UROLOGICAL SURVEY   ( Download pdf )

 

RECONSTRUCTIVE UROLOGY

An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida
Xiao CG, Du MX, Li B, Liu Z, Chen M, Chen ZH, Cheng P, Xue XN, Shapiro E, Lepor H
Departments of Urology, Tongji Medical College, Xiehe Hospital, Huazhong University of Science and Technology, Wuhan, China
J Urol. 2005; 173: 2112-6

  • Purpose: Neurogenic bladder is a major problem for children with spina bifida. Despite rigorous pharmacological and surgical treatment, incontinence, urinary tract infections and upper tract deterioration remain problematic. We have previously demonstrated the ability to establish surgically a skin-central nervous system-bladder reflex pathway in patients with spinal cord injury with restoration of bladder storage and emptying. We report our experience with this procedure in 20 children with spina bifida.
  • Materials and Methods: All children with spina bifida and neurogenic bladder underwent limited laminectomy and a lumbar ventral root (VR) to S3 VR microanastomosis. The L5 dorsal root was left intact as the afferent branch of the somatic-autonomic reflex pathway after axonal regeneration. All patients underwent urodynamic evaluation before and after surgery.
  • Results: Preoperative urodynamic studies revealed 2 types of bladder dysfunction- areflexic bladder (14 patients) and hyperreflexic bladder with detrusor external sphincter dyssynergia (6). All children were incontinent. Of the 20 patients 17 gained satisfactory bladder control and continence within 8 to 12 months after VR microanastomosis. Of the 14 patients with areflexic bladder 12 (86%) showed improvement. In these cases bladder capacity increased from 117.28 to 208.71 ml, and mean maximum detrusor pressure increased from 18.35 to 32.57 cm H2O. Five of the 6 patients with hyperreflexic bladder demonstrated improvement, with resolution of incontinence. Urodynamic studies in these cases revealed a change from detrusor hyperreflexia with detrusor external sphincter dyssynergia and high detrusor pressure to nearly normal storage and synergic voiding. In these cases mean bladder capacity increased from 94.33 to 177.83 ml, and post-void residual urine decreased from 70.17 to 23.67 ml. Overall, 3 patients failed to exhibit any improvement.
  • Conclusions: The artificial somatic-autonomic reflex arc procedure is an effective and safe treatment to restore bladder continence and reverse bladder dysfunction for patients with spina bifida.

  • Editorial Comment
    A successful but not rewarding patient treatment of malfunctioning bladders with spina bifida became possible with both the introduction of sphincterotomy of the external urethral sphincter and intermittent clean self-catherisation in order to protect and preserve the upper urinary tract.
    In the last two decades there was no real breakthrough in the treatment options for pediatric spina bifida patients. The most commonly used drugs in adults were not approved for children. This includes the direct injection of Botulinum toxin into the detrusor or the external sphincter (1-3).
    Through the extraordinary work of Shapiro et al., it was recognized that in patients with spinal cord changes apart from lower urinary tract malfunction, fetal muscle and innervation changes could be seen (4). The “defect in the development” of the lower urinary tract is complete by the 20th week of pregnancy, but that there is no correlation between the smooth muscle cell mal-development and the severity of the spinal cord defect.
    It is stunning to see in the present paper that surgery on the spinal roots might be a treatment solution for the malfunction of the lower urinary tract (5). Xiao et al. presented initially their work by creating an artificial somatic-autonomic reflex pathway to treat neurogenic bladder in spinal cord injured patients (6). They have now apparently found a way for a successful treatment using the same technique in spina bifida patients (7).
    In the present study they enrolled 20 children with spinal bifida and performed intradural anastomoses of the ventral root of the L5 with the ventral root of S3. Twelve of 14 patients with a former areflexic bladder improved their bladder pressure from 18.35 to 32.57 cm H2O. Five of the 6 patients with a detrusor-sphincter dyssynergia increased their bladder capacity from 94.33 to 177.83 mL and postoperatively decreased the post voiding residual from 70.17 to 23.67 mL within 8 to 12 months.
    Most of these children (12 male, 8 female; 5 - 14 years) had successful results and were able to void voluntarily (n = 16), whereas one had to scratch the skin dermatome of L5 to initiate the micturation (n = 1). In 17 (85%) patients, they noted improved bladder function (the young patients had an increased bladder storage and bladder sensory in the emptying function and maintained the ability to sense for a full bladder and felt the desire to void). However, some possible side effects might be the partial loss of the L5 motor function.
    The surgical option to improve the neurogenic bladder of young patients with spina bifida will increase possibilities in their future life. Because of the success rate, specialized groups should confirm these results with an equivalent follow-up. It seems to be possible that this surgical approach will teach us that the pathology described by Shapiro et al. might be reversible, partial or complete, up to a certain age (4).

References
1. Aslan AR, Kogan BA: Conservative management in neurogenic bladder dysfunction. Curr Opin Urol. 2002; 12: 473-7.
2. Cruz F, Silva C: Botulinum toxin in the management of lower urinary tract dysfunction: contemporary update. Curr Opin Urol. 2004; 14: 329-34.
3. Schurch B, Corcos J: Botulinum toxin injections for paediatric incontinence. Curr Opin Urol. 2005; 15: 264-7.
4. Shapiro E, Seller MJ, Lepor H, Kalousek DK, Hutchins GM, Perlman EJ, Meuli M: Altered smooth muscle development and innervation in the lower genitourinary and gastrointestinal tract of the male human fetus with myelomeningocele. J Urol. 1998; 160 (3 Pt 2): 1047-53; discussion 1079.
5. Sievert KD, Xiao CG, Hennenlotter J, Seibold J, Merseburger AS, Kaminsky J, Nagele U, Stenzl A: Voluntary micturition after intradural nerve anastomosis. Urologe A. 2005; 44: 756-61. [in German]
6. Xiao CG, Du MX, Dai C, Li B, Nitti VW, de Groat WC: An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients. J Urol. 2003; 170(4 Pt 1):1237-41.
7. Xiao CG, Du MX, Li B, Liu Z, Chen M, Chen ZH, Cheng P, Xue XN, Shapiro E, Lepor H: An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida. J Urol. 2005; 173: 2112-6.

Dr. Karl-Dietrich Sievert, Dr. M. Horstmann,
Dr. Markus Kuczyk & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany