Metabolic factors in the causation of urinary tract stones in patients with enterocystoplasties

Long-term complications and outcomes of augmentation cystoplasty in children with neurogenic bladder

Augmentation cystoplasty (AC) is an effective surgical procedure for patients with neurogenic bladder whenever conservative treatments have failed. The present study aimed to determine the risks of metabolic complications, malignancy, long-term outcomes and histopathologic changes of native bladder and the augmented intestine after AC in children with neurogenic bladder. Pediatric patients < 18 years who underwent AC between 2000 and 2020 were enrolled. Early postoperative complications, long-term outcomes and histopathologic changes in mucosal biopsies of native bladder and the augmented intestine after AC were reviewed. Twenty-two patients with a mean age of 7.6 ± 4.4 years were included. The ileum was used in 19 patients and the sigmoid colon in 3 patients. The length of hospital stay was 14.8 ± 6.8 days. Post-operatively, the urinary continence rate improved from 22.7 to 81.8% (p < 0.001). Hydronephrosis resolved in 17 of 19 patients. Vesicoureteral reflux resolved in 16 (64.0%) of the refluxing ureter units and was downgraded in 7 (28.0%). Grades of hydronephrosis and reflux significantly improved following AC (p < 0.001). The estimated glomerular filtration rate also significantly increased (p = 0.012). Formation of urinary tract stones was the most frequent late complication (in 8 patients, 36.4%). Life-threatening spontaneous bladder perforation occurred in 1 patient. After a mean follow-up of 13.4 ± 5.9 years, there were no cases of mortality, new-onset symptomatic metabolic acidosis, or changes in serum electrolytes. Of the 17 patients who were followed for > 10 years, no cases of malignancy or metaplastic changes were identified in the native bladder or augmented bowel epithelium. AC is a safe and effective procedure with low surgical and metabolic complication rates. In addition, AC provides a satisfactory continence rate and long-term protection of renal function, increases functional capacity, and regresses reflux and hydronephrosis. Individualized surveillance is recommended for the early identification of urolithiasis and metabolic disturbances.

Complication profile of augmentation cystoplasty in contemporary paediatric urology: a 20-year review

BACKGROUND

The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics.

METHODS

Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined.

RESULTS

Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH₂ O, P < 0.001). Bladder capacity improved significantly (67-89%, P = 0.041). The median follow-up was 4.5 years (interquartile range: 1.9-10 years). Bladder urolithiasis affected 13 (18%) patients, and symptomatic urinary tract infections 36 (51%) patients. Formation of a continent catheterisable channel contributed a number of complications relating predominantly to stenosis (50%). Repeat augmentation cystoplasty was necessary in three (4%) cases.

CONCLUSION

Augmentation cystoplasty is a surgical intervention that improves bladder metrics. Given the potential complications, careful patient selection and appropriate pre-operative counselling are essential. Furthermore, pro-active post-operative management and transitional care are vital in the surgical care of children following augmentation cystoplasty.

Bladder Augmentation (Enterocystoplasty): the Current State of a Historic Operation

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of enterocystoplasty, a historical operation for bladder dysfunction but with continued and increasing modern relevance.

RECENT FINDINGS

Since the advent of third line neuromodulation techniques for neurogenic and idiopathic overactive bladder (OAB), the usage of enterocystoplasty has decreased. However, this procedure continues to be utilized in pediatric urology patients and the most refractory OAB patients. Adult urologist should be familiar with this operative technique in an effort to manage pediatric patients transitioning to adulthood. Minimally invasive techniques for this surgical procedure have been described with very limited outcome data. It is important for all urologists to be familiar with enterocystoplasty, both technically and with the unique needs of these patients postoperatively. Further studies evaluating the outcomes of this procedure in idiopathic overactive bladder patients and efforts to standardize recommendations for neurogenic bladder patients will help guide care in the future.

Giant vesical lithiasis, complication of enterocystoplasty: case report

Frequent and recurrent pathology, bladder stone is a constant complication in enterocystoplasty enlargement. The occurrence of this lithiasis is due to some factors such as urinary tract infections, mucus secretion by the intestine segment moved, poor urinary emptying and foreign bodies (sutures, staples) intra-vesical. Clinical signs are not specific. However the formation of giant lithiases remains exceptional. Some cases have been documented in the literature. The occurrence of this affection must be prevented by dietary measures and regular follow up. New therapies for the control of mucus in the bladder tank have been emerged. Open surgical remains the most common. Today, One port trocar endoscopy enables to handle and extracted lithiases of every size.

Pelvic Organ Prolapse and Pregnancy in the Female Bladder Exstrophy Patient

PURPOSE OF REVIEW

Classic bladder exstrophy (BE) remains one of the most demanding reconstructive challenges encountered in urology. In female BE patients, the long-term sequela of both primary and revision genitoplasty, as well as intrinsic pelvic floor deficits, predispose adult women to significant issues with sexual function, pelvic organ prolapse (POP), and complexities with reproductive health.

RECENT FINDINGS

Contemporary data suggest 30-50% of women with BE develop prolapse at a mean age of 16 years. Most women will require revision genitoplasty for successful sexual function, although in some series over 40% report dyspareunia. Current management for pregnancy includes elective cesarean section with involvement of high-risk obstetrics and urologic surgery. This review encapsulates contemporary concepts of etiology, prevalence, and management of POP and pregnancy in the adult female BE patient.

Urinary tract stone development in patients with myelodysplasia subjected to augmentation cystoplasty

Patients with myelodysplasia who have undergone augmentation cystoplasty are at risk for urinary tract stones. We sought to determine the incidence and risk factors for stone development in this population. The charts of 40 patients with myelodysplasia who have undergone augmentation cystoplasty were reviewed. None had a prior history of urinary tract stones. All patients were seen on an annual basis with plain abdominal imaging, renal ultrasonography, and laboratory testing. Statistical analysis included a multivariable bootstrap resampling method and Student's t-test. Fifteen (37.5%) patients developed stones, 14 with bladder stones and 1 with a solitary renal stone, at a mean of 26.9 months after augmentation. Five (33.3%) developed recurrent bladder stones. The patient with a renal stone never developed a bladder stone. The mean follow-up for the stone formers was 117.2 months and for non-stone formers was 89.9 months. The stone incidence per year was 6.8%. Risk factors included a decline in serum chloride after augmentation (P = .02), female sex, younger age at time of augmentation, longer time period since augmentation, and bowel continence. A significant proportion of patients with myelodysplasia subjected to augmentation cystoplasty develop urinary tract stones, predominantly in the bladder. Dehydration may play a role in development of lower urinary tract stones as the decline in serum chloride suggests contraction alkalosis, which could lead to constipation and improved bowel continence. Therefore, improved hydration should be a goal in this cohort.

Characterization of Urolithiasis in Patients Following Lower Urinary Tract Reconstruction with Intestinal Segments

PURPOSE

Urinary diversion and augmentation cystoplasty are associated with long-term complications, including metabolic derangements, infectious complications, and urolithiasis. The aim of this series was to characterize upper and lower urinary tract (LUT) calculi in this population.

METHODS

A retrospective chart review was performed on all patients with a history of urinary diversion or augmentation cystoplasty who subsequently underwent treatment for urolithiasis between January 1998 and May 2015. Data collected included demographics, perioperative characteristics, type of reconstructive procedure, urine culture, stone analysis, and metabolic evaluation. A statistical analysis was performed.

RESULTS

Ninety-nine patients were identified with a history of urolithiasis and incontinent urinary diversion (28), neobladder (21), continent cutaneous diversion (12), and augmentation cystoplasty (38). LUT stones were more common than upper tract stones in all except for incontinent diversions, which only had one lower tract stone (p = 0.0001). Twenty-three percent of stones were metabolic. Several metabolic derangements were noted, including hypocitraturia (100%), elevated urine pH (100%), low urine volume (70%), and hyperoxaluria (35%). There was a 44% rate of recurrent urolithiasis.

CONCLUSIONS

Given the high rate of stone recurrence among patients with a history of urinary diversion and augmentation cystoplasty, all measures should be taken to prevent recurrent stones. In addition to actions aimed to prevent infectious stones such as bladder and pouch irrigation, we recommend these patients undergo a full metabolic workup with targeted dietary changes and medical therapies.

Bladder stones after bladder augmentation are not what they seem

INTRODUCTION

Bladder and renal calculi after bladder augmentation are thought to be primarily infectious, yet few studies have reported stone composition.

OBJECTIVE

The primary aim was to assess bladder stone composition after augmentation, and renal stone composition in those with subsequent nephrolithiasis. The exploratory secondary aim was to screen for possible risk factors for developing infectious stones.

STUDY DESIGN

Patients treated for bladder stones after bladder augmentation at the present institution between 1981 and 2012 were retrospectively reviewed. Data were collected on demographics, surgeries and stone composition. Patients without stone analysis were excluded. Stones containing struvite, carbonate apatite or ammonium acid ureate were classified as infectious. The following variables were analyzed for a possible association with infectious bladder stone composition: gender, history of cloacal exstrophy, ambulatory status, nephrolithiasis, recurrent urea-splitting urinary tract infections, first vs recurrent stones, timing of presentation with a calculus, history of bladder neck procedures, catheterizable channel and vesicoureteral reflux. Fisher's exact test was used for analysis.

RESULTS

Of the 107 patients with bladder stones after bladder augmentation, 85 met inclusion criteria. Median age at augmentation was 8.0 years (follow-up 10.8 years). Forty-four patients (51.8%) recurred (14 multiple recurrences, 143 bladder stones). Renal calculi developed in 19 (22.4%) patients with a bladder stone, and 10 (52.6%) recurred (30 renal stones). Overall, 30.8% of bladder stones were non-infectious (Table). Among patients recurring after an infectious bladder stone, 30.4% recurred with a non-infectious one. Among patients recurring after a non-infectious stone, 84.6% recurred with a non-infectious one (P = 0.005). Compared with bladder stones, renal stones were more likely to be non-infectious (60.0%, P = 0.003). Of patients with recurrent renal calculi after an infectious stone, 40.0% recurred with a non-infectious one. No clinical variables were significantly associated with infectious stone composition on univariate (≥0.28) or bivariate analysis (≥0.36).

DISCUSSION

This study had several limitations: it was not possible to accurately assess adherence with bladder irrigations, and routine metabolic evaluations were not performed. The findings may not apply to patients in all clinical settings. While stone analysis was available for 3/4 of the stones, similar rates of incomplete stone analyses have been reported in other series.

CONCLUSIONS

In patients with bladder augmentation, 1/3 of bladder stones and >1/2 of renal stones were non-infectious. Furthermore, an infectious stone does not imply an infectious recurrent stone and no known clinical variables appear to be associated with stone composition, suggesting that there is a possible metabolic component in stone formation after bladder augmentation.

Long-term complications following bladder augmentations in patients with spina bifida: bladder calculi, perforation of the augmented bladder and upper tract deterioration

BACKGROUND

We desire to review our experience with bladder augmentation in spina bifida patients followed in a transitional and adult urologic practice. This paper will specifically focus on three major complications: bladder calculi, the most frequent complication found following bladder augmentation, perforation of the augmentation, its most lethal complication and finally we will address loss of renal function as a direct result of our surgical reconstructive procedures.

METHODS

We reviewed a prospective data base maintained on patients with spina bifida followed in our transitional and adult urology clinic from 1986 to date. Specific attention was given to patients who had developed bladder calculi, sustained a spontaneous perforation of the augmented bladder or had developed new onset of renal scarring or renal insufficiency (≥ stage 3 renal failure) during prolonged follow-up.

RESULTS

The development of renal stones (P<0.05) and symptomatic urinary tract infections (P<0.0001) were found to be significantly reduced by the use of high volume (≥240 mL) daily bladder wash outs. Individuals who still developed bladder calculi recalcitrant to high volume wash outs were not benefited by the correction of underlying metabolic abnormalities or mucolytic agents. Spontaneous bladder perforations in the adult patient population with spina bifida were found to be directly correlated to substance abuse and noncompliance with intermittent catheterization, P<0.005. Deterioration of the upper tracts as defined by the new onset of renal scars occurred in 40% (32/80) of the patients managed by a ileocystoplasty and simultaneous bladder neck outlet procedure during a median follow-up interval 14 years (range, 8-45 years). Development of ≥ stage 3 chronic renal failure occurred within 38% (12/32) of the patients with scarring i.e., 15% (12/80) of the total patient population. Prior to the development of the renal scarring, 69% (22/32) of the patients had been noncompliant with intermittent catheterization. The onset of upper tract deterioration (i.e., new scar formation, hydronephrosis, calculus development, decrease in renal function) was silent, that is, clinically asymptomatic in one third (10/32 pts).

CONCLUSIONS

This paper documents the need for high volume bladder irrigations to both prevent the most common complication following bladder augmentation, which is the development of bladder calculi and to reduce the incidence of symptomatic urinary tract infections. It provides a unique perspective regarding the impact of substance abuse and patient non-compliance with medical directives as being both the most common cause for both spontaneous bladder rupture following augmentation cystoplasty and for deterioration of the upper tracts. These findings should cause the surgeon to reflect on his/her assessment of a patient prior to performing a bladder augmentation procedure and stress the need for close follow-up.

Understanding roles of porcine small intestinal submucosa in urinary bladder regeneration: identification of variable regenerative characteristics of small intestinal submucosa

Neuropathic bladders are the result from damages to the central or peripheral nervous system, and ultimately may require surgical reconstruction to increase bladder volumes and to reduce the risk of damages to the kidneys. Surgical reconstruction through bladder augmentation has traditionally been practiced using a segment of the ileum, colon, or stomach from the patient through enterocystoplasty. However, the use of gastrointestinal segments can lead to serious adverse consequences. Porcine small intestinal submucosa (SIS), a xenogeneic, acellular, biocompatable, biodegradable, and collagen-based bioscaffold is best known to encourage bladder regeneration without ex vivo cell seeding before implantation in various experimental and preclinical animal models. Although it has been demonstrated that SIS supports bladder cell growth in vitro, and SIS-regenerated bladders are histologically and functionally indistinguishable from normal functional tissues, clinical utilization of SIS for bladder augmentation has been hampered by inconsistent preclinical results. Several variables in SIS, such as the age of pigs, the region of the small intestine, and method of sterilization, can have different physical properties, biochemical characteristics, inflammatory cell infiltration, and regenerative capacity due to cellular responses in vitro and in vivo. These parameters are particularly important for bladder regeneration due to its specific biological function in urine storage. Clinical application of SIS for surgical bladder reconstruction may require graft materials to be prepared from a specific region of the small intestine, or to be further formulated or processed to provide uniform physical and biochemical properties for consistent, complete, and functional bladder regeneration.

Adolescent urology: A challenge for adult urologists

The medical care of adolescents has become a growth area in many disciplines. There are two major aspects. Firstly, adolescents have specific medical and emotional needs which are not fulfilled either by paediatric or by adult specialists. Secondly, some childhood problems, particularly the congenital deformities, have no equivalent in adult life and so lifelong care is mandatory. Renal damage, especially dysplasia and scarring, leads to a substantial risk of early onset hypertension and, occasionally, to renal failure. Bladder outlet obstruction in utero, such as from a posterior urethral valve, causes irreversible changes to the wall that will act adversely on the kidneys in adolescence or early adulthood. The incidence of renal failure in early adulthood is about 36%. Bladder reconstruction with bowel has been very beneficial in preventing renal failure and improving continence. Life long follow-up is needed because of the high incidence of complications. These include stones, hyperchloraemic acidosis, perforation, anastomotic stenosis and, possibly, cancer. Patients have a normal expectation of sexuality and fertility. Their desires cannot always be achieved but they require considerable emotional and surgical support.

Complications after bladder augmentation or substitution in children: a prospective study of 86 patients

OBJECTIVE

• To evaluate complications after urinary bladder augmentation or substitution in a prospective study in children.

PATIENTS AND METHODS

• Data of 86 patients who underwent urinary bladder augmentation (80 patients) or substitution (6 patients) between 1988 and 2008 at the authors' institute were analysed. • Ileocystoplasty occurred in 32, colocystoplasty in 30 and gastrocystoplasty in 18. Urinary bladder substitution using the large bowel was performed in six patients. • All patients empty their bladder by intermittent clean catheterization (ICC), 30 patients via their native urethra and 56 patients through continent abdominal stoma. Mean follow-up was 8.6 years. • Rate of complications and frequency of surgical interventions were statistically analysed (two samples t-test for proportions) according to the type of gastrointestinal part used.

RESULTS

• In all, 30 patients had no complications. In 56 patients, there were a total of 105 complications (39 bladder stones, 16 stoma complications, 11 bowel obstructions, 5 reservoir perforations, 7 VUR recurrences, 1 ureteral obstruction, 4 vesico-urethral fistulae, 4 orchido-epididymitis, 4 haematuria-dysuria syndrome, 3 decreased bladder capacity/compliance, 3 pre-malignant histological changes, 1 small bowel bacterial overgrowth and 7 miscellaneous). • In 25 patients, more than one complication occurred and required 91 subsequent surgical interventions. Patients with colocystoplasty had significantly more complications (P < 0.05), especially more stone formation rate (P < 0.001) and required more post- operative interventions (P < 0.05) than patients with gastrocystoplasty and ileocystoplasty.

CONCLUSIONS

• Urinary bladder augmentation or substitution is associated with a large number of complications, particularly after colocystoplasty. • Careful patient selection, adequate preoperative information and life-long follow-up are essential for reduction, early detection and management of surgical and metabolic complications in patients with bladder augmentation or substitution.

In vitro investigations of tissue-engineered multilayered urothelium established from bladder washings

OBJECTIVE

Human urothelial cells (HUCs) are commonly isolated from native urothelium requiring open or endoscopic surgery. The aim of this study was to raise primary monolayer cultures of HUCs from bladder washings, to generate multilayered urothelial sheets in vitro, to characterise the sheets immunologically, and to prove their viability.

METHODS

Irrigation fluids were taken from 29 adult patients. Isolated cells were cultured in serum-free keratinocyte medium. Confluent monolayer cultures were stratified, and evolved cell sheets were harvested after 10-16 d. Pancytokeratins and cytokeratin 20 (CK20) in the stratified cultures and the detached sheets were immunologically detected. To exclude the presence of mesenchymal cells, antibodies against fibroblast surface antigen and smooth muscle alpha-actin were used. In addition, expression of p63 and uroplakin III was investigated. The viability of the detached cell sheets was proven by establishing explant cultures of small sheet sections.

RESULTS

Confluent primary HUC cultures were established in 55.2% of the collected bladder washings between days 15-20. Multilayered urothelium developed in 62.5% of the monolayers. Histology revealed stratified cell layers similar to native urothelium. Both stratified cultures and detached sheets stained 100% positive for pancytokeratins and partially for CK20, indicating differentiation into superficial cells. No positive staining was observed with the mesenchymal markers used. p63 was expressed partially. Uroplakin III expression was not observed. Cell sheet viability was confirmed by rapid cell outgrowth in explant cultures.

CONCLUSIONS

Isolation of HUCs from bladder washings is a minimally invasive approach to establish primary urothelial cultures for creating autologous multilayered urothelial sheets.