The Assessment of Lower Urinary Tract Function in Children with Anorectal Malformations before and after PSARP

Abstract

Background: Lower urinary tract dysfunction (LUTD) with anorectal malformations (ARM) is usually associated with sacral and spinal abnormalities and less commonly due to iatrogenic pelvic nerve damage during surgery. Posterior sagittal anorectoplasty (PSARP) is believed to have a minimal deleterious effect on lower urinary tract function. Aim: The aim of this study was to assess the effects of PSARP on lower urinary tract function by means of urodynamic studies (UDS) performed before and after the definitive surgery in patients with ARM. Materials and Methods: The study was conducted between January 2003 and July 2005, in 17 cases of ARM (high/supralevator, n = 13 and low/infralevator, n = 4). All patients were subjected to preoperative UDS and then again 6 weeks after the PSARP. The parameters observed were maximum cystometric capacity (MCC), leak point pressure or end filling pressure (LPP/EFP), uninhibited detrusor contractions (UDCs) and compliance. Results: Associated vertebral anomalies were present in 38.5 % (5 of 13) in high ARM compared with 25 % in low ARM. The incidence of preoperative lower urinary tract dysfunction in various forms was found to be 70.5 % (12 of 17 patients) and postoperatively the incidence was found to be 76.4 % (13 of 17 patients). The pre- and postoperative mean MCC, volume at P_det < 20 cm, volume at P_det < 30 cm and LPP were compared and found to be statistically not significant (p = 0.578, p = 0.551, p = 0.875 and p = 0.863, respectively). UDCs were present in 29.4 % patients (5 of 17) preoperatively and 35.3 % (6 of 17) patients postoperatively; however, only 16.6 % (2 of 12) developed fresh UDCs. The incidence of LUTD did not differ if the patient had undergone PSARP or required abdominal dissection with PSARP. All 6 patients with vertebral or sacral anomaly had LUTD. Conclusion: There seems to be a high incidence of LUTD in ARM even in the absence of clinical and radiological evidence of lower urinary tract abnormalities. In addition, it was noted that there are changes, although statistically insignificant, in the neurovesical function of these patients following PSARP.

Key words

anorectal malformations - urodynamic study - lower urinary tract dysfunction

References

• 1 Boemers T M, Bax K M, Rovekamp M H. et al . The effect of posterior sagittal anorectoplasty and its variants on lower urinary tract function in children with anorectal malformations.  J Urol. 1995;  153 191-193
• 2 Boemers T M, Beek F J, van Gool D J. et al . Urologic problems in anorectal malformation. Part 1: urodynamic findings and significance of sacral anomalies.  J Pediatr Surg. 1996;  31 407-410
• 3 Boemers T M, van Gool D J, de Jong T P. et al . Lower urinary tract dysfunction in children with benign sacrococcygeal teratoma.  J Urol. 1994;  151 174-176
• 4 Bozkurt P, Kilic N, Kaya G. et al . The effects of intranasal midazolam on urodynamic studies in children.  Brit J Urol. 1996;  78 282-286
• 5 Chang P L, Fan H A. Urodynamic studies before and/or after abdominoperineal resection of the rectum for carcinoma.  J Urol. 1983;  130 948-951
• 6 Davies M R, Cywes S, da Fonseca J M. et al . Intraoperative damage to the male urethra and pelvic visceral motor nerves during posterior sagittal anorectoplasty.  Pediatr Surg Int. 1994;  9 8-11
• 7 De Gennaro M, Rivosecchi M, Lucchetti M C. et al . The incidence of occult spinal dysraphism and the onset of neurovesical dysfunction in children with anorectal malformation.  Eur J Pediatr Surg. 1994;  4 (Suppl. 1) 12-14
• 8 Emir H, Soylet Y. Neurovesical dysfunction in patients with anorectal malformations.  Eur J Pediatr Surg. 1998;  8 95-97
• 9 Greenfield S P, Fera M. Urodynamic evaluation of the patient with an imperforate anus: a prospective study.  J Urol. 1991;  146 539-541
• 10 Holschneider A M, Kraeft H, Scholtissek C. Urodynamic investigation of bladder disturbances in imperforate anus and Hirschsprung's disease.  Z Kinderchir. 1982;  35 64-68
• 11 Kakizaki H, Nonomura K, Asano Y. et al . Preexisting neurogenic voiding dysfunction in children with imperforate anus: problems in management.  J Urol. 1994;  151 1041-1044
• 12 Kilic N, Emir H, Sander S. et al . Comparison of urodynamic investigation before and after posterior sagittal anorectoplasty for anorectal malformation.  J Pediatr Surg. 1997;  32 1724-1727
• 13 Leveckis J, Boucher N R, Parys B T. et al . Bladder and erectile dysfunction before and after rectal surgery for cancer.  Brit J Urol. 1995;  76 752-756
• 14 Mosiello G, Capitanucci M L, Gatti C. et al . How to investigate neurovesical dysfunction in children with anorectal malformations.  J Urol. 2003;  170 1610-1613
• 15 Norgaard J P, van Gool J D, Hjalmas K. et al . Standardization and definitions in lower urinary tract dysfunction in children. International Children's Continence Society.  Brit J Urology. 1998;  81 (Suppl. 3) 1-16
• 16 Pena A, Devries P A. Posterior sagittal anorectoplasty: important technical considerations and new applications.  J Pediatr Surg. 1982;  17 796-811
• 17 Sheldon C, Cormier M, Crone K. et al . Occult neurovesical dysfunction in children with imperforate anus and its variants.  J Pediatr Surg. 1991;  26 49-54
• 18 Taskinen S, Valanne L, Rintala R. Effect of spinal cord abnormalities on the function of the lower urinary tract in patients with anorectal abnormalities.  J Urol. 2002;  168 1147-1149
• 19 Tsakayannis D E, Shamberger R C. Association of imperforate anus with occult spinal dysraphism.  J Pediatr Surg. 1995;  30 1010-1012
• 20 Wiener E S, Kiesewetter W B. Urologic abnormalities associated with imperforate anus.  J Pediatr Surg. 1973;  8 151-157