30th ESPU Congress - Lyon, France - 2019

S16: NEUROPATHIC BLADDER 2

Moderators: Anju Goyal (UK), Yazan Rawashdeh (Denmark)

ESPU Meeting on Friday 26, April 2019, 14:56 - 15:52


14:56 - 14:59
S16-1 (PP)

MACE FLUSH VOLUMES INCREASE WITH LONG-TERM USE: A RETROSPECTIVE COHORT STUDY OF CHILDREN AND ADOLESCENTS WITH SPINA

Konrad SZYMANSKI, Rosalia MISSERI, Martin KAEFER, Richard RINK and Mark CAIN
Indiana University, Urology, Indianapolis, USA

PURPOSE

Little is known about whether Malone antegrade continence enema (MACE) flush volumes change with prolonged use in the setting of intermittent bowel distension and somatic growth.  Our aim was to determine (1) if MACE volumes changed over long-term follow-up in children with spina bifida (SB), and (2) if this was related to length of follow-up, increasing age, or both.

MATERIAL AND METHODS

We retrospectively reviewed medical records patients with SB at our institution after a MACE procedure performed before their 21st birthday.  Those without MACE volume data were excluded.  Demographic and clinical variables were obtained.  Outcomes were assessed annually, within 12 months of each anniversary.  Data nearest to the anniversary was used.  Analysis involved generalized linear models.

RESULTS

Overall, 166 patients underwent a MACE procedure at a median 6.8 years. Median follow-up was 4 years.  MACE was used 6-7/week 91.6% of the time.  

 MACE volumes increased over time, from a median 400ml at baseline, to 600ml at 1 year after surgery, 700ml at 4 years to 800ml at 8 years.  After adjusting for age and variation between patients, irrigation volumes increased by an average 15ml/year (p<0.0001, Figure).  Compared to children who had a MACE procedure before age 5.5, older children used higher volume flushes: +93ml for 5.5-6.5 years (p=0.03), +186ml for 6.5-9 (p<0.0001), and +234ml for children older than 9 (p<0.0001).

CONCLUSIONS

MACE volume flushes increase with long-term use.  While this increase is related to chronic use, the main difference appears to be due to increasing age, which corresponds to somatic growth.


14:59 - 15:02
S16-2 (PP)

MICTURITION REEDUCATION IN CHILDREN WITH CEREBRAL PALSY

Bieke SAMIJN 1, Christine VAN DEN BROECK 2, Frank PLASSCHAERT 3, Ellen DESCHEPPER 2, Piet HOEBEKE 3 and Erik VAN LAECKE 3
1) Ghent University, Rehabilitation sciences, Ghent, BELGIUM - 2) Ghent University, Ghent, BELGIUM - 3) Ghent University Hospital, Ghent, BELGIUM

INTRODUCTION

Urinary incontinence is the most frequently observed lower urinary tract symptom in children with cerebral palsy (CP). The objective of the study was to investigate the effectiveness of urotherapy in children with CP. Being continent can positively influence quality of life and health status of the child.

MATERIAL AND METHODS

A prospective case-control study including 21 urinary incontinent children with cerebral palsy and 24 typically developing children with urinary incontinence was conducted between 2014 and 2018.
Children received treatment for one year with three-monthly examination. Treatment was individualized to every patient. Children started with three months of standard urotherapy. Every three months treatment was adapted to primary problems and pharmacotherapy and/or specific interventions could be added to the initial treatment strategy. Time-effects were analyzed by means of multilevel modeling.

RESULTS

Seven children with CP became dry during the day and 5 children became dry during the night. Significant time-effects (p < 0.05) in children with CP were found with a higher voided volume, lower frequency of daytime incontinence, lower amount of urine loss, lower frequency of enuresis, less lower urinary tract symptoms, better micturition pattern and less fecal incontinence after training. In general, results demonstrate effectivity rate of urotherapy is lower and changes occur slower in time in children with CP compared to typically developing children.

CONCLUSIONS

Urotherapy can be an effective long-term treatment for urinary incontinence in children with CP. Therapy should be multidisciplinary, individually adapted to child and feasible for the child and social environment.


15:02 - 15:05
S16-3 (PP)

THE OUTCOME OF PREOPERATIVE VESICOURETERAL REFLUX IN CHILDREN WITH NEUROGENIC BLADDER AFTER AUGMENTATION CYSTOPLASTY

Sang Won KIM, Yong Seung LEE and Sang Won HAN
Yonsei University College of Medicine, Urology, Seoul, REPUBLIC OF KOREA

PURPOSE

Although the reflux should be improved and upper tract deterioration would be avoided if poor bladder dynamics are corrected, there is still a concern regarding the outcomes of preoperative VUR in children who underwent augmentation cystoplasty. The objective of this study was to evaluate the fate of vesicoureteral reflux after augmentation cystoplasty in children with neurogenic bladder.

MATERIAL AND METHODS

Since June 2006, 55 male and 38 female patients with low compliant neurogenic bladder have undergone augmentation cystoplasty in our institution. All patients had undergone augmentation with either of generous detubulized ileocystoplasty or seromuscular sigmoidocystoplasty. Among these, 26 patients demonstrated VUR confirmed by preoperative videourodynamics.  After excluding 7 children due to loss of follow-up, congential anomaly on bladder and simultaneous procedure for reflux, 19 children (23 refluxing renal units) were finally included in this study.

RESULTS

The mean age at augmentation cystoplasty was 11.8 years and mean follow duration was 76.9 months. Concomitant bladder neck procedures were performed in 6 children (5 fascial sling, 1 artificial sphincter). The postoperative videourodynamic study manifested a significant improvement of bladder capacity, diminution of intravesical pressure, and resolution of reflux. After the surgery, 16(69.6%) no longer had reflux, 4(17.4%) showed improvement in reflux, and 3(13%) demonstrated no change in reflux. In addition, 100% patients with reflux Grades I and II had complete cessation of reflux. Five patients demonstrated febrile urinary tract infection during follow up and 2 patients required reflux procedures (1 nephrectomy, 1 endoscopic injection therapy). Of these 5 children, three had remnant VUR and the mean preoperative compliance was worse in children with postoperative febrile urinary tract infection (13.1 vs 5.2ml/cmH2O, p=0.045).

CONCLUSIONS

Our review showed a 69.6%VUR resolution and 17.4% improvement rate achieved by augmentation cystoplasty alone. However, 26.3% of patients experienced febrile urinary tract infection after surgery during follow up. Patients with poor preoperative compliance and remnant VUR required careful follow-up after augmentation cystoplasty.


15:05 - 15:08
S16-4 (PP)

CHANGES OF SYMPTOMS AND URODYNAMIC PARAMETERS IN PATIENTS WITH SECONDARY TETHERED CORD SYNDROME AFTER SURGICAL UNTETHERING

Jae Hyun JUNG, Kwanjin PARK, Jungyo SUH, Young Jae IM and Junghoon LEE
Seoul National University Hospital, Urology, Seoul, REPUBLIC OF KOREA

PURPOSE

Few reports are available for the successful release of secondary TCS (2TCS) in spinal dysraphism. This reflects current challenge to 2TCS in diagnosis and management. However, proper release of 2TCS may offer the optimal results. We realized that most urological deterioration if they are relevant to 2TCS, would be reversed following surgery. We reported our experience focusing on both detection of urologic deterioration due to 2TCS and postoperative improvement.

MATERIAL AND METHODS

Charts of 26 patients who underwent release for 2TCS between 2011 and 2017 were retrospectively reviewed. Symptomatology, concomitant neuro-orthopedic problems, pre/postoperative video-urodynamic study (vUDS) and postoperative voiding status were examined. Release of 2TCS was conducted by experienced neurosurgeon with the aid of intraoperative monitoring bulbocavernous reflex to avoid neural damage.

RESULTS

Median age at surgery was 9.3 years (4-15) and median follow-up was 28 months (16-47) following surgery. Urologic deterioration was the first sign of 2TCS in 17 (61%) patients, and all patients showed evidence of detrusor-sphincter dyssynergia (DSD) in vUDS. Postoperatively, two patterns of improvement seen. Patients with deformed bladder, decreased compliance and capacity preoperatively experienced better bladder shape, improved urodynamic profiles. However, they still require intermittent catheterization (IC) and anticholinergics. Patients with normal capacity and compliance also showed normalized urodynamic profile. Moreover, they sometimes showed spontaneous voiding from their sensation with further follow-up.

CONCLUSIONS

The possibility of 2TCS should be included in case of urological deterioration. DSD should be sought in vUDS. Early diagnosis of 2TCS with vUDS may lead to better results.


15:08 - 15:11
S16-5 (PP)

NEED FOR BOTOX INJECTION AND AUGMENTATION CYSTOPLASTY AFTER ISOLATED BLADDER NECK PROCEDURE IN PATIENTS WITH MYELOMENINGOCELE

Matthew SMITH, Andrew STRINE, Brian VANDERBRINK, Paul NOH, Eugene MINEVICH, Curtis SHELDON, Pramod REDDY and W. Robert DEFOOR, JR.
Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, Cincinnati, USA

PURPOSE

In patients with neurogenic bladder dysfunction, a bladder neck procedure (BNP) may be required to achieve urinary continence.  However, a BNP may lead to bladder deterioration and upper-tract changes when performed in isolation.  The purpose was to assess the long-term outcomes after an isolated BNP and to identify any risk factors for bladder deterioration.

MATERIAL AND METHODS

A retrospective cohort study was performed for patients with myelomeningocele who underwent an isolated BNP between 2004-2017.  Primary outcomes included the need for Botox injection (BTI) or augmentation cystoplasty (AC) and time to these additional procedures.  Secondary outcomes included the association between urodynamic parameters and need for BTI or AC.

RESULTS

A total of 36 patients were identified during the study period.  The median age at surgery was 8.7 years (IQR 6.8-12.3).  BTI or AC was performed in 18 (50%) patients at a median of 17.8 months (IQR 11.2-29.3) after an isolated BNP.  A median of 1 (IQR 1-3) BTI was performed in 11 (30.6%) patients.  AC was performed in 9 (25%) patients, including 2 patients who previously underwent BTI.  No preoperative demographics, clinical data, or urodynamic parameters were associated with the need for BTI or AC.  Patients with no bladder deterioration had an increased bladder capacity from 350 to 450 mL (p=0.05); while those undergoing BTI or AC had a decreased percentage estimated bladder capacity from 112 to 70% (p<0.001), increased maximum Pdet from 43 to 67 cm H2O (p=0.01), and higher rate of de novo upper-tract changes.

CONCLUSIONS

The need for BTI or AC is high after an isolated BNP in patients with myelomeningocele.  BTI is an alternative to AC for bladder deterioration after an isolated BNP.


15:11 - 15:14
S16-6 (PP)

IS BOTULINUM TOXIN INJECTION USEFUL IN ALL TYPES OF NEUROPATHIC BLADDERS?

Laura BURGOS LUCENA 1, Alberto PARENTE 1, Rubén ORTIZ 1, Jose María ANGULO 1, Laura PÉREZ 2, Miriam SÁNCHEZ 3 and Manuel DE LA TORRE 1
1) Hospital Gregorio Marañón, Paediatric Urology, Madrid, SPAIN - 2) Hospital Gregorio Marañón, Paediatric Surgery Department, Madrid, SPAIN - 3) Hospital Doctor Negrín, Paediatric Surgery Department, Las Palmas De Gran Canaria, SPAIN

PURPOSE

Botulinum-A toxin endoscopic injection (BTI) is widely used in patients with refractory neuropathic bladder (NB). But it is still not clear if it is a valid treatment for all NB patients. Our aim is to analyse the different aspects that could be involved in the results and outcome

MATERIAL AND METHODS

Our series of patients with NB who underwent BTI were retrospectively analysed collecting data about urodynamic parameters, treatment compliance, continence and other surgical procedures. Patients were divided for comparison in 2 groups according to the baseline urodynamic study: group A includes those with mostly unhibited detrusor contractions (UDC) and group B those with low compliant bladders.

RESULTS

Twenty-six patients were treated with BTI (2005-2018) once (n=5), two times (n=9) and three or more times (n=12). Eleven patients had mostly UDC (group A) and 15 had a non-compliant bladder (group B). In group A only improvement in bladder pressure after the 2nd BTI was significant. In group B, improvement in median bladder capacity was significant after the 1st and 2nd BTI and compliance improvement was always statistically significant. However after the first BTI, there were not differences between both groups. After the third BTI, differences in the compliance and volume improvements were statistically significant. Persistent UDC was found in group A (n=2p, 18%) and B (n=4p, 26%). Six patients (54,5%) in group A and 6 (40%) in group B had VUR that was solved in 100% and 66% of cases respectively. During follow-up 5p from group B (33,3%) needed a BA. Final continence was 100% and 66,6% in group A and B respectively.

CONCLUSIONS

BTI has proven to be safe and effective in refractory NB. The degree of continence observed after BTI in our series was lower for patients with low-compliant bladders, although a significant number of them also achieved continence and avoided bladder augmentation. Further studies are needed in order to standardise criteria.


15:14 - 15:17
S16-7 (PP)

MANAGEMENT OF NEUROPATHIC DETRUSOR OVERACTIVITY WITH ELECTROMOTIVE DRUG ADMINISTRATION(EMDA) OF BOTULINUM TOXIN A IN CHILDREN

Mahmoud Abdalla Salem TRBAY 1, Mohamed ZAKI 2, Hamdan AL HAZMI 2, Fahad AL YAMI 2 and Khalid Fouda NEED 2
1) King Saud University - College of medicine, division of urology/surgery department, Riyadh,Saudia Arabia, Surgery - Urology, Al Dir'aiyah, SAUDI ARABIA - 2) King Saud University - College of medicine, division of urology/surgery department, Riyadh,Saudia Arabia, Riyadh, SAUDI ARABIA

PURPOSE

Botulinum toxin A injection is a well established line of treatment for neuropathic detrosur overactivity in children with Meylomeningeocele (MMC) who don’t respond to the traditional anticholinergic medications. However, it needs cystoscopy and anaesthesia.
Intravesical electrolytic drug administration(EMDA) is an attractive way of delivery of Botulinum toxin A through urothelium as it avoid the need for cystoscopy and anaesthesia, but its effectiveness is controversial.
This prospective study investigate the success rate of this method of administration.

MATERIAL AND METHODS

We included children with refractory neuropathic overactivity due to MMC.
Patients were assessed with voiding diary,urodynamic and ultrasound before and after 3 months of the procedure.
10 IU/kg with maximum of 300 IU of Botulinum Toxin A were administered using EMDA equipment on outpatient basis.
Data were analyzed with SPSS software, using paired T test with P value < 0.5.

RESULTS

17 patients with mean age of 9.1 years (range 4-14).
no side effects related to the technique of administration.
Eight out of twelve patients (66.6%) showed complete resolution of hydronephrosis.
Eight out of fifteen incontinent patients(53%) showed dryness in between catheterization.
There was no statistical significant improvement regarding the maximum bladder capacity (209+/- 91 MLK versus 213+/- 87 ), P < 0.817.
The maximum detrusor pressure decreased significantly from 74.5+/-46.8 to 53.7+/-34.5 cm H2o with P < 0.003.

CONCLUSIONS

EMDA of Botulinum toxin A is safe, reliable and attractive technique.
IT saves the patients from cystoscopy and anaesthesia.
Randomized controlled trials with large number of patients are required to validate the result.


15:17 - 15:20
S16-8 (PP)

SHOULD WE AVOID MITROFANOFF FORMATION IN EARLY LIFE?

Alexander CHO 1, Anand UPASANI 1, Peter CUCKOW 1, Divyesh DESAI 1, Imran MUSHTAQ 1, Naima SMEULDERS 1 and Abraham CHERIAN 2
1) Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital, London, UNITED KINGDOM

INTRODUCTION

Formation of a continent-catheterisable-channel in pre-school children is controversial due to concerns regarding compliance and complications. We compared channel-outcomes including complications and usage-by-age in infancy and early-childhood.

MATERIAL AND METHODS

Patients under 4-years with Mitrofanoff-formation (2007-2017) were included. All families were counselled preoperatively. Parental/patient compliance were prospectively-collected. Channel-type, indication, complications and re-intervention were noted. Statistical-analysis:Mann-Whitney-U-Test.

RESULTS (SUMMARISED IN TABLE 1)

27-Patients (M:F 13:14)
Median age at surgery:29m(1d-47m); Median follow-up:3.5yrs(9m-13yrs)
Mitrofanoff:Appendix (n=22); Ileal Monti (n=4); Ureter (n=1)

Indications for Formation:
Cloaca(n=5); Cloacal-Exstrophy(n=5), Pre-transplant(n=3); Acquired urethral-stenosis(n=4); Reconstruction post-eRMS(n=3); Urethral-abnormalities with indwelling-SPC(n=2); Prune-Belly variant(n=2); UTIs, non-neurogenic-bladder(n=2); Neuropathic-bladder(n=1).

Patient & Parental Compliance with CIC:24/27 (89%)

Operative Re-intervention: 9/27 (33%)

- Age-at-surgery vs. further surgery = Did not reach statistical significance (p=0.254)

Leakage via Mitrofanoff: 2/27 (7%)

----------------------------------------------------------------------

Table:Summary based on age at time of Mitrofanoff formation

 

Under 1’s

1 year
of age

2 years
of age

3 years
of age

Total

Number

4

8

3

12

27

Age: Median(range)

5m
(1d to 8m)

15m
(13m-21m)

29m
(26m-32m)

44m
(36m-47m)

29m
(1d-47m)

F/up: Median(range)

27m
(9m-156m)

33m
(9m-120m)

101m
(22m-122m)

43m
(12m-129m)

42m
(9m-156m)

Synchronous Cystoplasty (26%)

-

-

2

5

7

Compliance

4/4

6/8

2/3

12/12

89%

Disuse

 

1

 

 

 

Further Intervention / Complications

Mitrofanoscopy

2

2

1

1

4

Leakage

 

 

 

2

2

Stenosis

 

1

1

 

2

Revision

 

 

 

1

1

CONCLUSIONS

This first age-focused study of Mitrofanoff formation in pre-school children demonstrates 89% compliance. The complication-rate does not differ from the published literature. Its creation in this population may be appropriate with careful patient selection and family counselling.


15:20 - 15:44
Discussion
 

15:44 - 15:49
S16-9 (VP)

INTRAVESICAL ELECTROMOTIVE BOTULINUM TOXIN TYPE A ADMINISTRATION IN CHILDREN WITH MYELOMENINGOCEL

Lida SHARIFI RAD 1, Seyedeh-Sanam LADI-SEYEDIAN 2, Behnam NABAVIZADEH 2 and Abdol-Mohammad KAJBAFZADEH 3
1) Tehran University of Medical Sciences, Pediatric Urology and Regenerative Medicine Research Center and Department of Physical Therapy, Tehran, ISLAMIC REPUBLIC OF IRAN - 2) Tehran University of Medical Sciences, Pediatric Urology and Regenerative Medicine Research Center, Tehran, ISLAMIC REPUBLIC OF IRAN - 3) Children's Hospital, Urology, Tehran, ISLAMIC REPUBLIC OF IRAN

PURPOSE

Electromotive drug administration (EMDA) presents a minimally-invasive method of intravesical instillation of therapeutic agents without the need of general anesthesia. It employs a combination of iontophoresis, electrophoresis, and electroporation to deliver drugs into deep tissue layers using an electrical current created between two electrodes. The video shows feasibility of BoNTA/EMDA in myelomeningocel (MMC) patients who had urinary incontinence secondary to neuropathic detrusor overactivity (NDO).

MATERIAL AND METHODS

During 2008-2017, BoNTA/EMDA was performed in 35 patients with MMC who had NDO and urinary incontinence for the first time in our center. Applying an electrode bladder catheter, 10 IU/kg of Dysport® (BoNTA) was inserted into the bladder for EMDA without anesthesia as an outpatient basis. The EMDA equipment was connected to the electrode of indwelling catheter and two dispersive electrodes, a pulsed current generator delivered 10-20 mA for 20 minutes. At the end of the procedure, the electrodes were separated, and the bladder was emptied. The preliminary assessments were voiding diary, urodynamic study (UDS), kidney and bladder ultrasounds.

RESULTS

According to our prior reports, urinary incontinence improved in 75% of the patients between two consecutive clean intermittent catheterizations after BoNTA/EMDA treatment at 1 year follow up. Mean maximal cystometric capacity significantly increased in the most of the patients after the treatment.

CONCLUSIONS

BoNTA/ EMDA is a feasible, safe, reproducible, cost effective, long lasting and pain free method as an outpatient’s basis with long-term duration of effects without anesthesia or cystoscopy procedure.


15:49 - 15:52
Discussion