The majority of infants with myelomeningocele have Neurogenic Lower Urinary Tract Dysfunction (NLUTD). Careful assessment and management aims to minimise development of life changing upper urinary tract damage. In 2018, Timberlake et al. reported that vesicoureteric reflux (VUR) and/or bladder trabeculations were better predictors of adverse outcomes than urodynamic parameters(1). The aim of this study was to review the results of urinary tract assessments in infants with myelomeningocele and review whether upper tract deterioration seen on ultrasound was related to urodynamics parameters or bladder appearance and/or VUR during initial video-urodynamics (VUD).

Infants born with myelomeningocele and managed at a single tertiary children’s hospital between 2012 and 2019 were identified through diagnostic coding. The medical records of those who underwent back closure followed by bladder assessment at the centre were reviewed retrospectively and data was collected regarding timing of surgery, initial bladder management, KUB ultrasound (USS) as a newborn and at the time of VUD, DMSA reports, urodynamic parameters and management thereafter. Results are given as median (interquartile range, IQR). Statistical analysis was undertaken using ‘Wizard for Mac’.

46 neonates (26 female) underwent back closure at 2 days of age (IQR 2). CIC was commenced routinely after birth in all except 2 who were difficult to catheterise, one of whom required an indwelling catheter. All newborn USS were normal (other than structural variants). VUD were undertaken at 3.9 months (3.5-4.3), NLUTD was confirmed in 45 (98%). Hyper-reflexic detrusor contractions were seen in 33 (72%), abnormal compliance in 17 (37%), VUR in 10 (22%), a trabeculated bladder in 7 (15%). 15 (33%) had VUR and/or bladder trabeculations. Routine upper tract imaging done at the time of VUD identified new abnormalities on USS in 7 (15%) including bladder abnormalities in 2 (diverticulae, bladder wall thickening), hydronephrosis in 2, calcification in 2 and pyelonephritis in one who had a recent UTI). Three infants had a UTI documented prior to VUD, one of whom had abnormal DMSA & USS and required a vesicostomy.

Abnormal USS was significantly associated with DMSA scan abnormalities (reported in 9/42 (21%)), p=0.02 (Fishers exact test). Univariate analysis did not correlate any urodynamic parameters or presence of VUR or [VUR and/or bladder trabeculations] with abnormal USS or DMSA. However, both abnormal DMSA (OR 21.8, 95% CI 1.8-256.9, p0.014) and presence of bladder trabeculation on XR screening (OR 59.2, 2.8-1,266.6, p0.009) were associated with abnormalities on USS.

In this cohort, bladder trabeculations detected during baseline urodynamics were associated with USS changes at 3-4 months of age. Whilst the number of patients studied is a limitation, this supports the findings of Timberlake et al.. Such infants are likely to be at increased risk of irreversible upper tract damage and warrant proactive bladder management and monitoring.

Timberlake M, Jacobs M, Kern A, Adams R, Walker C, Schlomer B. Streamlining risk stratification in infants and young children with spinal dysraphism: Vesicoureteral reflux and/or bladder trabeculations outperforms other urodynamic findings for predicting adverse outcomes. Journal of Pediatric Urology. 2018;14(4):319.e1-319.e7