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Management of children with myelodysplasia: urological alternatives
A G Klose1, C K Sackett, H G Mesrobian
1Section of Pediatric Urology, University of North Carolina School of Medicine, Chapel Hill.
Insights
Clean intermittent catheterization effectively reversed upper urinary tract deterioration in infants with myelodysplasia. This treatment, often combined with medication, showed high success rates, validating its use when deterioration is detected.
Area of Science:
- Pediatric Urology
- Nephrology
- Neurology
Background:
- Infants with myelodysplasia are at risk for upper urinary tract deterioration.
- Urodynamic criteria are used to select patients for intervention.
- Clean intermittent catheterization (CIC) is a potential prophylactic treatment.
Purpose of the Study:
- To review the effectiveness of CIC initiated upon detection of upper tract deterioration in myelodysplasia patients.
- To evaluate treatment outcomes in patients with vesicoureteral reflux and hydronephrosis.
Main Methods:
- Retrospective review of 130 myelodysplasia patients.
- Analysis of 25 patients with radiological upper urinary tract deterioration.
- Treatment included CIC alone, CIC with anticholinergic medication, or observation.
- Selective urodynamic evaluation was performed.
Main Results:
- 92% overall resolution or improvement rate of upper tract deterioration.
- 19 of 21 patients (90%) with vesicoureteral reflux showed resolution or improvement.
- Hydronephrosis resolved completely in 4 patients without reflux.
- Average follow-up was 41-47 months.
Conclusions:
- CIC instituted upon finding upper tract deterioration is highly effective in reversal.
- Current urodynamic criteria may lead to over-treatment; refinements are needed.
- Urethral dilation is a viable alternative for preventing upper tract deterioration.
Abstract:
Recent reports have suggested that the prophylactic use of clean intermittent catheterization in selected infants with myelodysplasia and with normal upper tracts may prevent their deterioration. The selection of these patients at risk depends on urodynamic criteria. We reviewed our experience with clean intermittent catheterization instituted when upper tract deterioration was found. Of 130 patients with myelodysplasia followed at our clinic 25 (19%) had or presented with radiological upper urinary tract deterioration. A total of 21 patients had vesicoureteral reflux and 4 had hydronephrosis without reflux. Treatment consisted of clean intermittent catheterization alone in 5 patients and combined with anticholinergic medication in 16. Four patients with no post-void residual urine were carefully observed without intervention. Urodynamic evaluation was performed selectively in 11 of these 25 patients for persistence of upper urinary tract deterioration or urinary incontinence after institution of treatment. Of the 21 children with reflux 19 (90%) had resolution or improvement for an average followup of 47 months. Hydronephrosis completely resolved in the 4 patients without reflux. Thus, the over-all resolution or improvement rate was 92% for an average of 41 months. Although these excellent results may not be superior to the prophylactic use of clean intermittent catheterization, they validate the assumption that upper tract deterioration can be reversed. The application of current urodynamic selection criteria may result in overtreating a significant number of infants who otherwise may not have upper tract deterioration. Further refinements in these criteria may be necessary to select better not only patients at risk but also to determine the frequency of imaging necessary in this urologically heterogeneous population. In addition, careful consideration should be given to urethral dilation as a third and equally viable alternative to prevent upper tract deterioration.