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Bladder Neck Surgery Without Augmentation In Children With Neurogenic Bladder: Upper Tract Changes With End Filling Pressures ≥40CM H20 For More Than 1 Year
Warren T. Snodgrass, M.D., Carlos Villanueva, M.D., Micah A. Jacobs, M.D., Patricio Gargollo, M.D..
UTSW, Dallas, TX, USA.
End filling pressure (EFP) ≥40cm H2O is considered a risk for VUR or hydronephrosis (HN) based on a prior report that 68% of patients had VUR and 81% HN, although it is not clear patients had active medical management (McGuire et al, 1983). We report upper tract changes in consecutive patients undergoing bladder neck (BN) surgery without augmentation who had only medical therapy for EFP ≥40cm on initial and subsequent postoperative urodynamics (UD) ≥ 1 year apart.
UD with fluoroscopy and renal ultrasonography were obtained 6 months, 12 months and annually following BN surgery without augmentation in consecutive children with neurogenic bladder (NGB). All UD catheters were placed through the Mitrofanoff. Those with initial postoperative EFP≥40cm with subsequent UD demonstrating EFP sustained over 40cm for at least 1 year are reported. Medical therapy included anticholinergics (AC) 0.2mg/kg/dose oxybutynin 4x daily ± intravesical oxybutynin 2x daily, and CIC every 3 hours ± overnight catheter drainage. Annual serum creatinines were obtained.
There were 18 children, 10males, mean age 9 years at surgery, of which 14 (78%) were dry, and 4 still leaked (3 used ≤ 2pads/24 hours). BN operations included 8 slings, 8 Leadbetter/Mitchell revisions+ slings, and 2 BN closures. Mean EFP 6 months postoperatively was 55cm (40-100), and after mean follow up of 39 months (12-72) mean EFP was 57 (40-90). 1 patient took no AC, 7 only oral AC, 2 oral +intravesical AC, and 8 used oral + intravesical AC + overnight drainage. Upper tract changes occurred in 6 (33%); transient unilateral HN that resolved with medical therapy in 3, new unilateral grade 2 VUR in 2, and bilateral grades 3/4 VUR in 1. Grade 2 VUR resolved in 1 on all subsequent UD for 4 years. All serum creatinines were normal.
We present the first longitudinal, prospective study of children with sustained EFP >40cm on medical therapy. Despite consistent UD EFP ≥40cm for a mean of 3 yrs (maximum 10 yrs) after BN surgery, upper tract changes occurred in only 33%, much less than previously reported. These changes were transient in 4/6 patients, leaving 1 with unilateral grade 2 and 1 with bilateral grade 3/4 VUR.
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