Introduction: Optimal urologic management for infants with spina bifida remains unclear. Since the goal of early UDS is to identify those at risk for upper tract injury, the Urologic Management to Preserve Initial Renal Function (UMPIRE) protocol calls for routine urodynamics (UDS) by 3 months old and annually for 5 years. However, pediatric UDS can be fraught for patients and families. We evaluate the utility of routine UDS in this retrospective study of children with spina bifida.
Methods: We included all infants with lipo- or myelomeningocele from 2015 - 2020. We recorded all ultrasound, voiding cystourethrogram (VCUG), and UDS results from birth to 3 years old per the UMPIRE protocol. Given poor inter-rater reliability in reading detrusor sphincter dyssynergia, we defined hostility on UDS as an end fill pressure > 40 cm H2O in the absence of a detrusor contraction. Upper tract changes (UTC) were defined as any bilateral increase of = 1 in Society of Fetal Urology (SFU) grade or unilateral increase of = 2 in grade on either ultrasound or VCUG. Urinary tract infection (UTI) was defined as symptoms (fever or lower urinary tract symptoms), > 100,000 cfu/mL of a single organism and > 10 WBCs/hpf. We then determined if hostile UDS findings preceded UTC or UTI from birth to 3 years old. Fisher’s exact test was used to test the association between hostility on UDS and UTC or UTI.
Results: Twenty-seven infants were included; demographic, imaging and UDS findings are shown in the Table. In the first 3 years of life, 2 patients (7%) developed hostility on UDS while one had hostility from birth. Nine patients (33%) had a UTI, and 3 were febrile. Nine patients (33%) developed changes on RBUS, including 4 with new bilateral grade 2 or 3 hydronephrosis. Two patients (7%) developed bilateral VUR, 1 with bilateral grade 4 reflux. Of 16 patients (57%) with UTI or UTC, 15 (94%) did not have preceding hostile changes on UDS. Hostile UDS results, either evident initially or in the interval, were not significantly associated with UTC or UTI (p=0.57, p=0.24, respectively). Four patients who did not have routine UDS never had UTC or UTI.
Conclusions: Routine UDS in the first 3 years of life did not predict development of UTC or UTI; even if hostile UDS patterns are observed, UTC or UTI may not occur. Further studies are needed to more precisely identify the subset of spina bifida children, if any, who benefit from routine UDS testing after birth.
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