[Decisional criteria in the management of vesico-ureteral reflux in children with congenital neurogenic bladder].

OBJECTIVES

To determine, in the particular case of neurogenic bladder, the best criteria for selection and grading of the modalities available for the treatment of vesicoureteric reflux, which is often associated.

METHODS

194 patients with congenital neurogenic bladder, including 76 cases with vesicoureteric reflux were retrospectively reviewed. The various treatments applied, their results and their complications were reviewed. Conclusions are drawn and proposals are made for the optimal management of vesicoureteric reflux in the particular context of congenital neurogenic bladder.

RESULTS

This series included 8 grade I, 28 grade II, 49 grade III and 23 grade IV and V. In more than 50% of cases, reflux was detected on during routine assessment of congenital neurogenic bladder, demonstrating the value of this assessment (25% of cases of reflux were detected before the age of one year). Management initially consisted of vesical drainage, often by intermittent catheterization, from the age of 2 to 3 years and antibiotic prophylaxis. This treatment was sufficient to correct reflux in 9 cases and to control it in 16 cases (no urinary tract infection, no deterioration of the upper tract). An elective anti-reflux operation was decided in 69 cases of VUR (1 grade I, 15 grade II, 38 grade III, 16 grade IV or V). Cohen's technique was performed in 3 cases and endoscopic injection of PTFE was performed in 3 cases. Most of these refluxing bladders were hypertonic and/or presented an abnormally high closing pressure. The operative criteria were: symptomatic reflux; persistent reflux; renal deterioration; non-compliance with treatment. Several complications were observed and are described.

CONCLUSION

Vesicoureteric reflux in the context of congenital neurogenic bladder plays a major role in the deterioration of renal function. These forms of reflux usually occur in hypertonic bladders. Urodynamic studies appear essential before deciding treatment. Intermittent catheterization is able to control or even correct a certain number of these cases of reflux and should be introduced by the age of 2 or 3 years. When surgery is required, Cohen's operation is the easiest to perform, but is associated with an increased complication rate. Injection of PTFE or macroplastic could constitute a good indication.