Is urodynamic evaluation a must in all operated cases of open neural tube defects
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)
- et al.
Age related bladder capacity and bladder capacity growth in children with myelomeningocele
J Urol
(1997) - et al.
Clean, intermittent self-catheterization in the treatment of urinary tract disease
J Urol
(1972) - et al.
An alternative approach to myelodysplasia management: aggressive observation and prompt intervention
J Urol
(1994) - et al.
Management of children with myelodysplasia: urological alternatives
J Urol
(1990) - et al.
Long-term urological response of neonates with myelodysplasia treated proactively with intermittent catheterization and anticholinergic therapy
J Urol
(1995) - et al.
The standardization of terminology of lower urinary tract function in children and adolescents: report from the standardisation committee of the International Children's Continence Society
J Urol
(2006) - et al.
Treatment of the neurogenic bladder in spina bifida
Pediatr Nephrol
(2008) - et al.
Can a quantitative means be used to predict flow patterns: agreement between visual inspection vs. flow index derived flow patterns
J Pediatr Urol
(2016 Aug) Neurogenic bladder: etiology and assessment
Pediatr Nephrol
(2008)
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Medical management of neurogenic bladder in patients with spina bifida: A scoping review
2023, Journal of Pediatric UrologyCitation Excerpt :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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