title: Predictors of upper tract damage in pediatric neurogenic bladder.
abstract: BACKGROUND
  Upper tract damage (UTD) is a life-threatening complication of neurogenic bladder (NB). Early identification of risk factors for UTD and institution of remedial measures may probably prevent UTD. The aim was to study the predictors of UTD in children 2 years or older with NB.
  
  
  METHODS
  This cross-sectional, observational study over 2 years included 30 children. UTD was defined as serum creatinine of >1 mg/dL or society of fetal urology grade III-IV hydronephrosis or hydroureteronephrosis on ultrasonography or renal scars on99mtechnetium dimercaptosuccinic scan or subnormal glomerular filtration rate (GFR) for age. The evaluated clinical variables were age at presentation, gender, palpable bladder lump, and recurrent urinary tract infection (UTI). Bladder wall thickness (BWT), grade and laterality of vesicoureteric reflux (VUR), status of the bladder neck, post-void residue (PVR), and level and type of intraspinal lesions were also noted. Urodynamic studies were performed for functional bladder assessment. A p-value <0.05 identified the risk factors.
  
  
  RESULTS
  UTD was detected in 15 (50%) with serum creatinine >1 mg% (2, 6%), SFU III-IV (11, 36%), renal scars (12, 40%), and subnormal GFR in (2, 6%) patients. Clinical risk factors for UTD were delayed presentation (p = 0.034), palpable bladder lump (p ≤ 0.001; OR 38.5; CI 5.6-262.5), and recurrent UTI (p = 0.033, OR 4.125, CI 0.913-18.630). The presence of significant PVR, trabeculated bladder, spin-top urethra, and bilateral VUR were identified as radiological risk factors for UTD. Mean BWT in patients with and without UTD was 4.69 ± 1.78 mm and 2.91 ± 1.08 mm respectively. BWT predictive of UTD was 3.05 mm (Figure). The mean detrusor leak point pressure (DLPP) did not vary significantly in those with and without UTD (36.82 ± 14.74 and 29.09 ± 10.44 cmH2O, respectively), yet 75% patients with DLPP > 40 cmH2O had UTD (p = 0.038, OR 5.4, CI 0.84-34.84). DLPP <40 cmH2O was associated with UTD in 35% patients.
  
  
  CONCLUSIONS
  The incidence of UTD in this series is in accordance with that reported with expectant management (40%) and is much higher than the 17% stated with proactive management. A limitation of this study is the small number of patients and heterogeneous clinical diagnosis.
  
  
  CONCLUSIONS
  Delayed presentation with palpable bladder lump, recurrent UTI, increased BWT, bilateral VUR, increased PVR, and DLPP > 40 cm H2O were identified as potential risk factors for UTD. This study highlights the significance of BWT as a predictor of UTD in NB.
authors.affiliation: Department of Pediatric Surgery & Surgery, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Raghu
authors.initials: R
authors.lastname: Prakash
authors.affiliation: Department of Pediatric Surgery & Surgery, Lady Hardinge Medical College, New Delhi, India. Electronic address: puriarchana@hotmail.com.
authors.forename: Archana
authors.initials: A
authors.lastname: Puri
authors.affiliation: Department of Radiology, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Rama
authors.initials: R
authors.lastname: Anand
authors.affiliation: Department of Pediatric Surgery & Surgery, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Ajay K
authors.initials: AK
authors.lastname: Jain
authors.affiliation: Department of Pediatric Surgery & Surgery, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Brahmanand
authors.initials: B
authors.lastname: Lal
authors.affiliation: Department of Pediatric Surgery & Surgery, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Vaibhav
authors.initials: V
authors.lastname: Garg
mesh_terms: D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D000070621:Cystography / Q000379:methods; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D006869:Hydronephrosis / Q000000981:diagnostic imaging* / Q000453:epidemiology; D015994:Incidence; D007223:Infant; D008297:Male; D016017:Odds Ratio; D011237:Predictive Value of Tests; D018570:Risk Assessment; D018608:Ultrasonography, Doppler / Q000379:methods; D001750:Urinary Bladder, Neurogenic / Q000000981:diagnostic imaging* / Q000601:surgery*; D014551:Urinary Tract / Q000000981:diagnostic imaging* / Q000503:physiopathology; D014563:Urodynamics
keywords: Bladder wall thickness; Detrusor leak point pressure; Detrusor sphincter dyssynergia; Neurogenic bladder; Upper tracts