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Upper Tract Changes Following Bladder Neck Surgery Without Augmentation In Children With Neurogenic Bladder
Warren Snodgrass, M.D., Carlos Villanueva, M.D, Patricio Gargollo, M.D., Micah Jacobs, M.D..
UTSW, Dallas, TX, USA.
We performed sling (S) or Leadbetter/Mitchell bladder neck revision with sling (LMS) in consecutive children with neurogenic outlet insufficiency and now report prevalence of new hydronephrosis (HN) or VUR postoperatively.
From 2000-2007 consecutive children had S, and from 2007-2011 consecutive patients had LMS. There were no other patients operated for neurogenic outlet insufficiency: none of these patients had prior or simultaneous augmentation. Postoperative treatment included CIC every 3 hours ± overnight drainage, and anticholinergics (AC) 0.2mg/kg/dose oxybutynin 3- 4x daily ± intravesical oxybutynin 2x daily. Fluoroscopic urodynamic (UD) and renal sonography were done at 6 months, 1 year, and annually. Follow up was measured to the last visit or to the time of additional bladder neck surgery.
There were 73 patients, of which 2 were excluded for simultaneous ureterocele surgery, leaving 35 S and 38 LMS for analysis. Of these, 20 (28%) had any sonogram or cystogram showing upper tract changes during a mean follow up of 46 months (5-110). There was transient SFU grade 2 HN, unilateral in 6 and bilateral in 1, and unilateral grade 3 HN in another, all of which resolved with medical therapy with mean follow up 23 months (0-72). New VUR occurred in 12 patients, (unilateral in 10): grades 1 (n=1), 2 (n=8), 3 (n=2) and 4 (n=3). There was spontaneous resolution in 4, Dx/HA injection in 6, and reimplantation in 2 during subsequent BN surgery. Mean UD end fill pressures (EFP) were >40cm (mean 50) in 21 patients and <40 (mean 24) in the remainder, with upper tract changes found in 7/21 (33%) vs 13/52 (25%) p=0.6. Changes occurred in 12/40 (30%) dry patients vs 8/33 (24%) not dry, p=0.6. VUR was significantly more common after LMS, 2/35 vs 10/38, p=0.03.
During mean follow up of 4 years, 28% of patients had any imaging study showing upper tract changes after BN surgery without augmentation. Most resolved, leaving no patient with persistent HN and 8 (11%) with VUR treated by injection or reimplantation. These changes were not predicted by continence status or EFP. VUR was more common after LMS than S, possibly due to dissection into the trigone.
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