ESPU-SPU Meeting on Friday 24, September 2021, 17:10 - 17:46
Stacy TANAKA 1, Jonathan ROUTH 2, Elizabeth YERKES 3, Duong TU 4, Christopher AUSTIN 5, John WIENER 6, Evalynn VASQUEZ 7, David JOSEPH 8, Jennifer AHN 9, M. Chad WALLIS 10, Tonya WILLIAMS 11, Charles ROSE 11, Michelle BAUM 12 and Earl CHENG 3
1) Vanderbilt University Medical Center, Urology, Nashville, USA - 2) Duke University Medical Center, Durham, USA - 3) Ann and Robert H. Lurie Children's Hospital of Chicago, Urology, Chicago, USA - 4) Texas Children's Hospital, Urology, Houston, USA - 5) Oregon Health Sciences University, Urology, Portland, USA - 6) Duke University Medical Center, Urology, Durham, USA - 7) Children's Hospital of Los Angeles, Urology, Los Angeles, USA - 8) Children's of Alabama, Urology, Birmingham, USA - 9) Seattle Children's Hospital, Urology, Seattle, USA - 10) Primary Children's Hospital, Urology, Salt Lake City, USA - 11) Centers for Disease Control and Prevention, Atlanta, USA - 12) Boston Children's Hospital, Nephrology, Boston, USA
Urodynamic risk assessment is an indicator for renal deterioration in patients with myelomeningocele. Interrater reliability of urodynamics tests was low; therefore, a process to standardize urodynamics interpretation and reconcile discrepancies was developed.
MATERIAL AND METHODS
The Urologic Management to Preserve Initial Renal Function (UMPIRE) Protocol follows infants with prenatally/postnatally closed myelomeningocele at nine centers. Baseline urodynamics are obtained at ≤3 months and the bladder is classified as low or intermediate risk, or hostile. The multi-step standardization of interpretation of urodynamics included review: 1) by the original site and two of four external reviewers (i.e. three pediatric urologists from three different clinical sites); 2) if discordant, by four external reviewers at an in person meeting; 3) if classification discordance persisted, by the original site again with reviewer feedback; and 4) if discordance still persisted, by all nine sites.
Of 365 children, 158 baseline urodynamic tests from 9 sites have completed the full review process. Baseline urodynamic tests indicated a hostile bladder in 15% (23/157); intermediate risk for 61% (96/157); and low risk for 24% (38/157). All three reviewers initially agreed on 50% of tests (79/157), concurrence was 68% (106/157) after Step 2, 94% (147/157) after Step 3; and 100% after Step 4 of the standardized protocol. Eleven of 34 bladders originally classified as hostile were downgraded after review.
We found variations in interpretation of baseline urodynamics, which could be contributing to decreased interrater reliability. We implemented a standardized review process that can inform future UMPIRE urodynamics interpretation.
Dawn D. SALDANO 1, Ellen C. BENYA 2, Ryan F. WALTON 1, Nicole M. LOWE 2, Ilina ROSOKLIJA 1 and Elizabeth B. YERKES 1
1) Ann & Robert H. Lurie Children's Hospital of Chicago, Urology, Chicago, USA - 2) Ann & Robert H. Lurie Children's Hospital of Chicago, Radiology, Chicago, USA
Video urodynamics (VUDS) provides relevant anatomical and functional correlates for medical and surgical decision making in patients with neurogenic bladder dysfunction, however, it requires radiation exposure. We aim to explore contrast-enhanced urodynamics sonography (CEUDS) using intravesical microbubble contrast during urodynamics (UDS) as reliable, non-radiation replacement for VUDS.
PATIENTS AND METHODS
A pilot study to compare VUDS to CEUDS was developed. Patients aged 12 years or less with neurogenic bladder secondary to spina bifida or caudal regression were prospectively enrolled to undergo a CEUDS immediately following a standard of care VUDS. Three UDS runs were performed, of which the last two were used for analysis. Images were obtained at set % Estimated Bladder Capacity (0, 25, 50, 75, 100, and so on) and with any observed urodynamic "events" to assess for open bladder neck or reflux. Each de-identified tracing was classified as safe, intermediate or hostile using the National Spina Bifida Patient Registry criteria. Concordance between VUDS and CEUDS tracings was recorded.
8 patients were enrolled and completed testing. Urodynamic classification matched in 8/8 VUDS-CEUDS pairs. Layering of microbubbles over residual contrast and ruptured bubbles after gentle warming were encountered on one occasion each and rectified. The pump did not interfere with microbubble quality and there was no suggestion of transducer interference by microbubbles.
Based upon this pilot data, substitution of CEUDS for VUDS appears to provide comparable bladder pressure information and without the use of radiation. Further studies will validate these observations for confident urologic decision making with other diagnoses, ages and body types.
Ching Man Carmen TONG 1, Israel FRANCO 2 and Stacy TANAKA 1
1) Monroe Carell Jr. Children's Hospital at Vanderbilt, Pediatric Urology, Nashville, USA - 2) Yale School of Medicine, Pediatric Urology, New Haven, USA
Tethered cord syndrome encompasses a constellation of symptoms including lower urinary tract dysfunction. Reported urodynamic patterns after tethered cord release (TCR) have been inconsistent. We hypothesize that application of a mathematical model can provide consistent data demonstrating urodynamic differences before and after TCR.
MATERIAL AND METHODS
We retrospectively reviewed records of pediatric patients who underwent TCR between 2015 and 2019, with urodynamic evaluation done prior to and after surgery. Using FIAS© software (MI, USA), detrusor activity (DA) work and vesicoelastic (VE) work were calculated using urodynamic pressure-volume tracings. End volume was standardized between the pre- and post-TCR study for each patient. The quotients of pre-/post-TCR work were calculated for DA work, VE work and total (DA+VE) work. These values were compared between those who had symptom improvement and the remainder of the patients by Mann-Whitney U test.
A total of 22 patients aged 5 months to 15 years (median: 7.65 years) met inclusion criteria. Eight had primary tethered cord. Urodynamic studies were performed at a median time of 1.1 months prior and 5.4 months after TCR. Of the 22 patients, 9 had lower urinary tract symptom improvement. There was a difference in the quotient of pre-/post-TCR work for total work (p=0.0083) and VE work (0.048) but not for DA work (0.133)
Changes in detrusor work were associated with symptom improvement. Of note, changes in work were discernible even in infants prior to toilet training with small bladder capacity. Detrusor work calculations offer a standardized method to assess bladder function.
Sasa MILIVOJEVIC 1, Vladimir RADLOVIC 1, Ivana DASIC 2, Jelena MILIN LAZOVIC 3, Goran DJURICIC 2 and Zoran RADOJICIC 1
1) University Children's Hospital Belgrade, Urology, Belgrade, SERBIA - 2) University Children's Hospital Belgrade, Radiology, Belgrade, SERBIA - 3) Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia, Belgrade, SERBIA
To examine the correlation between the bladder wall thickness and urodynamic findings in spina bifida children with overactive bladder (OAB) and detrusor sphincter dyssynergia (DSD).
MATERIAL AND METHODS
Between 2014 and 2019 we prospectively evaluated 61 consecutive spina bifida children with OAB and DSD ( 30 (49.2%) boys and 31 (50.8%) girls, aged 4 to 16 years; mean age 16.0±9.7 years. During the above period, as part of the assessment of treatment results, all the patients underwent echosonographic measurement of bladder wall thickness and urodynamic studies which were subsequently compared mutually.
After applying Spearman’s correlation coefficient, we ascertained negative strong significant correlation between bladder wall thickness and maximum bladder capacity (r= -0.728, p<0.001) and compliance (r= -0.715, p<0.001). There was strong, positive correlation between bladder wall thickness and maximal detrusor pressure (r= 0.713, p<0.001), leak point reassure (r= 0.760, p<0.001) and post void residual volume PVR (r= 0.753, p<0.001).
There is an correlation between the bladder wall thickness and urodynamic findings in spina bifida children with OAB and DSD. Therefore, we advise an echosonographic measurement of bladder wall thickness in spina bifida children with OAB and DSD, and it can especially help us while waiting for urodynamic testing.
Joshua CHAMBERLIN 1, Sarah HOLZMAN 2, Carol DAVIS-DAO 2, Amanda MACARAEG 3, Linda BEQAJ 3, Ahmed ABDELHALIM 4, Ranim MAHMOUD 5, Heidi STEPHANY 2, Kai-Wen CHUANG 2, Elias WEHBI 2 and Antoine KHOURY 2
1) Loma Linda University Children's Hospital and CHOC Children's, Pediatric Urology, Loma Linda, USA - 2) CHOC Children's and University of California, Irvine, Pediatric Urology, Orange, USA - 3) CHOC Children's Hospital, Division of Pediatric Urology, Orange, USA - 4) Mansoura University, Urology, El Mansoura, EGYPT - 5) Mansoura University, Pediatrics, El Mansoura, EGYPT
Patients with neurogenic bladder are at risk of developing bladder and renal deterioration secondary to increased intravesical pressures. We have shown previously that home manometry measurements predict urodynamic pressures. We evaluated the ability of home bladder manometry to identify patients at risk for high-grade hydronephrosis.
MATERIAL AND METHODS
Home manometry measurements were prospectively collected on patients with neurogenic bladder secondary to spina bifida performing clean intermittent catheterization. Patients used ruler-based bladder manometry to measure intravesical pressures/volumes at home. Home measurements were compared to hydronephrosis grade on ultrasound. Patients with grade IV/V vesicoureteral reflux were excluded. ROC curves and AUC were calculated to correlate home manometry pressures with high-grade hydronephrosis (SFU Grades 3-4).
Included were 78 patients with a total of 107 home manometry measurements. Fifty six percent were female, median age at follow-up was 10 (range 0-21) years. Home manometry mean bladder pressures greater than 20 cm water predicted the presence of high-grade hydronephrosis (sensitivity 86%, specificity 86%). Maximum bladder pressure on home manometry also predicted high-grade hydronephrosis (sensitivity 86%, specificity 78%). Based on home manometry, maximal bladder pressure and mean bladder pressure were highly predictive of high-grade hydronephrosis (AUC 0.90 and 0.88, respectively).
Home manometry maximal and mean bladder pressures strongly correlate with presence of high-grade hydronephrosis. Home manometry provides an easy screening tool for patients with neurogenic bladder to identify those requiring more aggressive management, without additional cost or morbidity.