Contemporary Urologic Management of Children with Neurogenic Bladder

Patricio C. Gargollo, MDDirector, Pediatric Urology Minimally Invasive and

Robotic SurgeryAssistant Professor in Urology, UT Southwestern Medical School

Department of Urology, Children's Medical Center, Dallas

Who am I and how did I get here?

• Baylor University Graduate • Harvard Medical School• Massachusetts General Hospital and

Harvard Medical School– 2 years general surgery– 4 years urology

• Children’s Hospital Boston– 3 years pediatric urology– Advanced fetal care center– Advanced Laparoscopic training

Paradigm Shift• Medical Therapy and Management

– Less Antibiotics– Less Radiation– Less Screening– Less Testing

• Surgical therapy– Laparoscopic Surgery– Robotic Assisted Surgery

• Less Pain• Less Scars• Less Time in the hospital

Outline

• Urology Goals• Physiology• Bladder Function/Malfunction• Bowel Function/Malfunction• Urology Studies• Surgical Treatments

Spina Bifida

Classification

Myelomeningocele

Meningocele

Lipoma of the cord

Occulta

Etiology

Risk Factors

Sex

Ethnic Background

Diet

Medications

Diabetes

Obesity

Socioeconomic status

Prevalence

166,000 affected in the US

1 in 1,000 live births

Texas Scottish Rite• 500 active patients

with MM

• 25 newborn patients annually

Spinal Defects Clinic

• Integrate care among all specialties• Provide “one-stop” shopping• Patient Population: 500 patients• Tuesday s • 14-18 patients 12:30-6 pm• Patients 1 month-2 years old

– Seen every 3-6 months• Patients 2 years and older

– Seen every 6 months to 1 year

Spinal Defects ClinicProviders

• Specialists:– Physiatrist– Orthopedist– Neurosurgeon– Urologist– Occupational Therapy– Physical Therapy– Social Work– Nursing – Project Nicaragua

NGB: CHILDHOOD MILESTONES

birth - toilet training (3-4 yrs)

continence management (TT- middle school)

teenage rebellion

transition to adult care

Goals

• Preserve renal function– No dialysis!

• Achieve social continence– Bladder– Bowel– No diapers!– Independence

Neural Pathway

Bladder FunctionBladder• Overactive• Underactive• Normal

Sphincter•Overactive•Underactive•Normal

Detrusor Sphincter Dyssynergia

Bladder-Overactive

Sphincter-Overactive

Neurogenic Detrusor Overactivity

Bladder-Overactive

Sphincter-Underactive

Areflexic Bladder

BladderUnderactive

Sphincter-Underactive

Bowel Function

Bowel Function: “Pellets”

Bowel Function:Diarrhea

Urology Studies

• Renal/Bladder ultrasound• VCUG• DMSA• Urodynamics

Urology Studies

• Renal/Bladder ultrasound

Urology Studies

• Renal/Bladder ultrasound

Urology Studies

• VCUG (Voiding cystourethrogram)

Urology Studies

• DMSA

Urology Studies

• UDS (Urodynamics)

Bladder Pressure

Sphincter Activity

Rectal/Abdominal Pressure

Time

Pressure

Time

Activity

Time

Pressure

Management and Outcomes

• No longitudinal studies of renal function, scarring

• Few longitudinal studies of bladder compliance

Means to AssessNeed for therapy, results, determined by:

• Imaging Renal US VCUG DMSA

• Urodynamics

Background

• Goals for management:– Preserve renal function, prevent scarring– Preserve bladder compliance

• No evidence that management impacts outcomes

• Reported endpoints– New HN, VUR– Change in UD – Augmentation rates

Management Options

• 3 options for management of children with MM from birth – age 3y:

– Imaging-based observation

– Universal therapy (CIC + anticholinergic)

– UD-based selective therapy

Surrogate Outcomes of Management

• Incidence of new HN, VUR

does HN or VUR predict renal damage?

• Development of adverse UD parameters

does tx prevent changes?

does tx restore compliance?

• Augmentation rates

management failure vs management decision?

Newborns: Tx vs Observation

• No evidence shows universal treatment superiority

• No study shows impact of tx on care-givers

• Cost catheters, oxybutynin

Newborn Protocol• ≤ 6 wks age Fluoroscopic UD Renal US, DMSA

• Renal US q 3mos x1y q 6mos UD, DMSA 1yr, 3yr

• Tx for: high risk UD + HN, VUR new HN, VUR, ∆ DMSA

• High Risk UD filling pressure> 40cm

Patterns:

Initial Assessment: UD• Varying Methods

5-7Fr UD catheters

infusion 1.5- 15cc/min

monopolar needle vs patch electrodes EMG

• Varying Terminology upper, lower motor lesions detrusor hypertonicity vs overactivity • Varying Diagnoses

DSD vs no DSD

Results: Initial UD 71 pts, mean age 3m (2wk – 6m)

Category Number of pts

“Normal” 16 (23%)

No detrusor contraction 22 (31%) <25 cm H2O 9

25-40 cm H2O 9

>40 cm H2O 4

Detrusor overactivity 33 (46%) <25 cm H2O 12

25-40 cm H2O 8

>40 cm H2O 13

Results: Initial UD 71 pts, mean age 3m (2wk – 6m)

Category Number of pts

“Normal” 16 (23%)

No detrusor contraction 22 (31%) <25 cm H2O 9

25-40 cm H2O 9

>40 cm H2O 4

Detrusor overactivity 33 (46%) <25 cm H2O 12

25-40 cm H2O 8

>40 cm H2O 13

“High risk

DLPP or Storage Pressure?

DLLP 50 cmSame risk?

Pressure during storage is more important than compliance

Churchill et al, 1994

Selective Therapy (UD-based)• UD identifies high risk before deterioration

• Therapy prevents renal, bladder damage

• Preserve renal function, decrease augmentation

Outcomes

71 pts

Low risk UD54 (76%)

High risk UD17 (24%)

Initial UD

F/u UD F/u UD

EFP <40n=12

1 new HN,2 new VUR

1 new HN+VUR

6/54* Δ to risk UD

* UD changes at mean 9mo (4-12)

Treatmentn=12

Observationn=5

1 new HN

No new HN/VUR

Outcomes • Renal damage: no data, f/u DMSA pending

• 25% f UTI: 9/17 (53%) high risk 9/54 (17%) low risk

10/18 (56%) CIC vs 8/53 (15%) obs , p=.001

• 18% VUR: 11/71 (15%) initially 3/60 (5%) new

Renal Outcomes: Baseline DMSA

38 patients– 35 (92%) normal scan– 3 (8%) abnormal scan, congenital nephropathy?

Pt DMSA finding Initial UD Pattern EFP Initial u/s Initial VCUG

fUTI

1 Unilateral, CRN 20 No hydro No VUR No

2 Unilateral, focal scar 40 No hydro No VUR No

3 Unilateral, CRN 62 Unilateral SFU Gr 3 Gr 5, 3 Yes

Renal Scar: Risk Factors

32% DMSA renal scar

MLR analysis:

VUR OR 8.12 (95%CI 2.92 – 23.14)

no UD parameter

bladder capacity

DLPP>40cm H2O

DSD

detrusor overactivity

95 pts NGB 7±4yrs

[40% taking anticholinergics]

Leonardo et al, 2007

Renal Scar: Risk Factors

16 (25%) had abnormal DMSA function < 40%, or focal scar

• VUR OR 2.06 (1.43 – 2.97)• f UTI OR 9.53 (2.64 – 34.34)

• DLPP 44±20 vs 46±28 ns• Compliance 8.8±5.9 vs 12±11 ns

DMSA, UD in sequential pts2005-07

113pts, 64 > 10ys age studied

Shiroyanagi et al, 2009

Renal Scar (non-NGB)

15% focal DMSA defect

• 15% VUR I-III 50% VUR IV-V

• Recurrent fUTI

541 consecutive pts fUTI and/or VUR

Results: Initial U/S, VCUG

• 14/71 (20%) abnormal

HN 3 (4%)

VUR 8 (11%)

HN+VUR 3 (4%)

Results– 18/71 (25%) had treatment by 1 year

12 initial “high risk” 6 initial “low risk” – new loss of compliance

– 14/71 (19%) VUR

11/71(15%) initially 3/60 (5%) new

– 18 (25%) with febrile UTI

10/18 (56%) CIC vs 8/53 (15%) obs, p=0.001

Conclusions• Majority of infants have low risk UD findings

• 83% of low risk pts have no change in UD or imaging during observation

• Compliance changes occurred before age 1yr

• Treated -risk patients lowered bladder pressures– No data yet on renal impact

• Initial management can be tailored by initial UD

Conclusions

• ~25% newborns have potentially adverse imaging and/or UD

~15% VUR

• ~10% have potentially adverse changes during obs

• Scar risk of fUTI ± VUR not known with NGB

• Potentially negative impact of CIC on renal function (fUTI)

Summary of Outcomes• Some pts with “normal” or “low risk” UD will convert to “high risk”

• Some pts with “high risk” UD have no clinical findings

Uncertain:

Is high bladder pressure alone a risk factor for renal damage?

Can therapy (CIC) cause renal damage, ie via febrile UTI?

Management

• Medical Management– Intermittent Catheterization– Anticholinergics

• Surgical Management– Bladder Procedures– Bladder Outlet Procedures– Catheterizable Channels– Procedures on the ureters

A.A.B.B.

D. D. C. C.

Neurogenic Voiding Dysfunction

Good bladderGood sphincter

Good bladderBad sphincter

Bad bladderBad sphincter

Bad bladderGood sphincter

GoalsMedical Social

Surgical Intervention• Last resort when medical therapy fails:

– Botox, Augmentation +/-– BN procedure : injection, suspension,

sling, urethral lengthening ((Piipi Salle, Kropp), AUS… last resort is BN closure

– Mitrofanoff- Monti-Yang +/-– Reimplant +/-– Malone ACE

Pediatric Reconstruction: Key Points

• In children- try to preserve bladder, not divert• Detubularize & reconfigure bowel: avoid hour glass!

– Intact bowel P- 60-100 cm H2O• Maintain terminal 10-20 cm distal ileum (B12

absorption – megaloblastic anemia, peripheral neuropathy, optic atrophy, dementia)

• Bladder neck closure as last resort only• Consider MACE & Mitrofanoff

Treatment:BladderCIC: Clean intermittent catheterization

DOES NOT INCREASE INFECTIONS IF DONE CORRECTLY!!!!!!!

CIC: Clean intermittent catheterization

Treatment:BladderCIC: Clean intermittent catheterization

Surgery:BladderBladder Botox

Surgery:Bladder Augmentation

Surgery:Bladder Augmentation

Surgery:Bladder Augmentation

Surgery:Bladder Augmentation

Results:•Prevent kidney damage•Continence

Surgery:•Increase bladder size•Decrease high pressures to kidneys

Intra-op

Intra-op

Intra-op

Intra-op

Catheterizable Stoma

Monti-Tube

Appendicovesicostomy

Surgery:Mitrofanoff

Surgery:Mitrofanoff

Post-op Care

Urethral Foley

Mitrofanoff or ACEMidline/Umbilicus Suprapubic Tube

RLQ or LLQ

ACEMidline or RLQ

Post-op Care

Urethral Foley

Mitrofanoff or ACESuprapubic Tube

ACE

1. Locations and origins may differ2. Bag drainage and plugs may differ

Post-op Care

Flushing “In” Irrigation “In and Out”

1) ACE Procedure2) Can be tap water3) Sit patient on toilet/bedside commode4) Serial increase in volume

VS

1) Bladder only2) Via Mitrofanoff, SPT or urethral foley3) Additional catheters must be closed 4) Sterile water or saline 60 cc BID5) This can be tricky but it’s important!

POD#1: AMBULATION

Routine Care:FAQs

1. How far does the ACE/Mitrofanoff go in?

2. Can I hurt anything?

3. How long does it take to heal?

4. What are the outcomes?

5. What are the risks?

Key Points

– Short term and long term issues– Behavior and diet changes– Many surgeries and treatments– Intense post-operative care and teaching– Requires both family and nursing support

Surgical Management

Minimally Invasive Pediatric Surgery• Shift

–Extirpative•Nephrectomy

– Reconstructive•Ureteral reimplant, augmentation, complex Reconstruction

• Feasible– Nephrectomy, pyeloplasty, ureteral

reimplantation

Robotic Assisted Continent Catheterizable Conduit

1

2

3

Robotic System

1: 8mm working port, mid-clavicular line

2: 12mm camera port, midline

3: 8mm working port, mid-clavicular line

X: 5mm port for sutures10 cm

10 cm

1750

1

2

3

Appendicovesicostomy/ ACE

X

Bagrodia, A., Gargollo, P.: Robot-assisted bladder neck reconstruction, bladder neck sling, and appendicovesicostomy in children: description of technique and initial results. J Endourol, 25: 1299, 2011

Complex Reconstruction

Neurogenic Incontinence• Various surgical techniques• Bladder neck sling for incontinence first

described in 1986• Sling without augmentation demonstrated

to be safe– Continence rates are low (36-57%)

• Sling with bladder neck reconstruction safe, with 82% continence (Snodgrass J Urol 184, p 1775, 2010)

Methods: Technique

Results

Results: Patient CharacteristicsCase Age

(years)Sex BMI

(kg/m2)Diagnosis Shunt

1 8 F 24.5 MMC N2 13 F 27.1 MMC Y3 13 M 29 MMC N4 5 F 16.7 LMC N5 11 F 31.2 MMC Y6 7 F 14.8 Tranverse myelitis N7 8 M 20.2 SCI N

BMI: Body Mass Index, Shunt: Ventriculoperitoneal shunt

Results: Cumulative outcomes• 86% of cases

completed robotically

• One complication (conversion)

• Two cases of de novo reflux (resolved)

Efficacy, efficiency, safety of robotic APV/BNR/BNS

• Efficacy:– All patients are dry– Low profile scars

• Efficiency:– Operative times are longer– Hospital durations are shorter

• Safety:– Acceptable complication rate

Complex Reconstruction

• Gargollo et. al. Comparison of Open and Robotic Assisted Appendicovesicostomy, Bladder Neck Reconstruction and Bladder Neck Sling IRUS, January 2011

• Robotic Cohort– Longer operative times– Lower Blood loss– Lower length of stay– Decreased Narcotic Use

Conclusions• The present series expands the

scope of robotic reconstruction in children

• Preliminary data demonstrates these procedure are feasible and safe

• Comparison with open APV with bladder neck reconstruction is required and ongoing

Thank you for your attention