Neurogenic Lower Urinary Tract Dysfunction in Pediatric Lumbosacral Myelomeningocele: Urodynamic Classification, Management and Outcome
Keywords:
neurogenic lower urinary tract dysfunction, pediatric, lumbosacral, myelomeningocele, urodynamic, managementAbstract
Objective: To evaluate the lower urinary tract dysfunction of patient with lumbosacral myelomeningocele, management and complications after surgical procedures.
Patients and Methods: Data of 62 myelomeningocele patients (27 males, 35 females) with age ranged from 1-15 years (mean = 5.93 + 3.27) were collected between 1995 and 2009 at Maharaj Nakorn Chiang Mai Hospital. Fifty had lumbosacral region and 12 had sacral region lesions. All patients underwent videourodynamic study.
Result: Results of videourodynamic study were analysed and divided into 2 groups. First group, 48 patients had neurogenic detrusor overactivity(NDO). Of 48 patients, 7 patients had Detrusor sphincter dyssynergia (DSD), and 41 patients had static sphincter activity. Second group, 14 patients had acontractile bladder and static sphincter activity. Of 62 patients, 42 had high risk for upper urinary tract damage due to low compliance (<10 ml/cmH20). Of these,15 had detrusor pressure > 40 cmH20 and 14 had vesicoureteral reflux(VUR) from VCUG study. Twenty had normal bladder compliance. Fourty four patients (33 in group 1(NDO) and 11 in group 2 (Acontractile bladder)) were conservatively treated with clean intermittent catheterization with/without antimuscarinic drugs. Regular follow-up with radiographic investigations and serum creatinine did not changed. Duration of follow-up in this group was 1 to 4 yr (mean 2.18 + 0.81). In surgical group including 18 patients (15 in group 1 and 3 in group 2) underwent various surgical procedures (augmentation gastrocystoplasty with bladder neck reconstruction (Kroppûs technique) in 10, autoaugmentation cystoplasty covered with demucosalized gastric patch with bladder neck recontruction in 4, and autaugmentation cystoplasty covered with demucosalized sigmoid patch with bladder neck recontruction in 4.) In augmentation gastrocystoplasty with bladder neck reconstruction group, 2 were converted to continent catheterizable stoma due to persistent incontinence. In surgical group, 2 had VUR, 1 had renal deterioration postoperatively. Average bladder capacity at Pdet 30 cmH20 pre- and postoperative were 148.05 + 95.32 (range 33-375) cc and 330.36 + 131.06 (range 77-485) cc (p=0.21) respectively. Duration of follow-up in surgical group was 2 to 12 yr (mean 5.85 + 2.98).
Conclusion: The anatomical site of myelomeningocele cannot predict lower urinary tract dysfunctions. Videourodynamics studies have an important role in making proper diagnoses, classifying and assessing the severity of the disease and management. In surgical group; although there was no statistical significance of capacity between preoperation and postoperation, but an improvement of augmented bladder capacity was satisfied.
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