ONE YEAR CLINICAL OUTCOMES WITH LUMBAR TO SACRAL NERVE REROUTING IN SPINA BIFIDA
Benjamin J Girdler*, Cindy Turzewski, Kevin Feber, William Nantau, Jose Gonzalez, Juan de Benito, Evan J Kass, Ananias C Diokno,
Gary Trock, Brian Bush, Kenneth M Peters, Royal Oak, MI

INTRODUCTION AND OBJECTIVE: The concept of restoring bladder function in spina bifida by the creation of a skin-CNS-bladder reflex arc by an intradural lumbar to sacral motor root microanastomosis was introduced by Xiao. Despite a reported success rate as high as 87% at one year, the procedure has not gained widespread acceptance outside of China. We report our one year experience with the novel procedure.
METHODS: Nine patients (3 males, 6 females) with median age of 8 (range 6 to 37) years qualified for the procedure following extensive preoperative evaluation. Nerve rerouting was then performed with intraoperative neurophysiological monitoring. Postoperative evaluation included neurological examination at 1 month, follow-up questionnaires and urodynamic testing including attempted stimulation of the reflex arc at 3, 6, 9 and 12 months. Ongoing patient follow-up will continue for three years.
RESULTS: Of the 9 patients, 5 patients had prior defect closure within 24 hours of birth, 3 underwent intrauterine closure and 1 had no prior surgery. Mean operative time was 183 (range 127-278) minutes. Mean EBL was 57 (range 10-100) mL. No intraoperative complications occurred. Length of stay averaged 3.4 (range 2-7) days. Perioperative complications included foot-drop in 1 patient, wound drainage in 3 patients, and prolonged inability to bear weight in 1 patient. At 1 month, neurological examination revealed major changes in gait in 2/9. 8/9 displayed variable weakness of one or more lower extremity muscle groups. 8 of 9 patients returned to or near baseline at 12 months with physical therapy and time. Interestingly, several months postop, several patients reported sudden worsening of urinary and/or fecal incontinence and/or increased sensation, then improved continence and the ability to initiate voiding. By 12 month UDTs, 7 children were able to voluntarily void a mean of 133 + 75 cc with an intermittent flow pattern and mean PVR = 119 + 125 cc. Stimulation of the appropriate dermatome caused a significant rise in detrusor pressure in 7 of 9 patients. Overall, 9/9 of patients demonstrated a reflex bladder contraction and/or the ability to initiate voiding by one year. Improvement in bowel function was reported on twelve month global assessment scores in 6 of 9 patients. 78% of patients reported that they would undergo the procedure again.
CONCLUSIONS: The ability to initiate voiding can be seen as early as 6 months after nerve rerouting. Early outcomes are associated with significant lower extremity complications that largely improve with physical therapy and time.
Source of Funding: Ministrelli Program For Urology Research and Education (mpUre)