Severe bladder trabeculation obviates the need for bladder outlet procedures during augmentation cystoplasty in incontinent patients with neurogenic bladder

Abstract

OBJECTIVE To evaluate whether the degree of preoperative bladder trabeculation in neurogenic bladder (NB) patients is a marker of significant outlet resistance. If so, severe trabeculation may obviate the need for concomitant bladder outlet procedure (BOP) during augmentation cystoplasty (AC). PATIENTS AND METHODS We retrospectively reviewed 48 incontinent patients with NB who had surgery. The patients were divided into two groups: group 1 (23 patients) had AC alone; group 2 (10) had AC with BOP. Children who had a BOP alone (15) were excluded from the study. Success was defined as a dry period of ≥4 h. Preoperative bladder trabeculation was classified as mild or severe. Data collected included continence status, imaging and urodynamic findings. RESULTS In group 1 patients before surgery, there was severe bladder trabeculation in 14 (61%), hydronephrosis in 13 (57%) and associated vesico‐ureteric reflux (VUR) in 16 (70%). The mean detrusor leak‐point pressure (DLPP) was 49.7 cmH2O and the bladder neck was open in nine (39%). Dryness with AC alone was achieved in 91% of group 1 patients. In group 2 patients (10 patients), there was severe bladder trabeculation in five, hydronephrosis in three, and VUR in two. The mean DLPP was 42.8 cmH2O and the bladder neck was open in eight. After surgery, eight of 10 patients achieved a dry period of 4 h. There was no significant difference between group 1 and 2 patients for age at surgery, gender, ambulatory status, hydronephrosis, degree of trabeculation, detrusor overactivity, DLPP and eventual outcome. The incidence of VUR was higher in group 1 patients (P = 0.009) and more patients in group 2 had an open bladder neck (P = 0.031). CONCLUSION Severe bladder trabeculation in incontinent patients with NB might predict an element of intrinsic outlet resistance. In this subset of patients, dryness was achieved by AC alone without further BOP. The degree of bladder trabeculation should be considered in the surgical decision‐making process for incontinent children with NB.

Value of urodynamic findings in predicting upper urinary tract damage in neuro‐urological patients: A systematic review

“…Peculiarly, Khoury et al reported the resolution of VUR in 39/41 patients with a decrease in the hostility score ≤4 in the overall population after cystoplasty . Regarding data after bladder augmentation, Khoury et al also found that the rate of VUR was significantly lower ( P < 0.05) in augmented bladder treated with a concomitant bladder outlet procedure (0.2%) than when only cystoplasty was performed (70%) . Wang et al reported a positive correlation between the urodynamic risk score (DLPP >40 cmH 2 O + bladder compliance <9 mL/cmH 2 O + detrusor acontractility) and UUTD .…”

“…Mean follow‐up ranged from 0.5 to 11 years . In this young population, 951 (61%) were receiving treatment for their NLUTD at the time of the inclusion in 16/28 studies . Of those, 635 (67%) were managed by intermittent catheterization (IC) (see Table ).…”

“…Data on DLPP were found in 14/28 studies, but only in 5 (35.7%) mean values were available, ranging from 18 to 68 cmH 2 O . Categorization of the sample according to the cut‐off value ≥40 cmH 2 O was described apart from two reports, which defined high DLPP values higher than 25 and 30 cmH 2 O, respectively .…”

Current status of bladder neck reconstruction

“…Better preoperative criteria are needed to identify patients who do not need an outlet procedure and may respond to bladder augmentation alone. The presence of bladder trabeculation possibly indicates adequate outlet resistance and can be used in conjunction with the other known urodynamic variables [30]. Before embarking on a BOP it is imperative to ensure complete patient compliance and motivation, besides providing realistic information on the expected long-term outcome and potential complications of the procedure.…”

A Convex Hull‐Based New Metric for Quantification of Bladder Wall Irregularity in Pediatric Patients With Congenital Anomalies of the Kidney and Urinary Tract

“…Bladder wall detrusor hypertrophy in the short term can delay diagnosis of a progressive problem because the elevated pressures do not necessarily affect full bladder emptying. Morphologic changes accompanying this process are bladder wall thickening and progressive changes in the bladder wall shape or contour …”