Long-term outcomes of cutaneous vesicostomy in patients with neuropathic bladder caused by spina bifida

Summary Objective To evaluate the outcomes of patients who underwent cutaneous vesicostomy for management of neuropathic bladder secondary to spina bifida. We hypothesize that vesicostomy, in select patients, is beneficial to prevent upper urinary tract deterioration (UTD), reduce febrile urinary tract infections (UTIs), and preserve renal function. Study design We performed a retrospective chart review on patients with spina bifida who underwent cutaneous vesicostomy at our institution between 2000 and 2016. Demographic information, indication for vesicostomy, pre and postoperative laboratory/radiologic studies, incidence of febrile UTIs, and urodynamic findings were abstracted. Results A total of 14 patients (eight females and six males) were identified. The indication for vesicostomy was UTD in four, recurrent febrile UTIs in five, parental request in two, both UTD and recurrent febrile UTIs in two, and both UTI and parental request in one patient. Seven patients had a median of three (range one to five) febrile UTI prior to surgery for cutaneous vesicostomy. Median creatinine level before surgery was 0.26 mg/dL (range 0.16–0.97). Either unilateral or bilateral ≥SFU Grade 2 hydronephrosis was present in six patients. Median age at vesicostomy creation was 26.5 months (range 4–96). Mean functional bladder capacity assessed during preoperative urodynamic studies was 107 mL (range 20–279), and detrusor sphincter dysynergia was present in all patients. High-grade vesicoureteral reflux (grade ≥3) was present in three patients, all with UTD. Mean follow-up after vesicostomy was 62.4 ± 39.3 months. After vesicostomy, only two of the seven patients with history of febrile UTIs experienced an additional febrile UTI. The median serum creatinine level was 0.36 mg/dL (range 0.2–0.58) at last follow-up. Moreover, 11/14 patients had no hydronephrosis and just two patients had unilateral SFU grade 1 hydronephrosis ( Table ). Discussion Worsening UTD, recurrent febrile UTIs, and high-pressure bladder despite maximal medical therapy are several reasons to consider more aggressive management of neuropathic bladders. In young patients, vesicostomy is able to protect the upper urinary tract, decrease rates of febrile UTI, and delay the need for bladder augmentation. Conclusion Vesicostomy is a safe method for temporary diversion of the lower urinary tract in patients with spina bifida who are refractory to conservative and minimally invasive treatments. Table . Summary of patients. Nr Sex Preop Cr (mg/dL) Preop renal US Number of preop UTIs Preop UDS (Cap/Pdet max /DOA/DSD) Age at surgery (months) Follow-up (months) Number of postop UTIs Cr at last follow-up (mg/dL) Final US Age at vesicostomy takedown (months) 1 F NA Normal 1 20/50/+/+ 27 26 2 NA Normal 2 F 0.22 Normal 3 65/43/+/+ 15 38 0 0.33 Normal 3 M NA L Gr 2 HN 3 166/55/+/+ 96 23 0 0.52 Normal 4 M 0.97 R Gr 1 HN 0 72/52/+/+ 85 3 0 0.58 Normal 5 F 0.25 R Gr 2 HN 5 100/72/+/+ 86 62 1 0.2 R Gr 1 HN 6 F NA Bil Gr 4 HN 1 131/100/+/+ 26 120 0 0.27 NA 62 7 F 0.26 Bil Gr 2 HN 5 98/52/+/+ 34 71 0 NA Normal 8 F NA NA NA NA 24 58 0 0.42 Normal 84 9 M 0.31 L Gr 1 HN 0 279/18/+/+ 39 71 0 0.41 Normal 10 M NA NA NA NA 4 74 0 0.38 Normal 60 11 F NA L Gr 2 HN 2 NA 9 132 0 0.36 L Gr 1 HN 59 12 M NA NA NA NA 12 NA 1 0.28 Normal 96 13 M 0.16 Bil Gr 3 HN 0 35/50/+/+ 39 72 0 NA Normal 14 F 0.33 Bil Gr 1 HN 0 107/49/−/+ 7 69 0 NA Normal Cr = creatinine, preop = preoperative, US = ultrasonography, UTI = urinary tract infection, Cap = functional bladder capacity (mL), Pdet max = maximal detrusor pressure during filling phase (cmH 2 O), L = left, R = right, HN = hydronephrosis (per SFU grading system), M = male, F = female, NA = not available.