Congenital Bladder Abnormalities

Pediatric Urology

Pediatric Urology continued Detrusor overactivity occurring during bladder filling is defined as an involuntary detrusor contraction . 15 cm of water from baseline.13 Bladder underactivity is also abnormal and recognized in patients who are filled to . 150% of their expected bladder capacity and have a poor or absent detrusor contraction. During filling, normal detrusor compliance is 10 cm of water at capacity, or 5% of the child’s normal capacity per cm of water, or about 20 cm of water at expected bladder capacity.12,13 Infants tend to have higher voiding pressures than children, and boys tend to have higher voiding pressures (by 5 to 15 cm of water) than girls.2,19 Urethral obstruction is suggested when there are high voiding pressures accompanied by poor flow rates. EMG pads may show a staccato voiding pattern. A low flow rate may be indicative of an anatomical obstruction and bladder emptying should be assessed. This review of pediatric urodynamics is comprehensive and provides an excellent source of classic references. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Drzewiecki BA, Bauer SB. Urodynamic testing in children: indications, technique, interpretation and significance. J Urol. 2011;186:1190-1197. Yeung CK, Sihoe JDY, Bauer SB. Voiding dysfunction in children: nonneurogenic and neurogenic. In: Wein AJ, Kavoussi LR, Novick AC et al, eds. Campbell-Walsh Urology, 9th ed. Philadelphia; Saunders Elsevier; 2007:3604-3655. Kaufman MR, DeMarco RT, Pope JC 4th, et al. High yield of urodynamics performed for refractory nonneurogenic dysfunctional voiding in the pediatric population. J Urol. 2006;176:1835-1837. Bauer SB, Hallett N, Khoshbin S, et al. Predictive value of urodynamic evaluation in newborns with myelodysplasia. JAMA. 1984;252:650-652. Nogueira M, Greenfield SP, Wan J, et al. Tethered cord in children: a clinical classification with urodynamic correlation. J Urol. 2004;172(4 Pt 2):1677-1680; discussion 1680. Guerra LA, Pike J, Milks J, et al. Outcome in patients who underwent tethered cord release for occult spinal dysraphism. J Urol. 2006;176(4 Pt 2):1729-1732. Palmer LS, Richards I, Kaplan WE. Subclinical changes in bladder function in children presenting with nonurological symptoms of the tethered cord syndrome. J Urol. 1998;159:231-234. Guzman L, Bauer SB, Hallett M, et al. Evaluation and management of children with sacral agenesis. Urology. 1983;22:506-510. Bauer SB. Neurogenic bladder: etiology and assessment. Pediatr Nephrol. 2008;23:541-551. Bauer SB, Labib KB, Dieppa RA, Retik AB. Urodynamic evaluation of boy with myelodysplasia and incontinence. Urology. 1977;10:354-362. Peters CA, Bolkier M, Bauer SB, et al. The urodynamic consequences of posterior urethral valves. J Urol. 1990;144:122-126. Nijman RJM, Bower W, Butler U, et al. Diagnosis and management of urinary incontinence and encopresis in childhood. In: Abrams P, Cardozo L, Khoury S, et al, eds. 3rd International Consultation on Incontinence. Paris: Health Publications Ltd; 2005:967-1057. Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol. 2006;176:314-324. Hoebeke P, Bower W, Combs A, et al. Diagnostic evaluation of children with daytime incontinence. J Urol. 2010;183:699-703. Lorenzo AJ, Wallis MC, Cook A, et al. What is the variability in urodynamic parameters with position change in children? Analysis of a prospectively enrolled cohort. J Urol. 2007;178:2567-2570. Hjälmås K. Urodynamics in normal infants and children. Scand J Urol Nephrol Suppl. 1988;114:20-27. Bael A, Lax H, de Jong TP, et al. The relevance of urodynamic studies for Urge syndrome and dysfunctional voiding: a multicenter controlled trial in children. J Urol. 2008;180:1486-1493; discussion 1494-1495. Palmer LS, Richards I, Kaplan WE. Age related bladder capacity and bladder capacity growth in children with myelomeningocele. J Urol. 1997;158(2 Pt 2):1261-1264. Ulla Sillén U, Abrahamsson K. Urodynamics in infants and children. In: Corcos J, Schick E (eds.), Textbook of Neurogenic Bladder, 2nd ed. London: Informa; 2008:483-497. Congenital Bladder Abnormalities Ellen Shapiro, MD, FACS, FAAP New York University School of Medicine, New York, NY [Rev Urol. 2012;14(1/2):38 doi: 10.3909/riu0550] © 2012 MedReviews®, LLC H iguchi and colleagues from the Mayo Clinic (Rochester, MN) published an interesting study to determine if ileal/colonic bladder augmentation in patients with congenital bladder abnormalities such as myelomeningocele, bladder exstrophy, or posterior urethral valves is an independent risk factor for bladder malignancy.1 These entities may have an inherent risk of neoplastic transformation in the absence of bladder augmentation. Records were reviewed from 1986 to 2010. Follow-up from augmentation (109 ileal and 44 colonic) was for at least 10 years with a median interval of 27 years. Controls were treated with clean intermittent catheritization and anticholinergic medications and were matched with the augmentation group for bladder dysfunction, sex, and age. This study of 153 patients showed no significant difference in the incidence of bladder cancer in the augmentation group (7 patients, 4.6%) vs control subjects (4 patients, 2.6%). When age at diagnosis, stage, mortality rate, or mean survival was analyzed, there was no significant difference between the two groups. The authors did find that chronic immunosuppression following renal transplantation significantly impacted the incidence of bladder cancer that was independent of augmentation status (15% vs 2.8%). In addition, those patients on immunosuppression who developed cancer also had a history of viral infections with cytomegalovirus, BK virus, and/or Epstein-Barr virus after transplantation. In the United States, approximately 2% of individuals will develop bladder cancer by age 78 years, with the majority presenting with localized disease.2 The current study found a 3.6% incidence of bladder cancer in patients with congenital bladder dysfunction presenting at a median age of 51 years. The data also show a twofold greater increase in bladder cancer in individuals with congenital bladder abnormalities vs the general population in which bladder cancer occurs at a much younger age with locally advanced disease or nodal metastases (81%). References 1. 2. Higuchi TT, Granberg CF, Fox JA, Husmann DA. Augmentation cystoplasty and risk of neoplasia: fact, fiction and controversy. J Urol. 2010;184:2492-2496. Horner MJ, Ries LAG, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2006, National Cancer Institute. http://www.joplink.net/prev/201003/ref/16-001.html. Accessed February 28, 2012. 38 • Vol. 14 No. 1/2 • 2012 • Reviews in Urology 40041700002_LiteratureReview.indd 38 20/07/12 2:11 PM