+
MODEL
Journal of Pediatric Urology (2014) xx, 1e5
New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder W. Snodgrass a,*, C. Villanueva b, P. Gargollo a, M. Jacobs a a b
UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9142, USA University of Nebraska Medical Center, 988102 Nebraska Medical Center, Omaha, NE 68196-8102, USA
Received 23 December 2013; accepted 20 February 2014
KEYWORDS Bladder neck; Augmentation; Vesicoureteral reflux; Hydronephrosis; Neurogenic bladder
Abstract Objective: We report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence. Materials and methods: Consecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Results: There were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (40 cm) or continence status (dry vs. wet). Conclusions: Upper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation. ª 2014 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
* Corresponding author. UT Southwestern and Children’s Medical Center, 1935 Medical District Dr., MS F4.04, Dallas, TX 75235. Tel.: þ1 214 456 2481; fax: þ1 214 456 8803. E-mail addresses: [email protected] (W. Snodgrass), [email protected] (C. Villanueva), patricio. [email protected] (P. Gargollo), micah.jacobs@childrens. com (M. Jacobs).
Introduction Surgery on the bladder outlet to achieve urinary continence in children with neurogenic bladder is known to potentially increase detrusor pressures, sometimes resulting in hydronephrosis (HN) and/or vesicoureteral reflux (VUR). This
http://dx.doi.org/10.1016/j.jpurol.2014.02.005 1477-5131/ª 2014 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
+
MODEL
2 development was previously reported (in the 1980s) following artificial urinary sphincter (AUS) implantation [1e4], but now, more than 25 years later, the risk for upper tract changes remains unclear. Given reports that preoperative urodynamics (UD) do not predict postoperative detrusor pressure responses [5], we performed bladder outlet procedures for neurogenic incontinence in consecutive children without augmentation, beginning in 2000. We now present a descriptive study reporting rates of new HN and VUR in these patients.
Materials and methods The diagnosis of bladder outlet insufficiency was made in children with neurogenic bladders and urinary incontinence with detrusor leak point pressure 40 cm despite oral anticholinergics. CIC was done every 3 h, sometimes supplemented with overnight continuous catheter drainage in those with an EFP >40 cm.
Upper tract imaging Preoperative renal sonography and cystography during UD were obtained in all patients. Similar postoperative imaging was scheduled for 6 months and 1 year. Renal sonography was done annually thereafter, while cystography during UD was done annually or every other year. Sonogram outcomes were described using Society for Fetal Urology (SFU) terminology. VUR was graded according to International Reflux Study recommendations.
W. Snodgrass et al.
Bladder outlet surgery From 2000 to 2007, fascial sling was wrapped tightly 360 around the bladder neck (BNS) without a urethral catheter, and then elevated and secured to the pubic periosteum using 2-0 polypropylene sutures [6]. In an attempt to improve continence, beginning in mid2007 Leadbetter/Mitchell bladder neck (BN) revision (LMS) was done to reduce the caliber of the proximal urethra and BN by 50% before the 360 tight fascial sling was placed. This LMS procedure began with a transverse incision distally from 3 to 9 o’clock in the urethra near its exit from the pelvis. The incision was then extended bilaterally proximally to and then through the BN, ending just below the trigone. Care was taken to maintain uniform width of the dorsal urethral strip into and above the BN. This strip was then tubularized using 4-0 polydioxanone continuous suture in a single layer. Then, the sling was wrapped tightly 360 and secured to the pubic periosteum. A urethral catheter was not used postoperatively [7]. In all cases, the bladder was hitched to the undersurface of the rectus muscle near the umbilicus, and a Mitrofanoff channel created in the umbilicus, preferentially using the appendix. Postoperative urinary drainage was through an 8Fr feeding tube in the Mitrofanoff channel and a suprapubic tube, with diversion maintained for approximately 1 month. After catheter removal, all patients resumed preoperative oxybutynin dosing and CIC. Initially, overnight catheter drainage was reserved for those found to have detrusor pressures >40 cm water on UD, but beginning in 2010 it was recommended for all patients until the first postoperative UD was obtained. Those with an EFP >40 cm continued use thereafter.
Continence Continence was defined as “dry”, no urinary leakage requiring pads. Outcomes are reported at last clinical follow-up. Patients undergoing BN closure for persistent incontinence or subsequent augmentation are reported according to their last assessment before this procedure. UD data, medical therapy, imaging results, and continence outcomes were all recorded at the time of service into a database, which was reviewed with institutional review board approval.
Statistical analysis Chi-square software.
analysis
was
done
using
Internet-based
Results From 2000 to 2012, 83 consecutive children underwent bladder outlet surgery. None had prior or simultaneous augmentation. Three boys who had primary BN closure when BNS (n Z 1) or LMS could not be done were excluded from the review. Another two girls were excluded because
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
+
MODEL
New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery of simultaneous duplicated ureterocele surgery affecting upper tract assessment. One boy had intestinal dehiscence from Malone Antegrade Continence Enema (MACE), resulting in pelvic inflammatory reaction with loss of the Mitrofanoff and sling, and he was also excluded. There was no follow up in two patients after BNS. Therefore, the final study cohort included 36 BNS and 39 LMS done in 44 boys and 31 girls (mean age 7.5 years [range 3e18 years]). Anticholinergic therapy was oral (n Z 60), intravesical (n Z 4), or oral plus intravesical (n Z 9). Two patients did not take anticholinergics. Overnight catheter drainage was used as long-term management in 14 patients. During a mean follow-up period of 48 months (range 4e100 months), 17 (23%) patients had at least one renal sonogram or cystogram showing HN or VUR. HN and VUR were both seen at different times in three of these patients. Transient SFU grade 2 HN was found on the first postoperative sonogram in two patients: unilateral in one, and bilateral in the other. Similar unilateral grade 2 HN was found in another five children at a mean follow-up time of 37 months (range 18e66 months). Unilateral grade 3 HN occurred in one boy at 34 months. All grade 2 HN resolved with medical therapy, consisting of only re-emphasizing compliance with CIC and anticholinergics in three, increasing anticholinergics to four times daily in two or adding intravesical instillation in two, and adding overnight catheter drainage in one patient. No HN was subsequently seen during a mean follow-up of 27 months (range 12e72 months). The boy with grade 3 HN had intravesical instillation added to his regimen of oral anticholinergic plus overnight drainage, and had complete resolution of the HN at follow-up renal sonography 4 months later. New VUR was observed in 12 patients (unilateral in 10), with grades I (n Z 1), II (n Z 8), III (n Z 2), and IV (n Z 3) found at the initial postoperative cystogram in five or at a mean of 35 months (range 22e70 months). Spontaneous resolution occurred without treatment in two patients and in another with addition of overnight drainage, all with grade II VUR. Otherwise, we considered the presence of VUR an indication for its treatment, assuming it increased risk for renal scarring. Dextranomer/hyaluronic acid (Dx/ HA) injection was done in seven patients, with resolution in five and persistent grade 2 in the other two. Reimplantation was done in two patients at the time of additional BN surgery for persistent incontinence. Mean UD EFPs were >40 cm (mean 49 cm) in 23 patients, 40 cm and upper tract changes. For example, the mean EFP in those with new HN was 32.5 cm (range 6.0e70.0 cm), with only three patients having pressures >40 cm. All SFU grade 2 HN resolved during the sonography when it was first discovered by draining the bladder, while the case of unilateral grade 3 HN diminished to grade 2 by drainage. All these patients were managed by medical therapy without recurrence. The etiology of new VUR diagnosed postoperatively was unclear. It was found in the initial UD after surgery in 5/12 patients, all following LMS. Possibly, elongation of the proximal urethra to near the ureteral orifices disturbed the trigone in these children, but VUR was not observed in the other 34 LMS cases, despite presumably similar surgery. High intravesical pressures distorting the trigone or overcoming ureteral coaptation did not appear to explain new VUR, as only four patients had EFPs 40 cm, while the remaining eight had a mean EFP of 20 cm when reflux occurred. However, it is possible that EFP was reduced in some cases by the onset of VUR acting as a pop-off. In two cases, new VUR was found at the time of UD during assessment for tethered cord, both with EFPs 40 cm, which was been reported to be effective in a systematic literature review [10]. We chose a 3-h interval for CIC to approximate a normal bladder-emptying schedule. In a prior comparison of patients undergoing BN surgery with and without augmentation, we reported no differences in health-related quality of life based on increased anticholinergic use or CIC frequency in those not augmented [11]. In 1986, three retrospective studies called attention to upper tract changes following AUS placement without augmentation in children, mostly with neurogenic bladders. Roth et al. [1] reported HN in 9/44 (20%) patients at a mean of 32 months, which resolved in five with medical management, and was treated by augmentation in another three with no mention of a preliminary trial of CIC and anticholinergics. Bauer et al. [4] found new HN in 3/ 35 (9%) myelodysplastics, one attributed to cord tethering, while Light and Pietro [2] reported HN in 4/20 (20%) patients with myelodysplasia, including two who apparently had diminished compliance preoperatively that worsened after surgery. Neither stated when changes occurred. Both reported that these patients were unresponsive to medical therapy, but neither the anticholinergic medication and dose nor means for bladder emptying were described. A decade later, Kronner et al. [5] described outcomes retrospectively in 45 patients who had AUS implantation, drawn from a larger cohort of 80 children with myelodysplasia from which the other 35 were excluded because of prior or simultaneous augmentation. Differences in these two groups, if any, were not clear, as decisions regarding augmentation were at the discretion of various surgeons without defined criteria. During a mean follow-up of 49 months augmentation was done in nine (20%) patients for upper tract deterioration (not further described), of which four also had “poor” bladder compliance with a mean of 8 5 cm/mL water. Pre-augmentation medical therapy was not described. More recently, Dave et al. [12] retrospectively reviewed the records of 48 children with myelodysplasia and incontinence who had surgical therapy, of which 15 had various BN surgeries without augmentation. As with Kronner et al. [5], the decision-making process for augmentation was not described. Four patients without augmentation had a trabeculated bladder with HN and VUR preoperatively. New HN or VUR occurred during a mean follow-up of 135 months in the other 11 children. All had medical therapy with CIC (every 4 h) and anticholinergics, but medication and dosing were not stated. BNS without augmentation was reported Gormley et al. [13] in 12 adolescent girls, mostly with myelodysplasia, with another three having prior or simultaneous enterocystoplasty for “poor” bladder compliance. Of the 12 patients with only BNS, four had prior ureteral reimplantation. Postoperative UD cystography and renal sonography were obtained annually. During a mean follow-up of 54 months, upper tracts were stated to be normal in all. We are not aware of other reports on BNS without augmentation that describe upper tract status after surgery. Our series is unique in that it involved consecutive patients with neurogenic outlet incompetency undergoing BNS
W. Snodgrass et al. or LMS. There was no selection bias, as none had prior or simultaneous augmentation, and no other patient had surgery for an incompetent outlet during the study period. In addition, all followed a similar protocol for postoperative assessment and medical therapy, with data recorded prospectively. Persistent upper tract changes (all VUR) occurred in only 9/75 (12%) children. Other patients with VUR or HN resolved these findings with medical management. No child had augmentation for upper tract deterioration. These data suggest patients with HN or VUR after BN surgery for neurogenic incontinence should have medical therapy such as we describe before considering enterocystoplasty. A weakness of this study is the lack of information regarding individual renal function changes, if any, in these patients both with and without HN or VUR. Dimercaptosuccinic acid scintigraphy was not included in the protocol during the reported study period. In addition, although serum creatinines were all normal, we did not determine creatinine clearances. Another potential criticism of our report is continence outcomes in these patients. We strictly defined dryness as no pad use. Consequently, some patients who only experienced dampness contained by 1e2 pads per day, and so were improved over their preoperative status, were still considered wet for this analysis, in part because such leakage, though slight, could provide a pop-off mechanism to compensate for increased bladder pressures and prevent new HN or VUR. A detailed analysis of all these patients will be reported separately, but of the 75, 36 (48%) were not dry, including 10 who used fewer than two pads daily, three who underwent re-operative LMS, 18 who had BN closure, and five who were wet with more than two pads per day at last evaluation. The other 52% were dry, not requiring pads for urinary incontinence. Others describing BN sling procedures, the majority done with augmentation, report dryness in 37%, 47%, 59%, and 88%, respectively [14e17].
Conclusions New HN and/or VUR developed in 23% of patients within a mean follow-up of 48 months after BNS or LMS without augmentation. All HN and 25% of VUR resolved with changes in medical therapy, while Dx/HA injection was successful in 71% of attempted procedures for reflux. These data support initial medical or minimally invasive therapy for new HN and VUR. Upper tract changes were not predicted by continence status or by EFP. VUR occurred more often after LMS, but 75% of patients undergoing LMS did not develop postoperative reflux. No patient required augmentation for upper tract changes.
Conflict of interest None.
Funding None.
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
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New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery
References [1] Roth DR, Vyas PR, Kroovand RL, Perlmutter AD. Urinary tract deterioration associated with the artificial urinary sphincter. J Urol 1986;135:528e30. [2] Light JK, Pietro T. Alteration in detrusor behavior and the effect on renal function following insertion of the artificial urinary sphincter. J Urol 1986;136:632e5. [3] Churchill BM, Gilmour RF, Khoury AE, McLorie GA. Biological response of bladders rendered continent by insertion of artificial sphincter. J Urol 1987;138:1116e9. [4] Bauer SB, Reda EF, Colodny AH, Retik AB. Detrusor instability: a delayed complication in association with the artificial sphincter. J Urol 1986;135:1212e5. [5] Kronner KM, Casale AJ, Cain MP, Zerin MJ, Keating MA, Rink RC. Bladder calculi in the pediatric augmented bladder. J Urol 1998;160:1096e8. [6] Snodgrass WT, Elmore J, Adams R. Bladder neck sling and appendicovesicostomy without augmentation for neurogenic incontinence in children. J Urol 2007;177:1510e4. [7] Snodgrass W, Barber T. Comparison of bladder outlet procedures without augmentation in children with neurogenic incontinence. J Urol 2010;184(Suppl. 4):1775e80. [8] Snodgrass W, Barber T, Cost N. Detrusor compliance changes after bladder neck sling without augmentation in children with neurogenic urinary incontinence. J Urol 2010;183: 2361e6. [9] Bolduc S, Moore K, Lebel S, Lamontagne P, Hamel M. Double anticholinergic therapy for refractory overactive bladder. J Urol 2009;182(Suppl. 4):2033e8.
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[10] Guerra LA, Moher D, Sampson M, Barrowman N, Pike J, Leonard M. Intravesical oxybutynin for children with poorly compliant neurogenic bladder: a systematic review. J Urol 2008;180:1091e7. [11] Snodgrass W, Keefover-Hicks A, Prieto J, Bush N, Adams R. Comparing outcomes of slings with versus without enterocystoplasty for neurogenic urinary incontinence. J Urol 2009; 181:2709e14. [12] Dave S, Pippi Salle JL, Lorenzo AJ, Braga LH, Peralta-Del Valle MH, Bagli D, et al. Is long-term bladder deterioration inevitable following successful isolated bladder outlet procedures in children with neuropathic bladder dysfunction? J Urol 2008;179:1991e6. [13] Gormley EA, Bloom DA, McGuire EJ, Ritchey ML. Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol 1994;152:822e5. [14] Barthold JS, Rodriguez E, Freedman AL, Fleming PA, Gonzalez R. Results of the rectus fascial sling and wrap procedures for the treatment of neurogenic sphincteric incontinence. J Urol 1999;161:272e4. [15] Chrzan R, Dik P, Klijn AJ, de Jong TP. Sling suspension of the bladder neck for pediatric urinary incontinence. J Pediatr Urol 2009;5:82e6. [16] Perez LM, Smith EA, Broecker BH, Massad CA, Parrott TS, Woodard JR. Outcome of sling cystourethropexy in the pediatric population: a critical review. J Urol 1996;156:642e6. [17] Castellan M, Gosalbez R, Labbie A, Ibrahim E, Disandro M. Bladder neck sling for treatment of neurogenic incontinence in children with augmentation cystoplasty: long-term followup. J Urol 2005;173:2128e31.
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
MODEL
Journal of Pediatric Urology (2014) xx, 1e5
New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder W. Snodgrass a,*, C. Villanueva b, P. Gargollo a, M. Jacobs a a b
UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9142, USA University of Nebraska Medical Center, 988102 Nebraska Medical Center, Omaha, NE 68196-8102, USA
Received 23 December 2013; accepted 20 February 2014
KEYWORDS Bladder neck; Augmentation; Vesicoureteral reflux; Hydronephrosis; Neurogenic bladder
Abstract Objective: We report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence. Materials and methods: Consecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Results: There were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (40 cm) or continence status (dry vs. wet). Conclusions: Upper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation. ª 2014 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
* Corresponding author. UT Southwestern and Children’s Medical Center, 1935 Medical District Dr., MS F4.04, Dallas, TX 75235. Tel.: þ1 214 456 2481; fax: þ1 214 456 8803. E-mail addresses: [email protected] (W. Snodgrass), [email protected] (C. Villanueva), patricio. [email protected] (P. Gargollo), micah.jacobs@childrens. com (M. Jacobs).
Introduction Surgery on the bladder outlet to achieve urinary continence in children with neurogenic bladder is known to potentially increase detrusor pressures, sometimes resulting in hydronephrosis (HN) and/or vesicoureteral reflux (VUR). This
http://dx.doi.org/10.1016/j.jpurol.2014.02.005 1477-5131/ª 2014 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
+
MODEL
2 development was previously reported (in the 1980s) following artificial urinary sphincter (AUS) implantation [1e4], but now, more than 25 years later, the risk for upper tract changes remains unclear. Given reports that preoperative urodynamics (UD) do not predict postoperative detrusor pressure responses [5], we performed bladder outlet procedures for neurogenic incontinence in consecutive children without augmentation, beginning in 2000. We now present a descriptive study reporting rates of new HN and VUR in these patients.
Materials and methods The diagnosis of bladder outlet insufficiency was made in children with neurogenic bladders and urinary incontinence with detrusor leak point pressure 40 cm despite oral anticholinergics. CIC was done every 3 h, sometimes supplemented with overnight continuous catheter drainage in those with an EFP >40 cm.
Upper tract imaging Preoperative renal sonography and cystography during UD were obtained in all patients. Similar postoperative imaging was scheduled for 6 months and 1 year. Renal sonography was done annually thereafter, while cystography during UD was done annually or every other year. Sonogram outcomes were described using Society for Fetal Urology (SFU) terminology. VUR was graded according to International Reflux Study recommendations.
W. Snodgrass et al.
Bladder outlet surgery From 2000 to 2007, fascial sling was wrapped tightly 360 around the bladder neck (BNS) without a urethral catheter, and then elevated and secured to the pubic periosteum using 2-0 polypropylene sutures [6]. In an attempt to improve continence, beginning in mid2007 Leadbetter/Mitchell bladder neck (BN) revision (LMS) was done to reduce the caliber of the proximal urethra and BN by 50% before the 360 tight fascial sling was placed. This LMS procedure began with a transverse incision distally from 3 to 9 o’clock in the urethra near its exit from the pelvis. The incision was then extended bilaterally proximally to and then through the BN, ending just below the trigone. Care was taken to maintain uniform width of the dorsal urethral strip into and above the BN. This strip was then tubularized using 4-0 polydioxanone continuous suture in a single layer. Then, the sling was wrapped tightly 360 and secured to the pubic periosteum. A urethral catheter was not used postoperatively [7]. In all cases, the bladder was hitched to the undersurface of the rectus muscle near the umbilicus, and a Mitrofanoff channel created in the umbilicus, preferentially using the appendix. Postoperative urinary drainage was through an 8Fr feeding tube in the Mitrofanoff channel and a suprapubic tube, with diversion maintained for approximately 1 month. After catheter removal, all patients resumed preoperative oxybutynin dosing and CIC. Initially, overnight catheter drainage was reserved for those found to have detrusor pressures >40 cm water on UD, but beginning in 2010 it was recommended for all patients until the first postoperative UD was obtained. Those with an EFP >40 cm continued use thereafter.
Continence Continence was defined as “dry”, no urinary leakage requiring pads. Outcomes are reported at last clinical follow-up. Patients undergoing BN closure for persistent incontinence or subsequent augmentation are reported according to their last assessment before this procedure. UD data, medical therapy, imaging results, and continence outcomes were all recorded at the time of service into a database, which was reviewed with institutional review board approval.
Statistical analysis Chi-square software.
analysis
was
done
using
Internet-based
Results From 2000 to 2012, 83 consecutive children underwent bladder outlet surgery. None had prior or simultaneous augmentation. Three boys who had primary BN closure when BNS (n Z 1) or LMS could not be done were excluded from the review. Another two girls were excluded because
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
+
MODEL
New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery of simultaneous duplicated ureterocele surgery affecting upper tract assessment. One boy had intestinal dehiscence from Malone Antegrade Continence Enema (MACE), resulting in pelvic inflammatory reaction with loss of the Mitrofanoff and sling, and he was also excluded. There was no follow up in two patients after BNS. Therefore, the final study cohort included 36 BNS and 39 LMS done in 44 boys and 31 girls (mean age 7.5 years [range 3e18 years]). Anticholinergic therapy was oral (n Z 60), intravesical (n Z 4), or oral plus intravesical (n Z 9). Two patients did not take anticholinergics. Overnight catheter drainage was used as long-term management in 14 patients. During a mean follow-up period of 48 months (range 4e100 months), 17 (23%) patients had at least one renal sonogram or cystogram showing HN or VUR. HN and VUR were both seen at different times in three of these patients. Transient SFU grade 2 HN was found on the first postoperative sonogram in two patients: unilateral in one, and bilateral in the other. Similar unilateral grade 2 HN was found in another five children at a mean follow-up time of 37 months (range 18e66 months). Unilateral grade 3 HN occurred in one boy at 34 months. All grade 2 HN resolved with medical therapy, consisting of only re-emphasizing compliance with CIC and anticholinergics in three, increasing anticholinergics to four times daily in two or adding intravesical instillation in two, and adding overnight catheter drainage in one patient. No HN was subsequently seen during a mean follow-up of 27 months (range 12e72 months). The boy with grade 3 HN had intravesical instillation added to his regimen of oral anticholinergic plus overnight drainage, and had complete resolution of the HN at follow-up renal sonography 4 months later. New VUR was observed in 12 patients (unilateral in 10), with grades I (n Z 1), II (n Z 8), III (n Z 2), and IV (n Z 3) found at the initial postoperative cystogram in five or at a mean of 35 months (range 22e70 months). Spontaneous resolution occurred without treatment in two patients and in another with addition of overnight drainage, all with grade II VUR. Otherwise, we considered the presence of VUR an indication for its treatment, assuming it increased risk for renal scarring. Dextranomer/hyaluronic acid (Dx/ HA) injection was done in seven patients, with resolution in five and persistent grade 2 in the other two. Reimplantation was done in two patients at the time of additional BN surgery for persistent incontinence. Mean UD EFPs were >40 cm (mean 49 cm) in 23 patients, 40 cm and upper tract changes. For example, the mean EFP in those with new HN was 32.5 cm (range 6.0e70.0 cm), with only three patients having pressures >40 cm. All SFU grade 2 HN resolved during the sonography when it was first discovered by draining the bladder, while the case of unilateral grade 3 HN diminished to grade 2 by drainage. All these patients were managed by medical therapy without recurrence. The etiology of new VUR diagnosed postoperatively was unclear. It was found in the initial UD after surgery in 5/12 patients, all following LMS. Possibly, elongation of the proximal urethra to near the ureteral orifices disturbed the trigone in these children, but VUR was not observed in the other 34 LMS cases, despite presumably similar surgery. High intravesical pressures distorting the trigone or overcoming ureteral coaptation did not appear to explain new VUR, as only four patients had EFPs 40 cm, while the remaining eight had a mean EFP of 20 cm when reflux occurred. However, it is possible that EFP was reduced in some cases by the onset of VUR acting as a pop-off. In two cases, new VUR was found at the time of UD during assessment for tethered cord, both with EFPs 40 cm, which was been reported to be effective in a systematic literature review [10]. We chose a 3-h interval for CIC to approximate a normal bladder-emptying schedule. In a prior comparison of patients undergoing BN surgery with and without augmentation, we reported no differences in health-related quality of life based on increased anticholinergic use or CIC frequency in those not augmented [11]. In 1986, three retrospective studies called attention to upper tract changes following AUS placement without augmentation in children, mostly with neurogenic bladders. Roth et al. [1] reported HN in 9/44 (20%) patients at a mean of 32 months, which resolved in five with medical management, and was treated by augmentation in another three with no mention of a preliminary trial of CIC and anticholinergics. Bauer et al. [4] found new HN in 3/ 35 (9%) myelodysplastics, one attributed to cord tethering, while Light and Pietro [2] reported HN in 4/20 (20%) patients with myelodysplasia, including two who apparently had diminished compliance preoperatively that worsened after surgery. Neither stated when changes occurred. Both reported that these patients were unresponsive to medical therapy, but neither the anticholinergic medication and dose nor means for bladder emptying were described. A decade later, Kronner et al. [5] described outcomes retrospectively in 45 patients who had AUS implantation, drawn from a larger cohort of 80 children with myelodysplasia from which the other 35 were excluded because of prior or simultaneous augmentation. Differences in these two groups, if any, were not clear, as decisions regarding augmentation were at the discretion of various surgeons without defined criteria. During a mean follow-up of 49 months augmentation was done in nine (20%) patients for upper tract deterioration (not further described), of which four also had “poor” bladder compliance with a mean of 8 5 cm/mL water. Pre-augmentation medical therapy was not described. More recently, Dave et al. [12] retrospectively reviewed the records of 48 children with myelodysplasia and incontinence who had surgical therapy, of which 15 had various BN surgeries without augmentation. As with Kronner et al. [5], the decision-making process for augmentation was not described. Four patients without augmentation had a trabeculated bladder with HN and VUR preoperatively. New HN or VUR occurred during a mean follow-up of 135 months in the other 11 children. All had medical therapy with CIC (every 4 h) and anticholinergics, but medication and dosing were not stated. BNS without augmentation was reported Gormley et al. [13] in 12 adolescent girls, mostly with myelodysplasia, with another three having prior or simultaneous enterocystoplasty for “poor” bladder compliance. Of the 12 patients with only BNS, four had prior ureteral reimplantation. Postoperative UD cystography and renal sonography were obtained annually. During a mean follow-up of 54 months, upper tracts were stated to be normal in all. We are not aware of other reports on BNS without augmentation that describe upper tract status after surgery. Our series is unique in that it involved consecutive patients with neurogenic outlet incompetency undergoing BNS
W. Snodgrass et al. or LMS. There was no selection bias, as none had prior or simultaneous augmentation, and no other patient had surgery for an incompetent outlet during the study period. In addition, all followed a similar protocol for postoperative assessment and medical therapy, with data recorded prospectively. Persistent upper tract changes (all VUR) occurred in only 9/75 (12%) children. Other patients with VUR or HN resolved these findings with medical management. No child had augmentation for upper tract deterioration. These data suggest patients with HN or VUR after BN surgery for neurogenic incontinence should have medical therapy such as we describe before considering enterocystoplasty. A weakness of this study is the lack of information regarding individual renal function changes, if any, in these patients both with and without HN or VUR. Dimercaptosuccinic acid scintigraphy was not included in the protocol during the reported study period. In addition, although serum creatinines were all normal, we did not determine creatinine clearances. Another potential criticism of our report is continence outcomes in these patients. We strictly defined dryness as no pad use. Consequently, some patients who only experienced dampness contained by 1e2 pads per day, and so were improved over their preoperative status, were still considered wet for this analysis, in part because such leakage, though slight, could provide a pop-off mechanism to compensate for increased bladder pressures and prevent new HN or VUR. A detailed analysis of all these patients will be reported separately, but of the 75, 36 (48%) were not dry, including 10 who used fewer than two pads daily, three who underwent re-operative LMS, 18 who had BN closure, and five who were wet with more than two pads per day at last evaluation. The other 52% were dry, not requiring pads for urinary incontinence. Others describing BN sling procedures, the majority done with augmentation, report dryness in 37%, 47%, 59%, and 88%, respectively [14e17].
Conclusions New HN and/or VUR developed in 23% of patients within a mean follow-up of 48 months after BNS or LMS without augmentation. All HN and 25% of VUR resolved with changes in medical therapy, while Dx/HA injection was successful in 71% of attempted procedures for reflux. These data support initial medical or minimally invasive therapy for new HN and VUR. Upper tract changes were not predicted by continence status or by EFP. VUR occurred more often after LMS, but 75% of patients undergoing LMS did not develop postoperative reflux. No patient required augmentation for upper tract changes.
Conflict of interest None.
Funding None.
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
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MODEL
New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery
References [1] Roth DR, Vyas PR, Kroovand RL, Perlmutter AD. Urinary tract deterioration associated with the artificial urinary sphincter. J Urol 1986;135:528e30. [2] Light JK, Pietro T. Alteration in detrusor behavior and the effect on renal function following insertion of the artificial urinary sphincter. J Urol 1986;136:632e5. [3] Churchill BM, Gilmour RF, Khoury AE, McLorie GA. Biological response of bladders rendered continent by insertion of artificial sphincter. J Urol 1987;138:1116e9. [4] Bauer SB, Reda EF, Colodny AH, Retik AB. Detrusor instability: a delayed complication in association with the artificial sphincter. J Urol 1986;135:1212e5. [5] Kronner KM, Casale AJ, Cain MP, Zerin MJ, Keating MA, Rink RC. Bladder calculi in the pediatric augmented bladder. J Urol 1998;160:1096e8. [6] Snodgrass WT, Elmore J, Adams R. Bladder neck sling and appendicovesicostomy without augmentation for neurogenic incontinence in children. J Urol 2007;177:1510e4. [7] Snodgrass W, Barber T. Comparison of bladder outlet procedures without augmentation in children with neurogenic incontinence. J Urol 2010;184(Suppl. 4):1775e80. [8] Snodgrass W, Barber T, Cost N. Detrusor compliance changes after bladder neck sling without augmentation in children with neurogenic urinary incontinence. J Urol 2010;183: 2361e6. [9] Bolduc S, Moore K, Lebel S, Lamontagne P, Hamel M. Double anticholinergic therapy for refractory overactive bladder. J Urol 2009;182(Suppl. 4):2033e8.
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[10] Guerra LA, Moher D, Sampson M, Barrowman N, Pike J, Leonard M. Intravesical oxybutynin for children with poorly compliant neurogenic bladder: a systematic review. J Urol 2008;180:1091e7. [11] Snodgrass W, Keefover-Hicks A, Prieto J, Bush N, Adams R. Comparing outcomes of slings with versus without enterocystoplasty for neurogenic urinary incontinence. J Urol 2009; 181:2709e14. [12] Dave S, Pippi Salle JL, Lorenzo AJ, Braga LH, Peralta-Del Valle MH, Bagli D, et al. Is long-term bladder deterioration inevitable following successful isolated bladder outlet procedures in children with neuropathic bladder dysfunction? J Urol 2008;179:1991e6. [13] Gormley EA, Bloom DA, McGuire EJ, Ritchey ML. Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol 1994;152:822e5. [14] Barthold JS, Rodriguez E, Freedman AL, Fleming PA, Gonzalez R. Results of the rectus fascial sling and wrap procedures for the treatment of neurogenic sphincteric incontinence. J Urol 1999;161:272e4. [15] Chrzan R, Dik P, Klijn AJ, de Jong TP. Sling suspension of the bladder neck for pediatric urinary incontinence. J Pediatr Urol 2009;5:82e6. [16] Perez LM, Smith EA, Broecker BH, Massad CA, Parrott TS, Woodard JR. Outcome of sling cystourethropexy in the pediatric population: a critical review. J Urol 1996;156:642e6. [17] Castellan M, Gosalbez R, Labbie A, Ibrahim E, Disandro M. Bladder neck sling for treatment of neurogenic incontinence in children with augmentation cystoplasty: long-term followup. J Urol 2005;173:2128e31.
Please cite this article in press as: Snodgrass W, et al., New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.02.005
