IS INCREASING BLADDER OUTLET RESISTANCE WITHOUT AUGMENTATION SAFE IN NEUROGENIC BLADDER?
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.
|Male: Female||1 : 1.14|
|Caudal Regression||2 (6.7%)|
|Sacral Agenesis||2 (6.7%)|
|VP Shunt||16 (55.2%)|
|Ureteral Reimplant||1 (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 Hydronephrosis||1 (3.3%)|
|Grade 2||1 (3.3%)|
|Grade 3||2 (6.7%)|
|Grade 5||1 (3.3%|
|Group 1 (N=30)||Group 2 (N=63)||p-value|
|Preop Percent predicted bladder capacity|
|Preop Detrusor end filling pressure (mmHg)|
|Mean (SD)||26.1(17.1)||37.0 (22.1)||0.035|
|Preop Detrusor leak point pressure (mmHg)|
|Preop Compliance (ml/cm H2O)|
|Patient||Initial BNP||Underwent subsequent BNI||Underwent repeat BNP||Underwent AC (Indication)||Developed VUR||Developed HDN|
|1||Biologic sling||X (OA)|
|2||Fascial sling||X||Grade 1|
|8||Fascial sling||X||BNC||X (C)|
|10||Fascial sling||X||Fascial sling||X (OA)|
|11||Fascial sling||X (C)|
|12||Fascial sling||X||X (OA)|
|13||Fascial sling||X (C)|
|16||Young Dees Leadbetter BNR||X (C)||Grade 3||Moderate|
|20||Biologic sling||X (IO)||Grade 3||Moderate|
|21||Fascial sling||X (SI)|
|23||Biologic sling||X||Young Dees Leadbetter BNR|
|24||Young Dees Leadbetter BNR||BNC||X (C)|
|27||Biologic sling||BNC||X (C)|
|28||Biologic sling||X (IO)|
|Preoperative (Mean)||Postoperative (Mean)||Mean of Difference||Paired T-test p-value|
|Detrusor Leak Point Pressure||56.5||50.0||-6.5||Insufficient complete pairs|
|Detrusor End Filling Pressure||29.8||44.7||14.8||0.028|
|Expected Bladder Capacity (%)||93.4%||67.3%||-26.1%||0.005|
|Augment = No (18)||Augment = Yes (12)||p-value|
|Preop Percent predicted bladder capacity||0.325|
|Preop Detrusor end filling pressure (mmHg)||0.816|
|Preop Detrusor leak point pressure (mmHg)||0.317|
|Postop Percent predicted bladder capacity||0.043|
|Postop Detrusor end filling pressure (mmHg)||0.698|
|Postop Detrusor leak point pressure (mmHg)||-|
|Change in predicted bladder capacity||0.605|
|Change in Detrusor end filling pressure (mmHg)||0.460|
|Change in Detrusor leak point pressure (mmHg)||-|
|Change in Compliance||0.036|
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