1. Contemporary Urologic Management of Children with Neurogenic Bladder
Patricio C. Gargollo, MD
Director, Pediatric Urology Minimally Invasive and Robotic Surgery
Assistant Professor in Urology, UT Southwestern Medical School
Department of Urology, Children's Medical Center, Dallas

2. 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

3. Paradigm Shift Medical Therapy and Management Surgical therapy
Less Antibiotics
Less Radiation
Less Screening
Less Testing
Surgical therapy
Laparoscopic Surgery
Robotic Assisted Surgery
Less Pain
Less Scars
Less Time in the hospital

4. Outline Urology Goals Physiology Bladder Function/Malfunction
Bowel Function/Malfunction
Urology Studies
Surgical Treatments

5. Spina Bifida

6. Classification
Myelomeningocele
Meningocele
Lipoma of the cord
Occulta

7. Etiology Risk Factors Sex Ethnic Background Diet Medications Diabetes
Obesity
Socioeconomic status

8. Prevalence
166,000 affected in the US
1 in 1,000 live births

9. Texas Scottish Rite 500 active patients with MM
25 newborn patients annually

10. 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

11. Spinal Defects Clinic Providers
Specialists:
Physiatrist
Orthopedist
Neurosurgeon
Urologist
Occupational Therapy
Physical Therapy
Social Work
Nursing
Project Nicaragua

12. NGB: Childhood Milestones
birth - toilet training (3-4 yrs)
continence management (TT- middle school)
teenage rebellion
transition to adult care

13. Goals Preserve renal function Achieve social continence No dialysis!
Bladder
Bowel
No diapers!
Independence

14. Neural Pathway

15. Bladder Function Bladder Sphincter Overactive Underactive Normal

16. Detrusor Sphincter Dyssynergia
Bladder
-Overactive
Sphincter
-Overactive

17. Neurogenic Detrusor Overactivity
Bladder
-Overactive
Sphincter
-Underactive

18. Areflexic Bladder
Bladder
Underactive
Sphincter
-Underactive

19. Bowel Function

20. Bowel Function: “Pellets”

21. Bowel Function:Diarrhea

22. Urology Studies
Renal/Bladder ultrasound
VCUG
DMSA
Urodynamics

23. Urology Studies
Renal/Bladder ultrasound

24. Urology Studies
Renal/Bladder ultrasound

25. Urology Studies
VCUG (Voiding cystourethrogram)

26. Urology Studies
DMSA

27. Urology Studies UDS (Urodynamics) Bladder Pressure Sphincter Activity
Rectal/Abdominal Pressure
Sphincter Activity

28. Pressure
Time
Activity
Time
Pressure
Time

29. Management and Outcomes
No longitudinal studies of renal function, scarring
Few longitudinal studies of bladder compliance

30. Means to Assess Need for therapy, results, determined by: Imaging
Renal US
VCUG
DMSA
Urodynamics

31. 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

32. 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

33. 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?

34. Newborns: Tx vs Observation
No evidence shows universal treatment superiority
No study shows impact of tx on care-givers
Cost catheters, oxybutynin

35. Newborn Protocol ≤ 6 wks age High Risk UD filling pressure> 40cm
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:

36. Initial Assessment: UD
Varying Methods
5-7Fr UD catheters
infusion cc/min
monopolar needle vs patch electrodes EMG
Varying Terminology
upper, lower motor lesions
detrusor hypertonicity vs overactivity
Varying Diagnoses
DSD vs no DSD
Inf

37. 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
>40 cm H2O 4
Detrusor overactivity
33 (46%) 12 8 13

38. 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
>40 cm H2O 4
Detrusor overactivity
33 (46%) 12 8 13
“High risk

39. DLPP or Storage Pressure?
Same risk?
DLLP 50 cm
Pressure during storage is more important than compliance
Churchill et al, 1994

40. Selective Therapy (UD-based)
UD identifies high risk before deterioration
Therapy prevents renal, bladder damage
Preserve renal function, decrease augmentation

41. Outcomes 71 pts High risk UD 17 (24%) Low risk UD 54 (76%) Treatment
Initial UD
High risk UD
17 (24%)
Low risk UD
54 (76%)
F/u UD
F/u UD
Treatment
n=12
Observation
n=5
6/54*
Δ to  risk UD
1 new HN,
2 new VUR
EFP <40
n=12
1 new HN
1 new HN+VUR
* UD changes at
mean 9mo (4-12)
No new HN/VUR

42. Outcomes Renal damage: no data, f/u DMSA pending
25% f UTI: /17 (53%) high risk
9/54 (17%) low risk
10/18 (56%) CIC vs 8/53 (15%) obs , p=.001
18% VUR: /71 (15%) initially
3/60 (5%) new

43. 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 3 62
Unilateral
SFU Gr 3
Gr 5, 3
Yes

44. Renal Scar: Risk Factors
95 pts NGB
7±4yrs
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
[40% taking anticholinergics]
Leonardo et al, 2007

45. Renal Scar: Risk Factors
DMSA, UD in sequential pts
113pts, 64 > 10ys age studied
16 (25%) had abnormal DMSA
function < 40%, or focal scar
VUR OR (1.43 – 2.97)
f UTI OR (2.64 – 34.34)
DLPP ±20 vs 46± ns
Compliance 8.8±5.9 vs 12± ns
Shiroyanagi et al, 2009

46. Renal Scar (non-NGB) 15% focal DMSA defect 15% VUR I-III 50% VUR IV-V
541 consecutive pts
fUTI and/or VUR
15% focal DMSA defect
15% VUR I-III
50% VUR IV-V
Recurrent fUTI

47. Results: Initial U/S, VCUG
14/71 (20%) abnormal
HN (4%)
VUR (11%)
HN+VUR 3 (4%)
8/54 (15%) observation
6/17 (35%) high risk
Of 3 HN:
1 obs – started CIC (B to F), HN resolved (u/s at 12mo)
2 tx – both resolved (u/s at 18mo, 11mo)
Of 8 VUR:
5 obs: 4 resolved (2.5 mo, 11mo, 10 mo, 11 mo), 1 awaiting f/u imaging
3 tx: 1 resolved 22mo, 1 persisted, 1 awaiting f/u imaging
Of 3 HN+VUR:
2 obs (1 resolved hydro, awaiting VUR f/u; 1 resolved VUR, persistent hydro
1 tx: both persisted

48. Results 18/71 (25%) had treatment by 1 year 14/71 (19%) VUR
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
Why therapy in the 6 obs pts?
Decr fxn on DMSA, increasing EFP
New VUR, hydro discovered on w/u for hyperkalemia, hyponatremia
Early UD done b/c of baseline hydro (“Mod, mild”)
UD sched at age 9mo
Febrile UTI
New unilateral VUR
New HN, VUR: 5 pts
fUTIs:
9/17 high risk (8 were on CIC)
9/54 low risk (1 who started getting fUTIs AFTER starting CIC/becoming high-risk)

49. 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
83% comes from:
54 obs patients
6 with EFP>40 (incl 1 with imaging changes)
3 with imaging changes
=9 with change in UD or imaging
So 45/54 (83%) with no change

50. 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)

51. Summary of Outcomes Uncertain:
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?

52. Management Medical Management Surgical Management
Intermittent Catheterization
Anticholinergics
Surgical Management
Bladder Procedures
Bladder Outlet Procedures
Catheterizable Channels
Procedures on the ureters

53. Neurogenic Voiding Dysfunction
Good bladder
Bad sphincter
Good bladder
Good sphincter B. A.
Bad bladder
Bad sphincter
Bad bladder
Good sphincter C. D.

54. Goals
Medical
Social

55. 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

56. Pediatric Reconstruction: Key Points
In children- try to preserve bladder, not divert
Detubularize & reconfigure bowel: avoid hour glass!
Intact bowel P cm H2O
Maintain terminal cm distal ileum (B12 absorption – megaloblastic anemia, peripheral neuropathy, optic atrophy, dementia)
Bladder neck closure as last resort only
Consider MACE & Mitrofanoff

57. Treatment:Bladder
CIC: Clean intermittent catheterization

58. CIC: Clean intermittent catheterization
DOES NOT INCREASE INFECTIONS IF DONE CORRECTLY!!!!!!!

59. Treatment:Bladder
CIC: Clean intermittent catheterization

60. Surgery:Bladder
Bladder Botox

61. Surgery:Bladder Augmentation

62. Surgery:Bladder Augmentation

63. Surgery:Bladder Augmentation

65. Surgery:Bladder Augmentation
Increase bladder size
Decrease high pressures to kidneys
Results:
Prevent kidney damage
Continence

66. Intra-op

67. Intra-op

68. Intra-op

69. Intra-op

70. Catheterizable Stoma
Monti-Tube
Appendicovesicostomy

71. Surgery:Mitrofanoff

72. Surgery:Mitrofanoff

73. Post-op Care Mitrofanoff or ACE Midline/Umbilicus Suprapubic Tube
RLQ or LLQ
ACE
Midline or RLQ
Urethral Foley

74. Post-op Care Mitrofanoff or ACE Suprapubic Tube ACE Urethral Foley
1. Locations and origins may differ
2. Bag drainage and plugs may differ

75. Post-op Care POD#1: AMBULATION Flushing “In” VS
Irrigation “In and Out”
1) Bladder only
2) Via Mitrofanoff, SPT or urethral foley
3) Additional catheters must be closed
4) Sterile water or saline 60 cc BID
5) This can be tricky but it’s important!
1) ACE Procedure
2) Can be tap water
3) Sit patient on toilet/bedside commode
4) Serial increase in volume
POD#1: AMBULATION

76. 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?

77. 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

78. Surgical Management

79. Minimally Invasive Pediatric Surgery
Shift
Extirpative
Nephrectomy
Reconstructive
Ureteral reimplant, augmentation, complex Reconstruction
Feasible
Nephrectomy, pyeloplasty, ureteral reimplantation
Minimally invasive techniques are rapidly being developed and integrated into urologic surgery. Over the last five years, the urologic literature is abound with novel techniques and adaptations to conventional laparoscopy including but not limited to laparoendoscopic single –site surgery (LESS), natural orifice translumental endoscopic surgery (NOTES), and robot-assisted laparoscopic surgery(RALS).[1-3] Robotic surgery in kids has been shown to be feasible, and increasingly complex operations are being undertaken (APV +/- Malone anterograde CE +/-ileocystoplasty)

80. Robotic Assisted Continent Catheterizable Conduit

81. Appendicovesicostomy/ ACE1 2
Robotic System X 3 1
10 cm
1: 8mm working port, mid-clavicular line
2: 12mm camera port, midline
3: 8mm working port, mid-clavicular line
X: 5mm port for sutures 2
1750
10 cm 3

83. 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

84. Complex Reconstruction

85. 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)
Between 70-95% of patients receiving a bladder outlet procedure also receive enterocystoplasty due to concern for small bladder capacityhigh intravesical pressures from increased outlet resistance, and ensuing upper tract damages; these were from AUS data with near-total occlusion of the outlet; Snodgrass and colleages described stable/improved urodynamic parameters in 26 patients with mean follow up of 39 months

86. Methods: Technique
The patient is placed supine on a surgical bean bag positioner. All potential pressure points are meticulously padded. A 14-French catheter is inserted per urethra once the patient is prepped and draped. Pneumoperitoneum is established using a Veress needle in an infraumbilical location. Given the thin nature of the abdominal wall in most pediatric patients, the working ports are secured to the patient’s skin with TroGARD® (Conmed Corporation 310 Broad St. Utica, NY). Once all ports are secured, the robot (da Vinci Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA) is docked. An inverted V-shaped incision was made at the umbilicus, ultimately serving as the future skin flap to bring to the appendicovesicostomy, and the 12-mm robotic camera was placed after Veress needle insufflation. Under direct visualization, two 8-mm robotic ports were placed: the first in the right midclavicular line slightly superior to the camera port and the second in the left midclavicular line just inferior to the umbilical site. A 12-mm assist port was placed between the left arm and the working camera port (Figure 1). A 12-mm trocar was used in order to accommodate suture needles and Lapra-Ty. 86

88. Results
The patient is placed supine on a surgical bean bag positioner. All potential pressure points are meticulously padded. A 14-French catheter is inserted per urethra once the patient is prepped and draped. Pneumoperitoneum is established using a Veress needle in an infraumbilical location. Given the thin nature of the abdominal wall in most pediatric patients, the working ports are secured to the patient’s skin with TroGARD® (Conmed Corporation 310 Broad St. Utica, NY). Once all ports are secured, the robot (da Vinci Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA) is docked. 88

89. Results: Patient Characteristics
Case
Age (years)
Sex
BMI (kg/m2)
Diagnosis
Shunt 1 8 F
24.5
MMC N 2 13
27.1 Y 3 M 29 4 5
16.7
LMC 11
31.2 6 7
14.8
Tranverse myelitis
20.2
SCI
17% of patients were normal weight (BMI<25) while 53% were obese or morbidly obese (BMI>30).
BMI: Body Mass Index, Shunt: Ventriculoperitoneal shunt

90. Results: Cumulative outcomes
86% of cases completed robotically
One complication (conversion)
Two cases of de novo reflux (resolved)

91. Efficacy, efficiency, safety of robotic APV/BNR/BNS
All patients are dry
Low profile scars
Efficiency:
Operative times are longer
Hospital durations are shorter
Safety:
Acceptable complication rate

92. 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

94. 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

95. Thank you for your attention