Society For Pediatric Urology

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John Weaver, M.D.1, Xander Knight, M.D.2, Joel Koenig, M.D.3, Joel Vetter, M.S.1, Douglas Coplen, M.D.1, Paul Austin, M.D.4.
1Washington University School of Medicine, Saint Louis, MO, USA, 2Oregon Health Science University, Portland, OR, USA, 3Mercy Childrens Hospital, Kansas City, MO, USA, 4Texas Children's Hospital, Houston, TX, USA.

Background:We hypothesized that, selectively choosing only patients with favorable preoperative characteristics for BNPs without AC, a significant number of children undergoing BNPs without AC would not develop changing bladder dynamics that lead to recurrent incontinence and risk for upper tract changes.
Methods:We retrospectively queried our institution’s EMR for all neurogenic bladder patients with spinal dysraphism as their primary diagnosis who underwent BNPs at our institution between 2000 and 2017.
We separated these patients into two groups. One group who did not undergo AC at the time of their initial BNP procedure (Group 1) and a second group of patients who had concomitant AC (Group 2).
Results:Group 1 included 30 patients. Demographic data for Group 1 can be found in Table 1. Group 2 included 63 patients.
Preoperative urodynamic data comparing the two groups is available in Table 2. Compared to Group 1, Group 2 had a higher proportion of patients with HDN (22.2% vs 3%) and VUR (38.1% vs 13.3%) preoperatively.
A summary of the postoperative outcomes for all 30 patients in Group 1 can be found in Table 3. No patient in this group was preoperatively or postoperatively diagnosed with any stage of CKD. Eighteen of the 30 patients were on anticholinergics prior to their initial surgery and 28 of the patients were on anticholinergics at some point following their initial BNP.
For Group 1, a list of preoperative to postoperative urodynamics changes can be found in Table 4. There was also a significant difference when comparing changes from preoperative to postoperative urodynamics in patients requiring augmentation to those who did not. See Table 5.
We were unable to identify any preoperative risk factors that predicted the need for AC, BNP or BNI. Additionally, when we separated patients based on their indication for augmentation, we were still unable to identify any preoperative risk factors that predicted the need for augmentation. We found that the type of bladder neck procedure that was performed did not predict any postoperative outcomes.
Conclusions:Our data illustrates BNR without AC is safe in selected patients with normal bladder compliance and normal/near normal expected capacity. None of our patients suffered any significant degree of renal injury and 47% of our patients did not require any major reconstructive procedure with six-year follow-up.
Table 1. Demographics of Group 1.
Male: Female1 : 1.14
Myelomeningocele21 (70.0%)
Lipomeningocele5 (16.7%)
Caudal Regression2 (6.7%)
Sacral Agenesis2 (6.7%)
VP Shunt16 (55.2%)
Prior Surgeries
Vesicostomy2 (6.7%)
Ureteral Reimplant1 (3.3%)
Cystolitholapaxy1 (3.3%)
Mean Age at Surgery (years)10.8 (3.8 - 17.8)
Mean Follow-up after surgery (months)74.5 (0.66 - 168.5)
Preoperative Hydronephrosis1 (3.3%)
Preoperative VUR
Yes4 (13.3%)
Grade 21 (3.3%)
Grade 32 (6.7%)
Grade 51 (3.3%

Table 2. Comparison of preoperative urodynamics between Group 1 and Group 2.
Group 1 (N=30)Group 2 (N=63)p-value
Preop Percent predicted bladder capacity
Mean (SD)89.5(31.6)46.1(22.1)<0.001
Preop Detrusor end filling pressure (mmHg)
Mean (SD)26.1(17.1)37.0 (22.1)0.035
Preop Detrusor leak point pressure (mmHg)
St. Dev.19.835.0
Preop Compliance (ml/cm H2O)
St. Dev.20.05.7

Table 3. Postoperative outcome data. Overactivity = OA, compliance = C, Intraoperative decision = IO
Patient Initial BNPUnderwent subsequent BNI Underwent repeat BNPUnderwent AC (Indication)Developed VURDeveloped HDN
1Biologic slingX (OA)
2Fascial slingXGrade 1
3Fascial slingXBNC
4Fascial sling
5Fascial sling
6Fascial sling
7Fascial sling
8Fascial slingXBNCX (C)
9Biologic slingMild
10Fascial slingXFascial slingX (OA)
11Fascial slingX (C)
12Fascial slingXX (OA)
13Fascial slingX (C)
15Fascial sling
16Young Dees Leadbetter BNRX (C)Grade 3Moderate
17Fascial sling
18Fascial sling
19Fascial slingX
20Biologic slingX (IO)Grade 3Moderate
21Fascial slingX (SI)
22Fascial slingXBNC
23Biologic slingXYoung Dees Leadbetter BNR
24Young Dees Leadbetter BNRBNCX (C)
25Biologic sling
26Biologic slingAUS
27Biologic slingBNCX (C)
28Biologic slingX (IO)
29Fascial sling
30Fascial slingX

Table 4. Comparison of Group 1 preoperative and postoperative urodynamics.
Preoperative (Mean)Postoperative (Mean)Mean of DifferencePaired T-test p-value
Detrusor Leak Point Pressure56.550.0-6.5Insufficient complete pairs
Detrusor End Filling Pressure29.844.714.80.028
Expected Bladder Capacity (%)93.4%67.3%-26.1%0.005

Table 5. Comparison of preoperative and postoperative urodynamics in Group 1 patients based on AC st
Augment = No (18)Augment = Yes (12)p-value
Preop Percent predicted bladder capacity0.325
St. Dev.39.612.6
Preop Detrusor end filling pressure (mmHg)0.816
St. Dev.13.621.9
Preop Detrusor leak point pressure (mmHg)0.317
St. Dev.13.125.3
Preop Compliance0.895
St. Dev.21.917.7
Postop Percent predicted bladder capacity0.043
St. Dev.27.529.2
Postop Detrusor end filling pressure (mmHg)0.698
St. Dev.24.924.5
Postop Detrusor leak point pressure (mmHg)-
St. Dev.-22.3
Postop Compliance0.062
St. Dev.22.78.2
Change in predicted bladder capacity0.605
St. Dev.46.129.4
Change in Detrusor end filling pressure (mmHg)0.460
St. Dev.30.627.8
Change in Detrusor leak point pressure (mmHg)-
St. Dev.--
Change in Compliance0.036
St. Dev.22.219.8

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