Improved bladder function after prophylactic treatment of the high risk neurogenic bladder in newborns with myelomentingocele.
OBJECTIVE
High pressure dyssynergic voiding may result in irreversible damage to the urinary tract. Prophylactic therapy in the form of clean intermittent catheterization and anticholinergic medication may significantly decrease the incidence of upper urinary tract deterioration. Whether prophylactic therapy in the high risk bladder may also lead to improved long-term bladder dynamics prompted us to study the effect of early versus late treatment of bladder hypertonicity and detrusor-sphincter dyssynergia on the ultimate need for bladder augmentation.


METHODS
We retrospectively reviewed urological outcomes in patients with myelodysplasia who were at risk for urological deterioration within year 1 of life based on bladder sphincter dyssynergia and/or high filling or voiding pressure. We recorded the dates when high risk voiding dynamics were initially observed, and when intermittent catheterization and anticholinergic therapy were initiated. Patients in whom treatment began at the time a high risk profile was noted (prophylactic group seen between 1985 and 1990) were compared to controls with the same high risk voiding parameters who did not receive early therapy (observation group seen between 1978 and 1984 with therapy instituted 1 year or longer after high risk was noted). The number of augmentations performed in each group was indexed to the total number of years of followup in the 2 populations, respectively. Patients with less than 2 years of followup were excluded from further analysis.


RESULTS
Of the 45 patients at risk clean intermittent catheterization and anticholinergic medication were immediately initiated in 18, while 27 were treated expectantly. Patients in the observation group were followed an average of 4.1 years (range 1.1 to 14) before clean intermittent catheterization and anticholinergic medication were started. Of the 27 children treated expectantly 11 (41%) required augmentation, whereas only 3 of the 18 (17%) treated prophylactically required enterocystoplasty. When the number of augmentations was indexed to total years of followup in each of the 2 groups (296 versus 156 years) patients in the expectant group were nearly twice as likely to require augmentation.


CONCLUSIONS
Identification and early proactive treatment of the high pressure, dyssynergic lower urinary tract significantly decreases the need for bladder augmentation as children with neurogenic bladder secondary to myelomeningocele mature.
Kaefer
M
M
Department of Urology, Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Pabby
A
A
Kelly
M
M
Darbey
M
M
Bauer
S B
SB
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D018680:Cholinergic Antagonists / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008333:Mandelic Acids / Q000627:therapeutic use*; D008591:Meningomyelocele / Q000150:complications*; D012189:Retrospective Studies; D012307:Risk Factors; D001743:Urinary Bladder / Q000503:physiopathology; D001750:Urinary Bladder, Neurogenic / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D014546:Urinary Catheterization
D018680:Cholinergic Antagonists; D008333:Mandelic Acids; C005419:oxybutynin