Dr. Patrick Mah - muacme.org Bladder 20-7-08.pdf · Dr. Patrick Mah MBBS (Melbourne ... No improvement: – Pre renal cause - post obstructive diuresis – Renal dysplasia ... Valve

VALVE BLADDERVALVE BLADDER

Dr. Patrick Dr. Patrick MahMah

MBBS (Melbourne)MBBS (Melbourne)

FRCS (FRCS (EdinEdin). AM ). AM

(Mal)(Mal)

POST VALVE ABLATIONPOST VALVE ABLATION

No improvement:No improvement:

–– Pre renal causePre renal cause-- post obstructive post obstructive diuresisdiuresis

–– Renal Renal dysplasiadysplasia

–– Sepsis and infectionSepsis and infection

–– Post renal cause:Post renal cause:

HydronephrosisHydronephrosis--vesicovesico uretericureteric obstruction obstruction (anatomic or functional)(anatomic or functional)

Severe refluxSevere reflux

Valve bladderValve bladder

Residual posterior urethral valveResidual posterior urethral valve


Posterior urethral valve affect no organ Posterior urethral valve affect no organ

more consistently and more profoundly more consistently and more profoundly

than the bladder.than the bladder.

Degree of damage varies considerablyDegree of damage varies considerably

Most patients suffer significant life long Most patients suffer significant life long

bladder dysfunction.bladder dysfunction.


Two long term problemsTwo long term problems

Upper tract drainage affectedUpper tract drainage affected

IncontinenceIncontinence

50 % will reach ESRF in their lifetime50 % will reach ESRF in their lifetime

–– Need dialysis or transplantation during first 2 Need dialysis or transplantation during first 2 decades of life.decades of life.

Abnormal bladder will be a threat to the Abnormal bladder will be a threat to the success of transplantationsuccess of transplantation

Upper Tract DamageUpper Tract Damage

Can occur at Can occur at

–– Newborn stage Newborn stage

–– Later childhoodLater childhood

Newborn: Newborn: HypercontractileHypercontractile bladderbladder

–– Bladder thickened and Bladder thickened and trabeculatedtrabeculated

–– Contracts with great forceContracts with great force

–– Compliance lowCompliance low

–– Situation may persist for months even after successful Situation may persist for months even after successful

valve ablation.valve ablation.

Upper Tract DamageUpper Tract Damage

Later childhoodLater childhood-- Rigid BladderRigid Bladder

–– Contraction is lessContraction is less

–– Poor compliancePoor compliance

–– Poor sensationPoor sensation

DEFINITIONDEFINITIONMitchell 1982Mitchell 1982

Chronic conditionChronic condition

Successful valve ablationSuccessful valve ablation

Bladder dysfunctionBladder dysfunction

Deterioration of upper urinary Deterioration of upper urinary

tractstracts

Urinary incontinenceUrinary incontinence

PATHOPHYSIOLOGYPATHOPHYSIOLOGYMitchell 1982Mitchell 1982

Poor bladder sensationPoor bladder sensation

High bladder volumesHigh bladder volumes

Poor compliancePoor compliance

High storage pressuresHigh storage pressures

Poor drainage of upper tractsPoor drainage of upper tracts

PATHOPHYSIOLOGYPATHOPHYSIOLOGYMitchell 1982Mitchell 1982

Comfortable with large bladder Comfortable with large bladder

volumes at high pressurevolumes at high pressure

Overflow incontinenceOverflow incontinence

Void infrequently and incompletelyVoid infrequently and incompletely

Full Valve Bladder SyndromeFull Valve Bladder SyndromeDuckettDuckett & Snow 1986& Snow 1986

Upper tract dilatation progresses despite Upper tract dilatation progresses despite adequate valve ablationadequate valve ablation

Sensation of bladder decreaseSensation of bladder decrease

Increase intra Increase intra vesicalvesical pressure occur at low pressure occur at low filling volumefilling volume

VUJ obstructs with bladder fillingVUJ obstructs with bladder filling-- no more urine no more urine enters bladderenters bladder

Upper tract fills with inherent dilatationUpper tract fills with inherent dilatation

After voiding, bladder fills up rapidly with After voiding, bladder fills up rapidly with drainage form upper tractsdrainage form upper tracts

Worsened by Worsened by polyuriapolyuria

Full Valve Bladder SyndromeFull Valve Bladder SyndromeDuckettDuckett & Snow 1986& Snow 1986

UrodynamicsUrodynamics::

–– Poor compliancePoor compliance

–– Delayed sensation of fullnessDelayed sensation of fullness

Treatment:Treatment:

–– Double/ triple voidingDouble/ triple voiding

–– CICCIC

–– Anti Anti cholinergicscholinergics

–– Bladder augmentationBladder augmentation

PATHOPHYSIOLOGYPATHOPHYSIOLOGYKoffKoff et al 2002et al 2002

Induced condition. Combination of:Induced condition. Combination of:

–– PolyuriaPolyuria

–– Impaired bladder sensationImpaired bladder sensation

–– Residual urineResidual urine

Bladder Bladder decompensationdecompensation

–– Increased residual urineIncreased residual urine

–– Upper tract dilationUpper tract dilation

–– Renal injuryRenal injury

PATHOPHYSIOLOGYPATHOPHYSIOLOGYKoffKoff et al 2002et al 2002

HydronephrosisHydronephrosis-- persistent or persistent or

progressiveprogressive

Bladder Bladder overdistentionoverdistention::

–– PolyuriaPolyuria (24 urine volume > 2 liter (24 urine volume > 2 liter

(10/18)(10/18)

–– Impaired bladder sensation (18/18)Impaired bladder sensation (18/18)

–– Residual urine (14/18)Residual urine (14/18)

DetrusorDetrusor DysfunctionDysfunction

Smooth muscle infiltrated with increased Smooth muscle infiltrated with increased

amount of Type III collagen and amount of Type III collagen and elastinelastin

–– Cause loss of complianceCause loss of compliance

–– Small capacity bladder Small capacity bladder

–– High pressure bladderHigh pressure bladder

Changes in neurotransmitter Changes in neurotransmitter receptroreceptro

concentration in obstructed bladderconcentration in obstructed bladder

–– HyperreflexiaHyperreflexia ((ElbadawiElbadawi 1989)1989)

Valve BladderValve Bladder

Is it a permanent disability?Is it a permanent disability?

Can the valve bladder improve?Can the valve bladder improve?

Can renal deterioration be prevented?Can renal deterioration be prevented?

Can bladder dysfunction normalize?Can bladder dysfunction normalize?

EVALUATIONEVALUATION

Voided volume chartVoided volume chart

UltrasoundUltrasound-- assess degree of assess degree of hydronephrosishydronephrosis

VideourodynamicssVideourodynamicss::

–– Ability of bladder to hold and empty adequate Ability of bladder to hold and empty adequate

volume at acceptable pressuresvolume at acceptable pressures

LasixLasix renographyrenography: relative renal function and : relative renal function and

drainagedrainage

Whitaker perfusion test Whitaker perfusion test ––measure measure intrarenalintrarenal

pressures at a given drainage ratepressures at a given drainage rate

Diuretic Diuretic RenogramRenogram

DTPA / MAG3DTPA / MAG3

URODYNAMICSURODYNAMICS

WHITAKER TESTWHITAKER TEST

DIAGNOSISDIAGNOSISGhanemGhanem et al 2004et al 2004

Video Video urodynamicsurodynamics

Correlation between abnormal Correlation between abnormal

urodynamicsurodynamics (poor compliance and (poor compliance and

detrusordetrusor overactivityoveractivity) with poor renal ) with poor renal

function.function.

UrodynamicsUrodynamics in Childrenin Children

TechniqueTechnique

–– Supra pubicSupra pubic

–– Double lumenDouble lumen-- one for infusion and one for one for infusion and one for bladder pressure monitoringbladder pressure monitoring

–– Rectal lineRectal line

Indication:Indication:

–– Deterioration of renal function in spite of Deterioration of renal function in spite of adequate valve ablationadequate valve ablation

–– In children > 6 years and still incontinentIn children > 6 years and still incontinent

URODYNAMICS URODYNAMICS –– 3 PATTERNS3 PATTERNS(Peters 1990)(Peters 1990)

MyogenicMyogenic failurefailure

DetrusorDetrusor hyperreflexiahyperreflexia

Decreased compliance/ small capacityDecreased compliance/ small capacity

URODYNAMICSURODYNAMICS((HolmdahlHolmdahl 1996)1996)

Dominant pattern changed with ageDominant pattern changed with age

Stages of developmentStages of development

InfantsInfants-- poor compliancepoor compliance

Older childrenOlder children--instability from instability from

hypercontractilityhypercontractility

Post pubertal boysPost pubertal boys-- myogenicmyogenic failurefailure


First 3 years of life:First 3 years of life:

–– Vanishing Vanishing hypercontractilityhypercontractility and increasing and increasing

bladder capacity, even though instability bladder capacity, even though instability

remain unchangedremain unchanged

4 4 –– 12 years12 years

–– Decreasing instability and Decreasing instability and hypercontractilityhypercontractility

–– Major problemMajor problem-- emptying difficultiesemptying difficulties


Voiding patterns during day and nightVoiding patterns during day and night

–– 10 incontinent and 6 continent boys with PUV10 incontinent and 6 continent boys with PUV

–– Small frequent voiding during the day with Small frequent voiding during the day with fewer or no fewer or no voidingsvoidings during night. High during night. High bladder volumes in morning bladder volumes in morning

–– Bladder unstable during day and stable at Bladder unstable during day and stable at night night

–– Voiding Voiding detrusordetrusor pressure was higher and pressure was higher and functional bladder capacity lower during the functional bladder capacity lower during the day than at nightday than at night

URODYNAMICSURODYNAMICS

Need regular Need regular urodynamicsurodynamics

Track changes in patternTrack changes in pattern

Alter managementAlter management

First 2 decades of lifeFirst 2 decades of life

AIMS OF TREATMENTAIMS OF TREATMENT

Preserve renal functionPreserve renal function

Achieve a Functional bladderAchieve a Functional bladder

–– StorageStorage

–– Continence Continence

RENAL INJURYRENAL INJURY

GlomerularGlomerular insults insults

–– Renal Renal dysplasiadysplasia-- irreversibleirreversible

Affect renal growth and developmentAffect renal growth and development

–– Obstructive Obstructive uropathyuropathy

Produce ongoing injuryProduce ongoing injury

ReversibleReversible

–– Infections:Infections:

RefluxReflux

Incomplete bladder emptyingIncomplete bladder emptying

MANAGEMENTMANAGEMENTAustin et al 1999Austin et al 1999

Aim to lower bladder pressure and Aim to lower bladder pressure and

promote bladder emptying:promote bladder emptying:

–– Timed voidingTimed voiding

–– αα blockersblockers

–– Clean intermittent Clean intermittent catheterisationcatheterisation

MYOGENIC FAILUREMYOGENIC FAILURE

Older childrenOlder children

Overflow incontinenceOverflow incontinence

Incomplete bladder emptyingIncomplete bladder emptying

–– Ensure that there is no residual obstructionEnsure that there is no residual obstruction

–– Not due to bladder neck hypertrophyNot due to bladder neck hypertrophy


–– Timed voidingTimed voiding

–– Double voiding/ Triple voidingDouble voiding/ Triple voiding

–– αα blockersblockers

–– CICCIC

DetrusorDetrusor HyperreflexiaHyperreflexia

Adequate emptyingAdequate emptying

Urine frequencyUrine frequency

Urine incontinenceUrine incontinence


–– Anti Anti cholinergicscholinergics

POORLY COMPLIANT BLADDERPOORLY COMPLIANT BLADDER


–– AntiAnti--cholinergicscholinergics

–– Augmentation Augmentation cystoplastycystoplasty

Clean Intermittent Clean Intermittent CatheterisationCatheterisation

Is it effective?Is it effective?

What time of regimen?What time of regimen?

–– Day time onlyDay time only

–– Day time and night timeDay time and night time

MANAGEMENTMANAGEMENT

KoffKoff et al 2002et al 2002

–– Not a permanent prenatal alteration in Not a permanent prenatal alteration in

bladder anatomy and functionbladder anatomy and function

–– Sustained postnatal bladder over Sustained postnatal bladder over

distentiondistention-- polyuriapolyuria, impaired bladder , impaired bladder

sensation and residual urine volumesensation and residual urine volume

–– Prevent bladder normalization after valve Prevent bladder normalization after valve

ablationablation

–– Bladder Bladder decompensationdecompensation-- upper tract upper tract

dilatation and renal injurydilatation and renal injury


KoffKoff et al 2002et al 2002-- 18 boys for 11 yr18 boys for 11 yr

Treat Treat overdistensionoverdistension

–– Daytime alone unsuccessful. Leaves the bladder Daytime alone unsuccessful. Leaves the bladder

full throughout the nightfull throughout the night

–– Nocturnal bladder emptying Nocturnal bladder emptying –– indwelling night time indwelling night time

catheter, intermittent nocturnal catheter, intermittent nocturnal catheterizatoncatheterizaton +/+/--

frequent nocturnal double voidingfrequent nocturnal double voiding

Once nocturnal bladder emptying was started , Once nocturnal bladder emptying was started ,

hydronephrosishydronephrosis markedly improved ( comparable to markedly improved ( comparable to

urinary diversion)urinary diversion)


HolmdahlHolmdahl et al 2003:et al 2003:

–– 35 boys with valve35 boys with valve

–– Intermittent CatheterizationIntermittent Catheterization

Improve GFRImprove GFR

Improve bladder compliance and capacityImprove bladder compliance and capacity

INCONTINENCEINCONTINENCE

81 % delayed day and night continence at 81 % delayed day and night continence at

5 years (Smith et al 1996)5 years (Smith et al 1996)

Only 53 % dry at 12 years (Churchill et al Only 53 % dry at 12 years (Churchill et al

1990)1990)

Improves by 20 yearsImproves by 20 years

Psychological impact during adolescence Psychological impact during adolescence

((ParkhouseParkhouse 1988)1988)

INCONTINENCEINCONTINENCE-- CAUSECAUSE

? Sphincter injuries? Sphincter injuries

? Bladder neck dysfunction? Bladder neck dysfunction

MultifactorialMultifactorial –– functional ability exceededfunctional ability exceeded

–– Poor bladder sensationPoor bladder sensation

–– Poor bladder compliancePoor bladder compliance

–– DetrusorDetrusor instabilityinstability

–– PolyuriaPolyuria ––renal tubular damage (several renal tubular damage (several litreslitres/day)/day)

HYDRONEPHROSISHYDRONEPHROSIS

Almost all have severe Almost all have severe hydronephrosishydronephrosis at at diagnosis (96.5%diagnosis (96.5%-- Scott 1985)Scott 1985)

Resolve after relieve of bladder outlet Resolve after relieve of bladder outlet obstructionobstruction

May or may not be associated with VURMay or may not be associated with VUR

Non refluxing Non refluxing hydronephrosishydronephrosis resolves in 49 % resolves in 49 % after Valve ablationafter Valve ablation

50 % have persistent 50 % have persistent hydronephrosishydronephrosis for yearsfor years

55--15 years later 25 % still have 15 years later 25 % still have hydronephrosishydronephrosis(Hulbert & (Hulbert & DucketDucket 1988)1988)

Only 8 % have obstruction at Whitaker testOnly 8 % have obstruction at Whitaker test

HYDRONEPHROTIC UPPER TRACTS HYDRONEPHROTIC UPPER TRACTS

–– 3 TYPES (3 TYPES (GlassbergGlassberg 1982)1982)

Drains independent of bladder volumeDrains independent of bladder volume

Drains only when bladder emptyDrains only when bladder empty

Obstructed independent of bladder volumeObstructed independent of bladder volume

High DiversionHigh Diversion

Failure to improve after valve ablationFailure to improve after valve ablation

No improvement in 2 to 3 weeksNo improvement in 2 to 3 weeks

–– VesicostomyVesicostomy

No improvement after 4 to 6 No improvement after 4 to 6 weeeksweeeks

–– Higher diversionHigher diversion

VESICOSTOMYVESICOSTOMY

Small, sick infantsSmall, sick infants

To small for safe instrumentationTo small for safe instrumentation

Preserve renal functionPreserve renal function

Somatic growthSomatic growth

90 % adequate drainage90 % adequate drainage

10 % inadequate drainage10 % inadequate drainage

? Loss of bladder volume/ capacity? Loss of bladder volume/ capacity

? Decrease bladder compliance? Decrease bladder compliance

UPPER TRACT DIVERSIONUPPER TRACT DIVERSION

Decompress upper tractsDecompress upper tracts

Control infectionControl infection

Long term results Long term results vsvs valve ablationvalve ablation

–– Krueger et al 1980 Toronto experienceKrueger et al 1980 Toronto experience

Better eventual renal function and somatic growthBetter eventual renal function and somatic growth

–– ReinbergReinberg, , DuckettDuckett & & HendrenHendren

No significant differenceNo significant difference


INDICATIONSINDICATIONS

Fail to respond to bladder level drainageFail to respond to bladder level drainage

Renal function deteriorateRenal function deteriorate

Recurrent urinary tract infectionRecurrent urinary tract infection

Increasing Increasing hydronephrosishydronephrosis


INDICATIONSINDICATIONS

Bladder drainageBladder drainage

–– Fall in Fall in creatininecreatinine by 10 % a day to a nadir of < 0.8 by 10 % a day to a nadir of < 0.8 mg/dl (70 mg/dl (70 umol/lumol/l))

–– Assess Assess creatininecreatinine at Day 10at Day 10< 20 mg/dl (176 < 20 mg/dl (176 umol/lumol/l) ) –– continue bladder drainagecontinue bladder drainage

> 20 mg/dl, and > 20 mg/dl, and hydronephrosishydronephrosis not improved, consider not improved, consider upper tract diversionupper tract diversion

Options of Upper tract diversionOptions of Upper tract diversion

–– Loop Loop ureterostomyureterostomy

–– PyelostomyPyelostomy

–– Sober Roux en YSober Roux en Y

IleocystoplastyIleocystoplasty

UreterocystoplastyUreterocystoplasty

Auto AugmentationAuto Augmentation

SeromuscularSeromuscular EnterocystoplastyEnterocystoplasty ––

Sigmoid colonSigmoid colon

THANK YOUTHANK YOU

Documents

Dr. Patrick Mah - muacme.org Bladder 20-7-08.pdf · Dr. Patrick Mah MBBS (Melbourne ... No improvement: – Pre renal cause - post obstructive diuresis – Renal dysplasia ... Valve