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Chapter 3
41
Surgical Approaches in Pediatric
Neurogenic Low Urinary Tract
Dysfunction
José AntonioMarch-Villalba
Abstract
This chapter explores surgical treatment modalities in pediatric urology for
patients with lower urinary tract dysfunction due to neurogenic etiologies. Specific
surgical strategies and innovative approaches are examined to enhance urinary
function and improve the quality of life in this pediatric population. The discussion
emphasizes the importance of comprehensive assessment and careful planning to tailor surgical interventions to the individual needs of each patient. Additionally, recent
advances in understanding and treating these conditions are addressed, providing a
comprehensive overview of available surgical options and their implications for preserving renal function and improving the quality of life for children with neurogenic
lower urinary tract dysfunction.
Keywords: pediatric, neurogenic, urinary tract dysfunction, treatment, surgery
. Introduction
Neurogenic lower urinary tract dysfunction (NLUTD) is a common complication
in children with neurological disorders such as spina bifida, cerebral palsy, and spinal
cord injuries [–].
NLUTD involves an alteration in the coordination between the nervous system and
the urinary tract, affecting the child’s ability to control urination. It is often associated
with neurological dysfunction that impacts the nerves controlling the bladder and
urinary tract muscles, resulting in hyperactivity and a non-compliant bladder, which
leads to abnormalities in bladder filling or emptying. This is a common problem in
children, accounting for of pediatric urology consultations. Therapeutic management focuses on improving symptoms and preventing damage to renal function
caused by recurrent infections or vesicoureteral reflux [, ].
While most children with NLUTD can be managed with conservative therapies,
such as anticholinergics, intermittent bladder catheterization, oral autoimmune
vaccines, and so on, surgical interventions may be necessary in some cases to improve
urinary tract function and prevent long-term complications [–].
Before considering surgical intervention, it is crucial to conduct a thorough evaluation of the pediatric patient with NLUTD. This includes a detailed medical history,
and Rosa MaríaGras-Martínez
Pediatric Surgical Procedures – An Updated Guide – Volume I
42
a comprehensive physical examination, and diagnostic tests such as urodynamic
studies, renal ultrasound, and voiding cystourethrography to assess the severity and
nature of the urinary tract dysfunction [–].
In this chapter, we will review the surgical approaches used in the management of
NLUTD in pediatric patients, focusing on reducing intravesical pressure, modifying
urethral resistance, and considering urinary diversion.
. Procedures to reduce intravesical pressure
. Botulinum toxin detrusor injection
Botulinum toxin has emerged as a promising therapeutic option in the management of NLUTD in pediatric patients. Its use has become widespread as an effective
alternative for controlling detrusor overactivity and reducing urethral resistance in
this population [, –]. Botulinum toxin works by blocking the release of acetylcholine at nerve endings, resulting in the relaxation of the detrusor muscle and a decrease
in uncontrolled contractile activity. This therapeutic approach has proven particularly
useful in cases refractory to other forms of conservative treatment, offering significant improvements in urinary symptoms and quality of life for pediatric neuropathic
patients. However, careful preoperative evaluation and postoperative follow-up are
required to optimize outcomes and minimize potential risks associated with the
procedure [–].
The use of botulinum toxin-A (Botox/BoNT-A) intradetrusor injections in the
neuropathic pediatric bladder (Figure ) has been the subject of numerous studies
Figure 1.
Scheme of the puncture and injection points of BOTOX in the bladder. Injecting 10units per kg of body weight up
to a maximum of 300units, with a dilution of 10units per ml of saline solution. 20 to 30 different trigger points
are injected in the detrusor with 1ml of dilution per point, respecting the trigone.
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
43
that have evaluated different aspects of its efficacy and safety. Published results
have consistently demonstrated a significant improvement in urinary symptoms and
quality of life following botulinum toxin injection into the detrusor. However, there is
some variability in reported outcomes, which may be partly attributed to differences
in injection techniques [–].
The reviewed studies have demonstrated that BoNT-A injections into the detrusor muscle are effective in reducing overactivity and involuntary contractions in
children with bladder neuropathy. This leads to a decrease in voiding frequency,
urinary urgency, and episodes of incontinence. Additionally, the reduction in
detrusor overactivity can improve urinary retention capacity and the quality of life
for patients [–].
Bladder compliance refers to the ability of the bladder to distend and store
urine efficiently without experiencing excessive increases in intravesical pressure.
In patients with a neuropathic bladder, loss of bladder compliance can result in
diminished storage capacity and an increased risk of complications such as incontinence and renal dysfunction. Botulinum toxin can improve bladder compliance
by reducing detrusor muscle activity and decreasing involuntary contractions. This
allows for more effective bladder distension during filling, resulting in increased
urinary retention capacity and a decrease in symptoms of overactive bladder.
Consequently, the risk of incontinence is reduced, and long-term renal function is
improved [–].
Indeed, botulinum toxin (BoNT-A) has been shown to temporarily decrease
detrusor contractility and improve bladder compliance in children with neuropathic
bladder, potentially delaying the need for surgical interventions aimed at increasing
bladder capacity. However, it is important to consider that the effects of BoNT-A are
temporary, typically lasting around to months, after which repeat injections
may be necessary to maintain therapeutic benefits. Therefore, while BoNT-A injections can provide valuable symptom relief and improve bladder function in pediatric
patients with neuropathic bladder, they may not eliminate the need for long-term
management strategies, including surgical interventions to address bladder capacity
issues. Ultimately, the decision to pursue surgical intervention should be individualized based on the patient’s clinical presentation, response to treatment, and overall
treatment goals, with consideration given to both short-term and long-term outcomes [–].
Specifically, in a recent systematic review involving pediatric patients with neurogenic bladder, it was found that continence rates ranged from to , with a
reduction in maximum detrusor pressure of –, an increase in maximum cystometric capacity of –, and improvement in bladder compliance (–) [].
Onabotulinum toxin A (administered at a maximum dose of IU injected at –
different sites) appears to be more effective in bladders exhibiting detrusor muscle
overactivity, while bladders that are non-compliant and lack detrusor overactivity are
less likely to respond [, ].
In summary, BoNT-A offers significant benefits in the treatment of detrusor overactivity and the improvement of bladder compliance in children with neuropathic
bladder. These benefits translate into a reduction in symptoms of overactive bladder,
improvement in urinary retention capacity, and enhanced quality of life for pediatric
patients [–].
The adverse effects of BOTOX use in children can vary depending on the study
and population studied, but some common adverse effects mentioned in the reviewed
articles include [–]:
Pediatric Surgical Procedures – An Updated Guide – Volume I
44
• Urinary retention: Following BOTOX treatment, some children may experience
difficulties in urination due to excessive relaxation of the detrusor muscle. This
may manifest as decreased urinary flow or the need for intermittent catheterization to empty the bladder.
• Urinary tract infections (UTIs): There is an increased risk of UTIs following
BOTOX treatment, especially in those requiring intermittent catheterization or
having trouble completely emptying the bladder.
• Incontinence: Although BOTOX is used to treat urinary incontinence, some children may experience overflow incontinence due to the inability to fully empty
the bladder following treatment.
• Dysuria: Irritation of the bladder mucosa due to BOTOX treatment can cause
discomfort during urination, such as pain or burning (dysuria).
• Fecal retention: In some cases, BOTOX may also affect the function of the anal
sphincter, leading to fecal retention and constipation in children.
The systemic effects of BOTOX after bladder injection in children are a critical
consideration in the management of pediatric patients undergoing this treatment.
While BOTOX is primarily localized to the site of injection and exerts its therapeutic
effects by blocking nerve signals to the targeted muscle, there is potential for systemic
absorption and distribution of the toxin [–].
Some systemic effects that have been reported in the literature include [–]:
• Systemic spread of toxin: Although rare, systemic spread of BOTOX beyond the
injection site can occur, leading to distant muscle weakness or paralysis. This
can manifest as weakness in adjacent muscles or more generalized weakness,
depending on the extent of systemic absorption.
• Flu-like symptoms: Children may experience flu-like symptoms such as fever,
malaise, and muscle aches following BOTOX injection, which are typically mild
and transient.
• Allergic reactions: While uncommon, allergic reactions to BOTOX, such as rash,
itching, or swelling at the injection site, have been reported in pediatric patients.
• Systemic toxicity: In rare cases, systemic toxicity due to excessive systemic absorption of BOTOX can occur, leading to symptoms such as difficulty breathing,
swallowing, or speaking, and generalized weakness or paralysis.
It is essential for healthcare providers to be vigilant for signs of systemic effects
following BOTOX injection in children and to monitor patients closely for any adverse
reactions. Additionally, healthcare providers should discuss the potential risks and
benefits of treatment with parents and caregivers before proceeding with BOTOX
injection and ensure that appropriate precautions are taken to minimize the risk of
systemic effects [, –].
Studies have compared the efficacy and side effects of a single intradetrusor injection versus multiple injections distributed throughout the bladder wall.
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
45
While some studies suggest that a single intradetrusor injection may be sufficient
to achieve similar results with lower risks of complications, others have found that
multiple injections may be more effective in certain patient subgroups. It is crucial to
consider these differences in injection technique when interpreting the results and
planning individualized treatment for neuropathic pediatric patients with bladder
dysfunction.
Regarding injection numbers and doses, across the studies, the number of injections and doses of BoNT-A varied depending on the specific protocol used. Typically,
multiple injections were administered into the detrusor muscle of the bladder under
cystoscopic guidance. Doses ranged from to units of BoNT-A per injection,
with some studies utilizing a single injection and others employing a multiple-injection approach [–].
Recurrent cases may include the return of incontinence symptoms after the
effects of the injection wear off. The duration of the Botox effect ranges between
and months. Repeating the injection is often necessary. Alternative treatments or
adjunct therapies may be considered if responses are inadequate [–].
Botox failure may involve a lack of response to the injection or significant side
effects. Alternative therapeutic options or further diagnostic evaluation may be
needed. Exploring other treatments like augmentation cystoplasty or neuromodulation techniques might be necessary [–].
In conclusion, botulinum toxin type A has been demonstrated to be a safe and
effective therapeutic option in managing neuropathic bladder in children. The
reviewed studies support its use in treating incontinence, overactive bladder, and
other lower urinary tract disorders in pediatric populations. However, further
research is warranted to fully understand its long-term efficacy and impact on the
quality of life of pediatric patients with neuropathic bladder [, –].
. Sacral neuromodulation and stimulation
Sacral neuromodulation (SNM) is a therapeutic approach used to manage
lowerurinary tract dysfunction (LUTD) in children, including those with neuropathic bladder dysfunction. It involves the targeted delivery of electrical stimulation to the sacral nerves, which play a crucial role in regulating bladder function
[,–].
Although there is a significant body of literature on transcutaneous neurostimulation in pediatric patients with idiopathic overactive bladder, studies focusing on
pediatric patients with neurogenic bladder are scarce [, –].
The first step in SNM involves the surgical implantation of a neuromodulation
device, often referred to as a “neurostimulator.” This device is typically placed under
the skin in the upper buttock area and is connected to thin, flexible wires called
“leads” that are positioned near the sacral nerves. Once the device is implanted, it
delivers mild electrical impulses to the sacral nerves via the leads. These electrical
impulses modulate the activity of the nerves, helping to regulate bladder function.
The stimulation parameters, such as frequency, amplitude, and pulse width, can
be adjusted based on the individual patient’s needs. Following implantation, the
neuromodulation device can be programmed and adjusted as needed to optimize
its therapeutic effects. Regular follow-up appointments with healthcare providers
are essential to monitor the child’s progress, make any necessary adjustments to the
stimulation parameters, and ensure the continued effectiveness and safety of the
treatment [–].
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The electrical stimulation provided by sacral neuromodulation has several
effects on bladder function in children with LUTD. It can help normalize bladder
contractions, reduce urinary frequency and urgency, improve bladder emptying, and
decrease episodes of urinary incontinence. Additionally, sacral neuromodulation may
also modulate sensory pathways involved in bladder sensation, leading to improvements in bladder control and continence [–].
Regarding sacral anterior root stimulation implants, there are few studies providing information about their application in neuropathic pediatric patients, as it is not a
commonly used technique [].
Transcutaneous electrical nerve stimulation (TENS) is a non-invasive neuromodulation technique that involves applying electrical stimulation to the skin to
modulate nerve activity [, –]. Although there are numerous studies in adults
and even a meta-analysis, none has specifically investigated the pediatric population.
To date, only two studies have investigated the immediate effect of transcutaneous
electrical nerve stimulation (TENS) on urodynamic parameters in children with
myelomeningocele. Myelomeningocele is a type of spina bifida characterized by
incomplete development of the spinal cord and its protective covering. Children with
myelomeningocele commonly experience bladder dysfunction, including neurogenic
bladder, which can lead to urinary incontinence, urinary tract infections, and renal
damage [–].
In the first study, researchers aimed to assess the immediate impact of TENS on
urodynamic parameters, such as detrusor pressure, maximum cystometric capacity,
and bladder compliance, in children with myelomeningocele. In the second study,
researchers replicated the treatment procedure two or three times weekly. The ages of
the patients ranged from to years [].
Self-adhesive surface electrodes were placed on the skin over the region of the
sacral dermatomes between S and S. This location, used in other similar studies,
is the closest region to the bladder innervations, which seems to facilitate nerve
recruitment [, ]. The exact location of the electrodes was determined by palpation
with the thumbs between the posterior superior iliac spine using an imaginary line
to identify the S vertebra. The duration of the TENS intervention was the same as
the urodynamic study (UDS), lasting from to minutes, depending on the age
and size of the child’s bladder. A symmetrical biphasic pulsed waveform current with
a frequency of Hz, a pulse width of s, and a maximum amplitude of mA
was used. The study concluded that the use of transcutaneous electrical nerve stimulation had a significant immediate effect on reducing maximum bladder pressure
during urodynamic studies in pediatric patients with neurogenic bladder. The results
were more significant among children under years of age. These findings provide
insights into the potential therapeutic effects of TENS in managing bladder dysfunction in children with myelomeningocele [, ].
In children aged –years, the use of TENS requires special consideration due to
their smaller anatomical size and different physiological responses. The procedure
typically involves the placement of self-adhesive surface electrodes over the sacral
dermatomes between S and S, chosen for their proximity to bladder innervations,
which helps facilitate nerve recruitment [–].
The standard TENS protocol for this age group involves a symmetrical biphasic
pulsed waveform current with a frequency of Hz, a pulse width of s, and
a maximum amplitude of mA. The duration of each session ranges from to
minutes, depending on the child’s bladder size and overall tolerance to the stimulation [, –].
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
47
Clinical observations suggest that TENS is a safe and well-tolerated intervention
in this young demographic. It has shown significant immediate effects on reducing
maximum bladder pressure during urodynamic studies, particularly in children under
years of age. Continuous monitoring and adjustments are crucial to optimize the
therapeutic benefits and minimize potential discomfort or adverse effects [, –].
.. Procedure for TENS application in children aged –years
. Preparation:
Explain the procedure to the child and their caregivers to ensure understand-
ing and cooperation [, –].
Ensure the child is comfortable and relaxed, possibly allowing them to hold a
favorite toy or watch a video during the procedure.
. Electrode Placement (Figure )
Posterior Tibial Nerve Stimulation: This technique inhibits reflex bladder
contractions, potentially increasing bladder storage capacity and reducing
urinary urgency. Place two electrodes: one on the inside of the ankle and the
second three to four fingers above the first.
Clean the skin over the sacral dermatomes (S–S) with an alcohol swab to
ensure good electrode adhesion.
Place the self-adhesive electrodes symmetrically over the target area.
. Device Seings:
Set the TENS device to a frequency of Hz and a pulse width of s.
Figure 2.
(a) Posterior tibial nerve stimulation. Place two electrodes, the first on the inside of the ankle, and the second
three to four fingers up. (b) Clean the skin over the sacral dermatomes (S2–S4) with an alcohol swab to ensure
good electrode adhesion. Place the self-adhesive electrodes symmetrically over the target area.
Pediatric Surgical Procedures – An Updated Guide – Volume I
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Gradually increase the amplitude to a maximum of mA, or until the child
feels a comfortable tingling sensation.
. Session Duration:
Each session should last between and minutes, with the duration
tailored to the child’s tolerance and response.
. Monitoring:
Monitor the child throughout the session for any signs of discomfort or
adverse effects.
After the session, check the skin under the electrodes for any signs of irritation.
. Follow-up:
Schedule regular follow-up appointments to assess the effectiveness of the
therapy and make any necessary adjustments to the treatment plan.
The findings support the potential of TENS as a valuable tool in managing bladder
dysfunction in young children with neurogenic bladder conditions. Its use can significantly improve quality of life by reducing urinary symptoms and enhancing bladder
function with minimal risks. Understanding the immediate impact of TENS on urodynamic parameters can inform the development of tailored treatment approaches aimed
at improving bladder function and overall quality of life in this population [, , ].
However, it is important to note that sacral nerve stimulation and transcutaneous neuromodulation are still considered experimental in children with neurogenic
bladder dysfunction and cannot be recommended outside the confines of clinical
trials [, ].
. Posterior sacral root Rhizotomy
Posterior Sacral Root Rhizotomy (SARS) is a surgical procedure performed to
treat neurogenic bladder dysfunction, particularly in patients with conditions such
as spinal cord injury or spina bifida. During the procedure, the surgeon selectively
cuts or divides specific sacral nerve roots at the posterior aspect of the sacrum. This
interruption of neural signals helps reduce abnormal bladder contractions, thereby
improving bladder function and reducing urinary incontinence. SARS is typically
considered when other treatments, such as medications or behavioral therapies, have
been ineffective in managing neurogenic bladder symptoms [].
Currently, there are no studies supporting its application in pediatric patients with
neurogenic bladder. The few existing studies on this procedure date back to the last
decade of the twentieth century.
. Detrusor myectomy
Detrusor myectomy is a surgical procedure used to treat neurogenic bladder
dysfunction (NBD) by making incisions in the detrusor muscle of the bladder.
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
49
This procedure aims to increase bladder capacity and improve bladder compliance, thereby reducing urinary incontinence and other symptoms associated with
NBD. During detrusor myotomy, the detrusor muscle is incised to create a bladder
diverticulum, which allows for increased bladder volume. The resulting flaps are
then anchored to prevent the closure of the myotomy. Detrusor myotomy is typically indicated when conservative treatments have failed to adequately manage
NBD symptoms [, , ].
The surgical procedure involves exposing the bladder extraperitoneally through
a low midline laparotomy or Pfannenstiel incision. The detrusor muscle is incised
coronally in the midline to create a bladder diverticulum, and the resulting flaps are
secured to prevent the myotomy from closing. The detrusor myectomy technique
remains largely unchanged from its original description. Through a Pfannenstiel
incision in the lower abdomen, as previously mentioned, the bladder is exposed.
A -way urethral catheter is placed to easily control bladder filling and emptying.
Initial bladder distention allows for clear definition and dissection of the peritoneum
off the bladder dome. A scalpel is then used to incise the detrusor muscle layer.
Using a combination of gentle traction and sharp dissection, the detrusor layer
covering the dome and anterior wall is stripped away to expose the bulging bladder
epithelium. Care is taken to avoid perforating the bladder mucosa. Although small
perforations can be repaired with sutures, the outcomes are generally less satisfactory. After the surgery, a urethral catheter is left for gravity drainage for –days
(
Figure ) [, ].
Although detrusor myectomy has been described in the scientific literature, there
are relatively few studies that both detail and apply this surgical intervention. One
notable study in this regard is the one conducted by Cartwright and Snow, which
provided a foundational description of the operative procedure for detrusor myotomy. This study, along with a few others, serves as a cornerstone for understanding
and implementing detrusor myotomy as a surgical treatment for neurogenic bladder
dysfunction.
Figure 3.
Detrusor myectomy. (a) A midline opening bladder serosa incision. (b) The detrusor muscle was incised coronally
in the midline to create a bladder diverticulum, (c) The resulting flaps were hitched to prevent closure of the
myotomy. (d) Closure of the first serosa incision.
Pediatric Surgical Procedures – An Updated Guide – Volume I
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The study retrospectively reviewed the medical records of consecutive
children under the age of who underwent detrusor myotomy (DM). These
children had neurogenic bladder dysfunction (NBD) due to various underlying
conditions such as myelodysplasia, sacral agenesis, lumbosacral lipoma, multiple
vertebral anomalies, and spinal neuroblastoma. Postoperatively, patients underwent intermittent catheterization, and follow-up assessments included cystometric
bladder capacity, renal function evaluation, and clinical assessment of continence
[, , ].
The results showed that surgery was performed on girls and boys, with a mean
age of .years. The main indications for surgery were urinary incontinence and
high-grade vesicoureteral reflux (VUR). The mean follow-up was .years. Bladder
capacity increased significantly postoperatively, and most patients achieved full continence or marked improvement. VUR was alleviated in most cases, and renal function developed normally in all except one patient. The study concluded that detrusor
myotomy is a viable and safe treatment option for pediatric NBD. However, optimal
results may require enhancing bladder outlet resistance in addition to increasing
bladder capacity [, ].
. Augmentation cystoplasty
Augmentation cystoplasty is a surgical procedure used to increase the size or
capacity of the bladder. This is typically achieved by adding a segment of tissue, often
from the intestines to the bladder wall, effectively enlarging its capacity to hold urine.
The procedure is commonly performed in cases where the bladder has lost its ability
to stretch due to conditions such as neurogenic bladder dysfunction or congenital
abnormalities. Augmentation cystoplasty aims to improve bladder function, reduce
urinary incontinence, and alleviate symptoms associated with bladder dysfunction
[, , ].
Often, in conjunction with augmentation cystoplasty, it is necessary to create a
catheterizable conduit. Additionally, when the patient also suffers from vesicoureteral reflux, ureteral reimplantation or ureteroneocystostomy may also be required
[, –].
The indications for augmentation cystoplasty in pediatric patients with neurogenic
bladder include neurogenic overactive bladder, impaired compliance, and refractory
urinary incontinence. These indications are based on a clinical assessment of the
patient, including urodynamic studies and evaluation of renal function. Specific
indications for this surgery include failure of minimally invasive treatments such as
bladder BOTOX injection, bilateral high-grade ureterohydronephrosis secondary to
vesicoureteral reflux associated with significant renal failure, and significant impairment of bladder accommodation associated with low capacity and elevated detrusor
leak pressure (> cmHO) [, –].
The most common tissues used for augmentation are ileal, sigmoid, and ureteric
segments. Complications from surgery can include postoperative infections (urinary
tract and wound), metabolic abnormalities (such as metabolic acidosis and electrolyte
imbalances), urinary continence issues, bladder stones, mucus production, hematuria, and bladder perforation. Neoplasms are more common as the patient reaches
adulthood [–].
Each bowel segment presents unique characteristics, with both advantages and
disadvantages. For instance, the ileum offers greater compliance compared to the
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