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Incidence of Secondary Bladder Procedures Following Bladder Outlet Procedure without Enterocystoplasty in Children with Myelomeningocele
Brian VanderBrink, MD, W. Robert DeFoor, MD, Eugene Minevich, MD, Paul Noh, MD, Shumyle Alam, MD, Curtis A. Sheldon, MD, Pramod Reddy, MD.
Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, USA.
Background: Refractory cases of neuropathic sphincteric incontinence can be treated with bladder outlet procedure (BOP). Conflicting reports existing regarding possible need for metachronous enterocystoplasty following BOP in this patient population. The purpose of this study was to examine our experience with BOP without concomitant enterocystoplasty in a myelomeningocele population to evaluate outcomes and report the incidence of any metachronous surgical procedure to address de novo postoperative altered bladder dynamics.
Methods: A retrospective cohort study was performed of all children with myelomeningocele who underwent BOP without enterocystoplasty from 2004 to 2012. Clinical, urodynamic and radiographic variables were compared prior to and after BOP for each patient.
Results: Thirty-three patients comprised the study group with median age of 8.5 years and follow-up of 19 months. Eleven patients (33%) underwent a metachronous bladder procedure for postoperative clinical, radiographic or urodynamic evidence of de novo postoperative altered bladder dynamics. Five patietns underwent BoTox injection and six patients underwent enterocystoplasty, with one of the patients not responding to previous BoTox injection. Urethral continence was achieved in 26/33 (79%) patients postoperatively; five of these incontinent patients had evidence of bladder deterioration. Preoperatively, median cystometric capacity was 99% of age expected capacity in all patients.
Preoperative Characteristics of Patients Divided by Outcome| VARIABLE | NO ADDITIONAL BLADDER SURGERY (n=22) | BLADDER DETERIORATION (n=11) | P Value | | Median Age (years) | 11.1 | 8.5 | 0.3 | | Female Gender | 12/22 | 2/11 | 0.07 | | Trabeculation Seen on VCUG | 3/22 | 3/11 | 0.26 | | Median Oxybutinin Dose (mg/24 hr) | 13 | 15 | 0.42 | | Median Cystometric Capacity (mL) | 340 | 330 | 0.34 | | % Age EBC | 113% | 103% | 0.27 | | Median Compliance (P/cm H2O) | 8 | 8 | 0.36 | | Median Detrusor Leak Point Pressure (cm H2O) | 41 | 33 | 0.3 | | Median Maximal Urethral Pressure (cm H2O) | 48 | 37 | 0.01 |
Postoperative Variables Characteristics of Patients Based on Outcome| VARIABLE | NO ADDITIONAL BLADDER SURGERY (n=22) | BLADDER DETERIORATION (n=11) | P Value | | Median Follow-Up (years) | 2 | 1.8 | 0.21 | | Urethral Continence | 20/22 | 6/11 | 0.03 | | Median Oxybutinin Dose (mg/24 hr) | 20 | 20 | 0.41 | | Median Cystometric Capacity (mL) | 400 | 225 | 0.06 | | % Change from Preoperative Cystometric Capacity | +18% | -32% | | | Median Maximum Detrusor Pressure (cm H2O) | 41 | 64 | 0.24 | | % Change from Preoperative Maximum Detrusor Pressure | -1% | +60% | | | Median Compliance (P/cm H2O) | 7 | 4 | 0.08 | | % Change from Preoperative Compliance | -15% | -57% | |
Conclusion: In our series, 33% of patients that underwent isolated BOP developed significant de novo postoperative changes in bladder dynamics leading to a secondary surgical procedure to lower bladder pressure when maximal medical therapy failed. Bladders with lower degree of outlet resistance may have a unpredictable response to isolated BOP and more likely to require additional bladder surgery
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