5th Joint Meeting of ESPU-SPU - Virtual

S12: NEUROPATHIC BLADDER 2

Moderators: Pedro Lopez Perreira (Spain)

ESPU-SPU Meeting on Friday 24, September 2021, 17:10 - 17:52


17:10 - 17:13
S12-1 (PP)

BASELINE URODYNAMIC FINDINGS IN INFANTS WITH MYELOMENINGOCELE FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION UMPIRE MULTI-CENTER LONGITUDINAL STUDY FROM 0-5 YEARS OF AGE

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

PURPOSE

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.

RESULTS

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.

CONCLUSIONS

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.


17:13 - 17:16
S12-2 (PP)

CAN CONTRAST ENHANCED URODYNAMICS SONOGRAPHY REPLACE VIDEO URODYNAMICS? A STRUCTURED COMPARISON PILOT

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

PURPOSE

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.

RESULTS

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.

CONCLUSIONS

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.


17:16 - 17:19
S12-3 (PP)

A QUANTITATIVE MODEL TO DEMONSTRATE URODYNAMIC IMPROVEMENT OF DETRUSOR WORK AFTER SPINAL CORD DETETHERING

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

PURPOSE

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.

RESULTS

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)

CONCLUSIONS

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.


17:19 - 17:22
S12-4 (PP)

THE CORRELATION BETWEEN THE BLADDER WALL THICKNESS AND URODYNAMIC FINDINGS IN SPINA BIFIDA CHILDREN WITH OVERACTIVE BLADDER AND DETRUSOR SPHINCTER DYSSYNERGIA.

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

PURPOSE

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.                                                                                                                             

RESULTS

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).

CONCLUSIONS

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.


17:22 - 17:34
Discussion
 

17:34 - 17:37
S12-5 (PP)

PEDIATRIC URODINAMIC STUDY WITHOUT PREVIOUS NEGATIVE URINE CULTURE, WHAT IS THE RISK?

Cristian SAGER, Felicitas LOPEZ IMIZCOZ, Carol BUREK, Yesica Ruth GOMEZ, Santiago WELLER, Javier RUIZ, Mariana VASQUEZ PATIÑO, Catalina TESSI and Tatiana SZLARZ
Pediatric Hospital Garrahan, Urology, Buenos Aires, ARGENTINA

PURPOSE

The reported incidence of urinary tract infection (UTI) following a urodynamic study (UDS) is between 3-20%. We hypothesize patients without UC prior to a UDS will not have a significant increase in the incidence of UTI during the 15 days following UDS (post-UDS UTI).

MATERIAL AND METHODS

Prospective cohort study including consecutive pediatric patients undergoing UDS in a single center, during a period of one year. Patients were divided in two groups: (G1) UDS with a previous negative UC and (G2) UDS without a previous UC analysis. A clean UC was obtained in all patients at the moment of the UDS (UDS-UC). Primary outcome was post-UDS UTI. Secondary outcome was to compare UC cost/patient in each group. All patients were followed 15 days after the UDS to detect onset of UTI symptoms.

RESULTS

402 patients were included in the study, 198 patients (G1) and 204 patients (G2). 213 patients (53%) were female. Median age was 10.5 years (G1) and 8 years (G2). Both groups were similar in terms demographic and clinical record data except for proportion of patients on CIC which was larger in G2 (78% vs 66.2% p<0.008). UDN-UC was positive in 32% of G1 vs 55% in G2 (p<0.001). However, the incidence of post-UDS UTI was 0.5% (G1) vs. 0.98% (G2) with no statistical difference between groups (p<0.58). G1 cost was 14 uds/patient higher than G2.

CONCLUSIONS

Patients without UC prior to UDS did not have a significant increase in postUDS-UTI.


17:37 - 17:40
S12-6 (PP)

HOME BLADDER MANOMETRY MEASUREMENTS CORRELATE WITH HIGH-GRADE HYDRONEPHROSIS AMONG PATIENTS WITH NEUROGENIC BLADDER

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

PURPOSE

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).

RESULTS

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).

CONCLUSIONS

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.


17:40 - 17:43
S12-7 (PP)

THE NATURAL HISTORY OF BLADDER DYNAMICS IN CLOACAL MALFORMATIONS.

Clare SKERRITT 1, Raquel QUINTANILLA AMORIS 1, Daniel DAJUSTA 1, V Rama JAYANTHI 1, Christina CHING 1, Kristina BOOTH 1, Marc A LEVITT 2, Richard J WOOD 1 and Molly E FUCHS 1
1) Nationwide Children's Hospital, Center for Colorectal and Pelvic Reconstruction, Columbus, USA - 2) Children's National Hospital, Department of Colorectal Surgery, Washington, USA

PURPOSE

Bladder dysfunction is common in girls with cloaca and it is unclear whether operative repair may worsen function. This study prospectively examined bladder function prior to cloacal repair to define the prevalence of abnormal urodynamics (UDS) before operative intervention.

MATERIAL AND METHODS

UDS was conducted on cloaca patients prior to definitive repair. Parameters recorded were bladder capacity (BC), maximum filling pressure (MFP), detrusor leak point pressure (DLPP), detrusor overactivity (DO) and post void residuals (PVR). Urodynamics catheters were placed at the time of endoscopy of the cloacal anatomy.

RESULTS

60 girls with cloaca underwent UDS from 2015 to 2020. Median age was 10.8 months (range 4.1 to 186 months). BC varied widely: 28 (46%) patients had ‘normal’ bladder capacity (80-150% expected BC), 13 (22%) patients had large bladders (>150% expected BC), 19(32%) patients had small bladders (<80% expected BC). 13 patients leaked; the average DLPP was 22 cm H2O. 2 DLPP occurred at > 40cm H2O.  The average MFP was 28cm H2O.  15 (25%) patients had MFPs > 40cmH2O. 10 (17%) patients had reduced compliance. 32 (53%) had DO. 19 (32%) patients did not void. 8 (13%) patients had minimal PVR (<20% BC), 16(27%) had moderate PVR (20<50% BC) and 12(20%) had significant PVR (>50% BC). According to the CDC Urologic and Renal Protocol for UDS1, 48 (80%) girls had safe bladders, 10 (17%) had intermediate and 2 (3%) had hostile bladders.

CONCLUSIONS

Most cloaca patients have safe bladders prior to definitive repair with only 3% having hostile parameters. Further study is needed to determine the cause of long term bladder dysfunction in cloaca patients and whether pre-operative bladder assessment should influence cloacal reconstructive options.


17:43 - 17:52
Discussion