P X SPINA BIFIDA X NEUROGENIC BLADDER

The Challenge of Predicting Risk in Children With Myelomeningocele

The ability to predict potential risk in young children with myelomeningocele remains a clinical challenge with significant clinical impact. Long-term health outcomes can be driven by early management decisions, yet we remain limited in our ability to risk-stratify these patients. The report by Corona et al attempts to provide clinical parameters to guide decision-making and interventions by identifying those at risk for subsequent deterioration of bladder function and who may ultimately need bladder augmentation. There have long been two approaches to these children: expectant management without active treatment and instituting CIC and medical therapy when evidence of bladder deterioration is detected. Alternatively, early active treatment with CIC and anticholinergics is advocated in those with evidence of a hostile bladder. This has previously been defined as detrusor sphincter dyssynergy; this report uses the detrusor leak point pressure or end fill pressure of greater than 40 cm H20 as the threshold for concern and likely need for augmentation.

The value of early therapy, in theory, is that it can prevent bladder deterioration that might be irreversible by the time it is clinically evident. This has never been definitively proven. Unfortunately, this report is not able to provide that proof, but it does offer a clear clinical parameter to use to more closely monitor these children. Heightened concern and closer follow-up may be very effective long-term management strategies.

The fact that neurogenic bladder dysfunction due to meningomyelocele is a dynamic condition that changes with the child’s growth is made evident in this patient cohort. Systematic follow-up is essential to optimize bladder function and thereby renal function and overall health. We have the tools to prevent upper tract deterioration yet need better insight as to when to employ those tools, including augmentation cystoplasty. The authors point out correctly that only a minority of patients came to augmentation, yet it must be recognized that this is a critically important minority. Renal damage in the setting of neurogenic bladder dysfunction is a clinical failure that is preventable with careful monitoring and timely intervention.

This report also highlights some of our knowledge gaps in caring for children with neurogenic bladder dysfunction. The authors present a dichotomous clinical indicator; however, given the dynamic nature of the condition, patterns of change in bladder function over time may be more useful and sensitive indicators of progressive injury. Urinary biomarkers may also provide useful information to perform ongoing dynamic risk stratification for these children. Interpretation of urodynamic patterns should also be closely re-examined to potentially define early markers of deterioration. The ongoing prospective registry is likely to provide some of these insights into these challenging and important patients.