Treatment of Vesicoureteric Reflux in the Neurogenic Bladder

Abstract

A retrospective co-operative study was conducted among 6 Italian paediatric surgical departments to assess the results of different forms of treatment of vesicoureteric reflux in patients with neurogenic bladder. Between January 1980 and December 1989 we studied 641 neurogenic bladders in children, mainly due to spina bifida; reflux was detected in 199 patients with 263 refluxing ureters. Details of treatment were available for only 170 patients and they were divided into 2 main groups: conservative medical treatment (n = 127) and primary surgical treatment (n = 43). Medical treatment consisted mainly of clean intermittent catheterisation and the administration of appropriate drugs. In the surgical group 36 reimplantations, 6 cystostomies and 1 STING were performed. Fifteen patients underwent surgery as a secondary procedure. The results showed that approximately 50% of patients with reflux were cured by clean intermittent catheterisation and drug therapy. Ureteric reimplantation can be safely performed in patients with neurogenic bladder provided that a normally compliant, non-hyper-reflexic bladder can be achieved by means of drugs or by bladder augmentation with bowel.

Is Resolution of Vesicoureteric Reflux by Conservative Management Predictable in Patients with Myelodysplasia?

“…Conservative management of VUR with decompressive measures has proved to be effective as the initial treatment, and most current protocols designed for the management of neurogenic bladder patients do not initiate the treatment with surgical interventions even in patients with high-grade VUR [5, 6]. Instead of this, the first course of action is aimed at treating bladder dysfunction.…”

“…In the presence of vesicoureteric reflux (VUR) which is a frequent accompaniment in patients with neurogenic bladders, the occurrence of upper urinary system deterioration is more likely [2, 3, 4]. The effectiveness of conservative management including pressure reduction by medication and regular emptying by clean intermittent catheterization (CIC) has been well documented [5, 6]. However, there remains a significant proportion of patients resistant to this type of management who eventually require surgical intervention and there is no conformity as to when to perform surgical correction.…”

Management of vesicoureteral reflux in neurogenic bladder

“…With CIC, bladder pressures can be sustained in an acceptable range, while high pressure dyssynergic voiding may be avoided, and there is arguably a greater likelihood that the child's bladder will grow normally with improved long-term dynamics [113]. In fact, CIC and medical therapy alone is associated with up to a 30%–50% resolution of VUR within 2–3 years [114]. Favorable outcomes have been seen more often in children who start CIC earlier.…”

“…CIC also relies heavily on the availability of an able and willing family member to perform the technique. A large portion of patients who worsen on CIC are those who did not adhere to regular catheterizations [14]. …”

“…With a highly compliant (>7 mL/cmH 2 O) bladder with preserved capacity (% EBC [estimated bladder capacity]>70%), even high grades of reflux have been successfully treated with ureteral reimplantation alone [611]. The reduction of bladder pressures in patients who undergo reimplantation is felt to be essential for favorable outcomes, and for this reason CIC and anticholinergics are commonly implemented following surgery [14]. More recently the use of alpha blockers has shown some promise in reducing bladder pressures via 2 mechanisms.…”