Pediatric Neurogenic Bladder Research Articles

Is body composition important in the context of renal function in pediatric neurogenic bladder?

Neurogenic bladder due to myelomeningocele (MMC) is a significant risk factor for chronic kidney disease in children. Cystatin C (CysC) is a more accurate GFR marker than creatinine as it is unaffected by muscle mass but may be influenced by fat mass and BMI. This study evaluates: (1) GFR measurement accuracy using CysC and creatinine in MMC-related neurogenic bladder, (2) the relationship between body composition via bioelectrical impedance analysis (BIA) and renal parameters, and (3) the use of BIA for non-invasive GFR and body composition assessment. Forty children (median age 9.96years) underwent serum creatinine, CysC testing, and BIA measurements. We assessed age, sex, spinal lesion level, anthropometric measurements, BMI, and activity using Hoffer's scale. GFR was calculated using five creatinine-based formulas, three CysC-based, and three combining CysC and creatinine, including BIA GFR as an alternative approach. Creatinine-based GFR estimates were significantly higher than CysC-based GFR. Although only 30% of MMC patients met the traditional BMI criteria for overweight/obesity, 62.5% were obese based on BIA-measured body fat percentage. Significant differences were found in CysC and CysC-based GFR equations within BMI and fat mass groups. Positive correlations were observed between CysC and body weight, BMI percentiles, body fat mass and fat-to-muscle ratio. Muscle mass positively correlated with creatinine. BIA-determined fat mass percentage is a more sensitive obesity indicator than BMI in MMC patients. CysC levels and CysC-based GFR equations are influenced by body fat mass, requiring consideration of adiposity to avoid misestimating renal impairment.

Experiences and barriers with home bladder manometry in the pediatric neurogenic bladder population: A qualitative study

Patients with neurogenic bladder are at risk of developing renal deterioration secondary to increased intravesical pressures. To date, urodynamics is the gold standard test to properly assess bladder dynamics. Home bladder manometry is a low-cost and simple method to evaluate bladder pressures and volumes during clean intermittent catheterization (CIC). Previous literature has shown that home manometry measurements correlate with urodynamic pressures and hydronephrosis on ultrasound. However, no studies have evaluated the challenges and barriers faced by caregivers with the process. Our objective was to investigate the experiences and perceptions of caregivers, healthcare providers, and nurses with home manometry. We conducted semi-structured interviews and focus group discussions with 23 stakeholders. Stakeholders included caregivers of pediatric spina bifida neurogenic bladder patients, providers, and nursing staff. Grounded Theory Methods were used to analyze transcripts and identify preliminary concepts that described attitudes towards the current home bladder manometry process. Interview participants were composed of 10 (43%) caregivers, 9 (40%) healthcare providers, and 4 (17%) nursing staff. The mean age was 39 years (range 26-66). The four themes identified during discussions were perspectives on home manometry, patient-specific characteristics, challenges with home manometry, and learning experience. All caregivers expressed understanding and agreement with the purpose and importance of home manometry. Emergent concepts identified as targets for improvement were the need for standardization of teaching processes with focus on hands-on practice, understanding of patient characteristics and the home environment that make the process more challenging, and the need for appropriate materials including extension tubing and catheters. Home bladder manometry is a feasible and beneficial way for neurogenic bladder patients to monitor their bladder pressures and volumes at home. This qualitative study offers valuable insights into the experiences and viewpoints of caregivers, healthcare providers, and nurses regarding both home manometry and the general experience with CIC.

LIU Zhishun's clinical experience of electroacupuncture for pediatric neurogenic bladder of lower motor neuron type in children

Professor LIU Zhishun's clinical experience of electroacupuncture (EA) for pediatric neurogenic bladder of lower motor neuron type in children is summarized. Considering the unique physiological and pathological characteristics of children, with the strategy of combining "disease-symptom-location" in the selection of acupoints, professor LIU Zhishun proposes that the main disease location is the bladder and kidney, with the involvement of the conception vessel, governor vessel, kidney meridian of foot-shaoyin and the bladder meridian of foot-taiyang. The primary acupoint prescription-1 (bilateral Zhongliao [BL 33], Ciliao [BL 32] and Huiyang [BL 35]) and primary acupoint prescription-2 (Guanyuan [CV 4], Zhongji [CV 3] and bilateral Sanyinjiao [SP 6]) are selected to promote the yang of the governor vessel, stimulate the yin of the conception vessel, and invigorate the bladder's qi transformation. Before acupuncture, the four-step method is applied to precisely locate Ciliao (BL 32) and Zhongliao (BL 33). During acupuncture, the importance of achieving deqi is emphasized, with deep insertion in the sacral area to reach the disease location. Based on the tolerance characteristics of children, low-frequency EA and gentle moxibustion treatment are applied.

Evaluation of Urinary L-FABP as a Tubular Damage Marker in Pediatric Neurogenic Bladder—A Pilot Study

Evaluation of Urinary L-FABP as a Tubular Damage Marker in Pediatric Neurogenic Bladder—A Pilot Study

Results of a defined surgical protocol for treating pediatric neurogenic bladder incontinence in a single institution

Incontinent pediatric neurogenic bladder (NB) patients face social ostracization and potential renal deterioration. Reconstructive surgery, after maximal medical therapy, requires a difficult decision-making process. Current literature for NB surgeries is difficult to interpret given definitions of dryness, use of augmentation cystoplasty (AC) and the lack of renal preservation. This study assesses the results of a defined surgical protocol to treat incontinent NB patients, using a new composite outcome measure, which includes upper tracts status and a definition of dryness. This is a retrospective cohort study assessing 33 consecutive incontinent NB patients (Spina bifida 31, Sacral agenesis- 2) who underwent one of 2 procedures between 2008 and 2021. AC with a Mitrofanoff procedure (MP) was performed in patients who had a high detrusor leak point pressure (DLPP) and significant bladder trabeculations (N=21, Group 1). Children with a low DLPP and non-trabeculated bladders, underwent a modified Young-Dees-Leadbetter/Mitchell procedure with a 360° autologous rectus fascial sling (BOP) with concomitant AC and MP (N-12, Group 2). Post-operative success was defined using a composite grading of success assessing dryness, upper tract stability and medication use. The mean age at surgery was 11.6 years (SD=6 years), with 21 in Group 1 and 12 in Group 2. Mean follow-up was 3.25 years, with a minimum 24-month follow-up period. Success rate was 90% in Group 1 and 66% in Group 2. No patient had upper tract deterioration following surgery. Redo-surgical intervention, was required in 38% of Group 1 and 50% of Group 2 patients. These include 3 bladder neck injections in Group 1 and 2 bladder neck closure in Group 2, with a final success rate to 95 % in Group 1 and 83 % in Group 2. Achieving dryness and preserving upper tracts is a challenge in incontinent NB patients. Dryness rates achieved in this study is comparable, given complications and redo-surgery. Primary bladder neck closure is a radical intervention, but Group 2 patients, may benefit from an upfront discussion of the pros and cons of a bladder neck closure primarily or as a secondary procedure. Isolated AC obtains acceptable results for a selected subset of incontinent NB patients with significant bladder trabeculation. For those requiring a BOP, the success rate is relatively lower with the higher rate of potential complications and need for redo-surgery.

Open minds on the road to improvement

In the absence of resoundingly clear evidence-based guidelines, we must either choose the approach that is most comfortable for our practice, or we must generate the data to inform consensus statements or guidelines. neurogenic bladder clean intermittent catheterization urinary tract infection quality improvement Periprocedural antibiotics for urodynamic studies of pediatric neurogenic bladder, empiric or culture-guided? A retrospective cohort studyJournal of Pediatric UrologyPreviewUrodynamic studies are fundamental in the care of children with neurogenic bladder. Children with neurogenic bladder who perform clean intermittent catheterization (CIC) are considered a high-risk group for infection after urodynamic studies. Current guidelines are not uniform regarding the duration, type, the need of prophylactic antibiotic treatment or performance of urine culture before urodynamic studies. Full-Text PDF

Editorial Comments.

No AccessJournal of UrologyPediatric Urology1 Apr 2023Editorial CommentsThis article comments on the following:Long-term Safety and Tolerability of Repeated Treatments With OnabotulinumtoxinA in Children With Neurogenic Detrusor Overactivityis a letter which has replyReply by Authors Armando J. Lorenzo Armando J. LorenzoArmando J. Lorenzo Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada Department of Surgery, University of Toronto, Toronto, Ontario, Canada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003157.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comments." The Journal of Urology, 209(4), p. 783 REFERENCES 1. . Long-term safety and tolerability of repeated treatments with onabotulinumtoxinA in children with neurogenic detrusor overactivity. J Urol. 2023; 209(4):774-784. Link, Google Scholar 2. . Feasibility of awake intravesical botulinum toxin injection in pediatric neurogenic bladder. J Urol. 2022; 208(3):702-710. Link, Google Scholar 3. . Fibrosis and the bladder, implications for function ICI-RS 2017. Neurourol Urodyn. 2018; 37(S4):S7-S12. Crossref, Medline, Google Scholar 4. . Botulinum toxin in patients at-risk for bladder augmentation: durable impact or kicking the can?. Neurourol Urodyn. 2022; 41(6):1406-1413. Crossref, Medline, Google Scholar © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology19 Jan 2023Long-term Safety and Tolerability of Repeated Treatments With OnabotulinumtoxinA in Children With Neurogenic Detrusor OveractivityJournal of Urology1 Apr 2023Reply by Authors Volume 209Issue 4April 2023Page: 783-783 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Armando J. Lorenzo Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada Department of Surgery, University of Toronto, Toronto, Ontario, Canada More articles by this author Expand All Advertisement PDF downloadLoading ...

Periprocedural antibiotics for urodynamic studies of pediatric neurogenic bladder, empiric or culture-guided? A retrospective cohort study

Urodynamic studies are fundamental in the care of children with neurogenic bladder. Children with neurogenic bladder who perform clean intermittent catheterization (CIC) are considered a high-risk group for infection after urodynamic studies. Current guidelines are not uniform regarding the duration, type, the need of prophylactic antibiotic treatment or performance of urine culture before urodynamic studies. To assess whether antibiotic prophylactic therapy before urodynamic studies should be empiric or culture-guided in children with neurogenic bladder who perform CIC. Urine samples were collected from children with neurogenic bladder who require CIC before undergoing a urodynamic study. Urine cultures were collected via sterile urethral catheterization one week before urodynamic studies between 2010 and 2018. Children with signs of urinary tract infection (UTI) or children with bladder augmentation were excluded. Resistance to commonly prescribed periprocedural antibiotic treatments was documented. The probability of antibiotic resistance according to sex, vesicoureteral reflux (VUR) status, consumption of prophylactic antibiotics, and self/caregiver performed CIC was determined by a χ2-test. A total of 278 urine cultures were collected from 185 children with neurogenic bladder. The median age was 8 years (IQR 5-12). The most common etiology for neurogenic bladder was spinal dysraphism (n=146, 77%). Bacterial growth was detected in 216 (78%) cultures, and the most commonly detected bacterial species was Escherichia. coli (n=155, 72%). Thirty-six (19%) children had VUR, and 14 of them received continuous prophylactic antibiotics. The probability of resistance to oral antibiotics was amoxicillin (22%), cephalexin (21%), cefuroxime (14%), ciprofloxacin (10%), nitrofurantoin (21%), and sulfamethoxazole/trimethoprim (SMX/TMP) (23%) (See "summary table") No significant differences were found by χ2-test in the probability of resistance to antibiotics according to sex, VUR status, continuous antibiotic prophylaxis or self/caregiver performed CIC. The study reveals high resistance level to commonly prescribed oral antibiotic treatments (20-30%). Several studies have challenged the need of routine urine cultures before urodynamic studies due to low risk of post-procedural infection. However, it should be mentioned that not all the patients participating in those studies were with neurogenic bladder or routinely performed CIC. Hence, in this specific group of children, routine urine cultures should not be abandoned. The limitations of the study are: Single-center, retrospective study with no data availability regarding the development of UTI after the urodynamic studies. Urine cultures of children with neurogenic bladder who require CIC demonstrate significant levels of resistance to commonly prescribed oral antibiotics. These findings support culture-guided periprocedural antibiotic prophylaxis.

Unusual surgical treatment option for an uncommon disease: Ureterocutaneostomy in an emphysemateous pyelonephritis patient.

Emphysematous pyelonephritis (EPN) is severe necrotising inflammation of renal parenchyma. Because of the devastating consequences of the pathology aggressive treatment can prevent permanent renal damage. Fifteen-year-old-girl patient without medical follow-up applied to emergency room with fever and vomiting. Computed Tomography (CT) revealed EPN. After diagnostic procedure minimal invasive procedures like double J catheter and nephrostomy tube insertion failed. While taking into account family’s treatment and medical follow-up compliance, also severe dilatation in both ureters made bilateral ureterocutaneostomy (UC) to be considered as a feasible option. UC creation can be thought as a safe and effective alternative surgical procedure. Pediatric neurogenic bladder (NB) population incompatible to treatment and follow-up are candidates for EPN development. We also believe that UC can be beneficial in terms of acute and long-term management of EPN in NB patients who the clinician thinks will not be compatible with complex surgical intervention, follow-up and treatment.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Sep 2022This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002822AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Awake Intravesical Botulinum Toxin in Pediatric Neurogenic Bladder Many pharmacological agents are derived from natural products. What started out as reports of poison-tipped arrows and blowgun darts led to interest about the paralytic properties of curare. The medical benefits of paralysis led to research into the mechanism of action and commercially available sources with reliable dosages and effects.1 One of the earliest motivations was to try to limit the effects on severe muscle contractions during electroconvulsive therapy. These efforts led to its role in general anesthesia as the paralytic agent tubocurarine.2 While other agents such as pancuronium have become more commonly used,3 the precedent was set. Botulinum toxin (Botox®) is the neurotoxin produced by Clostridium botulinum bacteria. It affects the acetylcholine receptors at the neuromuscular junction, leading to flaccid paralysis. It is a potent lethal naturally occurring toxin and has led to medical interest in much the same fashion as curare was developed into a therapeutic.4 Commercial botulinum toxin has been shown to help with muscle spasticity and to improve storage pressures in neurogenic bladder patients when injected intravesically. These treatments are usually carried out under general anesthesia. Overland et al (page 702) from San Francisco, California discuss the use of botulinum neurotoxin in an awake setting.5 They note that physiatrists have been injecting intramuscular botulinum toxin without general anesthesia or sedation in their cerebral palsy and spasticity patients. They present a small series of patients (sensate and nonsensate) who received bladder botulinum toxin injection without general anesthesia but with support standing by if needed. They had good results, with only 2 patients requiring conversion to general anesthesia or sedation, and mitigating factors such general anxiety and communication issues were present. Because botulinum toxin effects are limited and repeat injections are often necessary, performing the procedure without repeated general anesthesia not only is economical and conserves operating room time, but also helps limit anesthesia exposure. Do New Complications Develop during Puberty after Hypospadias Repair? We are currently in a period of reassessment of hypospadias methods and the reporting of complications and reoperations.6 An experienced pediatric urologist once noted that “everyone’s repair looks good at the time of surgery; tell me what it looks like at 1 year.”7 This concern about late-presenting issues has led many to advocate long-term followup through puberty. While logical, given the many anecdotal reports of late-presenting fistulas, or perhaps more accurately, late-reported fistulas, more is needed to be known about late effects, particularly in those patients who had more complex procedures. Do the growth of the penis during puberty, erections and onset of sexual activity risk greater complications later in life, when many of these patients may be transitioning out of pediatric urology care? Snodgrass and Bush (page 696) from Dallas, Texas report on their experience with patients who presented with late complications.8 All were peripubertal or postpubertal. They found in their retrospective review that 86% recalled complications occurring before puberty. They noted a bimodal presentation, with most being reported before puberty and a few developing later into adulthood, usually related to obstruction and stenosis. Selection and recall bias clearly can affect these findings, because one can only report on patients who are unhappy enough to present, and recall of exact onset can be difficult in some to pin down. Adolescents and young men who might not have relished recurrent operations on their penis as a child may not have the most reliable recall of exact onset of complications. This bimodal presentation supports the finding of Barbagli et al.9 An initial group will have issues attributed to evaluation, surgical technique and approach, and postoperative care. The later group are those older men who have had good early results but who develop late strictures and stenosis; this is believed due to neourethras created out of skin and lack of a natural corporal spongiosum support. Followup through puberty seems warranted, and patients who present later in life with a prior history of hypospadias repair deserve further investigation despite making it through adolescence doing well.

Botulinum toxin in patientsat-risk for bladder augmentation: Durable impact or kicking the can?

Deferring bladder augmentation (BA) may be desirable in a pediatric neurogenic bladder (NGB) with worsening compliance, but prior studies have questioned whether onabotulinum toxin A (BTX) demonstrates durable improvement in compliance. We present our overall experience with BTX and its role in mitigating the "at-risk" NGB, as determined by urodynamic characteristics. A retrospective single-institution review of all BTX procedures performed during January 2010 to October 2018 was conducted. Patients with <12 months follow-up after firstBTX injection were excluded. Urodynamic studies (UDS) were reviewed to assign National Spina Bifida Patient Registry (NSBPR) as well as institutionally developed (LCH) risk classification groups. Patients were considered "at-risk" for BA if they had any of the following: NSBPR risk grade of intermediate or hostile; LCH risk grades indicating end-fill pressure >25 cmH2 Oor detrusor sphincter dyssynergia (DSD); upper tract changes including new hydronephrosis; new or worsening vesicoureteral reflux; or other signs of a hostile urinary tract (i.e., febrile UTIs). UDS risk grades pre and post-first BTX injection were compared in this "at-risk" group, when available. Thirty-nine patients underwent 162 injection procedures over a median follow-up of 65 months interquartile range (IQR 49-81). Median age at firstBTX was 10 years and the median number of BTX injections per patient was 4(IQR 2-7; range 1-12) with a median time of 6 months between injections (IQR 4-10). Twenty-six patients were deemed "at-risk" at the time offirstBTX injection, and of those, 16 (61.5%) proceeded to BA at a median of 36 months (IQR 22.5-42). A small number (four) had BA due to upper tract changes or worsening pressures on BTX, while ninepatients (fivewith CKD) proceeded to BA given a lack of sufficient improvement to consider BTX a long-term viable option. Post-firstBTX UDS demonstrated downgrading of risk group in 38% and 63% using NSBPR and LCH classifications, respectively. Encouraging improvements in the urodynamic risk group were noted in some patients. With careful counseling and follow-up, BTX may safely extend the time to BA in some "at-risk" patients.

MP28-19 CONTEMPORARY TREND ANALYSIS OF INTRA-DETRUSOR BOTOX INJECTION AND AUGMENT CYSTOPLASTY FOR SPINA BIFIDA POPULATION IN US FREE-STANDING CHILDRENS HOSPITALS

You have accessJournal of UrologyCME1 May 2022MP28-19 CONTEMPORARY TREND ANALYSIS OF INTRA-DETRUSOR BOTOX INJECTION AND AUGMENT CYSTOPLASTY FOR SPINA BIFIDA POPULATION IN US FREE-STANDING CHILDRENS HOSPITALS Hsin-Hsiao Wang, Kenneth Softness, John Panagides, Dylan Cahill, Rachel Saunders, Ranveer Vasdev, Tanya Logvinenko, and Carlos Estrada Hsin-Hsiao WangHsin-Hsiao Wang More articles by this author , Kenneth SoftnessKenneth Softness More articles by this author , John PanagidesJohn Panagides More articles by this author , Dylan CahillDylan Cahill More articles by this author , Rachel SaundersRachel Saunders More articles by this author , Ranveer VasdevRanveer Vasdev More articles by this author , Tanya LogvinenkoTanya Logvinenko More articles by this author , and Carlos EstradaCarlos Estrada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002571.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intra-detrusor botulinum toxin (botox) injection has been utilized as a minimally invasive alternative to augmentation cystoplasty in patients with refractory neurogenic bladder. However, little data are available regarding its use on a national level. We sought to investigate the contemporary trends of intra-detrusor botox injection and augment cystoplasty in free-standing children’s hospitals. METHODS: We queried the Pediatric Health Information System (PHIS) database to identify patients with spina bifida from 2013 to 2019 who underwent intra-detrusor botox injection and augment cystoplasty based on CPT and ICD9/10 codes. Total spina bifida population under care in the free-standing children’s hospitals was estimated by all inpatient and ambulatory surgery encounters as denominators to calculate frequency by time for both intra-detrusor botox injections and augmentation cystoplasty. RESULTS: In total, we included 3,153 intra-detrusor botox injections and 1,828 augment cystoplasties between 2013 to 2019. 46% of patients were male. Median age at surgery was 10.6 (IQR 7.1-15.0) years. The contemporary trend (in quarters) for botox injection and augment cystoplasty are shown in Figure 1. There was a significantly increasing trend for intra-detrusor botox injection in patients with spina bifida (from 2.0% in 2013q1 to 12.3% in 2019q4, p<0.001 for the trend). Conversely, there was a decreasing but not significant trend for augment cystoplasty (from 3.9% in 2013q1 to 3.3% in 2019q4, p=0.11 for the trend). Strong seasonality (higher in summer) was seen in augment cystoplasty but not intra-detrusor botox injection group. The sensitivity analysis using only first intra-detrusor botox injection per patient led to similarly significant increasing trend with time. CONCLUSIONS: There is a significantly increased use of intra-detrusor botox injection in the management of neurogenic bladder in patients with spina bifida. The use of augmentation cystoplasty has slightly decreased, but not significantly. These trends are likely reflective of changing practice patterns, but the role of botox in the management of pediatric neurogenic bladder remains incompletely defined. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e468 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hsin-Hsiao Wang More articles by this author Kenneth Softness More articles by this author John Panagides More articles by this author Dylan Cahill More articles by this author Rachel Saunders More articles by this author Ranveer Vasdev More articles by this author Tanya Logvinenko More articles by this author Carlos Estrada More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP11-08 RESTRICTED ACCESS TO MIRABEGRON IN CHILDREN WITH NEUROGENIC BLADDER

You have accessJournal of UrologyCME1 May 2022MP11-08 RESTRICTED ACCESS TO MIRABEGRON IN CHILDREN WITH NEUROGENIC BLADDER Christopher Jaeger, Andrea Balthazar, Caleb Nelson, Tanya Logvinenko, and Hsin-Hsiao Scott Wang Christopher JaegerChristopher Jaeger More articles by this author , Andrea BalthazarAndrea Balthazar More articles by this author , Caleb NelsonCaleb Nelson More articles by this author , Tanya LogvinenkoTanya Logvinenko More articles by this author , and Hsin-Hsiao Scott WangHsin-Hsiao Scott Wang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002533.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Mirabegron, a beta-3 agonist, is approved to treat neurogenic bladder (NB) in children ≥3 years in the United States. It is efficacious with a more favorable side effect profile than anticholinergics in children with NB. Yet, some patients with NB experience coverage denials or substantial delays in starting the medication that could have deleterious effects on urologic health. Our objective was to understand the factors associated with mirabegron access at our center. METHODS: Institutional data was queried identifying all pediatric patients who were prescribed mirabegron from 2012 through 2021. Covariates included patient demographics, neurologic diagnosis, number of anticholinergic medications, mirabegron prescription & start date, insurance, and insurance-related communications. A multivariate logistic regression model was fitted to investigate the impact of various factors on restricted access. Restricted access is defined as insurance denial or a delay in the mirabegron start date by ≥30 days from the initial prescription date. RESULTS: 114 pediatric patients with NB, 88/114 (77%) with a spina bifida diagnosis, were prescribed mirabegron after its release in 2012. The median age at first mirabegron prescription was 12 years (IQR 9-17). 41 patients (36%) experienced restricted access to mirabegron - 29 were denied and 12 were delayed. For those whose access was restricted, the median overall delay was 112 days (IQR: 48-376) following the initial prescription vs 0 days (IQR: 0-1) for those whose access was not restricted. After adjusting for age and number of trialed anticholinergics, undergoing a prior authorization (PA) with an insurance provider (OR=24.0 (95% CI 7.5-109.0), p<0.001) was the only predictor significantly associated with restricted mirabegron access. Being 13 years or older was marginally associated with restricted access (OR= 2.5 (95% CI: 1.0-7.0), p=0.06). CONCLUSIONS: Mirabegron is an effective medication now approved for the treatment of pediatric NB. Over one-third of our NB patients have experienced significant barriers to mirabegron access at our institution. The need for PA was identified as the most significant risk factor associated with restricted access. Payor-mandated restrictions on mirabegron require patients to fail inferior medications and ultimately risk inadequate treatment. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e159 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Jaeger More articles by this author Andrea Balthazar More articles by this author Caleb Nelson More articles by this author Tanya Logvinenko More articles by this author Hsin-Hsiao Scott Wang More articles by this author Expand All Advertisement PDF DownloadLoading ...

Feasibility of Awake Intravesical Botulinum Toxin Injection in Pediatric Neurogenic Bladder

Cystoscopic injection of botulinum neurotoxin (BoNT) is typically performed under general anesthesia in pediatric patients with neurogenic bladder, accumulating anesthetic exposures and operating room costs. As most of these patients already tolerate clean intermittent catheterization (CIC), it has become our practice to offer a trial of awake injection. We report our initial experience here. We hypothesized that higher sensory level, female sex and absence of mental health issues or cognitive delay might predict successful first awake injection and decreased operative times. Surgical records from 2 academic hospitals from 2018-2020 were reviewed. Generalized linear models were fit to determine predictors of success and procedural length. Trial of awake injection was offered to 22 patients. Eighteen patients (8 female, 10 male, 4-20 years old) elected to proceed. All 18 patients were managed with CIC at baseline, 14 had anxiety or behavioral issues, 10 had cognitive delay and 7 had sensory level below S2. Two patients (11%) required conversion to general anesthesia and one of these subsequently opted for a repeat awake injection trial. Fifteen of the 18 patients (83%) had or planned subsequent injections awake. Of the remaining, 1 proceeded to bladder augment, 1 is considering ileovesicostomy and 1 requested subsequent injections under anesthesia. No intraoperative complications occurred. Awake BoNT injection is feasible in pediatric patients with neurogenic bladder managed with CIC, even in the setting of intact sensation, well-managed mental health issues or cognitive delay, thereby increasing the viability of BoNT as an early tool in the management of neurogenic bladder.

The Importance of Early Diagnosis and Management of Pediatric Neurogenic Bladder Dysfunction.

Neurogenic bladder dysfunction is a major source of urologic morbidity in children, especially in those with spina bifida (SB). Complications from progression of bladder dysfunction can include urinary tract infections (UTIs), urinary incontinence, upper tract deterioration, and renal dysfunction or failure. In these children, there has been a recent trend toward proactive rather than expectant management of neurogenic bladder. However, there is a lack of consensus on how to best achieve the three main goals of neurogenic bladder management: 1) preserving kidney function, 2) achieving continence (if desired by the family/individual), and 3) achieving social and functional urologic independence (if appropriate). Hence, our objective was to perform a narrative literature review to evaluate the approaches to diagnosis and management of pediatric neurogenic bladder dysfunction, with special focus on children with SB. The approach strategies vary across a spectrum, with a proactive strategy on one end of the spectrum and an expectant strategy at the other end. The proactive management strategy is characterized by early and frequent labs, imaging, and urodynamic (UDS) evaluation, with early initiation of clean intermittent catheterization (CIC) and proceeding with pharmacotherapy, or surgery if indicated. The expectant management strategy prioritizes surveillance labs and imaging prior to proceeding with invasive assessments and interventions such as UDS or pharmacotherapy. Both treatment strategies are currently utilized and data have historically been inconclusive in demonstrating efficacy of one regimen over the other. We performed a narrative literature evaluating proactive and expectant treatment strategies as they relate to diagnostics and management of Spina Bifida. From the available literature and our practice, a proactive strategy favors greater benefit in preventative management and may decrease risk of renal dysfunction compared with expectant management.

Are Tubular Injury Markers NGAL and KIM-1 Useful in Pediatric Neurogenic Bladder?

The lack of early biomarkers of renal damage in children with neurogenic bladder (NB) prompts us to investigate the role of promising proteins: neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). This prospective analysis was conducted on 58 children with NB and 25 healthy children. We assessed urinary levels of NGAL and KIM-1 in both groups. Age, sex, anthropometric measurements, activity assessment, renal function, and urodynamics parameters were analyzed. The differences between the median uNGAL and uKIM-1 in the NB group compared to control were recorded. However, only uNGAL levels were statistically significantly higher. Statistically significant correlation was found between gender, recurrent urinary tract infections, bladder trabeculation, its compliance, activity assessment, and uNGAL. To conclude, elevated levels of uNGAL may be considered a biomarker of tubular injury in children with NB due to MMC in contrast to uKIM-1.

The TGF-β1 pathway is early involved in neurogenic bladder fibrosis of juvenile rats.

This study investigated whole neurogenic bladder's progression changes, as well as the expression of TGF-β1 fibrosis pathway-related proteins in bilateral spinal nerve-amputated juvenile rats. Sixty-four 8-week-old rats (32 bilateral L6 + S1 spinal nerve amputated and 32 sham operated) were selected. Cystometry was performed. General assessments, Masson, Sirius red, immunohistochemical staining, and western blotting of fibrosis and TGF-β1 pathway-related proteins were conducted using bladder tissues. Cystometry results showed that the basal intravesical pressures and bladder capacities in nerve-amputated rats were significantly higher than those in sham-operated ones. Compared to the sham-operated groups, the bladder size and wall thickness in the nerve-amputated groups increased initially but then decreased over time. However, bladder weight continuously increased over time. Disintegration, thickening, and hypertrophy of the bladder wall were found over time in the amputated rats. Moreover, there was a significant increase in collagen III, and the ratio of collagen III/I was higher in amputated rats (P < 0.01). Finally, the expression of TGF-β1, TGF-βRI, Smad2, and collagen III and I increased in amputated bladder tissues, while Smad6 decreased over time. The main clinical features of pediatric neurogenic bladder (PNB) were detrusor paralysis and continuous intravesical pressure. Biological molecular findings are earlier than the pathophysiological findings. Therefore, early preventing bladder fibrosis by targeting TGF-β1/Smad pathway-related proteins once knowing the PNB diagnosis might be an alternative treatment for PNB. The study found that the main clinical features of PNB were detrusor paralysis, continuous intravesical pressure, and increased TGF-beta/Smad signal proteins over time. The study makes contributions to the literature because it suggests biological molecular findings are earlier than the pathophysiological findings by various staining in PNB. The study investigated whole neurogenic bladder's progression changes, as well as the expression of TGF-β1 fibrosis pathway-related proteins in the spinal nerve-injured PNB juvenile rat models, which suggests that early prevention of bladder fibrosis by targeting TGF-β1/Smad pathway-related proteins once knowing the PNB diagnosis might be an alternative treatment for pediatric neurogenic bladder.

Evaluation of the Pediatric Neurogenic Bladder Dysfunction of the Patients in the King Abdulaziz University Hospital, Jeddah, Saudi Arabia: Pediatric Neurogenic Bladder

A neurogenic bladder results from conditions that affect either the central or peripheral nervous system. This study reviewed all the pediatric neurogenic patients in the King Abdulaziz University Hospital from 2008 to 2018, using their medical records and histories. The patients’ ages were between one month and 16 years during their first diagnosis. Patients with more than 50% missing data were excluded. A total of 678 patients were diagnosed with neurogenic bladder during the study period. But only the data of 212 patients were processed for statistical analysis. The patients’ median age was 9 years. The causes of neurogenic bladder in these patients were 1) spina bifida in 110 patients (51.8% of the sample population), 2) non- neurogenic neurogenic bladder (Hinman syndrome) in 40 (18.8%) cases, 3) bilateral hydronephrosis in 72 (33.9%) patients, and 4) urine incontinence, which was the main complain in 132 (62%) patients. Sixty-four (30%) patients had urine retention and were dependent on catheter. Spina bifida was the main cause of neurogenic bladder in this study group. Upper tract status of the patients during their presentation had affected the complication rates and the decisions to administer surgical intervention.

Development and validation of a bladder trabeculation grading system in pediatric neurogenic bladder

Bladder trabeculation (BT) is commonly noted on cystogram images of patients with neurogenic bladder (NB). BT is associated with a hostile bladder often requiring prompt, more aggressive management. We aimed to define and validate a reliable grading system for BT severity. The proposed grading system will improve clinicians and radiologist's communication and serve as a foundation for future studies in the field of NB. The study was conducted in two phases: 1) Development of a grading system for BT and 2) testing of the proposed grading system for reliability and validity. Agreement between raters was assessed using Cohen's Kappa. Inter-rater reliability and intra-rater reliability was assessed using intra-class correlation coefficients (ICC) and Spearman's p (rho) correlation coefficient. The content of the grading system was assessed for face validity by senior pediatric urology and radiology experts. We observed inter-rater reliability with ICC of 0.998 (95%CI 0.996-0.999, p<0.001), and a Cohen's Kappa ranging from 0.795 to 1.0, p<0.001 and Spearman's p (rho) correlation coefficient ranging from 0.910 to 1.0, p<0.001 between raters on the decided grades of BT. In conclusion, we established a defined grading system for BT severity that has substantial inter/intra-rater reliability and validity. This grading system could be useful for improving clinician and radiologist's communication about the status of a child's bladder wall and serve as a foundation for future studies assessing severity of NB.

Albuminuria in Pediatric Neurogenic Bladder: Identifying an Earlier Marker of Renal Disease

ObjectiveTo investigate the role of albuminuria as a clinical marker of early renal disease in children with neurogenic bladder (NGB) in association with commonly used predictors of renal risk. MethodsCatheterized urine was obtained from 40 patients with NGB at a tertiary pediatric hospital. Albumin-to-creatinine ratio (ACR) was analyzed for associations with estimated glomerular filtration rate, vesicoureteral reflux, hydronephrosis, bladder dynamics, and renal scarring. ResultsAbout 32% (13/40) of NGB patients had elevated ACR (≥30 mg/g. Elevated ACR was associated with Caucasian race, clean intermittent catheterization, hydronephrosis, and vesicoureteral reflux on univariate analysis. In multivariable analysis, presence of vesicoureteral reflux and use of anticholinergic medication were significant predictors of ACR elevation. ConclusionAlbuminuria is an established clinical predictor of renal disease and risk for progression to renal failure. The presence of albuminuria in NGB patients with urinary tract abnormalities suggests these patients may be at increased risk for progressive renal disease. This supports the clinical utility of adding ACR to the evaluation of renal risk in pediatric NGB.