Urodynamic changes in patients with anterior urethral valves: before and after endoscopic valve ablation

PurposeTo retrospectively review a series of children with anterior urethral valves (AUV), with emphasis on patterns of urodynamic change and long-term outcome of endoscopic treatment.Patients and methodsWe reviewed the medical records of eight patients who had undergone thorough radiological and urodynamic exams before and after treatment. The diagnosis of AUV was based on radiological imaging and confirmed by urethrocystoscopy. The valves were ablated through either transurethral fulguration or resection. The upper urinary tracts were studied by renal scan and ultrasonography before and after the procedure. Bladder function was assessed urodynamically 3 months after surgery. Uroflowmetry was performed as soon as the children were toilet trained.ResultsEndoscopic ablation of AUV was successful in all cases and no surgical complications occurred. The initial symptoms resolved in all boys. VUR disappeared in two out of three patients, and five children had bladder trabeculation that was resolved after surgery. The final outcome was successful in seven patients (88%). The major urodynamic dysfunction was bladder hypercontractility that resolved following valve ablation. The mean maximum voiding detrusor pressure (P_detmax) decreased from 213.2 ± 17.9 cmH₂O to 80.7 ± 9.9 cmH₂O, 6 months after treatment (P < 0.001). None of the patients had low-compliant bladder, detrusor instability or myogenic failure. The voiding pattern in all toilet-trained patients was staccato and of an interrupted shape prior to surgery, but changed to a normal bell-shaped voiding pattern following valve ablation.ConclusionAUV should be considered in the differential diagnosis of patients presenting with infravesical obstruction. We recommend endoscopic valve ablation as the treatment of choice.     

Can urodynamic studies be dispensed with in the initial urologic management of children with meningomyelocele? A study of 30 cases and review of the literature

ObjectiveTo identify whether a relationship exists between information gathered from voiding patterns, neurological status and radiological findings, and the actual dysfunction seen on cystometry in children with spina bifida.Patients and methodsThirty consecutive children with spina bifida underwent clinical evaluation, urinary tract imaging and cystometry. The clinical and radiological data were correlated with actual bladder dysfunction.ResultsCystometry was abnormal in 87% with overactive detrusor in 77%. Seventeen patients (57%) had significant residual urine of whom all had neurological or voiding abnormalities. Irrespective of radiological findings (abnormal in 53%), 90% of these patients had detrusor overactivity and 10% an underactive detrusor. In the group with insignificant residual urine (n = 13), upper tract was abnormal in six (46%) of which four had neurological/voiding abnormalities and detrusor overactivity. The other two patients with normal neurologic status and voiding pattern had normal cystometry, but their upper tract damage was inexplicable. Of the patients with insignificant residual urine and normal upper tracts (n = 7), four had neurologic/voiding abnormalities, three with an overactive detrusor and one underactive detrusor, and of the other three, one had an overactive detrusor.ConclusionsPatients with significant residual urine can be presumed to have detrusor overactivity and may be initially managed with clean intermittent catheterization and bladder relaxants. Cystometry is indicated if upper tract shows deterioration. In patients with insignificant residual urine and abnormal clinical evaluation or radiology, detrusor overactivity can be presumed and urodynamic studies deferred. Patients with insignificant residual urine, normal radiology but abnormal clinical findings must undergo initial cystometry.     

Are urodynamic studies really needed during bladder augmentation follow-up?

ObjectiveWe assessed clinical and urodynamic outcomes, over a minimum 10-year follow-up period, of neuropathic bladder patients treated with a bladder augmentation (BA) to determine if periodic urodynamic studies are needed.Material and methodsThirty-two patients with poorly compliant bladders underwent BA at a mean age of 11 years (2.5–18). Mean follow-up was 12 years (10–14.5) and mean patient age at the end of the study was 22 years (12.2–33). During follow-up all patients were controlled at regular intervals with urinary tract imaging, serum electrolyte and creatinine levels, cystoscopy and urodynamic studies. Preoperative, 1-year post-BA and latest urodynamic studies results were compared.ResultsUrodynamic studies at 1-year post-BA showed a significant increase in bladder capacity and a decrease in end-filling detrusor pressure compared with preoperative values (396 vs 106 ml; 10 vs 50 cm H₂O, P < 0.0001). The increase in bladder capacity was more significant at the end of the study than after 1 year (507.8 vs 396 ml, P < 0.002). Thirteen patients had phasic contractions after 1 year and 11 at the end (not significant, NS), and these contractions were more frequent with colon than with ileum (NS). At the end of follow-up, phasic contraction pressure had decreased while trigger volume had increased (35 vs 28 cm H₂O; 247 vs 353 ml, NS). All patients are dry and have normal renal function, except one who had mild renal insufficiency before BA.ConclusionBA improves bladder capacity and pressure, and these changes are maintained over time (although phasic contractions do not disappear). Repeated urodynamic studies are only necessary when upper urinary tract dilatation or incontinence does not improve.     

Comparative efficacy and safety of extended-release and instant-release tolterodine in children with neural tube defects having cystometric abnormalities

AimTo evaluate the comparative efficacy and safety of extended-release (ER) and instant-release (IR) tolterodine preparations in a pediatric population with neural tube defects having cystometric abnormalities.Materials and methodsTwenty-five patients with neural tube defects and a similar demographic profile underwent a routine hemogram, liver function tests, renal function tests, urine culture, X-ray lumbo-sacral spine, and renal and bladder ultrasound. Vesicoureteric reflux was diagnosed by micturating cystourethrogram under fluoroscopy. Dimercaptosuccinic acid renal scintigraphy was performed to study the presence or absence of renal scars. Patients were treated with tolterodine ER (Group I: 2 mg once daily for 21 days) and tolterodine IR (Group II: 2 mg twice daily for 21 day) in a cross-over study with a 10-day washout period between administrations. Evaluation was by subjective assessment, visual analog scale, urodynamic assessment and adverse drug reaction monitoring.ResultsThere was ultrasound evidence of hydroureteronephrosis in 20% of the patients. One patient out of 25 had impaired renal function and eight patients had renal scarring on dimercaptosuccinic acid scans. Both forms of the drug increased the maximum cystometric bladder capacity, decreased detrusor leak pressures and increased compliance compared to pre-therapy levels (P = 0.0001). Visual analog scale showed a significant clinical improvement with both ER and IR tolterodine. A significant increase in maximum bladder capacity in the group receiving IR tolterodine as compared to the ER preparation was noted (P = 0.0001). The decrease in detrusor leak pressures and improvement in compliance were not significantly different between the groups. No adverse effects of hyperpyrexia, flushing or intolerance to outdoor temperatures, or dryness of mouth were observed in either group. No patient suffered from constipation.ConclusionER tolterodine 2 mg once daily is as effective and well tolerated in children with neurogenic bladder as IR tolterodine 2 mg twice a day. The latter was found to be more effective in terms of urodynamic parameters. ER formulation of tolterodine is less expensive and has the advantage of single dosage.     

Post-pyelonephritic renal scars are not associated with high voiding pressures

ObjectiveThe aim of this study was to evaluate whether renal scars and vesicoureteral reflux (VUR) are associated with bladder dysfunction in children after first clinical pyelonephritis.Patients and methodsSixty-four children were evaluated with urodynamics and voiding cystourethrography at a median of 8 weeks after their first episode of clinical pyelonephritis. All patients had ultrasonography and dimercaptosuccinic acid (DMSA) scintigraphy during the infection. After 2 years, DMSA scintigraphy was repeated in 58 patients. Re-infections were recorded.ResultsOveractive detrusor was found in 27 (42%) patients. There was no significant difference in the incidence of overactive detrusor between boys and girls. The maximal voiding pressure was higher in boys (median 92.5, range 48–191 cmH₂O) than in girls (median 82, range 37–150 cmH₂O) (P = 0.0117). Thirty-one (48%) patients had renal defects in scintigraphy during the infection. Ultimately, 12 patients (21%) developed renal scars; 11 patients (17%) had VUR. Renal defects in DMSA scintigraphy and the presence of VUR were not associated with overactive detrusor or high voiding pressures.ConclusionOveractive detrusor is a common finding after first episode of pyelonephritis. The dysfunction may explain the development of urinary tract infections in some children. There were no differences in the incidence of overactive detrusor or voiding pressures in patients with and without VUR, or in those with and without renal defects on DMSA scintigraphy. Urodynamic study is not a primary investigation in pyelonephritic children.     

Augmentation ureterocystoplasty in boys with valve bladder syndrome

ObjectiveChildren with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome.Patients and methodsEight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound.ResultsBladder capacity (as measured during cystometry at 30 cm H₂O) and compliance were significantly improved in all children following the procedure (P < 0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child.ConclusionUreterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.     

Vesicostomy vs primary ablation for posterior urethral valves: Always a difference in outcome?

ObjectiveA vesicostomy is believed to have a detrimental effect in boys with posterior urethral valves compared to primary valve ablation. We compared the outcomes of boys managed by initial vesicostomy with those undergoing primary fulguration.Materials and methodsThe outcomes of 54 boys (23 vesicostomy, 31 primary valve fulguration) over 1 year of age who had not undergone renal transplant were considered. Outcome parameters identified were ultrasound findings, continence status, glomerular filtration rate (GFR) and 1-year creatinine. Dryness was defined as completely dry both day and night with no need to wear pads. Results are presented with 95% confidence intervals.ResultsUltrasound examinations were normal in 9/19 (47.4%) of the vesicostomy group and 11/24 (45.8%) of the fulguration group. Graded ultrasound results were not significantly different (p = 0.24). The vesicostomy patients were more often dry (79% vs 64%, p = 0.43). The vesicostomy group had on average higher GFR (95.26 vs 85.79) and lower 1-year creatinine (49.58 vs 52.46) values. After accounting for age differences between groups, there was no significant difference in the GFR and 1-year creatinine values (p = 0.16 and p = 0.87, respectively).ConclusionsThere was a tendency for the major outcomes to be more favourable in the vesicostomy group. Although trends were non-significant, confidence intervals were wide and potential differences of clinical importance could not be discounted.     

Long-term efficacy and safety of tolterodine in children with neurogenic detrusor overactivity

ObjectiveWe evaluated long-term (≥12 months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity.Subjects and methodsSubjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4 months–4 years, tolterodine oral solution 0.2–2 mg twice daily; 5–10 years, tolterodine oral solution 0.5–4 mg twice daily; 11–16 years, tolterodine extended-release capsules 2, 4, or 6 mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries.ResultsThirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40 cm H₂O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10 cm H₂O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24 h decreased in all subjects, as did the number of catheterizations per 24 h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported.ConclusionsBoth tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.     

Bladder augmentation and artificial sphincter implantation: urodynamic behavior and effects on continence

ObjectiveTo quantify changes in bladder capacity, pressure and compliance after isolated bladder augmentation or augmentation associated with implantation of an artificial sphincter, and to compare the various types of augmentation.Patients and methodsPreoperative and postoperative urodynamic studies were performed in a group of 38 patients (18 males and 20 females; age range 2–19 years), who underwent a type of bladder augmentation.ResultsThe bladder improved in capacity in all patients (mean values: initial 137 ml, final 336 ml, individual increase 229 ml; 434%) except two, in which the augmentation was done with ureter. The mean pressure improved (initial 32 cm of H₂O, final 14, decrease per patient 18 cm of H₂O; 49%). The curve of compliance, progressively increasing typical of hyperreflexia and poor compliance, present in 70% of the cases preoperatively, improved in 78% cases postoperatively, although there were several different patterns. Urodynamic behavior was analyzed with regard to the tissue used for augmentation (ileum, ureter or sigmoid colon). In the sigmoid colon group, there were no significant differences in the urodynamic behavior of the bladder neo-reservoir in relation to the configuration used.ConclusionWith bladder augmentation comes an increase in bladder capacity, a reduction in pressure, and an improvement in compliance and continence. The level of change in capacity, pressure and compliance varies with the tissue used and the length and caliber of the insert. When the procedure is carried out using sigmoid colon tissue, there are no noteworthy differences among the various possible configurations.     

Total endoscopic management (TEM approach) of children with non-compliant neuropathic bladder: a preliminary report

PurposeWe prospectively evaluated the efficacy and durability of a combination of intradetrusor botulinum-A toxin (BTX-A) and endoscopic treatment of vesicoureteric reflux (VUR) to manage children with myelomeningocele (MMC) and non-compliant refluxing bladders who were not responding to standard conservative therapy. We also evaluated whether this combined therapy can lower intravesical pressure, increase bladder capacity, gain social continence and protect the upper tract from recurrent urinary tract infection.Material and methodsA total of 10 patients with a mean age of 5.9 ± 3.6 years (range 2–12 years) with MMC (eight females and two males) were prospectively involved in the study. All patients were fully compliant to clean intermittent catheterization, and all were non-responders (failed to gain continence and/or poor compliance) to the maximum tolerable dose of anticholinergics and catheterization. All patients were subjected to cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) of BTX-A in an infection-free bladder. They all had VUR (16 refluxing ureters, six patients with bilateral VUR) and did not show resolution in the pretreatment voiding cystourethrogram; accordingly, submucosal injection of Deflux^® was performed either with the second BTX-A treatment (initial four patients) or with the first BTX-A treatment (the other six patients). The grade of reflux was G III, IV and V in three, seven and six ureters, respectively.ResultsThe maximum bladder capacity increased significantly from 79 ± 49 to 155 ± 57 ml (p < 0.022), and the maximum detrusor pressure decreased significantly from 55 ± 16 to 37 ± 11 cm H₂O (p < 0.001). Fifteen out of 16 (93.75%) refluxing ureters were completely resolved (one of them on second attempt), and one (6.25%) (GV reflux) remained unchanged despite of two attempts. Of six incontinent patients, five reached complete dryness between catheterizations and one showed partial improvement.ConclusionsA combination of BTX-A and endoscopic correction of VUR is a simple and effective way to overcome the increased risk of high intravesical pressure and recurrent UTI. This treatment decreases the incidence of renal damage in children on whom conservative management fails to help, in a minimally invasive way.     

Modern staged repair of bladder exstrophy: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and many repairs are now offered. The purpose of this study was to evaluate long-term outcomes in a select group of patients in whom modern staged repair (MSRE) was undertaken.Patients and methodsFrom an institutionally approved database were extracted 189 patients who had undergone primary closure between 1988 and 2004. The records of 131 patients (95 males) who underwent MSRE with a modified Cantwell-Ransley repair by a single surgeon in 1988–2004 were reviewed with a minimum 5-year follow up.ResultsSixty-seven patients with a mean age of 2 months (range 6 h to 4 months) underwent primary closure, and 18 underwent osteotomy at the same time. Mean age at epispadias repair was 18 months (8–24). Mean age at bladder neck reconstruction (BNR) was 4.8 years (40–60 months) with a mean capacity of 98 cc (75–185). Analysis of bladder capacity prior to BNR revealed that patients with a mean capacity greater than 85 cc median had better outcomes. Seventy percent (n = 47) are continent day and night and voiding per urethra without augmentation or intermittent catheterization. Social continence defined as dry for more than 3 h during the day was found in 10% (n = 7). Six patients required continent diversion after failed BNR. Seven patients are completely incontinent. The mean time to daytime continence was 14 months (4–23) and the mean time to night-time continence was 23 months (11–34). No correlation was found between age at BNR and continence.ConclusionsPatients with a good bladder template who develop sufficient bladder capacity after successful primary closure and epispadias repair can achieve acceptable continence without bladder augmentation and intermittent catheterization.     

Botulinum toxin-A (Botox®) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: A systematic literature review

ObjectivesDescribe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).MethodsA MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis.ResultsA total of six articles evaluating the efficacy and safety of Botox^® in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10–12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65–87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H₂O and compliance was increased >20 ml/cm H₂O) variables, without major adverse events.ConclusionsBotox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.     

Urethral ratio on voiding cystourethrogram: A comparative method to assess success of posterior urethral valve ablation

ObjectiveTo develop a simple, objective and reproducible quantitative measurement to assess success of posterior urethral valve ablation.MethodIn 30 patients with posterior urethral valves the diagnosis was confirmed by voiding cystourethrogram (VCUG). Our protocol was to perform valve ablation, and repeat VCUG at 12 weeks postoperatively. Urethral ratio was calculated by dividing the posterior urethral diameter by the anterior urethral diameter. Thirty males undergoing VCUG for urinary tract infections were evaluated as normative controls.ResultsMedian age of controls was 12 months (2 days–6 years) and of study group was 13 months (1 day–11 years). Mean urethral ratio in pre-fulguration group was 4.94 (±2.97) and in post-fulguration group was 2.134 (±1.19) (P < 0.001). The mean urethral ratio in the control group of 1.73 (±0.577) was significantly different from the pre-fulguration group result (P < 0.001), but not significantly different in comparison to the post-fulguration group (P = 0.104).ConclusionCalculation of urethral ratio on VCUG as a method of assessment of outcome of fulguration is objective, reproducible, and allows preoperative and postoperative VCUG from different facilities to be compared. A post-fulguration urethral ratio of 2.5–3 represents an acceptable result postoperatively.     

Treatment with modified intravesical oxybutynin chloride for neurogenic bladder in children

ObjectiveWe have previously reported that intravesical oxybutynin chloride with hydroxypropylcellulose (modified intravesical oxybutynin) is an effective therapeutic agent for patients with detrusor overactivity. In this study, we report on the efficacy, safety and side effects of modified intravesical oxybutynin administration in children with neurogenic bladder.PatientsModified intravesical oxybutynin (1.25 mg/5 mL, twice a day) was administered to four children (three males and one female) with neurogenic bladder (detrusor overactivity and/or low compliance bladder), who were previously unresponsive to or experienced intolerable side effects from oral medications. A cystometrogram was obtained before, 1 week after, and 1 year after the first intravesical instillation of modified oxybutynin. We also carefully observed anticholinergic side effects, occurrence of urinary tract infection and degree of incontinence during this treatment.ResultsAfter 1 week, both cystometric bladder capacity and compliance were improved in all patients, and detrusor overactivity was undetectable in three of four patients. At 1 year, there was further improvement in bladder compliance in three patients, and detrusor overactivity was not observed in two patients. Significant improvement in the degree of incontinence was achieved. No systemic anticholinergic side effects were observed in any of the patients. One patient with vesicoureteral reflux discontinued the therapy after 2 months due to upper urinary tract infections.ConclusionModified intravesical oxybutynin is an effective and relatively safe therapeutic option for children with neurogenic bladders.     

The modern staged repair of bladder exstrophy in the female: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and several repairs are now offered, but there is a lack of long-term follow-up data. The purpose of this study was to evaluate long-term outcomes in a select group of female patients in whom modern staged repair was undertaken.Patients and methodsFrom an institutionally approved database 41 patients were identified. All had undergone primary bladder exstrophy closure in 1988–2005, at a mean age of 2 months (range 4 h to 3 months), with or without an osteotomy by a single surgeon, and all were followed up for a minimum of 5 years. Twelve patients underwent osteotomy at the time of primary closure. Eight had a classic transverse innominate and vertical iliac osteotomy, and four a transverse innominate only. Mean age at the time of bladder neck repair (BNR) was 4.2 years (39–65 months). Mean measured bladder capacity under gravity cystograms at the time of repair was 109 cc (80–179 cc).ResultsThirty patients (74%) were continent day and night, and voiding per urethra without augmentation or intermittent catheterization. Social continence, defined as dry for more than 3 h during the day but damp at night, was found in a further four cases (10%). Seven patients are completely incontinent with dry intervals of less than 1 h day and night. The mean time to daytime continence was 12 months (4–16 months) and to night-time continence was 19 months (10–28 months). Patients with a mean capacity greater than 100 cc had better outcomes. Six of the 30 patients achieved dryness after primary closure only, and all six had transverse innominate and vertical iliac osteotomy at the time of primary closure.ConclusionsFemale classic exstrophy patients with a good template who develop adequate capacity after a successful primary closure can achieve acceptable continence without bladder augmentation and intermittent catheterization. A select group will develop continence with closure alone without the need for bladder neck repair.     

脊髓脊膜膨出患儿尿动力学改变与上尿路损害的关系探讨

目的探讨脊髓脊膜膨出患儿尿动力学改变与上尿路损害的关系。方法对36例脊髓脊膜膨出患儿行泌尿系彩超、静脉肾盂造影及尿动力学检查,根据检查结果分析与上尿路损害密切相关的尿动力学危险因素。结果36例患儿中,泌尿系彩超检查提示15例存在上尿路损害,21例无上尿路损害。尿动力学检查提示上尿路损害组中逼尿肌漏尿点压（47．2±21．9）cm H3O,显著高于未损害组（15．7±9．6）cmH2O;逼尿肌漏尿点压〉40cmH2O的发生率为66．7％（10／15）,显著高于未损害组中发生率0．0％（0／21）;膀胱顺应性（4．5±2．4）mL／cmH2O,显著低于未损害组（12．8±13．2）mL／cmH2O;残余尿量（137．8±99．7）mL,显著高于未损害组（32．3±36．7）mL;残余尿量≥50mL的发生率为93．3％（14／15）,显著高于未损害组中的发生率19．0％（4／21）;排尿期逼尿肌反射低下或无反射的发生率为66．7％（10／15）,显著高于未损害组中的发生率14．1％（3／21）。差异均具有显著的统计学意义（P〈0．05）。结论膀胱漏尿点压升高、膀胱顺应性降低、排尿期逼尿肌反射低下或无收缩以及残余尿量增多与上尿路损害关系密切;逼尿肌漏尿点压〉40cmH2O、残余尿量〉150mL、排尿期反射低下或无反射的发生可有效提示上尿路损害。     

Posterior urethral valves after infancy–urodynamic consequences

This study describes a subset of patients with posterior urethral valves (PUV) who presented late in childhood. The objective was to identify factors that lead to back-pressure effects on the upper tracts, which persist in spite of adequate valve ablation in some patients, and seek factors that may preserve the upper tracts despite untreated obstruction in other patients. Six children with PUV diagnosed after infancy were evaluated. The pre-operative work-up included renal biochemistry, ultrasonography, voiding cystourethrography, and uroflowmetry. Detailed urodynamic studies, including uroflowmetry and slow-fill cystometry, were performed in all cases 6 months after surgery. Adequacy of valve fulguration was confirmed by urethroscopy. Three of the six patients had normal upper tracts; in these, there was marked improvement in peak urine flow rates after fulguration and bladder pressures were normal. The other three patients had bilateral hydroureteronephrosis, and two had chronic renal failure. This group had markedly decreased functional bladder capacity with loss of compliance at low bladder volumes and significant residual urine volumes in spite of adequate valve fulguration, suggesting myogenic detrusor failure. We conclude that in patients with PUV presenting beyond the age of 5 years, upper-tract deterioration may accompany high storage pressures in the bladder. In some boys with long-standing obstruction the upper tracts may escape damage; in our series this was associated with normal bladder dynamics and appeared unrelated to the severity or duration of outflow obstruction. Accepted: 13 August 1997     

Initial surgical treatment as a determinant of bladder dysfunction in posterior urethral valves

Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy; vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder; (2) vesicostomy group: small-capacity, hyperreflexic bladder; and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function.     

Leech in urinary bladder causing hematuria

ObjectiveTo estimate efficacy of normal saline in the management of hematuria caused by accidental entry of a leech per urethra into the urinary bladder.MethodsAn intervention study was carried out in the Department of Pediatric Surgery of Sylhet MAG Osmani Medical College between January 1998 and December 2003. A total of 43 boys (mean age 8 years, SD ± 2.6) were enrolled. In all cases, a leech had entered the urinary bladder through the urethra causing hematuria. All patients were equipped with a self-retaining Foley catheter. They were managed by infusing 50 ml of normal saline into the urinary bladder through the catheter that was then clamped for 3 h.ResultsAfter removing the catheter, in all cases the whole leech was spontaneously expelled intact, dead or alive, within 2–24 h during the subsequent act of micturition. Hematuria gradually diminished to a clear flow within the next 6 h in 27 cases, 12 h in 14 cases and 24 h in two cases. All patients were followed up for 2 weeks, and none developed recurrent hematuria.ConclusionCatheterization and irrigation of the urinary bladder with normal saline is a relatively simple, safe and inexpensive method of removing the leech and controlling hematuria.     

Gabapentin: A novel drug as add-on therapy in cases of refractory overactive bladder in children

ObjectiveTo determine the effectiveness of gabapentin as an add-on therapy in children presenting with overactive bladder (OAB) not responding to conventional anticholinergics.Materials and methodsChildren with refractory OAB were included prospectively from March 2009 to February 2010. The inclusion criterion was persistence of symptoms while on conventional anticholinergics for 6 months. Gabapentin was prescribed as an add-on therapy. The patients were followed 4 weekly with bladder diary and urodynamic study was repeated at 3 months.ResultsThere were 31 children, 26 of neurogenic OAB and 5 of non-neurogenic origin. Mean ± SD age was 8.5 ± 5.3 years. Data were analyzed in 30 patients as treatment was terminated in 1 due to adverse effects. Continence improved in 16 (53.3%) patients. Voiding volume improved from 175 ± 90 to 320 ± 110 ml (p < 0.03). Objective assessment of OAB symptom relief showed marked improvement (p < 0.05). Mean maximum cystometric bladder capacity improved from 210 ± 94 to 360 ± 110 ml (p < 0.02). The maximal detrusor contraction decreased from 75 ± 35 to 25 ± 15 cm H₂O (p < 0.02). Fourteen patients (46.7%) failed to respond to gabapentin therapy. These patients had baseline maximum cystometric bladder capacity <60% for age and maximum detrusor contractions >50 cm of water (p < 0.03).ConclusionsGabapentin gives moderate results in children with OAB refractory to conventional anticholinergics. In general, the drug is well tolerated with fewer adverse effects.