the term  neurogenic bladder  ( nb ) is employed to describe any disturbance of the bladder - sphincter system caused by or associated to alteration of bladder innervation and of the muscles of the pelvic floor . among several etiologies , it includes myelomeningocele , spinal cord injury , myelitis , multiple sclerosis and several other conditions that can reduce bladder capacity and compliance ( 1 ) . bladder neurological alterations are therapeutically challenging , due to high risk of renal failure ( 24 ) . renal failure is the main cause of death among patients with myelomeningocele in all ages ( 5 ) . nb treatment is intended to protect the superior renal tract , to promote urinary continence and , when possible , to preserve micturition . when conservative measures , such as clean intermittent catheterization , the use of anticholinergic drugs and intravesical injection of botulin toxin are insufficient , surgical treatment is indicated ( 6 ) . although most care centers use bladder augmentation as the primary choice of treatment , cystectomy and ileal conduit are also satisfactory for those patients ( 7 ) . evaluation of quality of life ( qol ) of patients with nb should always be part of the evaluation of symptoms and follow - up of results of treatments , as observed in other chronic and debilitating conditions ( 8 , 9 ) . measurement of qol is a fundamental parameter of treatment evaluation , since it allows for a multidimensional understanding of the patient 's life , including physical , mental , emotional and social well - being . the perspective of deterioration of renal function is an important source of psychological stress , anxiety and reduction of qol of patients with nb . despite this , few articles evaluate the impact of surgical treatment on qol of patients with nb . in literature , there are contradictory results in different casuistries ( 7 , 1013 ) . the objective of the present study was to evaluate qol before and after reconstructive urological surgeries preserving the bladder in patients with nb refractory to clinical treatment . from 2008 to 2012 , 67 patients with nb refractory to clinical treatment decided to participate in a study previously approved by the ethical and research committee and were submitted to bladder augmentation and to eventual complementary procedures by the same surgeon ; there were 22 female patients ( 32.8% ) and 45 male patients ( 67.2% ) , with a median age of 29.51.7 years . nb etiology included spinal cord injury ( n=33 ; 49.0% ) , myelomeningocele ( n=24 ; 35.8% ) and myelitis ( n=10 ; 15.2% ) . refractory clinical treatment was stablished when it was observed incapacity to control intravesical pressure , associated or not to deterioration of renal function and to urinary incontinence , using anticholinergic drugs , clean bladder catheterization and intravesical injection of botulin toxin , exclusion criteria included non - acceptance of participation of the study ( two patients ) . after hospital discharge , patients were followed weekly during the first two months and monthly after six months of surgery . prospectively , the data from the generic questionnaire about qol short form health survey ( sf-36 ) were analyzed . also , 36 patients answered the specific questionnaire for qol qualiveen. the question forms were completed in the ambulatory and were supervised by the physician that performed the surgeries . the pre and post - operatory data were statistically analyzed by the softwares r , version 2.7.1 and epi info version 6.04 . parametric data were analyzed by paired - t test and non - parametric data by wilcoxon test . for bladder augmentation it was utilized the distal ileum ( n=56 ; 83.6% ) , sigmoid colon ( n=8 ; 11.9% ) and stomach ( n=3 ; 4.5% ) . in 14 patients some complementary procedures were performed : cutaneous apendico - vesicostomy ( n=7 ) , continent cutaneous ileo - vesicostomy ( yang - monti technique ) ( n=2 ) ( 16 ) , unilateral ureteral reimplantation ( n=4 ) and cutaneous apendicostomy ( malone technique ) ( n=1 ) ( 17 ) . all patients were continent after 6 months of bladder augmentation surgery . in spite of the magnitude of the surgery , only prolonged ileum delayed hospital discharge in some cases . routinely , a cystostomy catheter was maintained for one week and through it it was instilled a mucolytic solution , preventing urinary obstruction ( retention ) by mucus . during the 6 months period of follow - up , there were no episodes of urinary tract infection or surgical wound infection , as well as no clinical metabolic disturbances . according to the analysis of the sf-36 questionnaire ( table-1 ) , patients presented higher qol at post - operatory period in the domains functional capacity , general health status , vitality , social aspects , emotional aspects and mental health . ureteral reimplantation was performed in 4 patients with grades iv and v vesico - ureteral reflux in order to protect the superior renal tract . cases with grades i and ii reflux were not surgically corrected due to low correlation with renal failure , following amelioration of bladder capacity ( 9 ) . the choice of gastrointestinal segment was based upon renal function and easiness of technique , in order to move the chosen segment to bladder without tension . three cases of gastro - cystoplasty were performed in patients with limited renal function , that contraindicated the use of ileum or colon , due to absorptive capacity of intestinal mucosa . = pontuaction limit from 0 to 100 ; = wilcoxon test values expressed as medianstandard deviation = ponctuation limit from 0 - 4 ; = ponctuation limites from-2 to+2 ; = wilcoxon test values expressed as medianstandard deviation the generic question form sf-36 presented higher indexes of qol at the post - operatory period in all domains , except physical limitation and pain . the use of a specific questionnaire for patients with spinal cord injury ( qualiveen ) completed the qol evaluation , since generic question forms may not correctly reflect important aspects of physical , social and psychological well - being of these individuals ( 8) . we started the use of ( qualiveen ) only for the last 36 patients , since it was not included in the original project . since this was a prospective study , the data of the initial patients could not be analyzed . also , the results of ( qualiveen ) showed lower impact on qol in all studied domains during post - operatory period . the generic evaluation of qol included in this instrument was in accordance to the previous relative positive effect of the surgical treatment . it is important to stress the heterogeneity of the present data in terms of baseline diseases and their evolution period , that varied from a few years ( patients with spinal cord injury and myelites ) , to lifetime ( patients with myelomeningoceles ) . forms of treatment also varied , in terms of the chosen gastrointestinal segment and of the need of the construction of continent conduits for catheterization . however , in order to unify the samples , bladder augmentation surgery was performed as primary surgical procedure and all patients presented bladder disturbances , including low compliance , elevated pressures and low capacity of storage . although there were differences , better quality of life was observed in all individuals , even in those without urinary incontinence in the pre - operatory period . these aspects corroborate the perception that health status is benefitted by reconstructive urological surgeries with bladder preservation . probably , there was better urinary continence during catheterization intervals , since this is a troublesome alteration in all patients . urinary continence probably benefitted secondarily social life and allowed for the performance of daily activities , as noted by the questionnaires . patients submitted to continent conduit for catheterization were able to empty more easily their bladder , with a better qol , since the difficulty during pre - operatory period to catheterize was corrected . interval spaces between catheterization were corrected allowing for the avoidance of urinary leakage . the absence of alteration of the sf0360 domains physical limitation and pain after surgery is predictable , since the surgical procedures were directed to the urinary tract problems . qol improvement during post - operatory period in patients with nb refractory to clinical treatment was also observed in previous studies ( 7 , 13 ) . although this correlation seems obvious , the absence of qv improvement following surgeries for urinary incontinence of patients with nb was also published ( 12 ) . since qol is a concept that includes social , psychological and physical aspects , different populations can experience these aspects differently , and it is important to perform studies in different centers ( 12 ) . although cystectomy and ileum conduit also present good results in terms of qol ( 7 ) , this technique present long term clinical risks , such as renal failure , and has been deprecated by most authors ( 19 ) . bladder augmentation associated to other techniques of urological reconstruction remains an excellent choice for nb patients , although without side effects as the presence of mucus in the urine and the need of intermittent catheterization ( 20 ) . being less aggressive and without an incontinent abdominal stoma , it is preferred in relation to cystectomy . future studies may discriminate better the implied factors related to qol improvement in patients submitted to reconstructive urological surgeries and contribute to better choice of therapies for this complex condition . surgical treatment of nb refractory to clinical treatment using reconstructive techniques in order to preserve the bladder is associated with improvement of qol indexes at post - operatory period , according to the sf-36 and qualiveen questionnaires .
abstracttreatment of neurogenic bladder ( bn ) aims to upper urinary tract protection . 
 when the conservative clinical measures are insufficient , surgical treatment is indicated . 
 though admittedly important , the quality of life ( qol ) has been little studied in these patients , there are even contradictory results . 
 the aim of this study was to evaluate qol before and after bladder augmentation in patients with bn refractory to medical treatment . 
 we analyzed , prospectively , the data of 67 patients who underwent surgical treatment for bn by questionnaire sf-36 and qualiveen qol before and after six months of operation . comparisons using paired t - tests and wilcoxon and the assumption of normality was assessed using the shapiro - wilk test were made . according to the analysis of the sf-36 questionnaire , the patients had higher qol indices in the postoperative period in the areas functional capacity , general state of health , vitality , social aspects , emotional aspects and mental health ( n = 67 ; p < 0.05 ) . 
 the questionnaire also revealed qualiveen best result in quality of life index in the postoperative period , and show lower specific negative impact by urinary problems ( n = 36 ; p < 0.05 ) . 
 the results show that , despite not being the main objective , the bladder augmentation results in significant improvement in qol , probably related to the perception of better health and the resolution of urinary incontinence . 
 thus , the bladder augmentation associated with other urologic reconstruction techniques allows the upper urinary tract protection , and contribute to a better quality of life of patients with bn .