Myoneurotisation of bladder: an innovation surgical approach to treatment of refractory neuromuscular dysfunction of bladder in children

Abstract

A significant number of children with dysuric disorders as a consequence of congenital spinal dysraphism have a good clinical effect of conservative therapy, which includes both medication and clean intermittent catheterization. Sometimes, it is necessary to increase the dose of anticholinergic drugs to achieve clinical effect. However, 10-20% of such patients are subjected to surgical treatment. To determine the indications for conservative or surgical treatment (or often their combination), the physician should reveal the leading mechanism of incontinence. Given that urination disorders in patients with myelodysplasia constitute 95–98%, particular attention should be paid to the comprehensive treatment of neurogenic bladder dysfunction (NBD) in this category of paediatric patients (E. Smith, 1965; J.D. van Gool et al., 2001). However, at present there is no radical surgery of neurogenic bladder .

Purpose. To explore the possibility of surgical bladder reinnervation in children with a refractory forms of neurogenic bladder dysfunction due to spinal disraphism.

Materials and methods. Considering the standardized method of surgical treatment of refractory to therapy NBD is no available in contemporary literature, especially connected with impaired bladder innervation, we have developed a new method of surgical treatment, which provides reinnervation (myoneurotization) of a bladder (Method of innervation of the neurogenic bladder. The patent for the invention №102801 UA МПК (2013.01): A61B 17/00). The method consists in the nerve implantation, which has somatic and autonomic innervation, in the wall of the bladder above the spinal cord lesion due to spinal digraphism to restore (replacement) its receptor and evacuation functions.

Results and discussion. Since 2001 by applying the proposed surgical technique at the clinics of the Shupyk National Medical Academy of Postgraduate Education (atthe Kyiv Municipal Children’s Clinical Hospital No. 1 and Zhytomyr Regional Children’s Clinical Hospital) were operated 9 paediatric patients with NBD. Age of patients ranged from 4 to 14 years (in average 6.5 years), among them 2 boys (22.2%) and 7 girls (77.8%). The clinical follow-up of patients was 15 years and was conducted in 5 patients (55.6%) with positive health outcome in 4 (80%) patients. The positive subjective changes distinguished by the patients were as follows: the emergence of the perception of bladder filling were noted by 5 (100%) patients, urine сontinence (dry period of up to 3 hours) – 4 (80%) patients, the urination stream – 5 (100%) patients. To positive objective changes were included such symptoms as follows: the decrease of postvoid residual urine volume in 5 (100%) patients (according to the ultrasonography and clean permanent catheterization), reduction of retention changes of the upper urinary tract in 5 (100%) patients (according to ultrasound screening), and improvement of renal function according to laboratory tests in 5 (100%) patients, reduction or complete elimination of vesicoureteral reflux according to X-ray examination in 100% of patients who earlier suffer from it, long-term remission of urinary tract infections with reduction/elimination of bacteriuria in 4 (80%) patients according to laboratory tests, including bacteriological one. There were no complications in postoperative period.

Conclusions. Thus, the innovative surgery of reinnervation bladder, the myoneurotisation of bladder, is a fairly effectious treatment of refractory forms of neuromuscular bladder dysfunction in children. The results of the method require further study of urodynamic parameters, which will give the opportunity to recommend the technique for widespread implementation in practice.