Introduction
Initial management of neuropathic bladder in spina bifida (SB) is conservative, but some can develop progressive hydronephrosis, vesicoureteral reflux (VUR), and recurrent urinary tract infections (UTI). Cutaneous vesicostomy (CV) is a viable intermediate option in these patients. However, there is no consensus on whether bladder augmentation is necessary at time of CV reversal.
Objective
The study aimed to evaluate the effect of CV on bladder function. We hypothesized that CV does not affect the intrinsically hostile nature of the native bladder and thus all patients in this SB population who undergo CV reversal will likely require additional bladder surgeries.
Study design
We conducted a retrospective study of patients with SB who underwent CV at our institution from 2012 to 2022. Detrusor pressure (Pdet) was defined as leak point or maximum detrusor pressure on urodynamic studies (UDS). Percent bladder capacity (BC) was calculated as maximum BC on UDS over age-adjusted BC. Bladder compliance was calculated as change in bladder volume over change in detrusor pressure. Interquartile range and Mann–Whitney U test were calculated with p < 0.05.
Results
38 patients underwent CV at median age of 16 months with median follow-up of 6.1 years. CV resulted in improvements in hydronephrosis, high-grade VUR, and febrile UTI. Eight patients (21 %) underwent CV reversal at median age of 6.1 years and the bladder was found to remain hostile prior to reversal with Pdet 39 cmH2O, bladder capacity 29 % of age expected, and bladder compliance of 2.6 mL/cmH2O. Two had colon chimney and six underwent catheterizable channel creation, of which three underwent synchronous augmentation and the other three required average of 3 intravesical botulinum toxin injections after reversal.
Discussion
Our UDS performed prior to CV reversal demonstrated hostile bladders with elevated detrusor pressures and low bladder capacities and compliance, which is consistent with prior literature showing that higher proportion of children with neuropathic bladders underwent bladder augmentation with CV reversal compared to children with VUR or posterior urethral valves. Limitations of the study include single center retrospective design, small number of patients who underwent CV reversal, and potentially subjective interpretation of UDS findings.
Conclusion
CV is an effective bridge in patients with SB who fail conservative management but does not appear to alter the primary pathologic condition that renders the native bladder hostile. All caregivers should be appropriately counseled that additional bladder procedures are typically required after CV reversal.
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