ESPU Meeting on Thursday 18, April 2024, 08:25 - 09:30
08:25 - 08:28
S07-1 (OP)
Rafael Enrique JORDAN BALLADARES, Hugo CRESPO, Taiane ROCHA CAMPELO, Renata CORREA, Emanuelle LIMA MACEDO, Raul GARCIA ARAGON, Marcela LEAL CRUZ, Sergio OTTONI, Gilmar GARRONE and Antonio MACEDO
CACAU-NUPEP, Pediatric Urology, Mexico, MEXICO
PURPOSE
The benefits of in-utero MMC repair to bladder function is still a topic of debate in pediatric urology. Since 2011 we prospectively follow MMC patients operated in utero. We decided to review all patients born between 2011 and 2013, projecting a follow-up of 10 to almost 12 years.
MATERIAL AND METHODS
We selected patients born between 2011 to 2013. We categorize patients according to the Leal da Cruz categorization (J Urol 2015) classification under 4 bladder patterns: high risk, hypocontractile, incontinent and normal to define the treatment. We reviewed clinical information and defined follow-up as the interval between first and last visit in the clinic. We excluded patients from the analysis who did not return for at least a second year evaluation. We registered the number of visits and UE/per patients to outline the relevance of the follow-up.
RESULTS
A total of 40 patients (aged 9 to 12 years, mean age: 10) were selected. Mean follow up was 49.68 months with 6.2 (median:10) urological visits and 3.46 UE per patient. First urological evaluation was at 5.5 months. At first UE (6.5 months) 82.5% had detrusor hyperactivity. We found 62.5% of high risk, 32.5% of incontinence, 2.5% of hypocontractile and 2.5% of normal pattern. CIC was needed in 65% and anticholinergics in 62.5%. 32.5% of the patients had at least 1 febrile UTI, and in 12.85% hospitalization was required. From these, 80% belonged to the high-risk group. Surgery was performed in 6 patients (15%) : 3 enterocystoplasty (Macedo), 1 enterocystoplasty LACE,1 vesicostomy and 1 sling. After the 5th and 6th UE (under treatment) high risk pattern prevalence was 46.15% and 45.45% respectively.
CONCLUSIONS
This analysis confirms our statements that fetal MMC surgery offers limited improvement in bladder function compared to postnatal surgery. At mean follow-up of 49.6 months at mean age 10 years, prevalence of surgery was 15% and CIC and anticholinergics did not normalize bladder pressure in around 46% of cases.
08:28 - 08:31
S07-2 (OP)
Javier RUIZ, Juan Pablo CORBETTA, Luciana DIAZ ZABALA, Nicolas ROSIERE, Santiago WELLER, Felicitas LOPEZ IMIZCOZ, Otilia BLAIN, Cristian SAGER, Carol BUREK and Yesica GOMEZ
Hospital de Pediatria Prof. J. P. Garrahan, Urology, Buenos Aires, ARGENTINA
PURPOSE
Anorectal malformation (ARM) represents a wide spectrum of congenital anomalies with different variables affecting the functional outcome.
The aim of the study is to report long term urological results in a male ARM cohort with urinary fistula (rectourethral bulbar -RB-, rectourethral prostatic -RP- and rectovesical -RV-) and identify variables that correlate with the urological outcome.
MATERIAL AND METHODS
Retrospective review of a prospectively maintained database of male ARM patients with recto-urinary fistula operated between 2009 and 2019 at our tertiary centre. Only subjects older than 4 years old with at least 1 year postoperative follow up were included. Primary outcome was urinary continence status, presence of neuro-vesical disfunction (NVD), need of urological reconstructive surgeries and incidence of chronic kidney disease (CKD).
RESULTS
Eighty-five patients were eligible for inclusion (50.5% rectobulbar, 37.5% rectoprostatic, 12% rectovesical). Median follow up was 5.9 years (r 1-16). Associated urological and spine anomalies were present in 46% and 50.5% of the cohort, respectively. At last follow-up, 92% were urinary continent, of which 22% needed major procedures to achieve it. NVD was present in 39%, and CKD in 25% of the cohort. History of RV fistula was associated with the presence of urinary incontinence (p<0.001), need of reconstructive surgeries (p<0.001) and CKD (P<0.002).
CONCLUSIONS
Overall urological long-term outcome in this large cohort of male ARM patients was in accordance with previous publications, with continence rate of 92% and CKD of 25%. The need of major reconstructive surgeries to achieve continence was more frequent in patients with rectovesical fistula.
08:31 - 08:34
S07-3 (OP)
Cem AKBAL 1, Ali ÖZEN 2, Bilge YAŞAR 2, Bahattin TANRIKULU 2, Müge KOÇAK 3 and M. Memet ÖZEK 2
1) Acıbadem Mehmet Ali Aydınlar University, Department of Urology, Istanbul, TURKEY - 2) Acıbadem Mehmet Ali Aydınlar University, Department of Neurosurgery, Division of Pediatric Neurosurgery, İstanbul, TURKEY - 3) Acıbadem Health Group, Department of Neurology, İstanbul, TURKEY
PURPOSE
Lipomyelomeningocele (LMM) is the one of the most common forms of spinal dysraphism. Because LMM and Myelomeningocele (MM) differ in many ways, it is important to assess the long-term urologic outcomes of LMM separately from MM to incorporate realistic continence and bladder-management scenarios when counseling families. In this study, lower urinary tract functional outcomes were evaluated and prospectively analyzed to determine prognostic factors in patients undergoing LMM repair.
MATERIAL AND METHODS
Fifty LMM patients underwent repair between March 2017 and December 2022; 35 over the age of four were included in this study. Patient admission complaints, neurological examinations, radiological scans, intraoperative findings, and neuromoniterization results were recorded. Patients were evaluated with Voiding Dysfunction Symptom Score (VDSS) questionnaire with urinary ultrasound after every three months, uroflowmetry with electromyography, post void residual urine and postoperative urinary tract infections were recorded.
RESULTS
Twenty patients were boys and 15 were girls. Average diagnosis age was 32 months (3 months, 14 years); average follow-up period was 30 months (12 months, 60 months). Seventeen were chaotic type, 11 were transitional type, six were dorsal type, and one was caudal type. Preoperative physical examinations revealed swelling on 32 patients’ backs, a spot on four patients’ backs, and extremity size difference in four patients. There was lower-extremity loss-of-strength in eight patients and urinary incontinence in six patients. Bulbocavernous reflex (BCR) could not be detected bilaterally in 12 patients and unilaterally in two patients. VDSS score was found to be higher in patients with chaotic and transitional type, whose intraoperative BCR could not be obtained unilaterally or bilaterally and patients with neurological deficits in the preoperative period (p<0.05).
CONCLUSIONS
Chaotic and transitional LMM, intraoperative BCR abnormality, and the presence of preoperative neurological deficit are poor prognostic factors for urological outcomes, and these patients should be closely followed like MM patients.
08:34 - 08:37
S07-4 (OP)
Sebastian TOBIA GONZALEZ 1, Lisandro PIAGGIO 2, Edurne ORMAECHEA 3, Edurne ORMAECHEA 3, S GERBAUDO 4, Jose FADIL ITURRALDE 4, Jose FADIL ITURRALDE 4, Jimena KRIKORIAN 5, Anabella MAIOLO 6, P PEÑA 7, P PEÑA 7, Maria Consuelo SIERRALTA 8, Andrea CASTRO DU PLESSIS 3, Maria Jose PEREZ 9 and Francisca YANCOVIC 7
1) Htal de Niños, Pediátric Urology, La Plata, ARGENTINA - 2) Hospital Penna, Urology, Bahia Blanca, ARGENTINA - 3) Hospital Italiano, Pediatric urology, Buenos Aires, ARGENTINA - 4) Hospital de Niños Victor J Vilela, Pediatric urology, Rosario, ARGENTINA - 5) Hospital de Niños "Sor Maria Ludovica", Pediatric Urology, La Plata, ARGENTINA - 6) Hospital de Niños "Sor Maria Ludovica", Pediaric Urology, La Plata, ARGENTINA - 7) Hospital Exequiel González Cortez, Pediatric Urology, Santiago, CHILE - 8) Hospital Luis Calvo Mackenna, Pediatric Urology, Santiago, CHILE - 9) Hospital "Victor Vilela", Pediatric urology, Rosario, ARGENTINA
PURPOSE
Myelomeningcele (MMC) is the main variant of spina bifida in pediatrics and is the main cause of neurogenic bladder in this population. The primary objective of this study is to analyze the rate of loss to urological follow-up in patients with neurogenic bladder secondary to MMC. As secondary objectives, it is proposed to evaluate the initial treatment proposed and the causes that led to the loss of patients to follow-up.
MATERIAL AND METHODS
A retrospective observational longitudinal review was carried out on a database of patients with a diagnosis of neurogenic bladder secondary to MMC treated in Urology Services of different pediatric centers in Argentina and Chile. Data from all patients with less than two years of follow-up were discarded. Data were collected for each patient regarding patient demographics: age (in years), sex (F/M), initial consultation date, and last consultation date. In addition, the initial treatment indicated and the treatment at the end of follow-up were evaluated, as well as the total follow-up period of each patient. In the case of loss to follow-up, the cause was evaluated.
RESULTS
Data from 667 patients were studied, 349 (52.32%) female. The average age at the beginning of the consultation was 1 year (1 - 18), the average age at the end of follow-up was 8 years (1-23), the average follow-up was 67 months (1-244). Proactive treatment was indicated only in 147 (22.04%) of the patients evaluated. Of the rest, 175 (26.24%) took only CIL and 184 (27.58%) had anticholinergics added during follow-up. A lack of follow-up of more than two years was observed in 365 (54.72%), with the cause unknown in 449 (67.31%). Only 54 (8.09%) of the patients presented some degree of chronic renal failure during follow-up.
CONCLUSIONS
Initial treatment is very variable in different centers. A large dropout is observed during follow-up, with the cause of most cases being unknown. We should evaluate in future reports how to contain patients with MMC in maximum complexity centers.
08:50 - 08:53
S07-5 (OP)
Salvatore CASCIO 1, Farah MAHER 2 and Michael RIORDAN 3
1) Children's Health Ireland at Temple Street and University College Dublin, Paediatric Urology, Dublin, IRELAND - 2) Children's Health Ireland at Temple Street, Paediatric Urology, Dublin, IRELAND - 3) Children's Health Ireland at Temple Street and Royal College of Surgeons in Ireland, Paediatric Nephrology, Dublin, IRELAND
PURPOSE
EUA/ESPU Spina Bifida (SB) guidelines recommend a baseline DMSA scan in the first year of life. A more selective approach to baseline DMSA scanning has been recommended by recent studies. The aim of our study was to determine if estimated GFR can be used in clinical practice to predict whether children with SB might have renal scarring on DMSA.
MATERIAL AND METHODS
Retrospective review of blood results of all the children who attended our multidisciplinary spina bifida clinic (SBC) over a 2 year period (2017-2019). Estimated GFR (eGFR) was calculated using cystatin C measurements (CYSeGFR) according to Le Bricon et al. DMSA scans were reviewed and differential renal function was also recorded. eGFRs results were correlated to normal and abnormal DMSA scan.
RESULTS
182 children were included in our analysis-106 female with a mean age of 5.5 years. 118 had a normal DMSA, 57 had abnormal DMSA and 7 had no DMSA. The mean age at DMSA was 4 years. 116 children underwent measurement of eGFR with cystatin C. The sensitivity and specificity of eGFR for predicting abnormal DMSA were 0.256 and 0.740 respectively. Positive predictive value 0.33 and negative predictive value 0.66.
CONCLUSIONS
The results of this study demonstrate that eGFR in isolation is not able to identify which children might have renal damage on DMSA scan. Future studies are required to evaluate if the association of an eGFR with other prognostic factors will increase the sensitivity and specificity.
08:53 - 08:56
S07-6 (OP)
Gürkan ERKOÇ 1, Ş. Kerem ÖZEL 2, Ferruh Kemal İŞMAN 3, İbrahi̇m ALATAŞ 4 and Çi̇ğdem ULUKAYA DURAKBAŞA 1
1) Istanbul Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Pediatric Surgery, Istanbul, TURKEY - 2) Istanbul Medeniyet University Faculty of Medicine, Pediatric Urology, Istanbul, TURKEY - 3) Istanbul Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Biochemistry, Istanbul, TURKEY - 4) Istanbul Baskent University Hospital, Pediatric Neurosurgery, Istanbul, TURKEY
PURPOSE
Renalase is a novel enzyme mainly expressed in renal tubules. The aim of this study was to evaluate urinary renalase determination for predicting renal scarring in children with neurogenic bladder dysfunction (NBD).
MATERIAL AND METHODS
Patients with NBD were enrolled. Two study groups were formed; those with unilateral renal scarring (S) and those with no scarring (NS) in DMSA scintigraphy. For control group (C), healthy children were included. Demographic data, height, weight, medical information, detailed urine and serum analysis for kidney function, CRP, beta-2 microglobulin, urinary microalbumin, use of catheterization were noted. Urinary renalase levels were measured by ELISA method.
RESULTS
81 patients were studied (S group n:30, NS group n:30, C group n:21). Mean age of the patients were 10±4,2 years in S group, 9±3,6 years in NS group and ve 8,7±2,9 years in C group, respectively. No significant difference was seen in gender, age, weight. Late onset of catheterization, urinary tract infections and pyelonephritis were more common in S group. Mean urinary microalbumin was 64.1±137.3 mg/l in S group and 12.7±23.8 mg/l in NS (p=0.005). Mean renalase was 179.5±39.8 ng/ml in S group, 164.3±41.6 ng/ml in NS group and 143.4±37.2 ng/ml in group C. Difference in urinary renalase between S and C was significant (p=0.013). Cut-off point of 195.2 ng/ml for renalase was significant for predicting renal scar (sensitivity 46,7%, specificity 90,5%, AUC 0,739, p=0,001). Urinary renalase more than 284 ng/ml was found to be significant in predicting renal function to be lower than 36.35% (sensitivity 66,7%, specificity 86,7%, AUC 0,724, p=0,025).
CONCLUSIONS
Urinary renalase determination is a noninvasive and easy method in detection of renal scarring in children with high specificity. Routine measurement of urinary microalbumin and renalase may be used as a practical diagnostic modality in the follow up of patients with NBD.
08:56 - 08:59
S07-7 (OP)
Tuğçe ATALAY 1, Ş. Kerem ÖZEL 2 and İbrahim ALATAŞ 3
1) Private Pediatric Incontinence Clinic, Pediatric Physiotherapy, Istanbul, TURKEY - 2) Istanbul Medeniyet University Faculty of Medicine, Pediatric Urology, Istanbul, TURKEY - 3) Istanbul Baskent University Hospital, Pediatric Neurosurgery, Istanbul, TURKEY
PURPOSE
Pelvic floor muscles (PFM) work synergistically with diaphragm in creating and maintaining intra-abdominal pressure. Aim of this study was to examine the effects of incentive spirometry (IS) in addition to pelvic floor rehabilitation (PFR) in children with neurogenic bladder dysfunction (NBD).
MATERIAL AND METHODS
Children over the age of 5 diagnosed with NBD due to spinal dysraphism were included. Patients were divided into two groups by simple randomization, PFR and PFR plus IS. PFR included diaphragmatic breathing, core stabilization exercises, and perineal sensory training. IS was given as home exercise. Pretreatment (PreT) and posttreatment (PoT) evaluation included PFM electromyographic (EMG) activation, diaper use, voluntarily voided urine volumes and emptied volumes with catheter together with clinical information of the patients. Results were analyzed statistically.
RESULTS
Total of 20 children (9 girls, 11 boys) were evaluated, 10 children in PFR group (11.3±4.19 years old) and 10 in PFR plus IS group (9.5±3.53 years old). There was no difference in age and gender between groups. PoT PFM EMG activation was significantly higher in the PFR plus IS group (6.63±3.5 mV) than in PFR group (4.1±1.4 mV) (p=0.05). Diaper use in PFR plus IS group (from 4.2±3.39 to 1.5±1.64 times per day) decreased compared to the PFR group (from 4.6±3.23 to 2.1±1.19 times per day). Voluntary voiding volume and emptied volumes with catheter increased in the PFR plus IS group (from 73±86.2 to 169.5±89.2, from 42±81,4 to 58,2±104,8) and in the PFR group (from 42.5±97.9 to 108±121, from 156,5±105,9 to 200±99,6, respectively).
CONCLUSIONS
In addition to PFR, respiratory-based approaches can be used in the treatment of children with NBD. These preliminary results show the beneficial effect of incentive spirometry on PFM EMG activation. Future studies are needed to improve the physiotherapeutic technique for better rehabilitation of NBD in children.
09:10 - 09:13
S07-8 (OP)
Kwanjin PARK and Young Jae IM
Seoul National University Children's Hospital, Urology, Seoul, REPUBLIC OF KOREA
PURPOSE
Following spinal cord untethering (SCU), regular urodynamic study (UDS) was recommended to follow in those with spinal dysraphism (SD). We hypothesized that measuring noninvasive postvoid residual urine (PVR) using portable ultrasound could be applied as screening test for UDS.
MATERIAL AND METHODS
The data of 153 SD patients who had undergone SCU at their infancy and showed spontaneous voiding were reviewed. During their regular follow-up of 3-6 months, PVR was measured during regular checking of wet diaper every 30minutes. PVR more than 20% of age-adjusted estimated capacity was considered abnormal and repetitive measurement was conducted. In those with confirmed abnormal PVR, UDS was immediately performed to find the reason. Otherwise, UDS was conducted in every 1-2 years until 5 years. The frequency of abnormal PVR, sensitivity and specificity of PVR abnormality expecting UDS abnormality, urodynamic findings in case of repetitive abnormal PVR and sparing effect of PVR for UDS were assessed.
RESULTS
During median 7.4 (6-10) years of follow-up, elevated PVR was found at least once during follow-up in 51 (33%) of patients but sustained elevation requiring UDS was seen in 21 (14%) of them. It frequently showed abnormality between 12-36 months and tended to normalize after toilet training. Among those with sustained elevation of PVR, 18 (86%) patients were found to have neurogenic bladder due to spinal cord retethering. No patient with transient elevation of PVR showed evidence for neurogenic bladder and treatment of fecal impaction normalized PVR in 28 (93%) patients. Assuming annual UDS is the rule, PVR has spared 675 (88%) cases of UDS among required number of 765 cases of 5 years follow-up.
CONCLUSIONS
Noninvasive measurement of PVR was an effective and safe screening tests sparing most cases of unnecessary UDS.
09:13 - 09:16
S07-9 (OP)
Peter CAI 1, Andrea BALTHAZAR 2, Regina THAM 3, Badar OMAR 3, Sangeeta MAUSKAR 4, Walter WICKREMASINGHE 4, Bartley CILENTO 3 and Caleb NELSON 3
1) Boston Children's Hospital, Paediatric urology, Boston, USA - 2) Texas Children's Hospital, Houston, USA - 3) Boston Children's Hospital, Urology, Boston, USA - 4) Boston Children's Hospital, Complex Care Service, Boston, USA
PURPOSE
Assessment of bladder emptying is challenging in non-verbal children with medical complexity due to the lack of indication that voiding has occurred. We sought to test the feasibility and efficacy of an enuresis alarm to guide timing of post-void residual (PVR) measurement in these patients.
MATERIAL AND METHODS
We prospectively enrolled 15 complex patients (<21 years old, nonverbal, diaper-voiding) hospitalized July-September 2023. Exclusion criteria were urinary tract infection or indwelling catheter. Protocol included a 4-hour period with alarm in place (PVR assessment after alarm trigger), and a 4-hour period of routine care (PVR assessment based on nurse observation of wet diaper). The primary endpoint of PVR volume with bladder scanner was analyzed with linear regression. Secondary endpoint was number of detected voids.
RESULTS
Median age was 10 years (0.8 to 16) and median weight was 20.7 kg (6.8 to 49.6). The most common diagnoses were cerebral palsy, spastic quadriplegia, and epilepsy. We excluded 4 patients who did not have at least one void in both the alarm and routine study periods from data analysis. Median number of detected voids were significantly different in the alarm versus routine care periods (3 vs. 1, p = 0.0312). Use of alarm was associated with a mean decrease of 21.09 mL (-40.60 to -1.58, p = 0.035) in PVR volume when adjusting for patient weight. Every 1 kg increase in weight was associated with a mean increase of 1.36 mL (0.53 to 2.19, p = 0.002) in PVR volume. No adverse events occurred.
CONCLUSIONS
An enuresis alarm facilitated detecting significantly more voids and smaller PVR volume in a population of complex non-verbal, diaper-voiding patients. Such alarms may prove useful to more accurately measure PVR in this challenging population.
09:16 - 09:19
S07-10 (OP)
Bieke SAMIJN 1, Christine VAN DEN BROECK 2, Frank PLASSCHAERT 3, Mathilde JOOS 2 and Erik VAN LAECKE 3
1) University Ghent, Ghent, BELGIUM - 2) Ghent University, Ghent, BELGIUM - 3) Ghent University Hospital, Ghent, BELGIUM
PURPOSE
Urinary incontinence and LUTS are common in patients with cerebral palsy (CP). Although recommended in typically developing children, non-invasive uroflow measurement is not routinely used in children with CP. The objective of the study is to investigate uroflowmetry in children with CP.
MATERIAL AND METHODS
A cross-sectional observational study is conducted including children with CP between five and twelve years old. Children are evaluated using uroflowmetry and the validated Dutch Vancouver Symptom Score for Dysfunctional Elimination Syndrome questionnaire.
RESULTS
Forty-five children were included, with a mean age of 8,3 years old and 58 % being male. 24 children (53%) were dry and 21 (47%) children were incontinent. A bell-shaped curve was most frequently seen and demonstrated by 19 (42%) children. A significant difference of flow pattern (p < 0.01) was noted between continence status, with more than 50 % of the dry children demonstrating a bell shaped curve and children with combined daytime incontinence and enuresis demonstrating only pathologically shaped curves. Within this last group, half of them could not void despite having a filled bladder. Voided volume as percentage of expected bladder capacity for age tended to be lower (36.3 % vs. 61.8 %; p = 0.04) in children with incontinence.
CONCLUSIONS
Non-invasive uroflow measurement could be useful in children with CP. Depending results, redirection to invasive urodynamic evaluation can be necessary. Special attention should be given to those who have combined daytime incontinence and enuresis and cannot void on uroflowmetry.