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Journal of Pediatric Urology (2018) xx, 1.e1e1.e7

aDepartment of Urology,University of TexasSouthwestern, Dallas, TX, USA

bDivision of DevelopmentalBehavioral Pediatrics,University of TexasSouthwestern, Dallas, TX, USA

cDevelopmental Disabilities,Texas Scottish Rite Hospital forChildren, Dallas, TX, USA

Correspondence to: M.D.Timberlake, University of TexasSouthwestern, Department ofUrology, 1935 Medical DistrictDrive Suite F4300, Mail codeF404, Dallas, TX 75235, USA

matthew.timberlake@utsouthwestern.edu

(M.D. Timberlake)

Keywords

Spinal dysraphism; Spina bifida;Urodynamics; Neurogenicbladder; Bladdertrabeculations; Vesicoureteralreflux

Received 30 December 2017Accepted 9 May 2018Available online xxx

Please cite this article in prdysraphism: Vesicoureteral reJournal of Pediatric Urology (

https://doi.org/10.1016/j.jpu1477-5131/ª 2018 Published b

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Streamlining risk stratification in infantsand young children with spinaldysraphism: Vesicoureteral reflux and/orbladder trabeculations outperformsother urodynamic findings for predictingadverse outcomes

Matthew D. Timberlake a, Micah A. Jacobs a, Adam J. Kern a,Richard Adams b,c, Candice Walker c, Bruce J. Schlomer a

Summary

BackgroundBaseline and interval dimercaptosuccinic acid (DMSA)scans and urodynamic (UD) studies are often obtained ininfants and young children with spinal dysraphism (SD).

ObjectiveTo identify practical UD parameters which accuratelystratify urologic risk young children with SD.

Study design130 expectantly managed infants/young children withSD and initial DMSA and UD before age 2 were reviewed.End fill pressure (EFP), bladder trabeculations, ves-icoureteral reflux (VUR), initial volume (IV) drained atUD catheter placement, and detrusor pressure at initialvolume (DPIV) were evaluated for association withsubsequent febrile urinary tract infection (UTI), DMSAabnormalities, and early clean intermittent catheteri-zation (CIC). A combination of factors to accuratelystratify risk was sought. Groups were compared by log-rank test. The association of CIC and febrile UTI inci-dence was evaluated.

Results31/130 patients developed DMSA abnormalities, 52/130started early CIC, and 61/130 developed a febrile UTI withmedian follow-up of 3.8 years. Trabeculations, VUR, EFP�40 cm H2O, IV �50% estimated bladder capacity (EBC),and DPIV >10 cm H2O were associated with subsequent

Figure Cumulative incidence of DMSA abnormalicompared with those with neither finding.

ess as: Timberlake MD, et al., Streamlining risk stratflux and/or bladder trabeculations outperforms other u2018), https://doi.org/10.1016/j.jpurol.2018.05.023

rol.2018.05.023y Elsevier Ltd on behalf of Journal of Pediatric Urology

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abnormal DMSA scan (p < 0.001). The best predictor wascombination of trabeculation and/or VUR (p < 0.001)(Figure). Among patients who maintained a non-trabeculated bladder without VUR during follow-up, 0/51developed DMSA abnormalities compared with 31/79 whodeveloped one or both (p < 0.001). Patients with trabe-culations and/or VUR were more likely to start early CIC(8/51 vs. 44/79; p< 0.001) and have febrile UTI (11/51 vs.50/79; p < 0.001). In those with trabeculations, CIC wasassociated with decreased incidence of febrile UTI (inci-dence rate ratio (IRR) 0.5, 95% CI 0.3e0.9); in thosewithout trabeculations, CICwas associatedwith increasedincidence of febrile UTI (IRR 1.8, 95% CI 1.1e3.1).

ConclusionsVUR, bladder trabeculations, EFP �40 cm H20, IV �50%of EBC, and DPIV >10 cm H2O were associated withsubsequent DMSA abnormalities in young children withSD managed expectantly. Many of these parameterswere associated with febrile UTI and early CIC. Thecombination of trabeculations and/or VUR outperformedother UD parameters in identifying those high and low-risk for adverse urologic outcomes. Routine DMSA scanmay have limited utility in patients with a non-trabeculated bladder without VUR, as none developedan abnormal DMSA. Most (71%) abnormal DMSAs were inpatients with trabeculations and/or VUR following afebrile UTI. Given these findings and that incidence offebrile UTI may be lower in those with trabeculationswhile on CIC, patients with trabeculations and/or VURshould be managed aggressively to protect kidneys.

ties for patients with trabeculations and/or VUR

ification in infants and young children with spinalrodynamic findings for predicting adverse outcomes,

Company.

inicalKey.com by Elsevier on October 10, 2018.8. Elsevier Inc. All rights reserved.

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