Long-term Follow-up of Spinal Cord Injured Patients with Vesicoureteral Reflux
Keywords:spinal cord injuries, vesico-ureteral reflux, hydronephrosis, urodynamics, long-term outcome
Objectives: to investigate the management of VUR, outcomes after treatment and factors associated with VUR outcomes in SCI patients.
Study design: Retrospective data collection
Setting: Maharat Nakhon Ratchasima Hospital
Subjects: Spinal cord injured patients admitted to the Rehabilitation ward between August 2008 and July 2019.
Methods: The medical records of 59 spinal cord injured (SCI) patients with 81 vesicoureteral reflexes (VUR) admitted to our hospital between August 2008 and July 2019 with minimum one-year follow-up were reviewed retrospectively. General demo- graphics, urological information, including bladder management, medications, urodynamic studies, eGFR, UTI, calculi and imaging, including hydronephrosis, bladder deformity and VUR grading, were investigated. Grading of VUR during follow-up were compared to the initial assessment and classified into good (transient or improved) vs poor (stable or progress) outcomes. Bivariate analysis was performed to examine an association between urological variables and good or poor outcomes.
Results: The majority of VUR (83%) developed within 4 years after SCI. Before VUR was detected, only 23.7% of the patients received antimuscarinic medication and the most common bladder management was indwelling catheterization (69.5%). Management post-VUR included indwelling catheterization (83.1%), antimuscarinics (98.3%) and antibiotics (72.7%). VUR outcomes were noted to be transient in 23.7%, improved in 30.5%, stable in 18.6%, and progressive in 27.1%. One patient had eGFR that revealed CKD stage 5 which needed hemodialysis. Three patients had impaired renal function assessed by renal scan. Follow-up VUR was categorized into 2 groups (good vs poor outcomes). Patients with low bladder compliance showed a significant association with poor outcome. High detrusor pressure (Pdet > 40 cmH2O) tended to have poor outcome but did not reach statistical significance. Indwelling catheterization and antibiotic prophylaxis for management of VUR did not show a significant difference in outcomes.
Conclusion: VUR remains an important complication in SCIpatients, leading to upper urinary tract deterioration. About half of VUR patients improved after conservative treatment. Bladder compliance was a factor associated with VUR outcome. Indwelling catheterization or antibiotic prophylaxis did not prevent progression of VUR. Early urological management and regular urological evaluation should be performed in SCI patients.
Bors E, Comarr AE. Vesicoureteric reflux in paraplegic patients. J Urol. 1952;68:691-8.
Hutch JA. Vesico-ureteral reflux in the paraplegic: cause and correction. J Urol. 1952;68:457-67.
Blais AS, Bolduc S, Moore K. Vesicoureteral reflux: from prophylaxis to surgery. Can Urol Assoc J. 2017;11:S13-8.
Hoberman A, Greenfield SP, Mattoo TK, Karen R, Mathews R, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Eng J Med. 2014;370:2367-76.
American Urological Association pediatric vesicoureteral reflux clinical guideline panel. Management and screening of primary versicoureteral reflux in children: AUA guideline. Baltimore: American Urological Association, 2010.
Lamid S. Long-term follow-up of spinal cord injury patients with vesicoureteral reflux. Paraplegia. 1988;26:27-34.
Fellows GJ, Silver JR. Long-term follow-up of paraplegic patients with vesico-ureteric reflux. Paraplegia. 1976;14:130-4.
Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A, Ronfani L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized controlled trial. Pediatrics. 2008;121:1489-94.
Conway PH, Cnaan A, Zaoutis T, Henry BV, Grundmeier RW, Keren R.Recurrent urinary tract infections in children:risk factors and association with prophylactic antimicrobials. JAMA. 2007; 298:179-86.
Thongchim C, Tamnanthong N, Arayawichanont P. Prevalence of vesicoureteric reflex in neurogenic bladder dysfunction patients from spinal cord lesion. J Thai Rehabil Med. 2010;20:52-7.
Teeraleekul W. Vesicoureteric reflux in patients with spinal cord lesion at Sappasitthiprasong Hospital. Mahasarakham Hosp J. 2010;7:48-52.
Suksathien R, Ingkasuthi K, Bumrungna S. Factors associated with hydronephtosis and vesicoureteral reflux in spinal cord injured patients. ASEAN J Rehabil Med. 2019;29:51-7.
Hu HZ, Granger N, Jeffery ND. Pathophysiology, clinical importance, and management of neurogenic lower urinary tract dysfunction caused by suprasacral spinal cord injury. J Vet Intern Med. 2016;30:1575-88.
Itzkovich M, Gelernter I, Biering-Sorensen F, Weeks C, Laramee MT, Craven BC, et al. The spinal cord independence measure (SCIM) version III: reliability and validity in a multi-center international study. Disabil Rehabil. 2007;29:1926-33.
Pannek J, Kennelly M, Kessler TM, Linsenmeyer T, Wyndaele JJ, Biering-Sorensen F. International spinal cord injury urodynamic basic data set (version 2.0). Spinal Cord Ser Cases. 2018;4:98-102.
Kaplan SA, Blaivas JG, Breuer A. Urogenital physiology. In: Downey JA, Myers SJ, Gonzalez EG, Lieberman JS, editors. The physiological basis of rehabilitation medicine. Boston: Butterworth-Heinemann; 1994. p. 501-17.
Musco S, Padilla-Fernández B, Del Popolo G, Bonifazi M, Blok BFM, Groen J, et al. Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: a systematic review. Neurourol Urodyn. 2018;37:1522-40.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group 2012. KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:1-150.
Report of the International Reflux Study Committee. Medical versussurgical treatment of primary vesicoureteral reflux. Pediatrics. 1981;67:392-400.
Ogawa T. Bladder deformities in patients with neurogenic bladder dysfunction. Urol Int. 1991;47:59-62.
Kavanagh A, Baverstock R, Campeau L, Carlson K, Cox A, Hickling D. Canadian urological association guideline: diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction. Can Urol Assoc J. 2019;13:E57-76.
Foley SJ, Mcfarlane JP, Shah PJ. Vesico-ureteral reflux in adult patients with spinal injury. Br J Urol. 1997;79:888-91.
Cho SY, Yi JS, Oh SJ. The clinical significance of poor bladder compliance. Neurourol Urodyn. 2009;28:1010-4.
Lee JS, Koo BI, Shin MJ, Chang JH, Kim SY, Ko HY. Differences in urodynamic variables for vesicoureteral reflux depending on the neurogenic bladder type. Ann Rehabil Med. 2014;38:347-52.
Linsenmaeyer TA, Hause JG, Millis SR. The role of abnormal congenitally displaced ureteral orifices in causing reflux following spinal cord injury. J Spinal Cord Med. 2004;27:116-9.
Wu CQ, Franco I. Management of vesicoureteral reflux in neurogenic bladder. Investig Clin Urol. 2017;58:54-8.
Çelebi S, Özaydin S, Baştaş CB, Kuzdan Ö, Erdoğan C,Yazici M, et al. Reliability of the grading system for voiding cystourethrograms in the management of vesicoureteral reflux: an interrater comparison. Adv Urol. 2016;5:1-4.
Gao Y, Danforth T, Ginsberg DA. Urologic management and complications in spinal cord injury patients: a 40- to 50-year follow-up study. Urology. 2017;104:52-8.
Afsar SI, Sarifakioglu B, Yalbuzdağ ŞA, Saraçgil Coşar SN. An unresolved relationship: the relationship between lesion severity and neurogenic bladder in patients with spinal cord injury. J Spinal Cord Med. 2016;39:93-8.