Efficacy of bladder irrigation and surveillance program in prevention of urinary tract infections and bladder calculi in children with an ileocystoplasty and bladder neck repair

A catheterizable serous-lined urinary outlet associated with the ileal bladder augmentation Abol-Enein and Ghoneim procedure: a safe and reliable procedure in children

Purpose

This study aims to evaluate the long-term outcome of the serous-lined extramural continent catheterizable outlet procedure (SLECCOP) associated with ileal bladder augmentation in children.

Methods

This was a monocentric and retrospective study (2002-2021) that included children (<18 years) undergoing the SLECCOP associated with W-shaped ileocystoplasty with a catheterizable channel (Abol-Enein and Ghoneim procedure). Patients who received other types of bladder augmentation or W-shaped ileocystoplasty without a catheterizable channel were excluded. Patient records were reviewed for demographic information, surgical data, and long-term outcomes.

Results

This study included 52 children [33 boys, median age: 8.5 (0.8-18) years]. Pathological conditions included 28 children with the bladder exstrophy and epispadias complex (BEEC), 11 with neurogenic bladders, and 13 with other pathologies. Two patients underwent total bladder substitution. Thirty-four (65%) patients had bladder neck reconstruction (BNR), with 23 undergoing the SLECCOP and ileocystoplasty and 11 having prior BNR. All stomas, except for two, were umbilical, and were associated with omphaloplasty in 28 patients with the BEEC. A total of 40 stomas were created using the appendix (77%) and 12 with a Monti tube (23%). Stoma-related complications included cutaneous strictures (n = 2, 4%) and leaks (n = 10, 19%), all treated by dextranomer/hyaluronic acid copolymer injection (n = 10). A redo surgery was required in three patients: extraserosal wrapping was performed for persistent leakage (n = 2, 4%), and surgical revision was required for the Monti tube procedure (n = 1, 2%). Three patients (6%) underwent dilatation for transient stoma stenosis. Leakage occurred in 20% of appendix channels (n = 8/40) and 17% of Monti tubes (n = 2/12). Strictures were reported in 3% of appendix channels (n = 1/40) and 8% of Monti tubes (n = 1/12). Bladder stones developed in four patients (8%). Channel leakage persisted in one patient (2%) at a median follow-up of 4.4 years (IQR 1.4-9.7).

Conclusion

W-Ileal bladder augmentation with the SLECCOP is an efficient technique for treating children with incontinence caused by different etiologies. The rate of channel complication is very low, specifically for strictures, in this complex population of patients.

Urinary Tract Infection in Parkinson's Disease

Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson's disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.

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.

Adherence with bladder irrigation following augmentation

BACKGROUND

Patients with bladder augmentation (BA) are routinely counseled to irrigate their bladders daily. However, reports of adherence with this regimen are lacking.

OBJECTIVE

To evaluate adherence to a bladder irrigation protocol and identify risk factors associated with adherence among adults with spina bifida (SB) and BA.

STUDY DESIGN

Adults with SB after BA followed in a multidisciplinary clinic were identified (2017-2019). All patients or caregivers were taught the importance of and the technique for the bladder irrigation protocol prior to and after BA. Patient demographics (age, gender, ambulatory status, and presence of a caregiver in clinics) and surgical details (type of BA, age at surgery, length of follow-up, presence of a catheterizable channel, position of stoma, bladder neck surgery, presence of Malone antegrade colonic enema or ventriculo-peritoneal shunt, and number of stone surgeries) were obtained from the medical record. Patients reported other variables in a standardized clinic questionnaire. Answers were confirmed by health care providers. The variables included who performs clean intermittent catheterization (CIC), size of catheter, frequency of CIC, use of overnight catheterization, difficulties with CIC, number of UTIs, and continence per urethra and per catheterizable channel. Adherence to bladder irrigation was also assessed in the questionnaire. ‛Strict adherence' was defined as bladder irrigation performed ≥6 times/week with ≥120 mL of saline. For statistical analysis, a more lenient definition of ‛higher adherence' was used: bladder irrigation ≥2 times/week with at least 60 mL. ‛Lower adherence' was defined as ≤1 time/week or with less than 60 mL. Factors associated with ‛higher adherence' were assessed with non-parametric tests (Bonferroni-corrected p-value: 0.002).

RESULTS

Adherence was assessed in 87 eligible patients (60.9% females; mean age of 28.8 ± 8.2 years). No patient (0.0%) reported ‛strict adherence', and 62 and 25 patients (71.3% and 28.7%) reported ‛higher' and ‛lower' adherence' to bladder irrigation, respectively. Nine patients (10.3%) in the ‛lower adherence' group did not irrigate at all. No variables were statistically significant on univariate analysis, including previous bladder stone surgery or having a channel (p ≥ 0.01). On exploratory analysis, higher adherence was only associated with self-catheterizations versus those performed by caregivers (76.7% vs 33.3%, p = 0.01).

CONCLUSIONS

Adherence to a bladder irrigation protocol in adults with SB and BA is poor. A history of bladder stones requiring surgery and the presence of a catheterizable channel do not appear to affect adherence. It remains unclear why some patients are more likely than others to irrigate their bladders. Future work will focus on methods to improve adherence.

The local microbiome after pediatric bladder augmentation: intestinal segments and the native urinary bladder host similar mucosal microbiota

INTRODUCTION

Next-generation sequencing (NGS) techniques have provided novel insights into the microbiome of the urinary bladder (UB). In children after bladder augmentation using either ileum (ileocystoplasty, ICP) or colon (colocystoplasty, CCP), the fate of the mucosal microbiome introduced into the urinary tract remains unknown.

OBJECTIVE

The aim was to compare the mucosal microbiome of the native UB vs the augmented intestinal segment (IS) using NGS.

STUDY DESIGN

Twelve children after bladder augmentation (ICP n = 6, CCP n = 6) were included. Biopsies were taken during routine postoperative cystoscopy from the native UB and the IS. Specimens underwent whole-genome DNA extraction, 16S rRNA gene amplification, NGS, and Quantitative Insights Into Microbial Ecology (QIIME) data analysis. Downstream statistical data analyses were performed in Calypso.

RESULTS

Patients' median age at the time of surgery was 11 years (6-17 years), and the median interval between augmentation and sampling was 7 years (4-13 years). α-Diversity (Shannon diversity index) was not significantly different between IS vs UB, ICP vs CCP, and male vs female. No general differences in the overall bacterial pattern (β-diversity) were found between IS, UB, ICP, and CCP groups. The groups overlapped in principal coordinate analysis (PCoA) and non-metric multidimensional scaling (NMDS) analysis (Figure). Age at sampling had a statistically significant influence on β-diversity at the genus level. Corynebacterium, Pseudoxanthomonas, Lactobacillus, Flavobacterium, and Micrococcus were the most dominating taxa detected over all samples. There was an obvious dominance of the genus Corynebacterium in the samples taken from the UB and IS in both ICP and CCP patients. Limitations of this study include the relatively small number of patients.

CONCLUSION

After bladder augmentation, the native UB and augmented ISs (ICP and CCP) host similar microbiota despite their distinct differences of originating mucosal anatomy.

Efficacy of bladder irrigation in preventing urinary tract infections associated with short-term catheterization in comatose patients: A randomized controlled clinical trial

BACKGROUND

Bladder irrigation can be performed to prevent catheter-associated urinary tract infections (CAUTI), but its efficacy has been not reported in short-term indwelling urinary catheterization. This clinical trial aimed to examine the efficacy of bladder irrigation with normal saline solution in preventing CAUTI in comatose patients admitted to intensive care units.

MATERIALS AND METHODS

Eligible patients were randomized to the experimental group or control group. The experimental group received daily bladder irrigation with 450 cc sterile normal saline, in 3 150-mL doses, for 3 consecutive days. Data on signs of CAUTI, including urine culture, axillary body temperature (primary outcomes), and other urine and blood parameters (secondary outcomes) were obtained at baseline and 5 days later.

RESULTS

Results of group comparisons and logistic regression analysis that controlled for fluid intake showed that the risk of CAUTI decreased by 99% in the experimental group compared with the control group (odds ratio, 0.01; P < .001). Additional findings indicated a decrease in axillary body temperature and improvements in urine appearance, urinary red cells and white cells, and erythrocyte sedimentation rates and white-cell counts in the blood following bladder irrigation.

CONCLUSION

Daily bladder irrigation with normal saline during 3 days demonstrated efficacy in preventing CAUTI in comatose patients.

We can rebuild it: reconstructive solutions for structural urologic diseases

Bladder augmentation and urinary diversion have become standard of care as surgical treatments for structural and functional disorders affecting the bladder, both in children and adults. With improved medical care, long-term survival of these patients is expected. Common medical problems that can occur such as metabolic side effects including acid-base imbalances and nutritional issues need to be anticipated and addressed. In addition, surgical problems caused by impaired urinary drainage, namely stones and urinary tract infections, and mechanical factors related to catheterizable channels and continence also may compound postoperative management. The risk of malignancy after bladder augmentation and substitution, and appropriate surveillance for this, remains to be clearly defined.