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

ABSTRACT

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.