End Filling Detrusor Pressure Research Articles

Long-term beneficial effects of mirabegron in pediatric patients with therapy-refractory neurogenic lower urinary tract dysfunction

Neurogenic lower urinary tract dysfunction (NLUTD) in children can cause renal failure and urinary incontinence if not treated sufficiently. Antimuscarinics (AM) and intradetrusor botulinum toxin injections (BoNT-A) with clean intermittent catheterization (CIC) are widely used treatment options for children with NLUTD. However, a considerable number will become refractory to these treatment options. This study aimed to evaluate the efficacy and long-term outcomes of mirabegron in children with NLUTD as an add-on and as a stand-alone treatment. Patients under 18 years of age with NLUTD who were refractory to AM and/or BoNT-A and were treated with mirabegron 50mg were retrospectively studied. Mirabegron was either used as monotherapy or in addition to AM and/or BoNT-A. Video-urodynamic studies (VUDSs) were performed before and after treatment with mirabegron. Changes in video-urodynamic parameters, the need for other NLUTD therapy during follow-up, patient-reported side effects, and urinary incontinence were outcomes of interest. A total of 34 patients with NLUTD were included. All patients were on CIC and the median age was 13.1 years (IQR 15.9-10.3). Median follow-up was 31.4 months (IQR 57.4-11.4). Bladder compliance improved by 89.9%, from 14.9 to 28.3ml/cm H2O (p-value<0.001). Maximum cystometric capacity, end-filling detrusor pressure, volume at first detrusor overactivity, vesicoureteral reflux, and urinary incontinence significantly improved after mirabegron. The add-on therapy group showed more significant improvements in video-urodynamic outcomes compared to the monotherapy group. The median time of requiring other NLUTD therapy was 25.5 months (IQR 39.8-14.8). None of the included patients reported side effects. Mirabegron is an effective treatment for children with therapy-refractory NLUTD with an average efficacy of 2 years after which additional therapy is required. Despite the retrospective character of this study, our results confirm the beneficial effect of mirabegron in children with therapy-refractory NLUTD, in particular when mirabegron is used as add-on therapy in those with low-compliance bladders.

Urinary tract imaging in infants with spina bifida: a selective approach to a baseline DMSA

There is no general agreement among paediatric urologists on how infants with spina bifida (SB) should be investigated after birth. Recently the EUA/ESPU guidelines have been published recommending a baseline DMSA scan in the first year of life and a Voiding Cystourethrogram (VCUG) or Videourodynamic (VUD) between the second and third month of life. The aim of this study was to evaluate the outcome of renal investigations in the first year of life in infants with SB to verify if an early DMSA scan is indicated in the management of this group of patients. All renal imaging, Renal and Bladder Ultrasound (RBUS), VCUGs, VUDs and DMSA were reviewed by two independent assessors to evaluate outcome. Seventy patients with spina bifida (40 girls) were enrolled between June 2015 and February 2020. An early VUD detected vesico-ureteral reflux (VUR) in 8/49 (16%) of patients. An early VUD also gave additional information on detrusor under or over activity, bladder trabeculation, end filling detrusor pressure (EFDP) and sphincteric incompetence. DMSA scan detected renal scarring in 4/68 (6%) patients. Three of these 4 patients had significant history of febrile UTIs while the fourth patient had grade 2 left sided VUR. The initial assessment of a newborn with myelodysplasia includes a Renal and Bladder Ultrasound during birth hospitalization. This study confirms the recently published EUA/ESPU guidelines on the management of neurogenic bladder in children and adolescents, which recommend a VUD or VCUG & Cystomanometry with Electromyogram (CMG) (if VUD not available) in the first 6-12 weeks of life. A selective approach to DMSA scan only in infants with SB who either had a febrile UTI or vesico-ureteric reflux would not have missed any scarring or dysplasia and would have saved 58 unnecessary nuclear scans.

Clinical urologic and urodynamic outcomes in patients with anorectal malformation and absent vagina after vaginal replacement

Introduction and objectivesAnorectal malformations (ARMs) represent a complex spectrum of anorectal and genitourinary anomalies and a paucity of evidence is available on long-term urologic outcomes in all ARM subtypes. It was our subjective bias from being a referral center for ARM patients that the subtype of rectovestibular fistula and absent vagina had higher risk of renal and bladder abnormalities than typical rectovestibular fistula patients. Therefore, to confirm or refute our clinical suspicions, the purpose of this study was to review this specific cohort of ARM patients and describe both the clinical urological and urodynamic outcomes. MethodsA retrospective cohort study was performed for 120 patients who were treated for ARM and vaginal replacement at our institution between 1991 and 2017. Fifteen patients with rectovestibular fistula and absent vagina were included in our review. Demographic and clinical data were abstracted from their medical records, including urodynamic findings, need for clean intermittent catheterization (CIC), urinary continence, and renal function. ResultsVaginal replacement surgery was undertaken concomitantly with ARM repair in 10 of the 15 patients (67%). One patient was lost to follow up, and mean follow up postoperatively was 39 months. In all but one patient, rectum or colon was used as the substrate for vaginal replacement. Of the 15 patients, 13 had continence data available. A total of 10 patients (77%) were able to achieve social continence. Overall six patients used CIC to manage their bladder and 40% of continent patients used CIC. Urinary continence outcomes in patients who had partial vaginal replacement compared to those with total vaginal replacement did not reveal a clinically significant difference. Continence was achieved in 3/4 patients (75%) with a history of tethered cord compared to 7/9 patients (78%) without a history of tethered cord release. Urodynamics were performed postoperatively in 7 of the 157 patients (47%). Uninhibited detrusor contractions (UDCs) were present in 3 out of 7 patients, and a cystometric capacity greater than expected was noted in 4 patients. Additionally, 2 patients had end filling detrusor pressure greater than 40 cm H2O. GFR data were available for 13 of the 15 patients and (85%) were classified as chronic kidney disease (CKD) stage I or not having any significant loss of renal function. ConclusionsIn this cohort of rectovestibular fistula and absent vagina, 77% reported achieving urinary continence. However CIC was employed in 40% of the patients which is higher than prior published noncloaca female ARM patient population. Urodynamic abnormalities were noted when performed and led to change in bladder management. Renal function measured with GFR was normal in 85%. Patients with rectovestibular fistula and absent vagina benefit from urologic screening given higher rates of lower urinary tract dysfunction that can require CIC to protect the upper urinary tract and achieve urinary continence. Type of studyCase series. Level of evidenceLevel IV.

Interrater Reliability in Interpretation of Neuropathic Pediatric Urodynamic Tracings: An Expanded Multicenter Study

Urodynamic findings often guide treatment for neuropathic bladder and are reported as objective data points in multi-institutional trials. However, urodynamic interpretation can be variable. In a pilot study pediatric urologists interpreting videourodynamics exhibited only moderate agreement despite similar training and practice patterns. We hypothesized the pilot study variability would be replicated in a multi-institutional study. We developed an anonymous electronic survey that contained 20 scenarios, each with a brief patient history, 1 urodynamic tracing and fluoroscopic imagery. All videourodynamics were completed during routine care of patients with neuropathic bladder at a single institution. Pediatric urologists from Centers for Disease Control and Prevention Urologic Protocol sites were invited to complete an interpretation instrument for each scenario. Fleiss kappa and 95% confidence limits were reported, with Fleiss kappa 1.00 corresponding to perfect agreement. The survey was completed by 14 pediatric urologists at 7 institutions. Substantial agreement was seen for assessment of fluoroscopic bladder shape (Fleiss kappa 0.73), while moderate agreement was observed for assessment of bladder safety, end filling detrusor pressure and bladder capacity (Fleiss kappa 0.50, 0.56 and 0.54, respectively). Fair agreement was seen for electromyographic synergy and presence of detrusor overactivity (Fleiss kappa 0.21 and 0.35, respectively). Experienced pediatric urologists demonstrate variability during interpretation of videourodynamic tracings. Subjectivity of assessment of electromyographic activity and detrusor overactivity was confirmed in this expanded study. Future work to improve the reliability of videourodynamic interpretation would improve the quality of clinical care and the quality of multi-institutional studies that use urodynamic data points as outcomes.

Initial urological evaluation and management of children with neurogenic bladder due to myelomeningocele

The proactive management of children with myelomeningocele (MMC) has contributed to decreasing their progression to end-stage renal disease, thanks to early urological evaluation and timing implementation of treatments. To demonstrate that early urological evaluation of the urinary tract in MMC shows functional alterations in most cases, and that it requires medical intervention, even when in some cases the complementary imaging studies do not show any abnormalities. A retrospective study including 60 patients aged <1 year with MMC who were followed by a multidisciplinary team. All of them underwent renal/bladder ultrasound, videourodynamic studies, renal scintigraphy/dimercaptosuccinic acid (DMSA), and laboratory tests for kidney function. The studied variables were: bladder capacity and pressure, presence of overactivity, vesicoureteral reflux (VUR), urinary dilations and abnormalities on renal scintigraphy/DMSA. All the patients received clean intermittent catheterization (CIC). See Summary Table all the patients showed alterations in at least some of the assessed urodynamic variables: reduced cystometric capacity, 21.6%; detrusor overactivity, 55%; end filling detrusor pressure >20cm H2O, 43.3%; inefficient bladder voiding, 98.3%; indirect dyssynergic patterns, 28.8%. The high-risk videourodynamic findings were observed in 28 cases (46.6%). DMSA was abnormal in 30%. Renal impairment was detected in 6.6% of cases. A total of 66% ofcases received oxybutynin. Almost all the children in this sample population showed urinary dysfunction, and approximately half of them had high-risk videourodynamic findings. Although many cases showed reflex urinary contractions, almost the entire sample had inefficient bladder voiding. An important limitation of this work was the lack of simultaneity in obtaining each of the requested studies. In the initial urological evaluation of patients with myelomeningocele, almost all the urodynamic studies showed abnormalities and one-third showed abnormal DMSA, which led to therapeutic actions being initiated, although imaging studies were normal in a great number of patients. CICalone, starting immediately after birth, is notsufficient. To eliminate or decrease upper tract damage, oxybutynin should be started in addition.

Monitoring bladder compliance using end filling detrusor pressure: Clinical results and related factors

ObjectiveTo assess the clinical significance of low compliance bladder (LCB) in women with lower urinary tract symptoms. Materials and MethodsMedical records of 1490 women undergoing videourodynamic studies (VUSs) were reviewed. Comprehensive medical histories, physical examinations, bladder diaries, and results of multichannel VUS were analyzed. This study adopted an end filling detrusor pressure (EFP) greater than 20 cmH2O to define LCB. ResultsAmong the study patients (n = 1490), 9.1% were diagnosed with LCB using a cutoff value of 17.5 cmH2O, which had a sensitivity and specificity of 89% and 92.7%, respectively. Results of multivariate analysis indicated that age (p = 0.005), maximum cystometric capacity (MCC; p = 0.002), detrusor overactivity (DO; p = 0.001), pelvic organ prolapse (POP; p = 0.018), recurrent urinary tract infection (p = 0.001), and radical abdominal hysterectomy (RAH; p < 0.001) as independent prognostic factors. Furthermore, our study results indicate that the MCC, urinary tract infection, and a history of RAH have a positive correlation with LCB, whereas, age, POP, and DO have a negative correlation with LCB. ConclusionOur idea using EFP (≥17.5 cmH2O) for screening women with LCB is feasible for clinical use.

Reliability of ambulatory urodynamics in patients with spinal cord injuries

To determine the test-retest repeatability of the urodynamic parameters commonly utilized in ambulatory urodynamics (AM) for patients with neurogenic lower urinary tract dysfunction (NLUTD). A test-retest repeatability study was performed on 64 consecutive patients with stable spinal cord injuries who underwent two AM studies 24 hr apart. The mean age was 43.2 years, with 47 males and 17 females. A significant intraclass correlation coefficient (ICC) was found between the two studies with respect to the functional bladder capacity (FBC; 0.74), the maximum detrusor pressure during the involuntary detrusor contraction (P(detmaxIDC); 0.84), and the post-void residual (PVR; 0.76). Of note, the ICC of the end filling detrusor pressure (P(detfill)) was not significant (0.25). The correlation with respect to the presence of involuntary detrusor contraction (IDC) was significant but low (κ = 0.40). Based on the logistic regression analysis, the variables that influenced the concordance with respect to the presence of the IDC were P(detmaxIDC) (directly) and P(detmax) (inversely). The variable that that influenced the concordance with respect to P(detmaxIDC) was PVR (directly). The variable that influenced the concordance with respect to PVR was the FBC (directly). AM is reliable for the reproduction of the main urodynamic parameters investigated in patients with NLUTD, except for the end filling detrusor pressure, which was a non-reliable parameter. The concordance of AM can be improved primarily by taking into account the values of the maximum detrusor pressure during involuntary detrusor contraction (P(detmaxIDC)).

1008 EFFECT OF REPEATED INTRADETRUSOR INJECTIONS OF BOTULINUM-A TOXIN ON URODYNAMICS AND CLINICAL PARAMETERS IN PATIENTS WITH REFRACTORY IDIOPATHIC DETRUSOR OVERACTIVITY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence: Evaluation & Therapy1 Apr 20111008 EFFECT OF REPEATED INTRADETRUSOR INJECTIONS OF BOTULINUM-A TOXIN ON URODYNAMICS AND CLINICAL PARAMETERS IN PATIENTS WITH REFRACTORY IDIOPATHIC DETRUSOR OVERACTIVITY Daniel Max Schmid, Sharmistha Roy-Guggenbuehl, Rachel Groebli-Bolleter, and Tullio Sulser Daniel Max SchmidDaniel Max Schmid Zurich, Switzerland More articles by this author , Sharmistha Roy-GuggenbuehlSharmistha Roy-Guggenbuehl Zollikerberg, Switzerland More articles by this author , Rachel Groebli-BolleterRachel Groebli-Bolleter Zurich, Switzerland More articles by this author , and Tullio SulserTullio Sulser Zurich, Switzerland More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1042AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our former study in 250 pat. shows that a first BoNT-A injection increased maximum cystometric capacity (MCC) and reduced clinical symptoms as urgency, frequency and incontinence. As we lacked knowledge of urodynamic effects of repeated injections, we evaluated in this study urodynamic parameters of consecutive BoNT-A injections in the detrusor muscle in patients with idiopathic OAB resistant to conventional treatment, who needed a second BoNT-A treatment after loss of efficacy of their first injection. METHODS Out of 73 pat. with repeated BoNT-A intradetrusor injections, 50 patients (40 women and 10 men) with relapsing symptoms of OAB underwent clinical checks and standard urodynamic studies before and 12 weeks after their first and second injection, respectively. We compared then the urodynamic parameters measured at baseline and after two consecutive injections of 100 U of BoNT-A. RESULTS The interval between 2 subsequent treatments reached from min. 4 mths. to max. 28 mths. (mean 12 mths.). We observed a significant increase of the MCC after every consecutive injection, as the MCC increased from a mean baseline of 240 ml to 385 ml after the first injection and to 425 ml after the second injection (p=0.04). The end filling detrusor pressure showed a significant decrease from baseline 40 cmH2O to a mean value of 34 cmH2O (first inj.) and then to 24 cmH2O (second inj.) (p=0.003). Bladder compliance improved from baseline 22 ml/cmH2O to 45 and 51 ml/cmH2O (p=0.0001), respectively. All our patients reported reduced OAB symptoms after treatments, and comparing quality of life, we saw no significant differences between a first and a consecutive injection. CONCLUSIONS Besides the well known efficacy of BoNT-A injections in pat. with refractory idiopathic OAB, we observed a continuous improvement of urodynamic parameters after consecutive treatments; in particular, bladder compliance even increased after a second treatment, banishing some former concern, that repeated injections could negatively affect bladder wall structure. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e406 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Max Schmid Zurich, Switzerland More articles by this author Sharmistha Roy-Guggenbuehl Zollikerberg, Switzerland More articles by this author Rachel Groebli-Bolleter Zurich, Switzerland More articles by this author Tullio Sulser Zurich, Switzerland More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1596 EFFECT OF REPEATED INTRADETRUSOR INJECTIONS OF BOTULINUM-A TOXIN ON URODYNAMICS AND CLINICAL PARAMETERS IN PATIENTS WITH REFRACTORY IDIOPATHIC DETRUSOR OVERACTIVITY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy II1 Apr 20101596 EFFECT OF REPEATED INTRADETRUSOR INJECTIONS OF BOTULINUM-A TOXIN ON URODYNAMICS AND CLINICAL PARAMETERS IN PATIENTS WITH REFRACTORY IDIOPATHIC DETRUSOR OVERACTIVITY Daniel Schmid, Sharmistha Roy-Guggenbuehl, Tullio Sulser, and Brigitte Schurch Daniel SchmidDaniel Schmid More articles by this author , Sharmistha Roy-GuggenbuehlSharmistha Roy-Guggenbuehl More articles by this author , Tullio SulserTullio Sulser More articles by this author , and Brigitte SchurchBrigitte Schurch More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1374AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nonneurogenic urinary incontinence is partially due to OAB, which refers to the symptom complex of frequency, urgency and nocturia. OAB is related to a disorder of the storage phase of the bladder. Our former study in 240 pat. shows that a first BoNT-A injection increased maximum cystometric capacity (MCC) and reduced clinical symptoms as urgency, frequency and incontinence. As we lacked knowledge of urodynamic effects of repeated injections, we evaluated in this study urodynamic parameters of consecutive BoNT-A injections in the detrusor muscle in patients with idiopathic OAB resistant to conventional treatment, who needed a second BoNT-A treatment after loss of efficacy of their first injection. METHODS Out of 66 pat. with repeated BoNT-A intradetrusor injections, 45 patients (35 women and 10 men) with relapsing symptoms of OAB underwent clinical checks and standard urodynamic studies before and 12 weeks after their first and second injection, respectively. We compared then the urodynamic parameters measured at baseline and after two consecutive injections of 100 U of BoNT-A. RESULTS The interval between two subsequent treatments reached from min. 4 months to max. 28 months (mean 12 months). We observed a significant increase of the MCC after every consecutive injection, as the MCC increased from a mean baseline of 245 ml to 380 ml after the first injection and to 420 ml after the second injection (p=0.04). The end filling detrusor pressure showed a significant decrease from baseline 41 cmH2O to a mean value of 34 cmH2O (first inj.) and then to 23 cmH2O (second inj.) (p=0.003). Bladder compliance improved from baseline 22 ml/cmH2O to 45 and 52 ml/cmH2O (p=0.0001), respectively. All our patients reported reduced OAB symptoms after treatments, and comparing quality of life, we saw no significant differences between a first and a consecutive injection. CONCLUSIONS Besides the well known efficacy of BoNT-A injections in pat. with refractory idiopathic OAB, we observed in this study a continuous improvement of urodynamic parameters after consecutive treatments; in particular, bladder compliance even increased after a second treatment, banishing some former concern, that repeated injections could negatively affect bladder wall structure. Zurich, Switzerland© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e617 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Schmid More articles by this author Sharmistha Roy-Guggenbuehl More articles by this author Tullio Sulser More articles by this author Brigitte Schurch More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urinary continence outcome after augmentation ileocystoplasty as a single surgical procedure in patients with myelodysplasia.

Preoperative prediction of urinary continence in patients with myelodysplasia requiring augmentation cystoplasty is uncertain. To determine reliable factors to predict postoperative urinary continence, we retrospectively analyzed preoperative videourodynamic parameters and urinary continence outcome in a group of patients with myelodysplasia who underwent augmentation ileocystoplasty. Of 75 patients with myelodysplasia with neurogenic bladder dysfunction refractory to conservative management (anticholinergic drugs and clean intermittent catheterization) who underwent augmentation cystoplasty as a single procedure we selected 14 girls and 12 boys without previous vesicostomy drainage and with preoperative and postoperative videourodynamic studies in whom detubularized ileocystoplasty was performed. Preoperative and postoperative evaluation included physical examination, assessment of renal function, urine culture, renal and bladder ultrasound and videourodynamic studies. We analyzed on preoperative videourodynamic studies bladder outlet morphology at 20 cm. water of filling detrusor pressure, leak point pressure, cystometric bladder capacity and end filling detrusor pressure. Videourodynamic bladder outlet morphology was classified as closed bladder outlet, insinuated bladder neck, bladder neck and urethra open up to the sphincter, and bladder outlet widely open. Patients were considered continent if they were able to remain dry between catheterization without pads. For analysis patients were divided into group 1-19 with preoperative incontinence and group 2-7 without urinary incontinence. After surgery 4 group 1 patients had urinary incontinence whereas all group 2 patients remained continent. Only 1 group 1 patients with leak point pressure less than 50 cm. H2O and 3 with leak point pressure greater than 50 cm. H2O were incontinent after surgery. Seven group 1 patients with cystometric bladder capacity greater than 75% and 8 with cystometric bladder capacity less than 75% of the age expected bladder capacity achieved continence. Two group 1 patients with filling detrusor pressure less than 40 cm. H2O and 2 with filling detrusor pressure greater than 40 cm. H2O continued with urinary incontinence after ileocystoplasty. Preoperative videourodynamic images of the 4 group 1 patients who remained incontinent after surgery demonstrated irrespective of the aforementioned urodynamic parameter widely open bladder outlet. Moreover, none of the postoperative continent patients had an open bladder neck and urethra on preoperative evaluation. According to our findings of the anatomical morphology of the bladder outlet (bladder neck/urethra) during the filling phase of videourodynamic studies at 20 cm. water filling detrusor pressure was the most reliable parameter to predict continence outcome after detubularized augmentation ileocystoplasty.

Bladder functional outcome after delayed vesicostomy closure and antireflux surgery in young infants with 'primary' vesico-ureteric reflux.

To evaluate bladder function by conventional urodynamic investigations in young infants with primary vesico-ureteric reflux (VUR) who had undergone an initial temporary cutaneous vesicostomy followed by later antireflux surgery and vesicostomy closure. From 1983 to 1990, nine boys (10-360 days old) with primary VUR were treated with an initial vesicostomy, followed by delayed closure of the vesicostomy and the simultaneous surgical correction of reflux. Severe VUR was detected bilaterally in seven and unilaterally in two infants at the time of the initial diagnosis. The mean (SD, range) age at vesicostomy was 12.4 (8, 3-23) months and the duration of bladder defunctionalization 38.7 (25.5, 18-90) months. All patients were assessed urodynamically after closing the vesicostomy, using rapid-fill cystometry with normal saline solution at room temperature. The mean (range) age at the time of urodynamic testing was 7.3 (5-15) years; the mean (SD, range) follow-up was 10.1 (4.1, 5-17) years. Six boys with bilateral VUR underwent successful ureteroneocystostomy; nephroureterectomy was required in one patient. In two patients the VUR resolved with time. After re-functionalization, the mean (SD, range) maximum cystometric capacity, expressed as a percentage of the mean bladder capacity for age, was 1.4 (0.5, 0.6-2.2)%. In three patients the bladder capacity was higher (> or = 40%) than expected for age, while one had diminished (< 70%) bladder capacity. The mean (range) end-filling detrusor pressure was 14.5 (5-42) cmH2O and the mean (SD, range) compliance 24 (13.9, 4-44) mL/cmH2O. Two patients had a compliance of < 10 mL/cmH2O, one of whom had associated unstable detrusor contractions of 90 cmH2O. The mean (SD, range) detrusor voiding pressure at peak flow was 47.3 (16.8, 5-76) cmH2O. One patient had a residual urine volume of 8% of bladder capacity. At the follow-up, only one patient (aged 5 years) with detrusor instability had urinary incontinence. This study shows that the bladder of young infants with primary VUR treated with temporary vesicostomy regained normal function after re-functionalization of the lower urinary tract.

URODYNAMIC FINDINGS IN BOYS WITH POSTERIOR URETHRAL VALVES AFTER TREATMENT WITH PRIMARY VALVE ABLATION OR VESICOSTOMY AND DELAYED ABLATION

Primary valve ablation and temporary vesicostomy with delayed valve ablation are alternative initial management procedures in neonates and infants with posterior urethral valves. To investigate whether initial vesicostomy followed by delayed valve ablation and simultaneous vesicostomy closure may lead to more alterations in bladder function than primary valve ablation only we retrospectively compared postoperative urodynamic findings in 2 small groups of patients. From 1980 to 1990, 15 male infants 19 days to 34 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including valve ablation only in 8 (group 1), and primary vesicostomy and delayed valve ablation associated with concomitant vesicostomy closure in 7 (group 2). Mean age at valve ablation and vesicostomy in groups 1 and 2 was 10.8 +/- 11.2 months (range 1 to 35) and 55.4 +/- 43.3 days (range 19 to 151), respectively. Average duration of vesicostomy diversion was 33.6 +/- 18.8 months (range 14 to 70). All patients underwent conventional urodynamics postoperatively using normal saline at room temperature. In groups 1 and 2 mean age at followup was 11.5 +/- 6.6 (range 5 to 16.2) and 9. 4 +/- 3.1 (range 4.10 to 14) years, respectively. Controls comprised 46 age matched males who underwent urodynamics using similar methodology. Postoperative urodynamic assessment of maximum cystometric bladder capacity and the incidence of detrusor instability in each treatment group were not statistically different. In group 1 bladder capacity was significantly higher than that in controls (p <0.0001). In group 2 mean end filling detrusor pressure was increased compared with that in group 1 (29 cm. water, range 15 to 60 versus 8, range 4 to 21). Compliance was significantly lower in group 2 than in group 1 (p <0.0005). Analysis of detrusor voiding pressure at maximum flow was not significantly different in the 2 groups. We noted detrusor under activity in 1 group 1 and 2 group 2 cases. In these patients post-void residual urine volume was 8% to 66% of cystometric bladder capacity. However, only 1 of these 3 patients who required augmentation cystoplasty needed intermittent catheterization. Urodynamic patterns of outflow obstruction developed in 1 patient in each group, including urethral stricture and bladder neck obstruction. At followup we observed no difference in renal function impairment in the 2 groups. Our retrospective study of rapid filling cystometry suggests that primary valve ablation for posterior urethral valves is associated with a better bladder function outcome than that in patients treated with vesicostomy and delayed valve ablation. Therefore, although cutaneous vesicostomy may be performed as initial management of posterior urethral valves, primary valve ablation is the most effective surgical option in these cases.