Hydronephrosis Resolution with Overnight Bladder Drainage in Children with Spina Bifida and Neurogenic Bladder
Sarah A. Holzman, MD, Carol A. Davis-Dao, PhD, Kathy H. Huen, MD, Amanda Macaraeg, BS, Kai-Wen Chuang, MD, Heidi A. Stephany, MD, Elias J. Wehbi, MD, Antoine E. Khoury, MD.
CHOC Children's and UC Irvine, Orange, CA, USA.
Patients with neurogenic bladder are at risk of upper tract deterioration, which can occur despite medical management with clean intermittent catheterization (CIC) and anticholinergic therapy. Overnight, patients may accumulate higher urine volumes and exceed safe bladder pressures. While storage capacity can be increased with surgical management, not all patients and families desire augmentation cystoplasty or are good candidates for the procedure. Here, we demonstrate the use of an overnight indwelling catheter in addition to conservative medical therapy for patients with neurogenic bladder.
Data was retrospectively collected on patients with spina bifida and neurogenic bladder who used an overnight catheter in addition to CIC. Inclusion criteria were patients using overnight catheter for at least three months. Exclusion criteria were patients starting overnight catheter at an outside center, pre-existing bladder augmentation, patients who did not comply with overnight catheter use, and patients with insufficient follow-up information available. Primary outcomes were renal bladder ultrasound findings (hydronephrosis grade, anterior posterior diameter (APD), presence of ureteral dilation) and serum creatinine. Patient data from visit prior to starting overnight catheter and data from the most recent visit using overnight catheter were compared using paired analyses. For patients with bilateral hydronephrosis, the highest APD and grade were used. Wilcoxon rank sum test and McNemar’s Chi square test were used for statistical analysis.
Fifty-three patients used an overnight catheter and after exclusions, 40 patients were eligible for analysis. Median age at the start of overnight catheter use was 4.1 years (IQR 1.9-8.2 years) and median time using overnight catheter was 2.9 years (1.9-4.8 years). Prior to overnight catheter use, 31 patients had hydronephrosis and while using overnight catheter, 19 had complete resolution of hydronephrosis and no patients developed new hydronephrosis (p <0.0001). Median APD decreased from 9.0 mm (IQR 2-12) to 0 mm (IQR 0-3.8) with overnight catheter use (p = 0.0004). Sixty three percent (25/40) had improvement in APD pre and post overnight catheter use. Eleven patients had no change in APD, while only four had increased APD and (Figure). For the 17 patients with dilated ureter, 13 resolved and four had continued dilated ureter after overnight catheter use (McNemar’s test, p = 0.0003). Twenty-four patients had pre and post overnight catheter serum creatine values available and there was no difference in median serum creatine following overnight catheter use (p = 0.84).
To our knowledge, this is the largest study of neurogenic bladder patients and overnight catheter drainage showing improvement in hydronephrosis and ureteral dilation. Overnight catheter drainage is a conservative solution for patients who may not be eligible or do not desire augmentation cystoplasty. Alternatively, overnight catheter can be used to safely extend the time frame until augmentation surgery can be performed or patients and their families are ready to pursue surgery. Future directions include studying patient compliance and satisfaction with overnight catheter use.
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