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Article of the week: In utero myelomeningocele repair and urological outcomes: the first 100 cases of a prospective analysis

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a podcast produced by our Resident podcasters, Giulia Lane and Kyle Johnson. The authors have also kindly produced a video describing their work.

These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

In utero myelomeningocele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function?

Antonio Macedo Jr*†, Sergio Leite Ottoni*, Gilmar Garrone*, Riberto Liguori*, Sergio Cavalheiro‡§, Antonio Moron¶§ and Marcela Leal Da Cruz*

 

*Department of Urology, CACAU-NUPEP, †Department of Pediatrics, Federal University of São Paulo, ‡Department of Neurosurgery, Federal University of São Paulo, §Santa Joana Maternity Hospital, and Department of Obstetrics-Fetal Medicine, Federal University of São Paulo, São Paulo, Brazil

 

Abstract

Objectives

To evaluate the first 100 cases of in utero myelomeningocele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function.

Patients and methods

We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak‐point pressure >40 cm H2O and high filling pressures also >40 cm H2O), incontinent, and underactivity (underactive bladder with post‐void residual urine), and patients were treated accordingly.

Fig.2. Hydronephrosis in relation to the underlying bladder pattern.

Results

We evaluated 100 patients, at a mean age of 5.8 months (median 4 months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico‐ureteric reflux.

Conclusion

The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.

 

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Editorial: Bladder function and fetal treatment of myelomeningocele

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In utero myelomeningocele repair and urological outcome: the first 100 cases of a prospective analysis. Is there an improvement in bladder function? Comments on bladder function and fetal treatment of myelomeningocele [1].

Prenatal care with maternal screening for neural tube defects and high‐resolution maternal fetal sonography has led to the early diagnosis of fetal myelomeningocele [2]. Revolutionary fetal surgery to correct myelomeningocele in utero has reduced the need for cerebrospinal fluid shunting and improved motor outcomes in these babies, based on 30‐month follow‐up data [3]. Sponsored by the National Institute of Health, the prospective randomized ‘Management of Myelomeningocele Study’ (MOMS) trial documented the outcomes of 158 patients assessed after either fetal repair prior to 26 weeks’ gestation or standard postnatal repair of the myelomeningocele defect. The trial was stopped early when evaluation showed that the primary outcome, rate of shunt placement, in the postnatal repair group (82%) was approximately double that in the prenatal surgery group (40%). Prenatal surgery also resulted in improvement in outcomes for mental development, motor function and ambulation, also evaluated at 30 months postnatally. However, prenatal surgery was associated with an increased risk of preterm delivery and uterine dehiscence at the time of delivery.

Bladder function was also evaluated at 30 months in the MOMS trial, comparing the need for clean intermittent catheterization (CIC) in 115 patients with adequate urological follow‐up, consisting of clinical outcomes in respect to continence, sonographic appearance of the kidneys and bladder and urodynamic evaluation [4]. Prenatal surgery did not significantly reduce the need for CIC measured at 30 months of age, but was associated with less bladder trabeculation and open bladder neck. Longer follow‐up was recommended and is in progress to document further bladder outcomes.

Macedo et al. [1] report similar short‐term bladder outcomes in 100 patients undergoing in utero myelomeningocele repair. Their report documented bladder characteristics in these patients at a mean postnatal age of ~6 months. In their unique cohort, antenatal diagnosis of fetal myelomeningocele was made at ~21 weeks’ gestation, in utero surgery was performed at ~25.5 weeks’ gestation and preterm birth occurred at ~33 weeks’ gestation, parameters consistent with the patients in the MOMs trial. Short‐term evaluation showed that ~53% of the patients had high‐risk bladders with poor compliance, ~27% were incontinent with weak sphincteric activity and only ~15% had normal urodynamic profiles. CIC was initiated in ~ 57% of the Macedo et al. cohort, again similar to the MOMs trial. The long‐term outcomes after potty training and during childhood and adolescence will be especially interesting in this valuable cohort.

Some of the pitfalls that will need to be accounted for include the validation and standardization of urodynamic testing [5]. Even at the same institution with clinicians who have undergone similar training, consistent interpretation of urodynamic studies can be variable, potentially affecting therapeutic options [6].

The goal of patients, parents and providers is to avoid the urological sequelae of myelomeningocele. To date, the reality is that the majority of these children, whether or not they have undergone in utero fetal repair or postnatal surgery, will require the assistance of CIC for urological health to protect the kidneys from excess pressure, to facilitate bladder emptying and urinary continence and prevent UTI.

 

References

  1. Macedo, A, Ottoni, SL, Garrone, G et al. In utero myelomeningocele repair and urological outcome: the first 100 cases of a prospective analysis. Is there an improvement in bladder function? BJU Int 2019; 123: 676– 81
  2. Meller, C, Aiello, H, Otano, L. Sonographic detection of open spina bifida in the first trimester: review of the literature. Childs Nerv Syst 2017; 33: 1101– 6
  3. Adzick, NS, Thom, EA, Spong, CY et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 2011; 364: 993– 1004
  4. Brock, JW, Carr, MC, Adzick, NS et al. Bladder Function After Fetal Surgery for Myelomeningocele. Pediatrics 2015; 136: e906– 13
  5. Bauer, SB, Nijman, RJ, Drzewiecki, BA, Sillen, U, Hoebeke, P, International Children’s Continence Society Standardization Subcommittee. International Children’s Continence Society standardization report on urodynamic studies of the lower urinary tract in children. Neurourol Urodyn 2015; 34: 640– 7
  6. Dudley, AG, Casella, DP, Lauderdale, CJ et al. Interrater reliability in pediatric urodynamic tracings: a pilot study. J Urol 2017; 197: 865– 70

 

Residents’ podcast: In utero myelomeningocele repair and urological outcomes

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Giulia Lane M.D. is a Fellow in Neuro-urology and Pelvic Reconstruction in the Department of Urology at the University of Michigan; Kyle Johnson is a Urology Resident in the same department.

In this podcast they discuss the following BJUI Article of the Week:

In utero myelomeningocele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function?

Abstract

Objectives

To evaluate the first 100 cases of in utero myelomeningocele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function.

Patients and methods

We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak‐point pressure >40 cm H2O and high filling pressures also >40 cm H2O), incontinent, and underactivity (underactive bladder with post‐void residual urine), and patients were treated accordingly.

Results

We evaluated 100 patients, at a mean age of 5.8 months (median 4 months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico‐ureteric reflux.

Conclusion

The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.

 

Read the full article

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

 

 

Video: In utero myelomeningocele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function?

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In utero myelomeningocele repair and urological outcomes: the first 100 cases of a prospective analysis. Is there an improvement in bladder function?

Abstract

 

Objectives

To evaluate the first 100 cases of in utero myelomeningocele (MMC) repair and urological outcomes in a prospective analysis aiming to define possible improvement in bladder function.

Patients and methods

We used a protocol consisting of a detailed medical history, urinary tract ultrasonography, voiding cystourethrography, and urodynamic evaluation. Patients were categorised into four groups: normal, high risk (overactive bladder with a detrusor leak‐point pressure >40 cm H2O and high filling pressures also >40 cm H2O), incontinent, and underactivity (underactive bladder with post‐void residual urine), and patients were treated accordingly.

Results

We evaluated 100 patients, at a mean age of 5.8 months (median 4 months), classified as high risk in 52.6%, incontinent in 27.4%, with underactive bladder in 4.2%, and only 14.7% had a normal bladder profile. Clean intermittent catheterisation was initiated in 57.3% of the patients and anticholinergics in 52.6%. Antibiotic prophylaxis was initiated in 19.1% of the patients presenting with vesico‐ureteric reflux.

Conclusion

The high incidence of abnormal bladder patterns suggests little benefit of in utero MMC surgery concerning the urinary tract.

 

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Urodynamics is acceptable and well-tolerated but best practice is not always provided: lessons from male patients interviewed during the UPSTREAM trial

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In a recently published qualitative study, we found that urodynamic testing was acceptable to men with lower urinary tract symptoms (LUTS), despite some reporting apprehension, discomfort or embarrassment and, at times, inadequate provision of information. Men’s experiences of urodynamics highlight ways in which clinical practice can be improved, including better communication about what to expect during and after the test, minimising embarrassment by ensuring privacy, and timely discussion of test results in sufficient detail.

Ninety percent of men aged 50‐80 live with at least one LUTS, which can negatively impact quality of life. LUTS prevalence and severity increase with age, and with demographic aging the management of LUTS is an increasing priority. Urodynamics with invasive multichannel cystometry is widely used when medications haven’t successfully relieved symptoms and surgery for bladder outlet obstruction is being considered. But there is ongoing debate about the extent to which urodynamics should be used, reflecting lack of evidence regarding the effectiveness of urodynamics and how acceptable it is to patients.

What we did

The Urodynamics for Prostate Surgery: Randomised Evaluation of Assessment Methods (UPSTREAM) randomised controlled trial is a 4-year study funded by the National Institute of Health Research Health Technology Assessment Programme (UK). The trial randomised 820 men with LUTS from urology departments in 26 hospitals in England to either a care pathway consisting of non-invasive routine tests, or one of routine tests plus urodynamics. At 18-months after randomisation, UPSTREAM assessed the effect of urodynamics on symptoms and rates of surgery in men with bothersome LUTS seeking further treatment.

In a large qualitative study nested within the UPSTREAM trial, we explored men’s attitudes to and experiences of urodynamics, to provide in‐depth qualitative evidence to inform clinical practice. We interviewed a diverse group of 41 men with LUTS, including those who had had urodynamics and those who had not.

 

What we found

  • All 25 men who underwent urodynamics reported that it was acceptable.
  • Of the 16 men who had not had urodynamics previously, 14 said they would have been willing to have it if needed (with four reporting some apprehension), while two said they would want more information about the test and its purpose.
  • Among patients who had had urodynamics, the test was well-tolerated, although there was variation in how uncomfortable men found it. Some men experienced short-lived negative after-effects (e.g. stinging, a urinary tract infection), but despite these issues said they would willingly have the test again.
  • A minority of men reported embarrassment, due to the intimate nature of urodynamics or not being prepared for its effects (e.g. spraying while urinating).
  • Embarrassment also depended on the degree of privacy available, including the number of people in the room during the test, room location and size (a larger room near a busy corridor was more socially awkward).
  • Patients valued urodynamics for its diagnostic insight, perceiving it as more informative than other tests. Patients felt that having urodynamics meant they had received all the investigative tests available and so had all possible facts regarding their condition.
  • Patients described gaps in the information provided by clinicians before, during, and after the test; for example, what to expect when the test was conducted and what the test results meant.
  • How and when results were explained varied: explanations were given during the test by the technician or nurse undertaking it, from a doctor straight after receiving the test, or at a separate appointment with a doctor a short time later. Men appreciated it when test results were available and discussed with a clinician immediately after the test.
  • While most men were satisfied with clinicians’ explanation of the results of urodynamics, this was not universal; rushed explanations were highlighted as problematic.

Recommendations

Based on men’s experiences, we recommend:

  1. Good communication before and during the procedure, in line with patient preferences, to ensure patients are well prepared and informed.
  2. Prioritising patient privacy, including minimising the number of people present during the test and introducing the staff members who are present.
  3. Discussing test results with patients promptly, in the amount of detail they wish.
  4. Training and guidance for urology clinicians and urodynamics technicians in these areas.

Acknowledgements

We acknowledge and thank the patients and clinicians involved in the UPSTREAM trial as well as the NHS trusts involved. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) program (project number 12/140/01). This study was designed and delivered in collaboration with the Bristol Randomised Trials Collaboration (BRTC), a UKCRC registered clinical trials unit which, as part of the Bristol Trials Centre, is in receipt of National Institute for Health Research CTU support funding. The views and opinions expressed are those of the authors and not necessarily those of the HTA program, NIHR, NHS, or the Department of Health and Social Care.

 

About the authors: 

Dr Selman and Dr Horwood are Senior Research Fellows at University of Bristol, specialising in qualitative research in randomised trials. Twitter: @Lucy_Selman, @JPHorwood

Prof Drake is Professor of Physiological Urology at Bristol Urological Institute, North Bristol NHS Trust, and at Translational Health Sciences, Bristol Medical School, University of Bristol. Twitter: @MarcusDrakeUrol, @UroweESU

Dr Amanda Lewis is a Clinical Trial Manager at the University of Bristol, currently working in the area of Urology research. Twitter: @ALBrooks2015

 

Guideline of guidelines: urinary incontinence

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Urinary Incontinence Guideliens

 

Abstract

The objective of the article is to review key guidelines on the management of urinary incontinence (UI) to guide clinical management in a practical way. Guidelines produced by the European Association of Urology (updated in 2014), the Canadian Urological Association (updated in 2012), the International Consultation on Incontinence (updated in 2012), and the National Collaborating Centre for Women’s and Children’s Health (updated in 2013) were examined and their recommendations compared. In addition, specialised guidelines produced by the collaboration between the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction on overactive bladder and the use of urodynamics were reviewed. The Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument was used to evaluate the quality of these guidelines. There is general agreement between the groups on the recommended initial evaluation and the use of conservative therapies for first-line treatment, with a limited role for imaging or invasive testing in the uncomplicated patient. These groups have greater variability in their recommendations for invasive procedures; however, generally the mid-urethral sling is recommended for uncomplicated stress UI, with different recommendations on the approach, as well as the comparability to other treatments, such as the autologous fascial sling. This ‘Guideline of Guidelines’ provides a summary of the salient similarities and differences between prominent groups on the management of UI.

Urinary Incontinence key points

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Conjoint USANZ and UGSA Guidelines on the management of adult non-neurogenic overactive bladder

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Guidelines

Abstract

Due to the myriad of treatment options available and the potential increase in the number of patients afflicted with overactive bladder (OAB) who will require treatment, the Female Urology Special Advisory Group (FUSAG) of the Urological Society of Australia and New Zealand (USANZ), in conjunction with the Urogynaecological Society of Australasia (UGSA), see the need to move forward and set up management guidelines for physicians who may encounter or have a special interest in the treatment of this condition. These guidelines, by utilising and recommending evidence-based data, will hopefully assist in the diagnosis, clinical assessment, and optimisation of treatment efficacy. They are divided into three sections: Diagnosis and Clinical Assessment, Conservative Management, and Surgical Management. These guidelines will also bring Australia and New Zealand in line with other regions of the world where guidelines have been established, such as the American Urological Association, European Association of Urology, International Consultation on Incontinence, and the National Institute for Health and Care Excellence guidelines of the UK.

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