Analysis of prognosticating factors at initial presentation of neurogenic bladder in patients with myelomeningocele

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 [0R=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% [0R=0.9 (95% CI: 0.01 - 0.70)] more risk for renal deterioration, 5 [0R=5 (95% CI: 2.5 - 10.2)] times more likely to need surgery and 70% [0R=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.

Long term outcomes of permanent I-125 prostate seed implant for early prostate cancer

OBJECTIVE: Since its introduction in the Philippines in 2001, low dose rate brachytherapy (permanent I-125 prostate seed implant) has become one of the widely utilized modality for the treatment of localized prostate cancer. This study aimed to evaluate the long-term clinical outcomes of low dose rate prostate brachytherapy (Permanent I-125 Prostate Seed Implant) in terms of overall survival (OS), disease specific survival (DSS), biochemical no evidence of disease (BNED), complications and mortality. MATERIALS AND METHODS: Two hundred and two consecutive patients who underwent permanent I-125 prostate seed implant from April 2002 to December 2012 were included in this study. The details of all patients were derived from the database of a single urologist. The median follow up is 6.3 years. Kaplan-Meier curves were used to evaluate overall survival, prostate cancer specific survival and biochemical no evidence of disease (defined by the ASTRO criteria) across all disease risks. Treatment-related complications and causes of mortality were also reviewed. RESULTS: The 11-year overall survival and disease-specific survival rates were 89.1% and 98%, respectively. The biochemical no evidence of disease was 82.7%. Log rank testing showed that survival in terms of OS, DSS, and BNED did not differ significantly regardless of risk stratification into low, moderate and high risk groups. The treatment-related morbidity rate for this series was 5.4%. CONCLUSION: Brachytherapy is an effective treatment for localized prostate cancer with favorable long term survival results, durable biochemical outcomes, and minimal toxicity.