Abstract General Information

Title

MYELOMENINGOCELE OPERATED IN UTERO AND THE INCONTINENT BLADDER PATTERN: EVALUATION AND FOLLOW UP. CAN WE PREDICT THE OUTCOME?

Introduction and objective

In-utero myelomeningocele repair is the gold standard treatment after the publication of the Manegment of Myelomeningocele Study (MOMS) trial. We selected from our prospective database collected from 2011, patients with the incontinent bladder pattern according to the Leal da Cruz categorization pattern (J Urol. 2015) to review clinical outcomes.

Method

We identified 30 patients with leakage pressure under 40 cmH20 at first urodynamic evaluation (incontinent pattern) and selected patients with a minimum active follow-up of 46 weeks in our clinic. Patients were followed yearly with sonogram and urodynamic evaluation.

Results

We found 11 patients, with a mean age of 10,2 years old, median age at diagnosis of 19 weeks, surgery performed at 25.6 weeks and birth at 33.2 weeks. The mean follow-up was 81.73 months. Mean age at first urological evaluation was 5 months, and urodynamic evaluation was 5.6 months. Febrile urinary tract infection incidence was 27.3%. The average initial Detrusor Leakage Point Pressure was 30 cmH2O. 71.4% of the patients had bladder capacity less than 50% of the expected age. Bladder compliance could not be determined in 63.7% of cases due to leakage. The predominant bladder pattern was overactivity with leakage (63%), followed by overactivity with reduced compliance and sphincter hypotonia (9.1%). A total of 5.7 urodynamic studies per patient were performed. Surgery was recommended for 7 patients and done in 6. Surgery consisted of Macedo catheterizable reservoir and Macedo-Malone Antegrade Continent Enema, associated with urethral sling (2 patients), bladder neck closure (3), Pippi-Salle (1). It took an average of 5 urodynamic evaluation before the final surgical decision was confirmed: the urodynamic study prior to the procedure indicated a high-risk bladder pattern in 42.8% and incontinent in 57.2% of the cases; and the average Detrusor Leakage Point Pressure was 24.4 cmH20. All patients are fully continent (urinary >4hs) and fecal, only one has a shorter interval of catheterizations (2.5 hours).

Conclusion

The indication of surgery for the incontinent pattern is substantially higher than the overall group.