Arindam, Dastidar (2009) Evaluation and Follow up of Surgically Managed Patients of Non Neurogenic Neurogenic Bladder. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION : Voiding dysfunctions are one of the most frequently seen clinical entities in Paediatric urology. Traditional belief that it is only a learned behavior related to toilet training gone awry and resolves spontaneously if left alone is, incorrect. It represents a spectrum ranging from benign incontinence to severe form like non Neurogenic Neurogenic bladder (Hinman’s Syndrome). What is understood is that it is an aberration in the normal development of lower urinary tract maturation and coordination. But why some patients have transient benign form of the disorder and others have chronicity and damaged upper tracts, is yet to be understood. Anticholinergic medication and behavioral modifications has been the cornerstone of managing these patients. Patients presenting late or with severe upper tract changes including major VUR require surgical intervention. This may be temporary diversion (Ureterostomy), continent catheterisable channel (Mitrofanoff) or even augmentation Cystoplasty. Role of surgery has not been clearly defined in this subset of patient in the literature; aim is to break the dyssynergia to prevent further damage to upper tracts. AIM : Evaluation and Follow up of Surgically Managed Patients of Non Neurogenic Neurogenic Bladder. CONCLUSION : Dysfunctional voiding syndrome has a spectrum of presentation. Majority of the children with this disorder are treated medically. Non Neurogenic Neurogenic bladder represents a severe form of dysfunctional voiding characterized by upper tract dilatation and renal damage. This rare subset of patient requires surgical intervention to protect the upper tract and achieve continence. 28 such patients were identified in the last 10 years and formed the basis of this study. Aim of surgery is to provide a low pressure reservoir which can be evacuated effectively. Surgical procedure should be individualized and guided by bladder quality, presence of reflux and renal function. Surgical procedures are classified into four groups 1) Reimplantation for major dilating VUR with a continent catheterisable channel (N=6) for bladder management. 2) Continent catheterisable channel alone (N=1) as bladder management. 3) Augmentation Cystoplasty with or without antireflux procedure & a Continent catheterisable channel (N=17). 4) Incontinent diversion (N=4). Diagnosis of dysfunctional voiding in a patient with reflux requires high index of suspicion. Some clues to an underlying detrusor sphincter dyssynergia are 1) Bladder trabeculation in the absence of Neurogenic cause or a PUV, 2) Dilatation of the contralateral upper tract in a unilateral reflux. 3) Dilatation of posterior urethra secondary to external sphincter spasm. 4) Poor compliance on CMG in spite of gross reflux. Refluxes in the setting of NNNB are major dialating types with evidence of renal scarring (out of 32 refluxing units in the study only 1 was a minor grade 1 reflux). Hence Reflux management forms an important component of treatment protocol. Outcome of reflux management is best when an antireflux procedure is combined with bladder augmentation and mitrofanoff (100%) vs reimplantation with mitrofanoff (71%) but without augmentation. However, augmentation was done only when advanced bladder changes were present. With planned surgical management and CIC, renal damage is partially reversible. Diversion could be a temporizing procedure in a young child or definitive treatment in older children with more advanced renal failure.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Non Neurogenic Neurogenic Bladder ; Surgically Managed Patients ; Evaluation ; Follow up Study. |
| Subjects: | MEDICAL > Paediatric Surgery |
| Depositing User: | Kambaraman B |
| Date Deposited: | 01 Aug 2017 03:06 |
| Last Modified: | 01 Aug 2017 08:20 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/2404 |
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