ENDOSCOPIC TREATMENT FOR URINARY-INCONTINENCE IN CHILDREN WITH A CONGENITAL NEUROPATHIC BLADDER

Objective To verify, in a retrospective analysis, the effectiveness of endoscopic treatment (collagen injection) in children with neurogenic bladder and neurogenic urinary incontinence. Patients and methods Fro m January 1992 to March 1997, 36 endoscopic collagen injections were p erformed to treat neurogenic urinary incontinence in 23 patients (mean age 10.9 years, range 6-17 at the time of the first procedure) select ed on the basis of clinical status and the patient's motivation, Ninet een patients were affected by myelomeningocele and four had an occult spinal dysraphism. All patients underwent a preoperative cystometric u rodynamic evaluation (without urethral pressure measurement) which sho wed detrusor areflexia in 12, normal reflexia in one and hyper-reflexi a in 10 patients. Bladder compliance was considered good (greater than or equal to 20 cmH(2)O) in 13 patients and low (10-20 cmH(2)O) in 10, four of whom had detrusor areflexia, Twenty-one children emptied thei r bladder by intermittent clean catheterization. The mean (range) foll ow-up was 19.2 (6-54) months. Twenty (group A) and 16 (group B) proced ures. performed early and late in the series, were analysed separately to determine any increase in effectiveness with surgical experience. The evaluation criteria were; the increase in the 'dry' internal (betw een catheterizations) before and after treatment/s (Delta dry); the pa tient's and parent's satisfaction; the number of endoscopic procedures and quantity of injected materials. Results There was an improvement (dryness of at least 2 h; Delta dry of 1 h) in 13 of 23 patients after 1-3 (mean 1.5) procedures; 10 patients had a 0.2 h increase in Delta dry after 1-3 injections and none was satisfied. There was no differen ce in the Delta dry (0.9 vs, 0.7 h) between groups A and B, and/or the patient's/parent's satisfaction, Success rates differed with urodynam ic patterns; seven of 10 patients showing no improvement had hyper-ref lexia and three of the remaining 12 with areflexia had hypocompliant b ladders, while nine of the 13 showing improvement had an areflexic det rusor and low-pressure bladders. Conclusion The efficacy of the treatm ent depends largely on the urodynamic selection of patients (mainly th ose with detrusor areflexia and good compliance). The outcome may be i mproved further by increasing the quantity of injected material and wi th a longer follow-up, performing the procedure again if advisable. A close postoperative clinical (pad test) and personal observation is ne cessary to evaluate the outcome and thus optimize the strategy of trea tment.