Severe bladder trabeculation obviates the need for bladder outlet procedures during augmentation cystoplasty in incontinent patients with neurogenic bladder
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OBJECTIVE: To evaluate whether the degree of preoperative bladder trabeculation in neurogenic bladder (NB) patients is a marker of significant outlet resistance. If so, severe trabeculation may obviate the need for concomitant bladder outlet procedure (BOP) during augmentation cystoplasty (AC). PATIENTS AND METHODS: We retrospectively reviewed 48 incontinent patients with NB who had surgery. The patients were divided into two groups: group 1 (23 patients) had AC alone; group 2 (10) had AC with BOP. Children who had a BOP alone (15) were excluded from the study. Success was defined as a dry period of > or = 4 h. Preoperative bladder trabeculation was classified as mild or severe. Data collected included continence status, imaging and urodynamic findings. RESULTS: In group 1 patients before surgery, there was severe bladder trabeculation in 14 (61%), hydronephrosis in 13 (57%) and associated vesico-ureteric reflux (VUR) in 16 (70%). The mean detrusor leak-point pressure (DLPP) was 49.7 cmH2O and the bladder neck was open in nine (39%). Dryness with AC alone was achieved in 91% of group 1 patients. In group 2 patients (10 patients), there was severe bladder trabeculation in five, hydronephrosis in three, and VUR in two. The mean DLPP was 42.8 cmH2O and the bladder neck was open in eight. After surgery, eight of 10 patients achieved a dry period of 4 h. There was no significant difference between group 1 and 2 patients for age at surgery, gender, ambulatory status, hydronephrosis, degree of trabeculation, detrusor overactivity, DLPP and eventual outcome. The incidence of VUR was higher in group 1 patients (P = 0.009) and more patients in group 2 had an open bladder neck (P = 0.031). CONCLUSION: Severe bladder trabeculation in incontinent patients with NB might predict an element of intrinsic outlet resistance. In this subset of patients, dryness was achieved by AC alone without further BOP. The degree of bladder trabeculation should be considered in the surgical decision-making process for incontinent children with NB.
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