Summary
Introduction
Patients with neurogenic bladder (NGB) and urinary incontinence (UI) due to low bladder
outlet resistance may require bladder neck procedures (BNPs) to achieve continence.
These patients may also have reduced bladder capacity and or elevated detrusor storage
pressures that require augmentation cystoplasty (AC). AC is not without complications
that include risks for bladder rupture, urolithiasis, urinary tract infections and
metabolic issues. Avoidance of AC would be helpful in patients with neurogenic urinary
incontinence that have safe bladder parameters in the setting of low bladder outlet
resistance.
Objective
To determine if pre-operative urodynamics could select children with NGBs and UI for
isolated BNPs without AC. Additionally we sought to determine the safety of BNPs without
AC and future need of AC with long-term follow-up.
Study design
This is an IRB-approved retrospective analysis of all patients undergoing BNPs for
management of neurogenic UI over a 17-year period. We separated these BNP patients
into two groups: No AC + BNP (Group 1) vs. AC + BNP (Group 2). Our primary analyses
focused on postoperative outcomes for patients in Group 1. Outcomes assessed included
additional surgical procedures, urodynamic changes, development of CKD, new hydronephrosis
(HDN) and vesicoureteral reflux (VUR). Secondary analysis included the timeline for
the development of any bladder deterioration that necessitated AC in Group 1.
Results
93 patients underwent BNP at a mean age of 10.8 years. Thirty did not have AC at the
time of surgery (Group 1). These children had larger (p < 0.001) and more compliant
(p < 0.001) bladders than Group 2 having simultaneous augmentation. At 6 years mean
follow-up in Group 1 patients, three developed new reflux and three had new hydronephrosis.
Nine (30%) had additional continence procedures. Twelve required (40%) AC at a mean
of 23 months after the initial BNP. No patients had AC after 5 years. Detrusor end
filling pressure increased 14.8 cm H2O (p = 0.028) and expected bladder capacity decreased
26.1% (p = 0.005) after isolated BNP.
Discussion
We found that from our cohort of patients who had normal bladder compliance and normal/near
normal expected capacity preoperatively 40% required subsequent AC. We were unable
to find pre-operative clinical parameters which predicted failure or conversion to
AC. We found that 43.3% of our BNP without AC patients had no subsequent invasive
procedures with mean 6-year follow-up. We found that none of our patients developed
any degree of CKD. Finally, we found that the majority of patients that converted
to AC after their BNP did so within the first 2 years after their initial BNP and
no patients required augmentation 5 years post their initial BNP. This data validates
that these patients require very strict follow up, particularly in the first 5 years
after surgery.
Conclusions
Graphical AbstractAugmentation free following their initial bladder neck procedure.
Keywords
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Article info
Publication history
Published online: November 28, 2020
Accepted:
November 21,
2020
Received in revised form:
September 22,
2020
Received:
January 19,
2020
Identification
Copyright
© 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
