Ilona Alova

Poor compliance with primary nocturnal enuresis therapy may contribute to insufficient desmopressin response.

PURPOSE Studies of desmopressin in children with primary nocturnal enuresis show a greater than 90% decrease in wet nights in 20% to 30%, a 50% to less than 90% decrease in 20% to 40% and less than a 50% decrease in up to 60%. Insufficient response to desmopressin is attributable to various factors, including differences in the primary nocturnal enuresis definition, underlying bladder dysfunction and/or desmopressin pharmacokinetic characteristics. However, little attention has been given to poor compliance with therapy as a possible explanatory factor. For a drug with an effect duration limited to the night after administration a high degree of compliance is essential to ensure consistent therapeutic effects. MATERIALS AND METHODS This was a substudy of an international investigation of treatment for 6 months or less with desmopressin tablets in children with primary nocturnal enuresis. Medication was dispensed at each visit as required and collected at each subsequent visit. Compliance was determined by pill counts by study staff. RESULTS Compliance data were available on 723 patients. Of the patients 81% to 91% ingested all medication as instructed during the initial run-in phases. However, this decreased to 77% and 71% during the first and second 3-month treatment periods, respectively. CONCLUSIONS Patient motivation and compliance are generally stronger in clinical trials than in clinical practice. However, this study shows that some patients were poorly compliant with medication even at study initiation and only 71% were fully compliant with long-term treatment. Decreased compliance was associated with a lower response rate. Patients should be encouraged to comply fully with treatment to achieve an optimal outcome.

Long-Term Effects of Endoscopic Injection of Dextranomer/Hyaluronic Acid Based Implants for Treatment of Urinary Incontinence in Children with Neurogenic Bladder

PURPOSE We prospectively evaluated the efficacy of dextranomer/hyaluronic acid based implants for the endoscopic treatment of neurogenic urinary incontinence. MATERIALS AND METHODS We prospectively studied patients undergoing endoscopic injection of dextranomer/hyaluronic acid for structural incontinence beginning in October 1997. Preoperative evaluation consisted of medical history, incontinence charts, urine culture, urinary tract ultrasound and videourodynamics, which were repeated regularly during followup. At each evaluation patients were classified as cured or significantly improved (treatment success), or not significantly improved (treatment failure). Followup ranged from 1 to 13 years (mean 7.4). RESULTS A total of 48 patients 5 to 20 years old with congenital (45 patients) or acquired (3) neurogenic bladder suffering from severe sphincteric incompetence were included. Of the patients 30 underwent 1, 13 underwent 2 and 5 underwent 3 treatment sessions. Mean injected volume was 4.6 ml per session. Five patients had previously undergone bladder neck surgery. Two patients lost to followup in the short term were classified as treatment failures. Of the patients 45 had more than 2 years of followup, of whom 19 (39.6%) were dry, 6 (12.5%) were significantly improved and 23 (47.9%) had no significant improvement observed. Female patients achieved a significantly higher success rate than males (p = 0.05). No significant clinical or urodynamic criterion was predictive of success or failure. Posttreatment bladder deterioration developed in 10 cases (7 successes and 3 failures), which were managed by bladder augmentation. CONCLUSIONS Endoscopic treatment of neurogenic urinary sphincter insufficiency with dextranomer/hyaluronic acid is effective in half of the patients. Recurrence of incontinence after 1 year is mainly a sign of bladder deterioration.

Impact of spinal dysraphism on urinary and faecal prognosis in 25 cases of cloacal malformation

OBJECTIVE Urinary and faecal continence are key challenges goal of cloacal malformation management. Most well-known prognostic factors are the length of common channel (CC) and the presence of a sacral defect, but the impact of associated spinal dysraphism is less well documented. The aim of this study was to investigate the impact of different types of dysraphism on urinary and faecal continence in this patient population. MATERIALS AND METHODS From 1991 to 2011, charts and office notes of 25 patients with cloacal malformation were retrospectively reviewed. At last clinic visit, urinary and faecal continence status according to Krickenbeck criteria were correlated with the length of CC, the presence of a sacral defect (sacral ratio), and the presence of different types of spinal cord dysraphism using magnetic resonance imaging (MRI) and Fishers exact test. RESULTS Mean follow-up was 8 years (4 months-21 years). The sacral ratio was abnormal (below 0.74) in 18 cases out of 25 (72%). MRI review showed normal spinal cord in eight out of 23 cases (Group 1), spinal cord anomaly in 15 out of 23 cases (65%) including nine cases of tethered cord complex (Group 2) and six cases of a short spinal cord (Group 3). While statistical analysis showed a difference regarding urinary prognosis between the groups (p=0.005), no significant difference was found regarding faecal prognosis. None of the six patients with short spinal cord were continent for both urinary and faecal prognosis. CONCLUSIONS This is the first study, which highlights the impact of different types of spinal dysraphism on functional outcome in patients with cloaca. Short spinal cord seemed to carry the worst prognosis. A prospective study with a larger series is mandatory to confirm these preliminary results.

Malformations ano-rectales

Resume Les malformations ano-rectales (MAR) sont la consequence d’anomalies du developpement de la partie terminale du tube digestif interessant l’anus et/ou le rectum qui surviennent precocement entre la 6e et la 10e semaines de developpement embryonnaire. Elles realisent un spectre malformatif dont la severite est fonction du niveau d’interruption du conduit ano-rectal et des malformations caudales associees (sacrum et cone terminal de la moelle). Les MAR s’associent dans plus de la moitie des cas a d’autres malformations pouvant s’integrer dans des syndromes connus. Si le traitement chirurgical permettant de restaurer une anatomie aussi proche que possible de la normale est essentiel, la prise en charge postoperatoire est tout aussi fondamentale pour obtenir chez ces patients, dont les mecanismes defecatoires sont toujours alteres, sinon une continence, au moins une proprete socialement acceptable.

CL137 - Devenir des patients après échec de traitement endoscopique d’incontinence

Les resultats de la chirurgie du col vesical apres echec de traitement endoscopique d’incontinence par implants de dextranomeres (Deflux ® ) n’ont pas ete evalue a ce jour 86 patients ont recu une a trois injections endoscopiques cervicales de dextranomer pour incontinence severe. Le traitement a echoue chez 41 patients (47,7 %) : deux garcons sont devenus continents a la puberte, 17 patients sont perdus de vue (6)ou en attente d’un traitement complementaire (11). 22 patients ont eu un geste complementaire sur le col : 7 sphincters artificiels, 8 plasties du col, 3 frondes peri cervicales et 6 injections iteratives (dont deux apres plastie du col). Lors des interventions, les implants de dextranomere ont ete aisement identifies avec une reaction inflammatoire locale moderee. 17 patients sont secs (15) ou significativement ameliores (2 : continence sociale satisfaisante) et 5 sont des echecs (dont 4 traitement endoscopiques iteratifs). Les injections endoscopiques de Dextranomer dans le col vesical ne paraissent pas compliquer significativement, ni compromettre les chances de succes d’une chirurgie ulterieure. Quand un traitement endoscopique a echoue apres une a trois sessions, les chances de succes d’injections ulterieures sont tres faibles.

CL114 - Rôle de l’oxybutinine dans la prise en charge du reflux vesico ureteral (RVU) du nourrisson

Il a ete rapporte que l’hyperactivite du detrusor est frequemment associee au RVU du nourrisson. L’oxybutinine n’a jamais ete evaluee dans ce contexte. 28 nourrissons avec RVU symptomatique ont eu une etude urodynamique. Une hyperactivite (contraction de 15cm d’H20) a ete observee chez 23 (12 filles et 11 garcons, de deux semaines a quatre mois). Tous ont recu une antibioprophylaxie et de l’oxybutinine (0,1-0,2 mg/kg/jour) pendant une moyenne de 6,5mois (2-18). Des cystomanometries ont ete repetees tous les deux a six mois (2,6 etudes par patient). Le traitement a ete bien tolere par tous les patients Le reflux a disparu chez 6 patients (3 garcons, 3filles). Chez les autres, l’hyperactivite a disparu sous oybutinine avec diminution de la pression du detrusor. Sous traitement un seul enfant a eu une recidive de pyelonephrite et a ete opere; deux autres ont ete operes pour reflux de haut grade persistant malgre normalisation de la fonction vesicale. 12 enfants ont ete suivis cliniquement au moins deux ans et deux ont ete perdus de vue. Cette etude non controlee confirme la frequence de l’hyperactivite du detrusor associee au reflux symptomatique du nourrisson. A l’heure ou l’interet de l’antibioprophylaxie est remis en cause, le role de la gestion du dysfonctionnement vesical reste a evaluer.

P371 - Durabilité du taux de continence obtenu avec des implants de dextranomer pour l’incontinence sévère de l’enfant : étude de 86 patients

Des taux de guerison ou d’amelioration significative a 18 mois de suivi chez environ 50% des enfants traites par injection endoscopique ont ete publies. Cette etude evalue la durabilite de ce resultat. 86 patients (3-18 ans) souffrant d’insuffisance sphincterienne severe (exstrophie-epispadias 33, vessie neurologique 44, ureteres ectopiques bilateraux 5, divers 4) ont ete traites et suivis en moyenne 60 mois (18mois-12ans). Un tiers avait eu un echec de chirurgie prealable sur le col. Bilan initial : questionnaire sur l’incontinence, ecbu, echographie de l’arbre urinaire et bilan video urodynamique. Cette evaluation a ete repetee six mois puis un an apres traitement et ensuite annuellement. 25 patients ont eu deux et 13 trois series d’injections. A chaque evaluation, le patient est classe comme sec(interval de secheresse d’au moins quatre heures), significativement ameliore (incontinence mineure; pas d’autre traitement) et echec. 32 (37,2 %) secs, 13 (15,1 %) significativement ameliores, et 41 (47,7 %) echecs. 2 patients epispades mâles sont devenus secs a la puberte, deux filles sont redevenues incontinentes. Tous les autres patients sont restes stables. Notre etude confirme une efficacite des traitements endoscopiques d’incontinence chez 50 % des patients a long terme.