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Contemporary Urologic Management of Children with Neurogenic Bladder Patricio C. Gargollo, MD Director, Pediatric Urology Minimally Invasive and Robotic.

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Presentation on theme: "Contemporary Urologic Management of Children with Neurogenic Bladder Patricio C. Gargollo, MD Director, Pediatric Urology Minimally Invasive and Robotic."— Presentation transcript:

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 Childrens Hospital Boston –3 years pediatric urology –Advanced fetal care center –Advanced Laparoscopic training

3 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

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

14 Neural Pathway

15 Bladder Function Bladder Overactive Underactive Normal 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

28 Time Pressure Time Activity Time Pressure

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 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 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

37 Results: Initial UD 71 pts, mean age 3m (2wk – 6m) CategoryNumber of pts Normal16 (23%) No detrusor contraction22 (31%) <25 cm H2O9 25-40 cm H2O9 >40 cm H2O4 Detrusor overactivity33 (46%) <25 cm H2O12 25-40 cm H2O8 >40 cm H2O13

38 Results: Initial UD 71 pts, mean age 3m (2wk – 6m) CategoryNumber of pts Normal16 (23%) No detrusor contraction22 (31%) <25 cm H2O9 25-40 cm H2O9 >40 cm H2O4 Detrusor overactivity33 (46%) <25 cm H2O12 25-40 cm H2O8 >40 cm H2O13 High risk

39 DLPP or Storage Pressure? DLLP 50 cm Same risk? 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 Low risk UD 54 (76%) High risk UD 17 (24%) Initial UD F/u UD EFP <40 n=12 1 new HN, 2 new VUR 1 new HN+VUR 6/54* Δ to risk UD * UD changes at mean 9mo (4-12) Treatment n=12 Observation n=5 1 new HN No new HN/VUR

42 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

43 Renal Outcomes: Baseline DMSA 38 patients –35 (92%) normal scan – 3 (8%) abnormal scan, congenital nephropathy? PtDMSA findingInitial UD PatternEFPInitial u/sInitial VCUG fUTI 1Unilateral, CRN20No hydroNo VURNo 2 Unilateral, focal scar 40No hydroNo VURNo 3Unilateral, CRN62 Unilateral SFU Gr 3 Gr 5, 3Yes

44 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

45 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 pts 2005-07 113pts, 64 > 10ys age studied Shiroyanagi et al, 2009

46 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

47 Results: Initial U/S, VCUG 14/71 (20%) abnormal HN 3 (4%) VUR 8 (11%) HN+VUR 3 (4%)

48 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

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

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 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 –Intermittent Catheterization –Anticholinergics Surgical Management –Bladder Procedures –Bladder Outlet Procedures –Catheterizable Channels –Procedures on the ureters

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

54 Goals MedicalSocial

55 Surgical Intervention Last resort when medical therapy fails: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 divertIn children- try to preserve bladder, not divert Detubularize & reconfigure bowel: avoid hour glass!Detubularize & reconfigure bowel: avoid hour glass! –Intact bowel P- 60-100 cm H 2 O Maintain terminal 10-20 cm distal ileum (B 12 absorption – megaloblastic anemia, peripheral neuropathy, optic atrophy, dementia)Maintain terminal 10-20 cm distal ileum (B 12 absorption – megaloblastic anemia, peripheral neuropathy, optic atrophy, dementia) Bladder neck closure as last resort onlyBladder neck closure as last resort only Consider MACE & MitrofanoffConsider MACE & Mitrofanoff

57 Treatment:Bladder CIC : Clean intermittent catheterization

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

59 Treatment:Bladder CIC : Clean intermittent catheterization

60 Surgery:Bladder Bladder Botox

61 Surgery :Bladder Augmentation




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

66 Intra-op




70 Catheterizable Stoma Monti-Tube Appendicovesicostomy

71 Surgery:Mitrofanoff


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

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

75 Post-op Care Flushing InIrrigation In and Out 1) ACE Procedure 2) Can be tap water 3) Sit patient on toilet/bedside commode 4) Serial increase in volume VS 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 its important! 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

80 Robotic Assisted Continent Catheterizable Conduit

81 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 sutures 10 cm 175 0 1 2 3 Appendicovesicostomy/ ACE X


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)

86 Methods: Technique


88 Results

89 Results: Patient Characteristics Case Age (years) Sex BMI (kg/m 2 ) DiagnosisShunt 18F24.5MMCN 213F27.1MMCY 313M29MMCN 45F16.7LMCN 511F31.2MMCY 67F14.8 Tranverse myelitis N 78M20.2SCIN 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 Efficacy: –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

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