Need For Bladder Augmentation Research Articles

Long-term bladder outcomes using a prescriber pattern scoring system for posterior urethral valves

Urinary drainage for posterior urethral valves can be achieved with valve ablation (VA) or diversion by vesicostomy (VES) or cutaneous ureterostomy (CU). The effect of these interventions on long-term bladder function remains debated, and voiding symptomatology after VES or CU reversal has been poorly characterized. The objective of this study was to examine the prevalence and scope of physician treatment patterns as a surrogate for retention or incontinence symptomatology among PUV patients undergoing primary VA or diversion by VES/CU and determine rates of progression to augmentation. This is a single-institution retrospective cohort study. Retention Scores (R) were calculated 1 point for: retention behavior (double/timed void), alpha-blocker, intermittent catheterization, or overnight indwelling catheter. Incontinence Scores (I) were calculated 1 point for: incontinence behavior (double/timed void), oral medication, or botulinum toxin. Patients with R score above 3 or I score above 2 were deemed to have severe retention or incontinence symptomatology respectively. End stage bladder (ESB) was defined as need for bladder augmentation. We identified 76 patients between 5 and 40 years old with median follow-up of 14.6 [5.0-40.4) years. There was no difference in the rates of severe retention or incontinence treatment pattern scoring between VA versus VES/CU (Figure). Rates of achieving R(1) status are similar between VA and VES/CU groups, though age of reaching R(1) was younger for those with VES/CU (4.8 years) compared to VA (6.6 years). There was no significant difference in rate of ESB by intervention category VA (9.4%) versus VES/CU (17.4%; p=0.323). Treatment of retention symptomatology was more common than treatment of incontinence symptomatology regardless of primary management, VA or VES/CU. This study also indicates that VES/CU patients were just as responsive as VA patients to conservative treatments (behavioral changes, pharmacotherapy) for any type of bladder symptomatology as the progression to treatment of severe symptomatology and ESB were similar between cohorts. In this cohort, bladder outcomes were not associated with type of urinary diversion (VA or VES/CU). Long term bladder outcomes for valve patients demonstrated similar treatment patterns and progression to end-stage bladder regardless of diversion status. Patients went on to ESB approximately 4.4 years after diagnosis at similar rates between groups.

Bladder Herniation as an Auto-Augmentation Technique in Bladder Exstrophy: Initial Experience in Patients with Small Bladder Plate

ObjectiveTo present our long-term experience of bladder plate herniation technique in patients with bladder exstrophy epispadias complex (BEEC) and inadequate bladder plate. MethodsTen BEEC patients with inadequate bladder plates were referred. The bladder underlying fascia was opened and the exstrophic bladder was fixed above the peritoneal cavity to herniate the peritoneal contents beneath the bladder plate so that the abdominal pressure would be directly transferred to the posterior bladder wall; causing gradual bladder expansion and auto-augmentation. In 5 patients, the inguinal hernia was fixed to increase the pressure transferred to the exstrophic bladder. The bladder capacity was measured while the patient was crying and when the bladder was enlarged. Cystometry and voiding cystourethrogram were performed before the application of this technique and during the next 6 to 8 months, to determine the bladder capacity for further primary bladder closure. ResultsThe bladder was enlarged during straining/crying without any complications. The average bladder capacity was increased about 2.5 to 3 times after 8 months of follow-up so that it was suitable for undergoing primary closure. None of the children needed bladder augmentation following the single-stage total BEEC reconstruction. ConclusionThis technique seems to be safe, effective, and feasible in patients with small-sized bladder and may be performed before the primary closure to increase the success rate. This technique may be effective in increasing the bladder capacity for staged bladder closure and bladder neck reconstruction without further need for bladder augmentation.

How early is early? Effect of oxybutynin on bladder dynamics within the first year of life in patients with spina bifida

Early proactive treatment of patients with high-risk neurogenic bladder from spina bifida (SB) may preserve renal function and decrease the need for bladder augmentation later in life. Timing of initiation of anticholinergic therapy (AC) medication and clean intermittent catheterization (CIC) is variable and based on imprecise studies. The authors hypothesized that initiation of AC after the initial video-urodynamic study (VUDS) may benefit bladder capacity even in children who do not meet the standard hostile criteria for starting AC. A retrospective review of a prospectively maintained VUDS database from August 2015 to March 2019 was performed. Patients with SB who had undergone initial VUDS between 1 and 7 months of age and had a subsequent follow-up study between 9 and 18 months of age were included. Multiple VUDS and clinical parameters including expected bladder capacity, actual capacity reached, pressure at actual capacity, presence of detrusor overactivity, presence of urinary tract dilation and reflux, and whether or not AC was started were extracted and compared. P-value of <0.05 was considered statistically significant. A total of 69 patients completed an initial study at median age of 2 months, and follow-up study at median age of 13 months. Anticholinergic therapy was started in 21 patients (10F, 11M). Decision to initiate AC was at discretion of the attending pediatric urologist performing the VUDS in real time. Changes between the initial and repeat VUDS are listed in the summary table below. Adverse effects of AC were reported in 25% (5/21) patients: urinary retention/UTIs (3), allergic reaction (1), and fatigue (1). The authors findings suggest that AC stabilizes storage pressure for those who initially have a higher storage pressure, while in those with initial low storage pressures, storage pressures worsened over time in the absence of AC. Patients started on AC experienced a faster rate of increase in bladder capacity. Limitations to this study included the unknown long term and sustainability of the improvement in bladder parameters, the lack of uniform criteria for the initiation of AC or CIC, and an unknown long-term degree of upper tract protection. This study found early initiation of AC in SB at 2 months of age had significant positive effects on growth of bladder capacity and stabilization of storage pressure. However, long-term effects of AC are still undetermined, and thus, longitudinal studies are needed to understand the precise indications for initiation of early AC treatment.

Long-term urological outcomes of spinal lipoma after prophylactic untethering in infancy: real-world outcomes by lipoma anatomy

Cohort study. Long-term urological outcomes in patients with spinal lipoma after prophylactic tethered cord release (TCR) in infancy were investigated. Children's hospital in Yokohama, Japan. Children under one year of age with spinal lipoma who underwent TCR between 1990 and 2010 were investigated. According to Arai's classification, lipomas other than filar lipoma were classified into four types: caudal, dorsal, transitional, and lipomyelomeningocele. The level of the conus medullaris was divided into three categories: L3-5, L5/S1, and sacral. Urological outcomes, including the need for clean intermittent catheterization (CIC), urinary incontinence, presence of renal deterioration, and the need for bladder augmentation, were investigated by both lipoma type and level of the conus medullaris. Fifty-three patients met the inclusion criteria. The median follow-up period was 14.2 years (interquartile range 9.6-17.6 years). Of the 53 patients, ten (19%) were on CIC, and six (11%) were incontinent. Overall, two patients (4%) had renal deterioration detected by DMSA renal scan, and two (4%) needed augmentation cystoplasty. Of the lipoma types, transitional type showed the worst outcomes with respect to need for CIC (54%) and urinary incontinence (38%). There were no significant differences in renal deterioration and the rate of bladder augmentation by lipoma type. No urological outcomes were significantly associated with conus level. Even after prophylactic TCR in infancy in children with spinal lipoma, 19% of patients needed CIC in long-term follow-up. Of the lipoma types, transitional type showed the worst outcomes with respect to need for CIC and urinary incontinence.

Long-term outcomes of cutaneous vesicostomy in patients with neuropathic bladder caused by spina bifida

To evaluate the outcomes of patients who underwent cutaneous vesicostomy for management of neuropathic bladder secondary to spina bifida. We hypothesize that vesicostomy, in select patients, is beneficial to prevent upper urinary tract deterioration (UTD), reduce febrile urinary tract infections (UTIs), and preserve renal function. We performed a retrospective chart review on patients with spina bifida who underwent cutaneous vesicostomy at our institution between 2000 and 2016. Demographic information, indication for vesicostomy, pre and postoperative laboratory/radiologic studies, incidence of febrile UTIs, and urodynamic findings were abstracted. A total of 14 patients (eight females and six males) were identified. The indication for vesicostomy was UTD in four, recurrent febrile UTIs in five, parental request in two, both UTD and recurrent febrile UTIs in two, and both UTI and parental request in one patient. Seven patients had a median of three (range one to five) febrile UTI prior to surgery for cutaneous vesicostomy. Median creatinine level before surgery was 0.26mg/dL (range 0.16-0.97). Either unilateral or bilateral ≥SFU Grade 2 hydronephrosis was present in six patients. Median age at vesicostomy creation was 26.5 months (range 4-96). Mean functional bladder capacity assessed during preoperative urodynamic studies was 107mL (range 20-279), and detrusor sphincter dysynergia was present in all patients. High-grade vesicoureteral reflux (grade ≥3) was present in three patients, all with UTD. Mean follow-up after vesicostomy was 62.4±39.3 months. After vesicostomy, only two of the seven patients with history of febrile UTIs experienced an additional febrile UTI. The median serum creatinine level was 0.36mg/dL (range 0.2-0.58) at last follow-up. Moreover, 11/14 patients had no hydronephrosis and just two patients had unilateral SFU grade 1 hydronephrosis (Table). Worsening UTD, recurrent febrile UTIs, and high-pressure bladder despite maximal medical therapy are several reasons to consider more aggressive management of neuropathic bladders. In young patients, vesicostomy is able to protect the upper urinary tract, decrease rates of febrile UTI, and delay the need for bladder augmentation. Vesicostomy is a safe method for temporary diversion of the lower urinary tract in patients with spina bifida who are refractory to conservative and minimally invasive treatments.

Renal Transplantation in Patients With “Valve Bladder”: Is Bladder Augmentation Necessary?

Introduction Posterior urethral valve is a common cause of renal failure in children. This disorder often results in small bladder and low compliance, which frequently requires bladder augmentation. Herein, we report our experience in 5 children with “valve bladder” who underwent renal transplantation without preliminary bladder enlargement. Materials and Methods Thirteen children with valve bladder undergoing renal transplantation were considered candidates for bladder augmentation. All had oligoanuria at transplantation. In 8 children, bladder augmentation was performed before renal transplantation; in the remaining 5, the decision was postponed until after transplantation. These children underwent transplantation with a ureteral reimplant, and a suprapubic catheter was in place for 2 months. Periodically, renal function, bladder capacity, and compliance were assessed, and renal ultrasonography was performed. Results At 1-, 2-, 4-, and 6-month follow-up, the 5 children who did not undergo bladder augmentation demonstrated normal renal function, with improved bladder capacity and absence of hydronephrosis. No significant difference was evident between the 2 groups (augmented vs nonaugmented) insofar as renal function, bladder capacity, or hydronephrosis. After transplantation, bladder augmentation was not deemed necessary in any of the 5 children because of complete restoration of clinical and urodynamic parameters. Conclusion Renal transplantation can be performed safely without preemptive bladder augmentation. Ureteral reimplantation is recommended, even in patients with small valve bladders. The decision about the need for bladder augmentation should be made only after normal diuresis is restored.

Treatment Strategies for Neurogenic Voiding Dysfunction

The main problems in neurogenic voiding dysfunction (NVD) are failure to store, failure to empty, and combined failure to store and empty. The management priorities in NVD should be as follows, in order: (1) preservation of renal function, (2) freedom from urinary tract infection, (3) efficient bladder emptying, (4) freedom from an indwelling catheter, (5) patient satisfaction with voiding management and (6) avoiding medication after proper management. Management of the urinary tract in patients with spinal cord injury must be based on urodynamic findings rather than inferences from a neurologic evaluation. Selecting high-risk patients is important to prevent renal function impairment in patients with chronic NVD. Patients with NVD should be regularly followed-up for lower urinary tract dysfunction using urodynamic study and any urological complication should be adequately treated. Avoiding a chronic indwelling catheter can reduce the incidence of developing a low compliant bladder. Intravesical instillation of vanilloids or injection of BOTOX provides an alternative treatment for refractory detrusor overactivity or low compliant bladder and can replace the need for bladder augmentation. When surgical intervention is necessary, a less invasive type of surgery and a reversible procedure should be considered first and unnecessary surgery in the lower urinary tract should be avoided. Keeping the bladder and urethra in good condition without interfering with neuromuscular continuity will give patients with NVD a chance to benefit from new technologies in the future. It is most important that the physician continues to try to improve the quality of life of patients with NVD. [ Tzu Chi Med J 2008;20(1):35–39]

Standing the test of time: long-term outcome of reconstruction of the exstrophy bladder

The surgical management of classic bladder exstrophy has evolved over time. Different techniques are used to address the challenge of reconstructing these patients. We review the long-term outcomes of bladder exstrophy treatment from the published literature with regard to urinary continence, voiding and secondary complications. Continence now can be achieved in up to 80% of children in specialist centres. Whether such success can sustained into adult life is uncertain. About 40% of adults are dry in the best hands. Up to 84% of children can void, but there is some evidence that this function is lost with time in 70%. The need for bladder augmentation is widely variable between series, reported in 0-70% of children. This reduces the ability to void spontaneously to about 50% of children. It brings with it the later risk of metabolic disturbance and stone formation. Adults with exstrophy have a 694-fold increase in the risk of bladder cancer by the age of 40 years.

Surgery Insight: advantages and pitfalls of surgical techniques for the correction of bladder exstrophy

Staged reconstruction repair of bladder exstrophy results in hydronephrosis or renal scarring in 15-25% of patients. A cosmetically acceptable and functional phallus can be achieved in 85% of patients, 20-30% of whom will require more than one operation for penile reconstruction. Episodes of penile glans loss or corporal loss are rarely reported with this technique. Widely disparate results relating to complete urinary continence and volitional voiding have been published, with urinary continence reported to occur in 7-85% of patients. The need for bladder augmentation to obtain urinary continence also varies, with reports that somewhere between 10% and 90% of patients require an augmentation procedure to gain urinary continence. Complete primary repair of bladder exstrophy using the penile disassembly technique results in hydronephrosis or renal scarring in 0-30% of patients, and hypospadias, as a consequence of this repair, will occur in 30-70% of patients. Loss of the glans and corpora appear more frequently with penile disassembly than in staged reconstruction of bladder exstrophy, however, the exact incidence of this complication is unknown. Reported complete urinary continence and volitional voiding rates are also varied following penile disassembly, ranging from 25-65%. A modified bladder-neck reconstruction to gain urinary continence is reportedly required in 15-90% of patients, with 5-10% requiring both bladder augmentation and bladder-neck reconstruction. Experience with complete primary repair of bladder exstrophy, using the penile disassembly approach, seems promising but is not a panacea. To outline the risks and benefits regarding the various surgical techniques for bladder exstrophy, we would recommend the establishment of a national registry for patients with this disorder.

Alterations in the molecular determinants of bladder compliance at hydrostatic pressures less than 40 cm. H2O.

Bladder outlet obstruction with intravesical pressures exceeding 40 cm. H2O often results in irreversible renal damage. Bladder outlet obstruction also results in alterations in bladder physiology, including wall thickening, reduced compliance and decreased capacity. If unchecked these changes may lead to the subsequent need for bladder augmentation. From a biomechanical standpoint, compliance is primarily related to extracellular matrix deposition, which in turn is dependent on the balanced activity of proteolytic enzymes (that is matrix metalloproteinases [MMPs]) and their endogenous inhibitors (that is tissue inhibitors of metalloproteinases [TIMPs]). To date, the threshold pressure above which alterations in these key determinants of bladder compliance occur has not been determined. Therefore, using a novel device of our own design, we applied hydrostatic pressures in the physiological range to human bladder smooth muscle cells to determine the effect on MMPs, TIMP-1 and transcription of the major structural collagens (types I and III). Human bladder smooth muscle cells (staining positive for alpha-smooth muscle actin) were plated at a density of 100,000 cells per 10 cm.2 and cultured for 2 days in Dulbecco's modified Eagle's medium (DMEM) with 10% fetal bovine serum. Cells were subsequently exposed to pressures of 0.3, 20 and 40 cm. H2O for 1, 3, 7 and 24 hours in serum-free DMEM. A computer interface maintained pressure levels for the duration of the experiments and collected pressure data. MMP-1 and 3, and TIMP-1 immunoassay and zymography for MMP-2 and 9 were performed. Polymerase chain reaction for human collagen types I and III was performed following reverse transcription of total purified mRNA. All experiments were repeated 3 times and statistical analysis was performed using a 2-tailed Student t test. Exposure of bladder smooth muscle cells to a sustained hydrostatic pressure of 20 cm. H2O for 7 hours in serum-free DMEM resulted in a time dependent decrease in MMP-1, 2 and 9 activity (15%, 37% and 25%) compared to controls maintained at atmospheric pressure (p <0.01). TIMP-1 levels increased an average of 10% after exposure to 20 cm. H2O. These changes became statistically significant when the cells were exposed to 40 cm. H2O pressure for 3, 7 and 24 hours (+14%, +21% and +50%, respectively). No statistically significant differences in MMP-3 and collagen type I or III mRNA levels were observed. Our results reveal that MMP-1, 2 and 9 are significantly down-regulated in a time and pressure dependent fashion following exposure of bladder smooth muscle cells to 20 cm. H2O for as little as 7 hours. TIMP-1 levels increased under similar conditions. These alterations in MMPs and TIMP-1 favor accumulation of extracellular matrix, structural components associated with bladder wall thickness and decreased compliance. These results are consistent with previous data from animal models of complete outlet obstruction. Our results support the concept that pressures 40 cm. H2O or less contribute to molecular changes consistent with decreased compliance associated with bladder dysfunction.

Can urodynamic studies predict bladder behaviour changes after artificial urinary sphincter implantation?

Objective To assess whether preoperative urodynamic studies can predict bladder behaviour changes that will necessitate bladder augmentation in patients with neuropathic incontinence after undergoing artificial urinary sphincter (AUS) implantation. Patients and methods We analysed 17 patients, with a mean age of 14.4 years at AUS implantation, who did not undergo bladder augmentation either before or at implantation. All patients were followed at regular intervals before and after implantation. Urodynamic studies were done at least three times before implantation and yearly thereafter. Bladder capacity and compliance were evaluated preoperatively and during the follow up, in order to determine whether these urodynamic measurements could predict the eventual need for bladder augmentation. Results After a mean follow up of 7.5 years bladder behaviour was unchanged in 11 patients while six required augmentation. In these six patients, normal bladder capacity and compliance decreased from 67 to 39.6% of age expected capacity (AEC) ( P = 0.004) and from 31.6 to 13.5 ml/cm of water ( P = 0.001), respectively. Four of the six had no clinical symptoms to suggest the change in bladder behaviour. The differences in the average preoperative and follow up values for both normal bladder capacity (72.4 vs 83.5% of AEC) and compliance (30 vs 33.7 ml/cm of water) were not significant in the non-augmented patients ( P = 0.2 and P = 0.3, respectively). Preoperative normal bladder capacity and compliance were 72% of AEC and 30 ml/cm of water, respectively, in the 11 non-augmented patients and 67% and 31 ml/cm of water in the six patients with augmentation. These differences between the two groups were not significant ( P = 0.06; P = 0.1). Conclusion Preoperative urodynamic studies do not predict bladder function outcome after AUS implantation. These patients require long-term careful observation to detect any asymptomatic change in detrusor behaviour.

The continent bladder: indications and techniques for the continent catheterizable segment

Continent catheterizable segments are a substantial part of the urologist's armamentarium for providing bladder drainage. It is used for a myriad of indications, and there are multiple techniques currently used for its formation. Despite refinements in these techniques significant complications still occur, and there is continued advancement and ongoing investigation. This review examines the current status of the continent catheterizable segment with regard to indications for its use, techniques in its formation, discussion of complications, and ongoing and future directions in research. The continent catheterizable segment is indicated when it is not feasible to use the urethra for evacuation (e.g. bladder exstrophy, neurogenic bladder, radiation injury, and marked urethral dysfunction) or to facilitate catheterization. Compliance with catheterization and irrigation regimens is essential in patient selection. Multiple methods exist for its formation, either with or without the need for bladder augmentation. Although Mitrofanoff techniques with multiple applications predominate, "hemi" augments with efferent limbs also play a significant role. Stoma placement should be performed to best facilitate catheterization. Complications relating to catheterizable segments mainly pertain to continence, stenosis, and ability to catheterize, with more significant morbidity relating to the bladder augmentation. Ongoing research to develop more physiologic tissue substitutes and less invasive techniques may hopefully be superseded by prevention of the underlying lower urinary tract pathology. Catheterizable segments allow the patient to control bladder evacuation, and continue to be refined by ongoing investigations in terms of indication and technique, with attendent decreasing morbidity.

Alterations in the Molecular Determinants of Bladder Compliance at Hydrostatic Pressures less than 40 cm. H 2O

Bladder outlet obstruction with intravesical pressures exceeding 40 cm. H2O often results in irreversible renal damage. Bladder outlet obstruction also results in alterations in bladder physiology, including wall thickening, reduced compliance and decreased capacity. If unchecked these changes may lead to the subsequent need for bladder augmentation. From a biomechanical standpoint, compliance is primarily related to extracellular matrix deposition, which in turn is dependent on the balanced activity of proteolytic enzymes (that is matrix metalloproteinases [MMPs]) and their endogenous inhibitors (that is tissue inhibitors of metalloproteinases [TIMPs]). To date, the threshold pressure above which alterations in these key determinants of bladder compliance occur has not been determined. Therefore, using a novel device of our own design, we applied hydrostatic pressures in the physiological range to human bladder smooth muscle cells to determine the effect on MMPs, TIMP-1 and transcription of the major structural collagens (types I and III). Human bladder smooth muscle cells (staining positive for alpha-smooth muscle actin) were plated at a density of 100,000 cells per 10 cm.2 and cultured for 2 days in Dulbecco's modified Eagle's medium (DMEM) with 10% fetal bovine serum. Cells were subsequently exposed to pressures of 0.3, 20 and 40 cm. H2O for 1, 3, 7 and 24 hours in serum-free DMEM. A computer interface maintained pressure levels for the duration of the experiments and collected pressure data. MMP-1 and 3, and TIMP-1 immunoassay and zymography for MMP-2 and 9 were performed. Polymerase chain reaction for human collagen types I and III was performed following reverse transcription of total purified mRNA. All experiments were repeated 3 times and statistical analysis was performed using a 2-tailed Student t test. Exposure of bladder smooth muscle cells to a sustained hydrostatic pressure of 20 cm. H2O for 7 hours in serum-free DMEM resulted in a time dependent decrease in MMP-1, 2 and 9 activity (15%, 37% and 25%) compared to controls maintained at atmospheric pressure (p <0.01). TIMP-1 levels increased an average of 10% after exposure to 20 cm. H2O. These changes became statistically significant when the cells were exposed to 40 cm. H2O pressure for 3, 7 and 24 hours (+14%, +21% and +50%, respectively). No statistically significant differences in MMP-3 and collagen type I or III mRNA levels were observed. Our results reveal that MMP-1, 2 and 9 are significantly down-regulated in a time and pressure dependent fashion following exposure of bladder smooth muscle cells to 20 cm. H2O for as little as 7 hours. TIMP-1 levels increased under similar conditions. These alterations in MMPs and TIMP-1 favor accumulation of extracellular matrix, structural components associated with bladder wall thickness and decreased compliance. These results are consistent with previous data from animal models of complete outlet obstruction. Our results support the concept that pressures 40 cm. H2O or less contribute to molecular changes consistent with decreased compliance associated with bladder dysfunction.

IMPROVED BLADDER FUNCTION AFTER PROPHYLACTIC TREATMENT OF THE HIGH RISK NEUROGENIC BLADDER IN NEWBORNS WITH MYELOMENINGOCELE

Purpose High pressure dyssynergic voiding may result in irreversible damage to the urinary tract. Prophylactic therapy in the form of clean intermittent catheterization and anticholinergic medication may significantly decrease the incidence of upper urinary tract deterioration. Whether prophylactic therapy in high risk bladder may also lead to improved long-term bladder dynamics prompted us to study the effect of early versus late treatment of bladder hypertonicity and detrusor-sphincter dyssynergia on the ultimate need for bladder augmentation. Materials and Methods We retrospectively reviewed urological outcomes in patients with myelodysplasia who were at risk for urological deterioration within year 1 of life based on bladder sphincter dyssynergia and/or high filling or voiding pressure. We recorded the dates when high risk voiding dynamics were initially observed, and when intermittent catheterization and anticholinergic therapy were initiated. Patients in whom treatment began at the time a high risk profile was noted (prophylactic group seen between 1985 and 1990) were compared to controls with the same high risk voiding parameters who did not receive early therapy (observation group seen between 1978 and 1984 with therapy instituted 1 year of longer after high risk was noted). The number of augmentations performed in each group was indexed to the total number of years of followup in the 2 populations, respectively. Patients with less than 2 years of followup were excluded from further analysis. Results Of the 45 patients at risk clean intermittent catheterization and anticholinergic medication were immediately initiated in 18, while 27 were treated expectantly. Patients in the observation group were followed an average of 4.1 years (range 1.1 to 14) before clean intermittent catheterization and anticholinergic medication were started. Of the 27 children treated expectantly 11 (41%) required augmentation, whereas only 3 of the 18 (17%) treated prophylactically required enterocytoplasty. When the number of augmentations was indexed to total years of followup in each of the 2 groups (296 versus 156 years) patients in the expectant group were nearly twice as likely to require augmentation. Conclusions Identification and early proactive treatment of the high pressure, dyssynergic lower urinary tract significantly decreases the need for bladder augmentation as children with neurogenic bladder secondary to myelomeningocele mature.

Improved bladder function after prophylactic treatment of the high risk neurogenic bladder in newborns with myelomentingocele.

High pressure dyssynergic voiding may result in irreversible damage to the urinary tract. Prophylactic therapy in the form of clean intermittent catheterization and anticholinergic medication may significantly decrease the incidence of upper urinary tract deterioration. Whether prophylactic therapy in the high risk bladder may also lead to improved long-term bladder dynamics prompted us to study the effect of early versus late treatment of bladder hypertonicity and detrusor-sphincter dyssynergia on the ultimate need for bladder augmentation. We retrospectively reviewed urological outcomes in patients with myelodysplasia who were at risk for urological deterioration within year 1 of life based on bladder sphincter dyssynergia and/or high filling or voiding pressure. We recorded the dates when high risk voiding dynamics were initially observed, and when intermittent catheterization and anticholinergic therapy were initiated. Patients in whom treatment began at the time a high risk profile was noted (prophylactic group seen between 1985 and 1990) were compared to controls with the same high risk voiding parameters who did not receive early therapy (observation group seen between 1978 and 1984 with therapy instituted 1 year or longer after high risk was noted). The number of augmentations performed in each group was indexed to the total number of years of followup in the 2 populations, respectively. Patients with less than 2 years of followup were excluded from further analysis. Of the 45 patients at risk clean intermittent catheterization and anticholinergic medication were immediately initiated in 18, while 27 were treated expectantly. Patients in the observation group were followed an average of 4.1 years (range 1.1 to 14) before clean intermittent catheterization and anticholinergic medication were started. Of the 27 children treated expectantly 11 (41%) required augmentation, whereas only 3 of the 18 (17%) treated prophylactically required enterocystoplasty. When the number of augmentations was indexed to total years of followup in each of the 2 groups (296 versus 156 years) patients in the expectant group were nearly twice as likely to require augmentation. Identification and early proactive treatment of the high pressure, dyssynergic lower urinary tract significantly decreases the need for bladder augmentation as children with neurogenic bladder secondary to myelomeningocele mature.

ARTIFICIAL URINARY SPHINCTER IN THE TREATMENT OF URINARY INCONTINENCE: PREOPERATIVE URODYNAMICS DO NOT PREDICT THE NEED FOR FUTURE BLADDER AUGMENTATION

Purpose The artificial urinary sphincter has been used to treat urinary incontinence in pediatric patients with neurogenic bladders secondary to myelodysplasia. Frequently bladder augmentation is performed in conjunction with the artificial urinary sphincter implantation. Identifying patients with adequate urinary reservoirs who are candidates for implantation without bladder augmentation is a clinical challenge. We reviewed our experience with the artificial urinary sphincter in children with myelodysplasia to determine whether preoperative urodynamic findings predict the need for future augmentation cystoplasty. Materials and Methods We identified 38 patients younger than 18 years at artificial urinary sphincter implantation who did not undergo augmentation enterocystoplasty before or at implantation. We evaluated preoperative bladder capacity and compliance to determine whether these standard preoperative urodynamic measurements predict the eventual need for bladder augmentation in these patients. Results In the 15 patients who required eventual bladder augmentation after artificial urinary sphincter implantation mean bladder capacity plus or minus standard deviation was 62.9 +/− 29.9% of age expected capacity and mean bladder compliance was 8.0 +/− 4.8 ml./cm. water. In the 23 patients who did not require eventual bladder augmentation mean bladder capacity was 59.2 +/− 25.4% of age expected capacity and compliance was 7.0 +/− 3.3 ml./cm. water. There was no statistically significant difference between the 2 groups. Conclusions Standard preoperative urodynamics do not predict the patients who undergo isolated artificial urinary sphincter implantation and eventually require bladder augmentation.

Neurogenic Bladder Dysfunction Due to Myelomeningocele: Neonatal Versus Childhood Treatment

Purpose We sought to determine whether the neonatal institution of treatment of neurogenic bladder dysfunction in myelomeningocele patients at high risk of urinary tract deterioration improves renal and bladder outcome. Materials and Methods We reviewed the records of patients with bladder dysfunction believed to be at high risk for renal deterioration based on urodynamic studies. All patients were treated with clean intermittent catheterization. We compared rates of urinary infection, hydronephrosis, reflux, continence and surgical intervention in 46 patients in whom treatment was started in year 1 of life and 52 treated after age 4 years. Results Renal outcome was similar in both groups with persistent hydronephrosis in 6 of 46 patients (13%) and 7 of 52 (14%), respectively. However, significantly fewer bladder augmentation procedures were required in patients started on treatment during year 1 of life (5 of 46, 11% versus 14 of 52, 27%, p <0.05). Conclusions In addition to any psychological benefit, early intervention with clean intermittent catheterization in children with neurogenic bladder dysfunction may help to prevent irreversible bladder dysfunction and limit the need for bladder augmentation.

The Long-Term Outcome of Posterior Urethral Valves Treated with Primary Valve Ablation and Observation

Purpose We believe that primary valve ablation with observation is the preferred management for posterior urethral valves. However, debate continues as to the role of high diversion. We examined the long-term outcome of a large series of patients treated with primary valve ablation, and compared it to the outcome of high diversion and vesicostomy. Materials and Methods We reviewed the records of 100 patients treated with primary valve ablation (74 percent), vesicostomy (13 percent) or high diversion (9 percent) before 1985. Median followup was 11.2 years. Results Overall 13 percent of our patients had end stage renal disease by age 15 years. Three patients initially treated with valve ablation and 3 initially treated with vesicostomy later underwent high diversion but none benefited from the secondary procedure. Four patients initially treated with valve ablation subsequently underwent vesicostomy but only 1 benefited. Bladder storage capacity was well preserved. Diurnal urinary continence developed in 46 percent of patients at age 10 years and only 1 remained incontinent after age 20 years. One patient with diversion who awaits transplantation had a small contracted bladder. Recent urodynamic studies in 10 cases of delayed urinary continence have not shown decreased bladder compliance or capacity. Kaplan-Meier analysis of outcomes of the different treatments indicated no statistical difference in patient age at end stage renal disease development. However, comparing the number of surgical procedures in the different treatment groups revealed a significant increase in the amount of surgery in infants with diversion. Our results were equivalent to those of the best published series, many of which strongly advocate high diversion. Conclusions By avoiding diversion in most cases bladder function is preserved and the need for bladder augmentation is decreased.

The Effect of Temporary Cutaneous Diversion on Ultimate Bladder Function

We evaluated the effect of temporary cutaneous diversion on bladder function in cases of various congenital uropathies. The clinical courses of patients who underwent reversal of vesicostomy or pyelostomy/ureterostomy in a 7-year period were reviewed. Indications for diversion included azotemia, massive hydronephrosis, high grade reflux and/or incomplete bladder emptying. Mean age at diversion was 15 weeks. Overall 75 cases were evaluated (posterior urethral valves in 31, neurogenic bladder in 16, reflux in 14, the syndrome of vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies in 8 and other in 6).Of 55 patients who underwent undiversion by direct closure only 2 required later augmentation for bladder/renal deterioration. Excluding the myelomeningocele patients on clean intermittent catheterization 45 of 46 who underwent direct closure were able to void spontaneously with acceptable post-void residuals. Urodynamics in 22 cases revealed normal bladder capacity at pressures below 30 cm. water in 19 (86 percent) after direct closure. We conclude that after a period of defunctionalization approximately 75 percent of children will have essentially normal bladder function. The frequency of bladder augmentation varied from 54 percent in patients with myelomeningocele to 14 percent in those with vesicoureteral reflux. This observation suggests that the need for bladder augmentation in the remaining patients is more related to the effect of the primary pathological condition on the detrusor rather than the diversion itself.

The effect of temporary cutaneous diversion on ultimate bladder function.

We evaluated the effect of temporary cutaneous diversion on bladder function in cases of various congenital uropathies. The clinical courses of patients who underwent reversal of vesicostomy or pyelostomy/ureterostomy in a 7-year period were reviewed. Indications for diversion included azotemia, massive hydronephrosis, high grade reflux and/or incomplete bladder emptying. Mean age at diversion was 15 weeks. Overall 75 cases were evaluated (posterior urethral valves in 31, neurogenic bladder in 16, reflux in 14, the syndrome of vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies in 8 and other in 6). Of 55 patients who underwent undiversion by direct closure only 2 required later augmentation for bladder/renal deterioration. Excluding the myelomeningocele patients on clean intermittent catheterization 45 of 46 who underwent direct closure were able to void spontaneously with acceptable post-void residuals. Urodynamics in 22 cases revealed normal bladder capacity at pressures below 30 cm. water in 19 (86%) after direct closure. We conclude that after a period of defunctionalization approximately 75% of children will have essentially normal bladder function. The frequency of bladder augmentation varied from 54% in patients with myelomeningocele to 14% in those with vesicoureteral reflux. This observation suggests that the need for bladder augmentation in the remaining patients is more related to the effect of the primary pathological condition on the detrusor rather than the diversion itself.