Analysis of Prognosticating Factors at Initial Presentation of Neurogenic Bladder in Patients with Myelomeningocele

Analysis of Prognosticating Factors at Initial Presentation of Neurogenic Bladder in Patients with Myelomeningocele
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Title:Analysis of Prognosticating Factors at Initial Presentation of Neurogenic Bladder in Patients with Myelomeningocele
Author/Abstract:

Sigfred Ian R. Alpajaro, MD and David T. Bolong, MD, FPUA
Section of Urology, Department of Surgery, University of Santo Tomas Hospital

Objective: Neurogenic bladder dysfunction (NBD) in myelomeningocele (MMC) remains a major
cause of renal decline. We evaluate the initial presentation, ultrasonographic, urodynamic and VCUG
findings in search of indicators that can guide in early decisions in treatment to avoid poor long-term
outcomes.

Materials and Methods: From 1989 to 2013, 178 patients with neurogenic bladder due to MMC had
records accessible for review. The median follow up was 10.4 years (0.9 - 25.0). Parameters reviewed
were: patients' initial presentation; Ultrasonography: hydronephrosis grade and bilaterality, bladder
wall thickness, and kidney size; Urodynamics: compliance, Detrusor Leak Point Pressure (DLPP),
bladder activity and sphincter synergy; VCUG: grade of reflux, bladder pattern, and bladder neck
appearance. Endpoints to which all parameters were compared were: 1. need for surgery, 2. continence 3. renal status, and 4. follow-up urodynamics

Results: Recurrent UTI at presentation was associated with 3.1 times [OR = 3.1 (95% CI: 1.3 - 8.5)]
need for surgery and incontinence at presentation was 11 times [OR=11.0 (95% CI: 3.8 - 33.4)] more
likely to be incontinent in the long term. Hydronephrosis was associated with 4.4 times [OR= 4.4
(95% CI: 1.3 - 19.0)] risk for renal deterioration and 6 times [OR = 6.3, (95% CI: 3.8 - 14.7)] need for surgery. Those with thickened bladder were 6 times [OR=6.0 (95% CI: 2.9 - 12.5)] more likely to
have needed surgery. Patients with urodynamic findings of low compliance are 2.7 times [OR 2.7(95%
CI: 1.2 - 6.3)] more likely to have needed surgery and high DLLP on initial consultation are 5.6 times
[OR=5.6 (95% CI: 1.2 - 51.6)] more likely to have renal deterioration and 2.1 times [OR 2.1 (95% CI:
1.1 - 4.4)] more likely needing surgery. On VCUG, those with "Christmas tree" pattern of bladder
have 90% [OR=0.9 (95% CI: 0.01 - 0.70)] more risk for renal deterioration, 5 [OR=5 (95% CI: 2.5 -
10.2)] times more likely to need surgery and 70% [OR=0.7 (95% CI: 0.1 - 0.9)] more likely to have
urodynamic deterioration. Finally, reflux, specifically bilateral, was associated with 4 times [OR =
4.0 (95% CI: 1.2 - 14.3)] risk renal deterioration as compared to those with no reflux findings and 9.6
times [OR=9.6 (95% CI: 4.1 - 23.8)] more likely to need surgery, while high-grade reflux had 90%
more risk [OR = 0.9 (95% CI: 0.1 - 0.8)] to have urodynamic deterioration.

Conclusions: Prognostication early in the course of NBD in MMC is possible. It is recommended that
patients with risk factors for deterioration be provided a more intensive regimen of treatment and
follow-up to prevent further morbidity.

Key words: Neurogenic Bladder, Myelomeningocele

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