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EVOLUTION OF BLADDER FUNCTION DURING EARLY CHILDHOOD AFTER IN UTERO MYELOMENINGOCELE REPAIR
PURPOSE
In utero myelomeningocele (MMC) repair has been reported to significantly reduce the need for hydrocephalus shunting and improve lower-extremity motor outcomes. The urological outcome is still controversial; however, recent data indicate a possible positive effect on postnatal bladder function. We aim to present the urologic outcome during early childhood after prenatal MMC repair.
MATERIAL AND METHODS
All patients operated prenatally for MMC at our institution are followed prospectively, in a 3-months interval in the first and a 6-months interval in the second year of life, then patients are followed yearly. Assessment includes urinary ultrasound, VCUG (initial assessment) and urodynamic study, need for clean intermittent catheterization (CIC) and anticholinergics, and the occurrence of urinary tract infections (UTI).
RESULTS
Of the 34 patients who underwent prenatal MMC closure since 2010, one patient died after birth due to respiratory failure. 33 patients were included in this study. Mean gestational age at fetal surgery was 24.6 weeks (21.7-25.6). Gestational age at birth was 35.5 weeks (25.3-37.6). The level of spinal lesion was lumbar (L3-5) in 25 and sacral (S1) in 8 patients. Apart from the MMC, postnatal investigations revealed posterior ureteral valves in one boy and hypodysplastic kidneys with mild to moderate renal insufficiency in two patients. Postnatal urodynamic evaluation revealed neurogenic bladder dysfunction in 40% (Tab.). At 6 months the percentage of neurogenic bladders increased to 64%. During further follow-up, none of the patients with normal bladder function developed neurogenic bladder dysfunction; one patient is even successfully toilet-trained by age 3 years. Vesico-ureteral reflux was found in 6 (15%) patients. From the patients with neurogenic bladders 3 (9%) had at least one febrile UTI, patients with normal bladder function were infect-free. Upper-tract dilatation was seen mainly postnatally and at 6 months (Tab.), whereas bladder wall thickening increased during the first year from 9% to 23 % and then remained stable during further follow-up. At 6 months, 14 patients (64%) with neurogenic bladders were under CIC and anticholinergic therapy. Two patients additionally received intravesical botox injection and one patient, in spite of initial therapy, developed upper tract deterioration and underwent vesicostomy at 6 months.
CONCLUSION
More than one third of patients after prenatal MMC repair did not show any signs of neurogenic bladder dysfunction during early childhood, and there was no new appearance of dysfunction after the age of 6 months. Our data suggest that prenatal MMC repair has a positive impact on the lower urinary tract function and yields less lower urinary tract dysfunction than expected after postnatal repair. However, further evaluation of bladder function in these patients throughout childhood is indispensable.

urodynamic and radiologic data

Timepoint	N	Urodynamics					Imaging
		Normal	Neurogenic bladder	Small capacity	Detrusor overactivity	Reduced compliance	Upper tract dilatation	Bladder wall thickening
months		%	%	%	%	%	%	%
0	33	61	39	24	33	6	6	9
6	22	36	64	50	32	14	18	14
12	17	29	71	56	25	17	0	23
18	12	33	67	16	25	8	0	25
24	9	44	56	22	22	44	0	33
36	4	50	50	0	0	50	25	25