patients, ≥ 50% improvement was reported in ten (76.9%) and complete resolution in seven (53.8%). However, all three patients in whom the maximum dose of OnabotA was reduced from 300 to 200 units complained of recurrent symptoms. Fourteen children avoided surgical reconstruction as a second line of treatment. Overall patient/parental reported satisfaction rate was 70.6% (12/17). ConclusionsIntra-detrusor OnabotA injection is a promising intervention for management of neuropathic bladder in selected patients. Our data demonstrate improvement in symptoms and urodynamic parameters. Although an optimal dose has not been determined for children, we found optimal response with a maximum administration of OnabotA up to 300 units.

Simultaneous Augmentation Cystoplasty and Cuff Only Artificial Urinary Sphincter in Children and Young Adults with Neurogenic Urinary Incontinence

We review our experience with artificial urinary sphincter and augmentation cystoplasty in patients with neurogenic bladder. This is the largest known series to specifically evaluate cuff only artificial urinary sphincter at augmentation cystoplasty. A total of 18 males underwent simultaneous artificial urinary sphincter and augmentation cystoplasty at our institution between 1982 and 2012, of whom 13 (72%) underwent cuff only artificial urinary sphincter. Outcomes included urinary continence, emptying modality, artificial urinary sphincter status, complications and additional procedures. Of the patients undergoing augmentation cystoplasty and cuff only artificial urinary sphincter 10 (77%) were initially continent. Average time of continence was 52.9 months. Four patients (31%) required no additional procedures and remained continent. Urinary incontinence developed in 3 patients (23%) immediately postoperatively and in 6 (46%) subsequently. Ultimately 9 patients (69%) required conversion to complete artificial urinary sphincter at a mean of 36.9 months postoperatively. Overall 12 patients (92%) were continent at followup. There were no artificial sphincter specific complications in patients undergoing the cuff only procedure with conversion to complete artificial urinary sphincter. After conversion to complete artificial urinary sphincter 3 patients (23%) experienced artificial sphincter specific complications. Reoperation was performed in 10 patients (77%), for 13 total procedures (1.3 per patient). There were no complications with cuff only artificial urinary sphincter and 6 complications with complete artificial urinary sphincter (p = 0.025). Finally, patients undergoing cuff only artificial urinary sphincter requiring revision were younger than those not requiring revision (15.6 vs 30.8 years, p = 0.026). Simultaneous cuff only artificial urinary sphincter and augmentation cystoplasty appears safe and efficacious in patients with neurogenic bladder, with fewer complications than complete artificial urinary sphincter, and may provide definitive urinary continence in up to a third of patients. This procedure is technically easy, allows for outpatient revision, provides time for the child to mature and may be cost effective in avoiding placement of additional components in this select patient population.

International children's continence society's recommendations for therapeutic intervention in congenital neuropathic bladder and bowel dysfunction in children

We present a consensus view of members of the International Children's Continence Society on the therapeutic intervention in congenital neuropatic bladder and bowel dysfunction in children. Discussions were held by a group of pediatric urologists and gastroenterologists appointed by the board. The following draft review document was open to all the ICCS members via the ICCS web site. Feedback was considered by the core authors and by agreement, amendments were made as necessary. The final document is not a systematic literature review. It includes relevant research when available as well as expert opinion on the current understanding of therapeutic intervention in congenital neuropatic bladder and bowel dysfunction in children. Guidelines on pharmalogical and surgical intervention are presented. First the multiple modalities for intervention that do not involve surgical reconstruction are summarized concerning pharmacological agents, medical devices, and neuromodulation. The non-surgical intervention is promoted before undertaking major surgery. Indicators for non-surgical treatments depend on issues related to intravesical pressure, upper urinary tract status, prevalence of urinary tract infections, and the degree of incontinence. The optimal age for treatment of incontinence is also addressed. This is followed by a survey of specific treatments such as anticholinergics, botulinum-A toxin, antibiotics, and catheters. Neuromodulation of the bladder via intravesical electrical stimulation, sacral nerve stimulation, transcutaneous stimulation, and biofeedback is scrutinized. Then follows surgical intervention, which should be tailored to each individual, based on careful consideration of urodynamic findings, medical history, age, and presence of other disability. Treatments mentioned are: urethral dilation, vesicostomy, bladder, augmentation, fascial sling, artificial urinary sphincters, and bladder neck reconstruction and are summarized with regards to success rates and complications. Finally, the treatment on neuropathic bowel dysfunction with rectal suppositories irrigation and transrectal stimulation are scrutinized.

International children's continence society's recommendations for initial diagnostic evaluation and follow‐up in congenital neuropathic bladder and bowel dysfunction in children

The objective of this ICCS standardization document is to report the initial diagnostic evaluation and subsequent work-up of children with neuropathic bladder dysfunction. Due to a paucity of level I or level II, "levels of evidence" publications, these recommendations are actually a compilation of best practices because they seem to be effective and reliable, although not with any control. Throughout the document, the emphasis is on promoting early, comprehensive evaluation of lower urinary tract function that is thorough but with a minimum of unnecessary testing. This includes what tests to order, when to order them and what to do with the results. Some of the recommendations may not be practical in various worldwide locations but the suggested testing should be considered the ideal approach to completely diagnosing and then promulgating treatments based on the full knowledge of the condition and its effect on urinary tract function. Once the findings are delineated, those lower urinary tract patterns of dysfunction that put the kidneys at risk for deterioration, that are barriers to attaining eventual continence, and that have long-term consequence to the lower urinary track can be obviated by specific management recommendations. The indications and timing of investigations to achieve these objectives are clearly defined in each diagnostic category and during follow-up. This document should be used as a basis for appropriate evaluation and timely surveillance of the various neuro-urologic conditions that affect children.

Analysis of the permanent renal injury risk factors in congenital neuropathic bladder

Analysis of the permanent renal injury risk factors in congenital neuropathic bladder

Artificial Urinary Sphincter: 11-Year Experience in Adolescents with Congenital Neuropathic Bladder

ObjectiveWe assess our experience over the last 11 years in the use of an artificial urinary sphincter (AUS) to treat urinary incontinence in children with neuropathic bladders. Materials and MethodsBetween 1994 and 2005 an AUS was implanted in 35 patients (mean age 14.4; range 11.5–18). Upper urinary tract (UUT) evaluations and urodynamic studies were performed in all patients pre- and post-AUS implantation. Thirteen patients underwent enterocystoplasty combined with AUS placement and 22 underwent AUS implantation alone. ResultsAn AUS was implanted in 35 patients. Mean follow-up is 5.5 years (range 0.4–11 years). Nine mechanical malfunctions occurred in seven patients (20%). Of the 22 patients who underwent AUS implantation alone, seven (31.2%) eventually required an enterocystoplasty because of unexpected bladder behaviour changes, usually within three years of AUS implantation. In seven patients (20%), a continent catheterisable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterisation (CIC) through the urethra. Three AUS (8.6%) were removed because of sphincter erosion at the bladder neck. All 32 patients (91.4%) with the AUS currently in place are dry, three void their bladders spontaneously, and 29 need CIC. ConclusionsAUS must be considered as an elective treatment in the surgical management of these patients because it produces better continence rates than other methods. However, these patients need long-term follow-up because their bladder behaviour may undergo unexpected clinically asymptomatic changes that could negatively affect their UUT and require bladder augmentation.

Autoaugmentation by Detrusor Myotomy: Its Lack of Effectiveness in the Management of Congenital Neuropathic Bladder

We present our long-term results in 17 patients with myelomeningocele undergoing autoaugmentation by vesicomyotomy. Surgery was performed from 1990 to 1994 on 17 patients with neurogenic bladder due to spinal dysraphism. Indications for autoaugmentation included upper tract deterioration and/or incontinence secondary to hypperreflexia, hypocompliance or low bladder volume. All patients had failed to respond to conservative medical and pharmacological treatments. Median patient age at surgery was 10.2 years (range 2.2 to 13.2). Outcomes were evaluated retrospectively according to changes in upper tract status, continence and urodynamic parameters. Median clinical and urodynamic followup is 75 months (range 4 to 126). Progressive hydronephrosis developed in 5 patients, which required subsequent enterocystoplasty in 4. Of 13 patients 8 (62%) remain incontinent. Of the 17 cases 12 (71%) were considered clinical failures on the basis of upper tract deterioration and/or ongoing incontinence. There were few clinically significant improvements in urodynamic parameters, as 14 of 15 cases (93%) were considered urodynamic failures on the basis of persistent hypocompliance and/or less than expected gains in safe bladder capacity with somatic growth. Although short-term reports of autoaugmentation have been promising, they do not appear durable. This procedure cannot be endorsed for the management of congenital neuropathic bladder.

Assessment and conservative management of the neuropathic bladder.

The etiologies and forms of congenital neuropathic bladder are described: contractile (25%), acontractile (15%), and intermediate (60%). The terminology relating to neuropathic bladder is defined and the principles of bladder management are highlighted: (1) must achieve a bladder that can fill at low pressure, (2) must achieve a bladder that can store urine at low pressure, (3) must achieve sphincter resistance that is sufficient to allow urine storage, and (4) must put in place a mechanism of achieving complete voluntary bladder emptying. The approach to investigation is set out in a logical sequence, and the methods of achieving the goals highlighted above are described. All of this is put in the context of managing the handicapped patient as a whole. It also is stressed that the aim is not just to achieve continence but perhaps even more importantly to protect renal function.

INITIAL EXPERIENCE WITH THE TRANSURETHRAL SELF-DETACHABLE BALLOON SYSTEM FOR URINARY INCONTINENCE IN PEDIATRIC PATIENTS

No AccessJournal of UrologyReconstruction1 Sep 2000INITIAL EXPERIENCE WITH THE TRANSURETHRAL SELF-DETACHABLE BALLOON SYSTEM FOR URINARY INCONTINENCE IN PEDIATRIC PATIENTS DAVID A. DIAMOND, STUART B. BAUER, ALAN B. RETIK, and ANTHONY ATALA DAVID A. DIAMONDDAVID A. DIAMOND More articles by this author , STUART B. BAUERSTUART B. BAUER More articles by this author , ALAN B. RETIKALAN B. RETIK More articles by this author , and ANTHONY ATALAANTHONY ATALA More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)67222-9AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: A new endoscopic technique to treat urinary incontinence in children using a self-detachable balloon device was studied. Materials and Methods: The study includes 11 patients with a mean age of 14.6 years and all of whom had intrinsic sphincter deficiency due to myelomeningocele in 9, spinal artery bleed in 1 and cloacal exstrophy in 1. All patients were on clean intermittent catheterization preoperatively and postoperatively. Endoscopic balloon treatment was performed on an outpatient basis. A mean of 5 balloons (range 2 to 8) were placed per patient. All patients underwent formal urodynamic study preoperatively and at 6 weeks and 6 months following balloon placement. Results: Of the 9 patients without prior bladder neck surgery 7 had improvement in urodynamic parameters, including urethral pressure profile in all 7 and functional bladder capacity in 6, 4 were markedly improved clinically and 2 were dry. Two patients with prior bladder neck surgery were clinically unchanged following balloon placement, although 1 had urodynamic improvement. Conclusions: Our initial experience with the transurethral self-detachable balloon system as a minimally invasive outpatient procedure to treat urinary incontinence in children has been encouraging. To date this procedure appears most applicable to the patient who has not undergone surgery and has a neurogenic etiology for urinary incontinence. References 1 : Exstrophy-epispadias complex in bladder anomalies. In: . Philadelphia: Saunders1998. Google Scholar 2 : Urethral lengthening with anterior bladder wall flap for urinary incontinence: a new approach. J Urol1994; 152: 803. Google Scholar 3 : Management of urinary incontinence by bladder tube urethral lengthening and submucosal implantation. J Urol1990; 144: 559. Link, Google Scholar 4 : Experience with the Kropp anti-incontinence procedure. J Urol1989; 141: 1160. Link, Google Scholar 5 : Use of the AS800 device in exstrophy and epispadias. J Urol1988; 140: 1202. Link, Google Scholar 6 : Detachable self-sealing membrane system for the endoscopic treatment of incontinence. J Urol1997; 158: 1045. Link, Google Scholar 7 : The long-term results of artificial sphincters in children. J Urol1991; 146: 396. Link, Google Scholar 8 : Polytetrafluoroethylene injection for urinary incontinence in children. J Urol1985; 133: 248. Link, Google Scholar 9 : Glutaraldehyde cross-linked bovine collagen in exstrophy/epispadias complex. J Urol1993; 150: 631. Link, Google Scholar 10 : Endoscopic treatment of vesico-ureteric reflux and urinary incontinence: technical problems in the paediatric patient. Br J Urol1995; 75: 538. Google Scholar 11 : Treatment of urinary incontinence in children by endoscopically directed bladder neck injection of collagen. J Urol1996; 156: 637. Link, Google Scholar 12 : Endoscopic treatment for urinary incontinence in children with a congenital neuropathic bladder. Br J Urol1998; 82: 694. Crossref, Medline, Google Scholar 13 : Failure to obtain durable results with collagen implantation in children with urinary incontinence. J Urol1997; 157: 2306. Link, Google Scholar 14 : Endoscopic treatment of urinary incontinence in children with primary epispadias. Br J Urol1998; 81: 309. Crossref, Medline, Google Scholar 15 : Migration and granulomatous reaction after periurethral injection of polytef (Teflon). JAMA1984; 251: 32. Google Scholar From the Department of Urology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts© 2000 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 164Issue 3 Part 2September 2000Page: 942-946 Advertisement Copyright & Permissions© 2000 by American Urological Association, Inc.Keywordsurethrapediatricsurinary incontinenceendoscopyMetricsAuthor Information DAVID A. DIAMOND More articles by this author STUART B. BAUER More articles by this author ALAN B. RETIK More articles by this author ANTHONY ATALA More articles by this author Expand All Advertisement PDF downloadLoading ...

Endoscopic treatment for urinary incontinence in children with a congenital neuropathic bladder.

To verify, in a retrospective analysis, the effectiveness of endoscopic treatment (collagen injection) in children with neurogenic bladder and neurogenic urinary incontinence. From January 1992 to March 1997, 36 endoscopic collagen injections were performed to treat neurogenic urinary incontinence in 23 patients (mean age 10.9 years, range 6-17 at the time of the first procedure) selected on the basis of clinical status and the patient's motivation. Nineteen patients were affected by myelomeningocele and four had an occult spinal dysraphism. All patients underwent a preoperative cystometric urodynamic evaluation (without urethral pressure measurement) which showed detrusor areflexia in 12, normal reflexia in one and hyper-reflexia in 10 patients. Bladder compliance was considered good (> or =20 cmH2O) in 13 patients and low (10-20 cmH2O) in 10, four of whom had detrusor areflexia. Twenty-one children emptied their bladder by intermittent clean catheterization. The mean (range) follow-up was 19.2 (6-54) months. Twenty (group A) and 16 (group B) procedures, performed early and late in the series, were analysed separately to determine any increase in effectiveness with surgical experience. The evaluation criteria were; the increase in the 'dry' interval (between catheterizations) before and after treatment/s (delta dry); the patient's and parent's satisfaction; the number of endoscopic procedures and quantity of injected materials. There was an improvement (dryness of at least 2 h: delta dry of 1 h) in 13 of 23 patients after 1-3 (mean 1.5) procedures; 10 patients had a 0.2 h increase in delta dry after 1-3 injections and none was satisfied. There was no difference in the delta dry (0.9 vs. 0.7 h) between groups A and B, and/or the patient's/parent's satisfaction. Success rates differed with urodynamic patterns; seven of 10 patients showing no improvement had hyper-reflexia and three of the remaining 12 with areflexia had hypocompliant bladders, while nine of the 13 showing improvement had an areflexic detrusor and low-pressure bladders. The efficacy of the treatment depends largely on the urodynamic selection of patients (mainly those with detrusor areflexia and good compliance). The outcome may be improved further by increasing the quantity of injected material and with a longer follow-up, performing the procedure again if advisable. A close postoperative clinical (pad test) and personal observation is necessary to evaluate the outcome and thus optimize the strategy of treatment.

Combined Reconstructive and Prosthetic Surgery In Complicated Lower Urinary Tract Dysfunction

The combined use of the appropriate reconstructive technique and available prosthetic material was evaluated to achieve an optimal functional result in complicated lower urinary tract dysfunction. The study included 16 male and 8 female patients. Urinary dysfunction was classified into 2 main categories: 1) neuropathic and 2) nonneuropathic. Of the patients 22 underwent some form of augmentation (21) or substitution (1) cystoplasty, 24 received an artificial urinary sphincter, 2 underwent abdominoperineal urethroplasty and 2 received a permanent urethral stent. One patient underwent renal transplantation and 1 received a penile prosthesis for concurrent impotence. A total of 20 patients (83.3%) became continent, 10 void spontaneously, while 14 must empty the bladder or pouch by clean intermittent self-catheterization. All patients have stable or improved renal function. Combined reconstructive and prosthetic surgery has an important role in the treatment of lower urinary tract dysfunction, with a high success rate and good quality of life.

Artificial Urinary Sphincter Insertion in Congenital Neuropathic Bladder

A series of 44 patients with neuropathic bladder dysfunction due to congenital myelodysplasia underwent implantation of an artificial urinary sphincter (AUS); in 26 patients a reconstructive procedure was performed at the same time. Five patients who initially had AUS implantation alone developed detrusor hyper-reflexia and required a clam cystoplasty. Forty patients (90%) are continent, 2 are occasionally damp and 2 are wet and awaiting further surgery; 66% of patients who underwent AUS insertion and reconstruction were found to have significant residual urine and they perform intermittent self-catheterisation (ISC). In patients with a good bladder capacity and normal compliance and detrusor hyper-reflexia controlled by anticholinergic drugs, cystoplasty is not necessary at the time of AUS insertion.

Surgical management of the congenital neuropathic bladder: J.R.W. Parry, D.E. Nurse, H.A.P. Boucant, et al. Br J Urol 65:164–167, (February), 1990

Surgical management of the congenital neuropathic bladder: J.R.W. Parry, D.E. Nurse, H.A.P. Boucant, et al. Br J Urol 65:164–167, (February), 1990

Surgical Management of the Congenital Neuropathic Bladder

We have previously described 3 types of lower urinary tract dysfunction in the congenital neuropathic bladder--contractile, intermediate and acontractile--accounting for 35, 40 and 25% of patients respectively. Subsequent urodynamic and surgical experience has shown that the intermediate type is commoner and the acontractile type less common than was thought. The contractile group accounts for 31% of patients and rarely requires surgery (a "clam" ileocystoplasty). The acontractile group accounts for only 9% but more commonly requires surgical treatment, usually the implantation of an artificial urinary sphincter (AUS). The intermediate group accounts for 60% of patients and usually requires surgery. If there is no significant sphincter weakness incontinence, a "clam" ileocystoplasty alone is performed; if there is sphincter weakness, a "clam and a cuff" procedure is performed with implantation of the remainder of the AUS at a later date, if required.

Combined Bladder Augmentation and Bladder Neck Suspension for Neuropathic Incontinence in Girls

We treated five girls with congenital neuropathic bladder, who had genuine stress incontinence combined with reduced detrusor compliance and/or detrusor hyperreflexia, by simultaneous Marshall-Marchetti-Krantz bladder-neck suspension and bladder augmentation using a sigmoid or ileocecal pouch. All are dry on 3 to 4 hourly intermittent self-catheterization and we suggest that this method represents a useful and much cheaper alternative to the artificial urinary sphincter.

Peripheral neurology as a predictor of bladder dysfunction in congenital neuropathic bladder.

Urodynamic findings and peripheral neurology were correlated in 62 patients with myelomeningocele. The primary motor and sensory levels bore no relation to bladder dysfunction. The ano-cutaneous reflex was a useful predictor, in that where the reflex was positive there was likely to be detrusor hyper-reflexia, a competent bladder neck and absence of sphincter weakness leakage. Where the reflex was absent, detrusor hyper-reflexia was absent or mild, the bladder neck usually incompetent and sphincter weakness leakage common. (Detrusor compliance could not be predicted from peripheral neurological findings). We consider the ano-cutaneous reflex to be a useful indication of bladder dysfunction and urodynamic studies are often unnecessary when it is positive.