Selective sacral rhizotomy in children with high pressure neurogenic bladders: preliminary results

Recent successful introduction of selective rhizotomy in the management of lower extremity spasticity in patients with myelodysplasia has prompted us to use it as a means of managing high pressure neurogenic bladders occasionally encountered in myelodysplastic patients. During the last 1 1/2 years 8 children have undergone selective sacral rhizotomy in an attempt to avert urinary diversion or bladder augmentation. Patient age ranged from 6.5 to 18.5 years. The level of the respective lesions was evenly distributed throughout the spine. At spinal surgery each patient had an electrode placed in the detrusor of the bladder via a suprapubic approach, electromyography electrodes were placed in the perineum and slow fill water cystometry was performed throughout the procedure. Standard electrophysiological stimulation of the nerve roots was performed to identify the rootlets that would only affect the detrusor and spare the external sphincter. Postoperative followup has been obtained on all patients. Of the patients 4 have exhibited significant improvement and they have not required augmentation, 2 have not shown any further deterioration in bladder function, 1 has demonstrated deterioration and 1 still lacks urodynamic followup. Postoperative cystometric studies have revealed a bladder capacity increase of 69% for the group. Uninhibited bladder contractions were abated in all but 1 patient. No patient has been rendered incontinent of urine from the procedure and no patient has had a problem with stool continence as a result of the rhizotomy. It appears that selective rhizotomy of the sacral roots has been able to increase bladder capacity as well as compliance in patients who normally would have been relegated to either bladder augmentation or urinary diversion. While these are encouraging results, some further followup is required to ascertain if the early improvements will be long-lasting.