Elsevier

Journal of Pediatric Urology

Volume 13, Issue 6, December 2017, Pages 614.e1-614.e4
Journal of Pediatric Urology

Is urodynamic evaluation a must in all operated cases of open neural tube defects

https://doi.org/10.1016/j.jpurol.2017.04.016Get rights and content

Summary

Background

Spina bifida is a common cause of pediatric neurogenic bladder. It causes renal failure in almost 100% of patients if the associated detrusor sphincter dyssynergia (DSD) is inadequately managed. Detrusor instability and high detrusor pressures (Figure) have been implicated as the major factors predictive of renal damage in these patients. Urodynamic studies provide early identification of “at risk” kidneys so that appropriate intervention can be made. However, the role in post-operative patients of spina bifida who have no clinical manifestations remains unclear.

Objective

To study the bladder dynamics in asymptomatic post-operative patients of spina bifida and to determine whether routine urodynamic study is justifiable.

Material and methods

Urodynamics was performed on 15 operated patients of spina bifida who did not have any neurological deficit and were asymptomatic.

Results

The mean age of the patients was 4.97 years. None of the patients had any urological complaints with their ultrasonography being normal. None had scars on nuclear scan. Of the 15 patients, 12 (80%) had abnormal findings on urodynamic assessment. Three patients (20%) had detrusor pressures greater than 40 cm of H2O. One patient had significant residual urine and detrusor instability.

Discussion

The use of urodynamic studies in asymptomatic patients of spina bifida remains controversial, with one school of thought advocating early invasive urodynamic testing. In contrast, some favor noninvasive sonological monitoring, reserving invasive tests only for patients with renal tract dilatation. In our subset of patients none had renal tract dilatation but three patients (20%) had “at risk” bladders. These patients would benefit from early intervention aimed at renal preservation. The study is limited by a small sample size because of the relative rarity of the patient profile included. A further multicenter study with a case–control design could conclusively indicate the role of urodynamic testing in these patients.

Conclusion

Patients of spina bifida, even when asymptomatic, have a high incidence of unsafe bladders. Early identification and appropriate measures can protect kidneys from long-term damage, hence urodynamic profiling is mandatory for identification of potentially high-risk bladders.

Figure
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Figure. Cystometry curves with and without detrusor hyperactivity.

Introduction

Spina bifida is the most common cause of neurogenic bladder in pediatric patients. The lifetime risk of renal failure in patients with detrusor sphincter dyssynergia approaches 100% in the absence of adequate treatment [1]. Close to 20% of these patients develop renal failure in the first year of life [1]. Thus the current management of pediatric neurogenic bladder involves conservation of renal functions as the primary objective, along with establishment of social continence [1]. Urodynamic studies (UDS) help to identify the “at risk” kidneys and thus, early institution of “renal protective” interventions. The role of urodynamics in asymptomatic patients still remains unclear. This study was designed to document the urodynamic profile of asymptomatic patients of lumbosacral myelomeningocele (LSMMC) and reflect on justification of early urodynamic study in this subset of patients.

Section snippets

Material and methods

The study was conducted on asymptomatic patients of LSMMC, who underwent repair before reaching 6 months of age and attended our out-patient department from January to December in the year 2015. None of the patients had any clinical motor or sensory deficit and all of them were continent for stool and urine. All the patients voided and emptied well, except one who had a slight elevation in post void residual (PVR) urine, but we were unable to confirm if all of them voided strictly through their

Results

Fifteen operated patients with LSMMC were included in the study. The male to female ratio was 4:1. The mean age at surgery was 86.26 days (interquartile range 64 days). The large study population and unavailability of prompt referral meant that study presentation was delayed. Furthermore, not all patients were operated on at our institution; some had been referred to us for follow-up after surgery. This explains the older ages of some patients at surgery. Patients included in the study had a

Discussion

Most cases of LSMMC have poor prognoses [7]. Hunt, in 1990, reported that only about 60% of individuals make it to adulthood, even in the developed countries such as the UK [8]. Renal failure is one of the most important causes of long-term morbidity and mortality. The risk factor for renal cortical damage has been identified as detrusor sphincter dyssynergia, bladder pressures greater than 40 cm of H2O, and detrusor instability (variability >20 cm of H2O) [8]. Urodynamic profiling of LSMMC

Conclusion

Patients of LSMMC, even when asymptomatic, have a high incidence of unsafe bladders. Early identification and institution of appropriate measures can protect their kidneys from long-term damage and decrease the incidence of incontinence with time. Urodynamic profiling must be made mandatory for all patients for identification of potentially unsafe bladders.

Conflict of interest

None.

Funding

None.

References (18)

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  • Medical management of neurogenic bladder in patients with spina bifida: A scoping review

    2023, Journal of Pediatric Urology
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    In support of proactive UDS, Sager et al. demonstrated high-risk VUDS abnormalities (vesicoureteral reflux (VUR), pressure >20cmH2O, or elevated pressure during overactivity) in 46% (28/60) of patients <1 year old despite many having normal dimercaptosuccinic acid (DMSA) scans [20]. Bawa et al. corroborated these findings by showing that 80% (12/15) patients had abnormal UDS without other clinical, imaging, or laboratory abnormalities [21]. Together, these studies suggest that baseline UDS may detect abnormalities that would be missed with an expectant paradigm.

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