Bladder enlargement + ureteral replantation?

Introduction There is controversy about whether patients should undergo simultaneous ureteral reimplantation and bladder enlargement in the treatment of vesicoureteral reflux (VUR) secondary to neurogenic bladder
.

A study exploring the need for simultaneous bladder enlargement and ureteral reimplantation in patients with VUR secondary to neurogenic bladder was published in BMC Urology
.

Background Neurogenic bladder is a high-pressure, low-compliance bladder with multiple VURs
.

High-grade VUR can lead to recurrent urinary tract infections, which can lead to severe kidney failure
.

In clinical practice, self-cleaning intermittent catheterization and anticholinergic therapy are generally used as conservative treatment options
.

Injecting botulinum toxin A into the bladder can also improve bladder compliance and capacity
.

Endoscopic antireflux surgery may be effective when bladder compliance and capacity are close to normal
.

After the above conservative treatment options are ineffective, bladder enlargement is one of the accepted standard treatment options
.

Currently the most widely used is ileal cystomegaly
.

There is controversy regarding the management of patients with neurogenic bladder secondary to VUR and whether patients should undergo both ureteral reimplantation and bladder enlargement
.

This study aimed to evaluate the necessity of ureteral reimplantation and bladder enlargement in patients with VUR
.

Methods: A total of 19 patients (10 males, 9 females) with neurogenic bladder secondary to VUR who underwent bladder enlargement from March 1983 to March 2016 were enrolled
.

Postoperative patients were followed up for a minimum of 5 years
.

All patients received self-cleaning intermittent catheterization and conservative treatment with anticholinergic drugs
.

The study retrospectively assessed changes in VUR grade, urodynamic outcomes, and postoperative complications
.

The study assessed patients' renal function by regularly checking their serum creatinine levels and glomerular filtration rate (eGFR)
.

Imaging urodynamics were performed preoperatively and postoperatively in patients with imaging urodynamics
.

This study used imaging urodynamic data at 6 months postoperatively
.

According to the International Continence Association, detrusor overactivity (DO) is defined as any involuntary detrusor contraction that occurs during the bladder filling phase, can be spontaneous or induced, and cannot be fully suppressed by the patient
.

Changes in bladder capacity and bladder compliance, presence of DO, and VUR grades were assessed
.

RESULTS: A total of 19 patients were included in this study.
The median age at the time of surgery was 14 years (range, 3-38 years)
.

The median follow-up of patients after bladder enlargement was 14.
8 years (range 5.
7-30 years)
.

The etiological diagnosis of the patient's neurogenic bladder was myelomeningocele, myelolipoma, and anal atresia (Table 1)
.

Table 1 Patient characteristics Only 1 of the 19 patients underwent early ureteral replantation
.

Patients with AC complications are shown in Table 2
.

Postoperative complications included bladder stones in 8 (42%) patients and fever due to urinary tract infection in 6 (31%) patients
.

Table 2 Perioperative complications Table 3 shows the changes in the VUR classification of patients from preoperative to postoperative
.

VUR occurred in 27 ureters in 19 patients, and the reflux grades were: 6 at grade V, 9 at grade IV, 5 at grade III, 6 at grade II, and 1 at grade
I.

Postoperative imaging urodynamics showed that 23 (85%) ureteral reflux was eliminated, 3 (11%) ureteral reflux was downgraded, and 1 (4%) ureteral reflux was unchanged
.

No patient experienced worsening of VUR during treatment
.

Table 3 Changes in VUR grade from preoperative to postoperative Imaging urodynamic examination results showed that the median bladder volume of VUR patients increased from 60 ml to 404 ml (p < 0.
05), and the number of postoperative DO was similar to that at the beginning of VUR.
was not statistically different (Table 4)
.

Table 4 Pre- and post-operative imaging urodynamic outcomes eGFR and chronic kidney disease (CKD) staging were measured at the last follow-up
.

The median eGFR value of 19 patients was 95ml/min/1.
73m2 (range 3.
3-154ml/min/1.
73m2); CKD stage was 11 cases of stage 1, 5 cases of stage 2, 1 case of stage 3, 0 cases of stage 4, 5 stage 2 cases
.

During follow-up, 3 patients (16%) developed chronic renal failure (CKD stage ≥3); 2 of these patients developed stage 5 CKD and received renal replacement therapy
.

None of the 3 patients with renal failure developed VUR after surgery
.

CONCLUSIONS: Our data suggest that ureteral reimplantation is not required in patients with VUR undergoing bladder enlargement
.

Data from long-term follow-up studies make this conclusion more convincing
.

This study is a retrospective study with a small number of cases and has certain limitations.
Follow-up prospective randomized studies are needed to continue to confirm
.

Reference: Hiroki Chiba, Takeya Kitta, Madoka Higuchi et al.
Ureteral reimplantation during augmentation cystoplasty is not needed for vesicoureteral reflux in patients with neurogenic bladder: a long-term retrospective study.
BMC Urology.
(2022) 22:48.
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