An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida.
OBJECTIVE
Neurogenic bladder is a major problem for children with spina bifida. Despite rigorous pharmacological and surgical treatment, incontinence, urinary tract infections and upper tract deterioration remain problematic. We have previously demonstrated the ability to establish surgically a skin-central nervous system-bladder reflex pathway in patients with spinal cord injury with restoration of bladder storage and emptying. We report our experience with this procedure in 20 children with spina bifida.


METHODS
All children with spina bifida and neurogenic bladder underwent limited laminectomy and a lumbar ventral root (VR) to S3 VR microanastomosis. The L5 dorsal root was left intact as the afferent branch of the somatic-autonomic reflex pathway after axonal regeneration. All patients underwent urodynamic evaluation before and after surgery.


RESULTS
Preoperative urodynamic studies revealed 2 types of bladder dysfunction- areflexic bladder (14 patients) and hyperreflexic bladder with detrusor external sphincter dyssynergia (6). All children were incontinent. Of the 20 patients 17 gained satisfactory bladder control and continence within 8 to 12 months after VR microanastomosis. Of the 14 patients with areflexic bladder 12 (86%) showed improvement. In these cases bladder capacity increased from 117.28 to 208.71 ml, and mean maximum detrusor pressure increased from 18.35 to 32.57 cm H2O. Five of the 6 patients with hyperreflexic bladder demonstrated improvement, with resolution of incontinence. Urodynamic studies in these cases revealed a change from detrusor hyperreflexia with detrusor external sphincter dyssynergia and high detrusor pressure to nearly normal storage and synergic voiding. In these cases mean bladder capacity increased from 94.33 to 177.83 ml, and post-void residual urine decreased from 70.17 to 23.67 ml. Overall, 3 patients failed to exhibit any improvement.


CONCLUSIONS
The artificial somatic-autonomic reflex arc procedure is an effective and safe treatment to restore bladder continence and reverse bladder dysfunction for patients with spina bifida.
Xiao
Chuan-Guo
CG
Departments of Urology, Tongji Medical College, Xiehe Hospital, Huazhong University of Science and Technology, Wuhan, China. xiaocg@mails.tjmu.edu.cn
Du
Mao-Xin
MX
Li
Bing
B
Liu
Zhao
Z
Chen
Ming
M
Chen
Zhao-Hui
ZH
Cheng
Ping
P
Xue
Xiao-Nan
XN
Shapiro
Ellen
E
Lepor
Herbert
H
D000293:Adolescent; D000714:Anastomosis, Surgical / Q000379:methods; D020211:Autonomic Dysreflexia / Q000503:physiopathology / Q000601:surgery*; D001341:Autonomic Nervous System / Q000502:physiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D012018:Reflex / Q000502:physiology*; D016135:Spinal Dysraphism / Q000503:physiopathology / Q000601:surgery*; D013126:Spinal Nerve Roots / Q000503:physiopathology / Q000601:surgery*; D001743:Urinary Bladder / Q000294:innervation*; D001750:Urinary Bladder, Neurogenic / Q000503:physiopathology / Q000601:surgery*; D014549:Urinary Incontinence / Q000503:physiopathology / Q000601:surgery*; D014563:Urodynamics / Q000502:physiology