Risk Of Upper Tract Deterioration Research Articles

Understanding an unusual urothelial disorder: cystitis cystica et glandularis

Objectives: To study the presentation and natural course of cystitis cystica et glandularis. Methods: A retrospective analysis of patients with histopathologically confirmed cystitis cystica et glandularis from March 2016 to March 2018 who at least completed their 2 years’ follow-up was performed. Perioperative details along with the last available follow-up were included in the analysis. Results: A total of 10 patients were included. The mean age (± standard deviation) was 33.4 (±14.0) years and nine (90%) were men. The most common presentation was storage and voiding lower urinary tract symptoms (80%) along with haematuria (40%) and dysuria (20%). Four patients had the presence of hydronephrosis in preoperative imaging, of which three patients had bilateral mild hydroureteronephrosis. All the patients underwent transurethral resection of the bladder tumour as all were diagnosed with urinary bladder mass on preoperative imaging. All the patients had a trigonal lesion with a bullous appearance partially obstructing the bladder neck. Six patients underwent double J stenting in the perioperative period. The mean (± standard deviation) follow-up duration was 32.8 (±7.5) months. Patients were kept on regular surveillance with imaging and cystoscopy as indicated. Eight patients (80%) developed recurrence in the follow-up period. The mean number of recurrences was 1.5 (±1.1). One of the patients had to undergo augmentation ileocystoplasty with bilateral ureteric reimplantation because of the recurrent lesion with small contracted bladder, while another patient underwent cystectomy with urinary diversion owing to recurrence and refractory lower urinary tract symptoms. Besides, there was no evidence of malignancy after this entity in any of the patients. Conclusion: Cystitis cystica et glandularis is a rare clinic pathological entity which often mimics bladder tumour. Cystitis cystica et glandularis is common in men and often presents with lower urinary tract symptoms. Transurethral resection forms the mainstay of treatment. However, it is often associated with upper tract hydronephrosis. Its controversial premalignant nature compounded with recurrence and risk of upper tract deterioration warrants close surveillance. Level of evidence: 4

Long-Term fate of the upper urinary tract and ITS association with continence in exstrophy patients

Scarce data is available in literature about the upper urinary tract outcomes of patients with Exstrophy-Epispadias Complex (EEC). After bladder closure during childhood, EEC bladders can become hostile to the upper tracts after bladder by exposing them to high pressures, leading to hydronephrosis (HN) and kidney damage. Similarly, vesicoureteral reflux (VUR) may be present and increase the likelihood for pyelonephritis. We sought to assess long-term upper urinary tract outcomes by evaluating renal function, HN and VUR; and to assess if upper urinary tract outcomes are associated with continence status. A retrospective review of EEC patients having ≥1 surger(y) (ies) at our institution from 1990 until 2019 was performed. Renal function was assessed by evaluating last available estimated glomerular filtration rate (eGFR) and creatinine values. HN was assessed on ultrasound and classified according to the SFU-classification. Patients with recurrent febrile urinary tract infections (UTI) or pyelonephritis underwent a voiding-cystourethrogram (VCUG) assessing VUR, graded following the 'International system of radiographic grading of VUR'. Descriptive and comparative statistical analysis were performed to assess if upper tract outcomes are associated with continence status. Forty-eight patients (75% male) had a median (IQR) follow-up of 18 (10-21) years. The table shows upper tract outcomes for the entire group and stratified by continence status. The median creatinine was 0.6 (0.2-0.9) mg/dL and median eGFR was 108 (72-160) mL/min/1.73m [2]. In two patients (4.2%), HN (SFU-grade 2) was detected. Thirty-six patients (75%) underwent VCUG, revealing high-grade VUR (stage IV-V) in 8 patients (17%) and low-grade VUR (stage I-III) in 7 patients (15%). Continence was associated with a higher need for VCUG (p=0.02) and a higher presence of VUR (p=0.03). Renal function in EEC patients and non-EEC patients is comparable when age matched. Only 6% had low-grade HN which was asymptomatic. 17% had high-grade VUR, which is little compared to literature (40-70%). However, results in literature are described in patients with a 'one-stage' bladder closure, whereas some of our patients had a 'two-stage' procedure. A one-stage procedure creates higher bladder pressures resulting in higher VUR-rates. Statistical analysis has showed that continence is associated with a higher prevalence of recurrent febrile UTI's or pyelonephritis and of VUR. No statistically differences were found between continent and incontinent patients concerning creatinine and eGFR value (p=0.52 and p=0.29), nor in the prevalence of hydronephrosis (p=0.36). However, results of this study suggest that continent patients may portend a higher risk of upper tract deterioration with recurrent febrile UTI's and pyelonephritis due to VUR. Close monitoring of the upper tract status is therefore as important as focus on continence. Large-scale prospective studies defining renal function as well as pyelonephritis rates are needed to optimize the management of the upper tracts in EEC patients.

Complications of Pediatric Bladder Reconstruction in the Adult Patient

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

Valve Bladder Syndrome Associated with Posterior Urethral Valves: Natural History, Work-up, and Management

This review focuses on the diagnosis, evaluation, and management of valve bladder syndrome (VBS) following initial treatment of posterior urethral valves (PUV). Based on current literature, we discuss the effect of PUV management in VBS and investigate the role of medications, catherization, surgery, and novel interventions. The current initial management of PUV involves valve ablation. Cutaneous urinary diversions are secondary options based on patient characteristics, PUV severity, and response to catheter drainage. VBS can independently occur as a consequence of PUV due to reduced nephron endowment leading to renal tubular dysfunction and polyuria, high bladder filling pressures secondary to a non-compliant bladder, and poor bladder emptying due to bladder neck hypertrophy. Options to mitigate the risk of upper tract deterioration include behavioral modifications and medical therapy (anticholinergics or alpha-blockers), bladder neck incision, clean intermittent catheterization and overnight catheter drainage, or more invasive approaches such as botulinum toxin injections and creation of a Mitrofanoff channel. Several experimental therapies to attenuate bladder fibrosis are currently under investigation. The management of VBS starts with initial management of PUV and is subsequently dependent on the evolving bladder filling dynamics and bladder neck hypertrophy affecting bladder filling and emptying. This requires a pre-emptive management protocol to identify VBS in boys with PUV to prevent renal damage using various therapeutic interventions. The lack of prospective studies to investigate effectiveness of available therapeutic options to treat VBS limits the development of an evidence-based approach for severity-based management of PUV-associated VBS.

Robot-Assisted Laparoscopic Dismembered Ureteral Reimplantation with Extracorporeal Tapering for Megaureter

Abstract Introduction: Children with symptomatic megaureter may have elements of obstruction, vesicoureteral reflux (VUR), or both, and are at risk for upper tract deterioration if left uncorrected. Although the gold standard is currently open reimplantation with ureteral tapering, some authors have advocated a laparoscopic/robotic approach.1–5 We present a series of seven pediatric patients with symptomatic megaureter and describe a novel technique for surgical correction involving a minimally invasive, three-port robot-assisted laparoscopic approach with a dismembered extravesical posterior ureteroneocystostomy after extracorporeal ureteral tapering through the ipsilateral port site. Materials and Methods: Since 2012, symptomatic pediatric megaureter has been managed at our institution by robot-assisted laparoscopic reimplantation with extracorporeal tapering. Chart review identified seven pediatric cases, including nine megaureters (two bilateral presentations). Baseline demographics collected included...

Urodynamic catheter moisture sensor: A novel device to improve leak point pressure detection.

High-quality urodynamic studies in patients with neurogenic lower urinary tract dysfunction are important, as UDS may be the only reliable gauge of potential risk for upper tract deterioration and the optimal tool to guide lower urinary tract management. Reliance on direct visualization of leakage during typical UDS remains a potential source of error. Given the necessity of accurate leak point pressures, we developed a wireless leak detection sensor to eliminate the need for visual inspection during UDS. A mean decrease in detrusor leak point pressure of 3 cm/H2 0 and a mean 11% decrease in capacity at leakage was observed when employing the sensor compared to visual inspection in children undergoing two fillings during a single UDS session. Removing the visual inspection component of UDS may improve accuracy of pressure readings. Neurourol. Urodynam. 35:647-648, 2016. © 2015 Wiley Periodicals, Inc.

Long-Term Outcomes Following Bladder Augmentation in Children with Neurogenic Bladder

Bladder augmentation remains the final step in the management of refractory neurogenic bladder (NGB) for many children who have failed medical management. The long-term risks and benefits of augmentation surgery are important to understand when counseling patients about management options and when following augmented patients postoperatively. Benefits of bladder augmentation include improved continence, decreased risk of upper tract deterioration, possibly improved quality of life, and even reduced risk of renal-related mortality. However, risks are not trivial and include the potential need for further surgery, calculi formation, bladder perforation, acid-base disturbances, vitamin B12 deficiency, and possibly malignancy. Therefore, patients considered for augmentation should be well counseled and selected and subsequently must be followed closely by an experienced urologist for the duration of their lives.

Effect of detethering on bladder function in children with myelomeningocele: Urodynamic evaluation

Aim of Work:To study the effect of detethering of the cord on urodynamic changes in patients with myelomeningocele.Materials and Methods:We retrospectively reviewed the urodynamic data of 37 patients. In all of them myelomeningocele primary repair was carried out. The patients were divided into two groups: (1) those who underwent detethering of the cord and (2) those who did not. Neurourological examination, filling cystometry, assessment of bladder management, and fecal continence were studied in all patients.Results:Eleven (29.7%) out of 37 patients underwent detethering of the cord. The mean age at presentation was 10.1 ± 4 and 10.8 ± 7 years in groups 1 and 2, respectively (P 0.7). Nocturnal and diurnal enuresis was found in 45% of group 1, while it was found in 69% of group 2. Fecal soiling was detected in 18% in group 1 and in 38.5% in group 2. Mean bladder capacity was 210 ± 125 cc and 199 ± 120 cc for groups 1 and 2, respectively (P 0.8). Uninhibited detrusor contractions were noticed in nine patients (82%) of group 1 and in 21 patients (81%) of group 2. Delta det LPP was lower in group 1 (35 ± 19 cm H2O) than in group 2 (46 ± 40 cm H20).Conclusion:Detethering of the cord had a positive impact on patients with myelomeningocele in terms of lowering of det LPP and accordingly decreasing the risk of upper tract deterioration.

PATIENTS WITH MULTIPLE SCLEROSIS AND NEUROVESICAL DYSFUNCTION ARE AT EXTREMELY LOW RISK FOR UPPER TRACT DETERIORATION

You have accessJournal of Urology1 Apr 2008PATIENTS WITH MULTIPLE SCLEROSIS AND NEUROVESICAL DYSFUNCTION ARE AT EXTREMELY LOW RISK FOR UPPER TRACT DETERIORATION Sophie G Fletcher, Alienor S Gilchrist, Elliot Frohman, and Gary E Lemack Sophie G FletcherSophie G Fletcher More articles by this author , Alienor S GilchristAlienor S Gilchrist More articles by this author , Elliot FrohmanElliot Frohman More articles by this author , and Gary E LemackGary E Lemack More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)61034-4AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "PATIENTS WITH MULTIPLE SCLEROSIS AND NEUROVESICAL DYSFUNCTION ARE AT EXTREMELY LOW RISK FOR UPPER TRACT DETERIORATION." The Journal of Urology, 179(4S), p. 353 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 353 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Sophie G Fletcher More articles by this author Alienor S Gilchrist More articles by this author Elliot Frohman More articles by this author Gary E Lemack More articles by this author Expand All Advertisement PDF downloadLoading ...

Preservation of renal function in children with myelomeningocele managed with basic newborn evaluation and close followup.

Children with myelomeningocele who leak with high intravesical pressures are at risk for upper urinary tract deterioration. Urodynamic study shortly after birth and routinely thereafter has been advocated to predict which newborns are at risk for upper tract deterioration. We hypothesize an approach that excludes routine application of urodynamic evaluation in neonates, reserving this study for use only when clinically indicated, is a safe and effective management option. Of 188 patients seen in the myelomeningocele clinic 84 underwent initial evaluation at age 6 months or less and comprise the study group. Initial evaluation consisted of a history, physical examination, urine culture and renal ultrasound. Infants with hydronephrosis or evidence of retention were placed into a high risk group and all others were placed into a low risk group. High risk patients underwent prompt urodynamic evaluation. High and low risk patients were followed closely at 2 to 4-month intervals with serial physical examination, upper tract imaging and urine culture. Conversion from low to high risk occurred with new onset hydronephrosis, febrile urinary tract infection, urinary retention or incidental finding of vesicoureteral reflux at the time of evaluation for continence. These findings warranted urodynamic evaluation and appropriate intervention. Upper tract deterioration, defined as new onset hydronephrosis, was distinguished from renal deterioration, defined as cortical thinning or scarring, failure of renal growth or decreased renal function on renal scan. A total of 18 infants were placed into the high risk group at initial evaluation, including 12 for retention and 6 for hydronephrosis. The majority of patients were treated with clean intermittent catheterization or vesicostomy. Of the 65 infants placed into the low risk group 29 were converted to high risk at a mean age of 3.1 years, most commonly for febrile urinary tract infection (45%), and appropriate intervention was instituted. Mean followup is 10.4 years (range 0.25 to 26.5). Despite the occurrence of upper tract deterioration, renal deterioration occurred in only 2 of the 162 total renal units (1.2%). Basic evaluation of the newborn with myelomeningocele along with careful followup and intervention when indicated results in an excellent rate of renal preservation and represents a safe method of management.

Preservation of Renal Function in Children With Myelomeningocele Managed With Basic Newborn Evaluation And Close Followup

Children with myelomeningocele who leak with high intravesical pressures are at risk for upper urinary tract deterioration. Urodynamic study shortly after birth and routinely thereafter has been advocated to predict which newborns are at risk for upper tract deterioration. We hypothesize an approach that excludes routine application of urodynamic evaluation in neonates, reserving this study for use only when clinically indicated, is a safe and effective management option. Of 188 patients seen in the myelomeningocele clinic 84 underwent initial evaluation at age 6 months or less and comprise the study group. Initial evaluation consisted of a history, physical examination, urine culture and renal ultrasound. Infants with hydronephrosis or evidence of retention were placed into a high risk group and all others were placed into a low risk group. High risk patients underwent prompt urodynamic evaluation. High and low risk patients were followed closely at 2 to 4-month intervals with serial physical examination, upper tract imaging and urine culture. Conversion from low to high risk occurred with new onset hydronephrosis, febrile urinary tract infection, urinary retention or incidental finding of vesicoureteral reflux at the time of evaluation for continence. These findings warranted urodynamic evaluation and appropriate intervention. Upper tract deterioration, defined as new onset hydronephrosis, was distinguished from renal deterioration, defined as cortical thinning or scarring, failure of renal growth or decreased renal function on renal scan. A total of 18 infants were placed into the high risk group at initial evaluation, including 12 for retention and 6 for hydronephrosis. The majority of patients were treated with clean intermittent catheterization or vesicostomy. Of the 65 infants placed into the low risk group 29 were converted to high risk at a mean age of 3.1 years, most commonly for febrile urinary tract infection (45%), and appropriate intervention was instituted. Mean followup is 10.4 years (range 0.25 to 26.5). Despite the occurrence of upper tract deterioration, renal deterioration occurred in only 2 of the 162 total renal units (1.2%). Basic evaluation of the newborn with myelomeningocele along with careful followup and intervention when indicated results in an excellent rate of renal preservation and represents a safe method of management.

VIDEO URODYNAMIC FINDINGS IN MEN WITH THE CENTRAL CORD SYNDROME

The central cord syndrome reportedly has a favorable prognosis and rehabilitation outcome. However, to our knowledge the status of the lower urinary tract in patients with the central cord syndrome is unclear. We report on 22 men with the central cord syndrome who were evaluated by video urodynamics. From 1986 to the present we identified 22 men with a mean age of 51 years who had the central cord syndrome and were included in the Houston Veterans Affairs spinal cord registry. All patients underwent video urodynamic evaluation a mean of 34.5 months after injury. Video urodynamic testing for vesicourethral dysfunction was normal in 3 patients, while it showed bladder outlet obstruction secondary to benign prostatic hyperplasia in 2, detrusor areflexia in 4, external detrusor-sphincter dyssynergia in 11, detrusor hyperreflexia with a synergistic external urethral sphincter in 1 and detrusor hypocontractility in 1. Urinary tract infection recurred in 3 patients with external detrusor-sphincter dyssynergia and urolithiasis developed in 2. Urodynamic testing revealed a high incidence of external detrusor-sphincter dyssynergia in men with the central cord syndrome. Due to the potential for upper tract deterioration all patients with the central cord syndrome should undergo baseline urodynamic studies. Those at high risk for upper tract deterioration with external detrusor-sphincter dyssynergia or a loss of compliance should be treated more aggressively with clean intermittent catheterization and anticholinergic medication when possible.

THE URODYNAMIC PROFILE OF MYELODYSPLASIA IN CHILDHOOD WITH SPINAL CLOSURE DURING GESTATION

Spinal dysraphism is the most common cause of neurogenic bladder dysfunction in newborns. Urodynamic findings in these patients include uninhibited bladder contractions, bladder areflexia, decreased compliance and detrusor-sphincter dyssynergia. Early urodynamic studies are recommended for spina bifida to help identify bladder characteristics that may cause a risk of upper tract deterioration. We recently evaluated a new early type of intervention involving closure of the neural tube defect during gestation in 25 patients at our institution. We hypothesize that this procedure results in decreased exposure of the spinal cord to amniotic fluid, which may improve neurological function. To date we have evaluated 16 of the 25 patients with video urodynamics. We compared the results to those in the literature on patients with myelomeningocele and without prenatal intervention. We performed urodynamic testing in 16 patients with a mean age of 6.5 months, including cystometrography, fluoroscopic evaluation of filling and voiding, pelvic floor electromyography and post-void residual urine measurement. In addition, we retrospectively reviewed renal ultrasound, voiding cystourethrography, catheterization need, number of urinary tract infections and medication in these cases. Uninhibited detrusor contractions and an areflexic bladder were identified in 6% and 43% of patients, respectively, while 19% had decreased compliance and 75% had leak point pressure greater than 40 cm. water. Mean bladder capacity was 40 cc and 31% of patients had much lower capacity than expected for age. Previous renal ultrasound and voiding cystourethrography showed evidence of upper tract dilatation and reflux in 2 cases, respectively. Intermittent catheterization and anticholinergic therapy were required by 1 patient each and 1 had a significant urinary tract infection. Urodynamic findings in this population are comparable to those previously reported in the literature in patients with spina bifida without prenatal closure of the spinal defect. The lower incidence of urinary tract infection and reflux in our study probably represents more aggressive early urological management rather than neurological improvement. These urodynamic studies were performed early in life and future evaluation may ultimately reveal improved bladder function compared with that in others with myelodysplasia. However, at this time we recommend that patients who undergo spinal cord defect closure during gestation be evaluated and treated in the same manner as those with myelomeningocele but without fetal intervention.

Role of Urologic Evaluation in the Adult Spina bifida Patient

Objective: To evaluate a population of adult spina bifida patients performing clean intermittent catheterization (CIC) and determine the indications for urologic consultation and intervention. Methods: We evaluated 52 adults (ages 18–37 years) with a history of lumbar myelomeningocele, all of whom performed CIC and were dry between catheterizations. We excluded 12 patients with conditions potentially predisposing to renal insufficiency (staghorn calculus, n = 3; multiple admissions for pyelonephritis, n = 5; history of vesicoureteral reflux, n = 2, and renal scarring on ultrasound, n = 2), leaving 40 patients evaluable. Each patient kept a catheterization diary for 2 weeks from which an average catheterized volume was recorded. Results: In patients with normal ultrasound and normal serum creatinine (<1.5 mg/dl), there were no individuals (0/20) whose average catheterized volume corresponded to a bladder pressure of >40 cm H₂O on cystometry. However, in the patients with hydronephrosis and/or elevated creatinine, 30% (6/20) had average catheterized volumes corresponding to a bladder pressure of >40 cm H₂O, and are therefore theoretically at risk for upper tract deterioration. Conclusion: Many spina bifida patients receive urologic care only as children, and those without urinary calculi or urinary incontinence are assumed to be urologically stable. However, certain patients have urodynamic parameters which put them at risk for renal deterioration even if they appear to be problem-free. We recommend a yearly renal ultrasound and serum creatinine determination in all adult spina bifida patients with immediate urologic consultation and urodynamics if either is abnormal.

Hydroureteronephrosis After Spinal Cord Injury: Effects of Lower Urinary Tract Dysfunction on Upper Tract Anatomy

The hypothesis that upper tract changes in the absence of vesicoureteral reflux are a function of chronically elevated intravesical pressure has had increasing impact on the management of the lower urinary tract in patients with lower tract dysfunction secondary to neurogenic bladder disease. The application of our growing ability to measure bladder and bladder outlet function objectively and in a more physiologic manner through expanding urodynamic techniques will continue to provide information that can be applied to the diagnosis and treatment of lower urinary tract dysfunction and hydroureteronephrosis after spinal cord injury. Current methods of classifying lower urinary tract behavior have not provided the ability to identify accurately those patients at greatest risk for upper tract deterioration. The application of new techniques and the use of new measures may increase our ability to identify these patients.

Management of the Obstructed Urinary Tract Associated with Neurogenic Bladder Dysfunction

The child with neurogenic bladder dysfunction may suffer from lower urinary tract obstruction, which, if untreated, can result in upper urinary tract deterioration. It is prudent to identify those newborns and infants who are at risk for upper urinary tract deterioration and advise an appropriate treatment protocol. In order to identify those children at risk, a thorough examination is required, along with appropriate upper urinary tract imaging studies and urodynamic assessment of the bladder. Infants and children at risk for upper tract deterioration are those who have intermittent or continuous detrusor pressure elevation above 40 cm H2O. We have identified the safe period, which is the time during which the bladder remains at a pressure lower than 40 cm H2O. Our management protocol for each child is individualized and based on increasing the safe period. The safe period can be increased with a combination of intermittent catheterization, administration of medications, and, in some cases, surgical reconstruction. With compulsive evaluation and intensive management, many of the previous upper urinary tract changes associated with the obstructed neurogenic bladder can be averted. With the above factors in mind, we have defined the period of bladder filling and storage where the pressure is below 40 cm H2O as the safe period. The ideal bladder for maintenance of normal upper tracts would have a long safe period and low voiding pressure. Our treatment protocol for the neurogenic bladder is therefore dependent on identifying those children who have very short or nonexistent safe periods. These are the children who are at risk for upper tract deterioration.