Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience. Part II: Continent cutaneous diversion using the Mainz pouch I

Multidisciplinary management of people with spina bifida across the lifespan

The average worldwide prevalence of neural tube defects (NTDs) is 1.0 per 1000 births. Its development is multifactorial due to genetic and non-genetic factors. Spina bifida (SB) is one of main representatives of NTD. The spinal cord lesion level is the main determinant of the level of paralysis, numbness, and difficulties with bladder/bowel functions. Myelomeningocele prenatal repair reduces hydrocephalus and hindbrain herniation and improves motor function. The severity of hydrocephalus is associated with poorer neurodevelopmental outcomes whether operated on prenatally or after birth. People with SB tend to have a lower IQ and cognitive difficulties. Early diagnosis, proactivity, and lifelong multidisciplinary follow-up are key protective issues. Invasive urological interventions should be considered in selected patients after failure of conservative treatment. Transition to adult care should be well planned as it is challenging. Health literacy is directly associated with success at transition. Sexuality and fertility should be addressed before/during puberty. Overall, the rates of fecal and urinary continence and skin breakdown increase with age, whereas the ability to ambulate declines with age. Bowel and urinary incontinence are independent predictors of lower health-related quality of life (HRQoL) in adults with SB. Bowel incontinence has negative impact on HRQoL regardless of frequency or amount. Long-term caregiver support should be offered at diagnosis. Survival at a mean of 50 years is poor, at 32%, due to central nervous system deaths, cancer, urological disease, and sepsis. Challenges to implementation of recommended practices exist, especially in low and middle-income countries.

Non-obstructive, non-refluxing uretero-colonic anastomosis by colonic sero-muscular excision and extra mural peri-ureteric wrap - A new technique in 17 children

INTRODUCTION

Uretero-enteric anastomosis with concomitant neobladder/augmentation/conduit becomes necessary when the bladder is unavailable or unfit for reimplantation or the ureters are short after high diversion or resection of lower ureteric pathology. Aiming to prevent both obstruction and reflux, we report a novel technique of sero-muscle denuded extra mural uretero-colic anastomosis.

OPERATIVE TECHNIQUE

(Fig 1) The ureter was brought through the colonic mesentery. An adjacent zone of colon "abcd" was chosen to receive the ureter and colonic sero-muscular layer was excised from this zone. The ureter was placed on the raw area and uretero-colic anastomosis was done (a-d).The edges of the sero-muscular layer (ab and cd) were sutured over the ureter to complete a submucosal tunnel. The augmentation/neo bladder was completed such that the implanted ureter lay within it between two regions of re-configured bowel, this adding to the anti-reflux mechanism created by the extra mural peri-ureteric wrap.

AIM

Surgical audit of this technique.

MATERIALS AND METHODS

17 children (exstrophy - 8, ectopic ureter with bladder agenesis/hypoplasia - 3, prune belly - 2, neurogenic bladder -2, eosinophilic cystitis -1 and posterior urethral valve -1) underwent colonic implantation of 23 ureters while 6 ureters were drained via a trans uretero-ureterostomy into the reimplanted ureter. Nine augmentation, seven neo bladders and one sigmoid conduit was performed. The colon was available for ureteric re-implant in all patients.

RESULTS

Pre-operatively 21 had hydroureteronephrosis. The bladder was agenetic/hypoplastic, small and fibrosed or poorly compliant. Eleven ureters had been diverted. Post operatively (mean follow up - 3.4 years) 16 of 30 renal units were normal, 11 had mild and three had moderate residual hydronephrosis, with no new hydronephrosis. Cystogram showed no reflux in 14 children and unilateral reflux in three (one re-diverted). Of 29 renal units drained directly or via trans uretero-ureterostomy by the uretero-colic reimplantation, none are obstructed, 26 have no vesico-ureteric reflux while three (10%) have reflux.

DISCUSSION

We report results comparable to other extra mural techniques into the bowel, mainly from adult literature. Pediatric refluxing ureters are often large megaureters with or without preliminary diversions. The technique described avoids obstruction although having a slightly higher incidence of recurrent VUR. The ureters with recurrent reflux were massively dilated preoperatively and showed decrease in ureteric diameter postoperatively. The wrap, made for a larger ureter could have become too roomy and allowed reflux.

CONCLUSION

This technique of non refluxing non obstructive uretero-colonic anastomosis has proven useful in selected situations.

Current Indications and Techniques for the Use of Bowel Segments in Pediatric Urinary Tract Reconstruction

Today, there are few indications for the use of bowel in pediatric urology. This is in large extent due to the successful conservative therapy in patients with neurogenic bladder and the improved success of primary reconstruction in patients with the bladder exstrophy-epispadias complex. Only after the failure of the maximum of conservative therapy or after failure of primary reconstruction, bladder augmentation, or urinary diversion should be considered. Malignant tumors of the lower urinary tract (e.g., rhabdomyosarcomas of the bladder/prostate) are other rare indications for urinary diversion. Replacement or reconstruction of the ureter with a bowel segment is also a quite rarely performed procedure. In this review, the advantages and disadvantages of the different options for the use of bowel segments for bladder augmentation, bladder substitution, urinary diversion, or ureter replacement during childhood and adolescence are discussed.

[Surgical urinary diversion in children from war and crisis areas-20-year experience report]

BACKGROUND

Because sick and injured children from war and crisis areas can often only be helped to a limited extent in their countries of origin, those children with the most complex diseases often receive medical treatment in Europe.

MATERIALS AND METHODS

To evaluate the postoperative outcome of reconstructive interventions in children from war and crisis areas, an evaluation of the clinic's internal database between 1997 and 2017 was carried out. The operative indication, the surgical procedure, any revisions or conversions and the overall mortality were analyzed.

RESULTS

During the above-mentioned period a total of 44 (male: 32, female: 12) children aged 3-14 years from Afghanistan, Angola, Central Asia and the Caucasus were treated. Indications for the reconstructive procedures were bladder exstrophy (n = 23), neurogenic bladder dysfunction (n = 9), penile partial amputation (n = 1) and traumatic bladder dysfunction (n = 11). In 26 children, a conduit was created, 11 children received a sigma rectum pouch and 1 child an ileocecal pouch, while 5 other children received bladder augmentation and 1 child an oral mucosal urethroplasty. In total, 7 revisions or conversions due to ureteral implantation stenoses and recurrent acidosis had to be performed. Five children died in their home country due to acidosis, sepsis, end stage renal failure, accident and social exclusion.

CONCLUSION

In the long term 39 of the 44 (88.6%) children live socially integrated in their home country and are regularly monitored by local aid organizations. When choosing the reconstructive intervention, the local conditions must be considered.

Comment on "neurogenic bladder in a girl after surgery for cloacal malformation"

In children with a neurogenic bladder and bowel, all options for continent and incontinent diversions have to be discussed in detail including all advantages and disadvantages with the patient, parents, caregivers and all disciplines involved.

Management and rehabilitation of neurologic patients with lower urinary tract dysfunction

Diverse lower urinary tract problems arise in neurologic disease, caused by dysfunctions of the bladder and outlet, both during urine storage and voiding. Most neurologic diseases cause some lower urinary tract dysfunction (LUTD), and the type of dysfunction is related to the location of the nervous system lesion. Clinical evaluation requires identification of risk factors for major morbidity, particularly renal dysfunction, and mechanisms underlying symptoms. A holistic approach is needed to cover influential aspects (e.g., cognitive function, mobility, and urinary tract infections) and related issues (e.g., sexual function, bowel function, and autonomic dysreflexia), requiring a multidisciplinary team. Comprehensive history and examination are supported by a bladder diary, urinalysis, and renal assessment, supplemented by urodynamic tests. The simplest classification of neurogenic LUTD describes both bladder and sphincter function, cataloging each structure as normal, overactive, or underactive. Treatment aims to protect life expectancy and improve quality of life, noting the possibility of neurologic disease progression and comorbid disorders. Conservative measures include fluid advice and assessment of suitable containment products. Urine storage can be improved with antimuscarinic medications, bladder injections with botulinum neurotoxin A, and less established methods such as nerve stimulation, intravesical instillations, and beta-3 agonist. For severe storage dysfunction, sacral neuromodulation or surgery to improve reservoir function, increase outlet resistance, or divert the urinary tract may be needed. Voiding is usually replaced by intermittent or indwelling catheterization, which has largely superseded triggered reflex voiding, bladder expression, or sphincterotomy. Treatment selection is hampered by a limited, low-quality evidence base.

Metabolic consequences after urinary diversion

Metabolic disturbances are well-known, but sometimes neglected immediate consequences or late sequelae following urinary diversion (UD) using bowel segments. Whereas subclinical disturbances appear to be quite common, clinically relevant metabolic complications, however, are rare. Exclusion of bowel segments for UD results in loss of absorptive surface for its physiological function. Previous studies demonstrated that at least some of the absorptive and secreting properties of the bowel are preserved when exposed to urine. For each bowel segment typical consequences and complications have been reported. The use of ileal and/or colonic segments may result in hyperchloremic metabolic acidosis, which can be prevented if prophylactic treatment with alkali supplementation is started early. The resection of ileal segments may be responsible for malabsorption of vitamin B12 and bile acids with subsequent neurological and hematological late sequelae as well as potential worsening of the patient's bowel habits. Hence, careful patient and procedure selection, meticulous long-term follow-up, and prophylactic treatment of subclinical acidosis is of paramount importance in the prevention of true metabolic complications.

Is concomitant bladder neck reconstruction necessary in neurogenic incontinent patients who undergo augmentation cystoplasty?

Purpose

In patients with neurogenic bladder due to spinal cord injury or disease who undergo augmentation cystoplasty (AC) for not only bladder dysfunction but also sphincteric incontinence, the need for concomitant bladder neck reconstruction at the time of AC has not yet been established. The aim of this study was to evaluate whether concomitant bladder neck reconstruction is necessary when performing AC.

Materials and Methods

We retrospectively investigated 35 patients who underwent AC from January 2006 to September 2010. Medical history, preoperative and postoperative fluoroscopic urodynamic study (FUDS) parameters, and responses to an incontinence questionnaire (ICIQ Korean version) were reviewed.

Results

A final analysis was performed on 17 patients (9 male, 8 female) who were diagnosed with sphincteric incontinence. Continence status, the number of pads used, and the bother score were significantly improved postoperatively in this subpopulation. Preoperatively, all patients used pads, and the average daily number was 2.2 (median; range 0 to 6). Postoperatively, the number of pads used decreased significantly to 0.9 (median; range 0 to 3) pads a day (p=0.002). Urodynamic parameters including bladder capacity, compliance, involuntary detrusor contraction, and bladder neck incompetence proven by FUDS were also significantly improved.

Conclusions

Our study demonstrated that both objective urodynamic parameters and subjective incontinence symptoms improved significantly after the completion of AC as a single procedure in patients with sphincteric incompetence. This implies that anti-incontinence bladder outlet surgery does not have to be performed simultaneously and can be considered later as a staged operation.

[Metabolic long-term complications after urinary diversion]

Metabolic long-term complications and consequences after urinary diversion are somewhat neglected. Subclinical metabolic disturbances are quite common; however, complications are rare. The absorptive surface of the bowel segment is lost for the physiological function of the gastrointestinal tract. Some studies demonstrated that at least some of the absorbent and secreting properties of the bowel are preserved if exposed to urine. For each bowel segment typical complications are reported. Using ileal and/or colon segments, hyperchloremic metabolic acidosis may occur. Studies demonstrated that metabolic effects are not as severe as suspected and could be prevented if a prophylactic treatment is started early.The resection of ileal segments is responsible for malabsorption of vitamin B(12) and bile acid; when using colonic segments, electrolyte disturbances are more common. Careful patient selection, meticulous follow-up and prophylactic treatment are crucial to prevent metabolic complications.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: non-surgical considerations

Segments from almost all parts of the bowel have been used for urinary diversion. As a result, the available absorptive surface area of the bowel is reduced, and the incorporation of bowel segments into the urinary tract may have metabolic consequences. This is an area somewhat neglected in the literature. Metabolic complications are rare, but sub-clinical metabolic disturbances are quite common. Several studies have demonstrated that some of the absorbent and secreting properties of the bowel tissue are preserved after incorporation into the urinary tract. Hyperchloraemic metabolic acidosis can occur if ileal and/or colon segments are used, as well as malabsorption of vitamin B(12) and bile acid after the use of ileal segments. These metabolic effects are not as severe as may be suspected and can be prevented by prophylactic substitution. Secondary malignancies can develop as a long-term consequence of bladder augmentation. Using colonic segments, tumours are most likely to occur at the ureteral implantation site. To prevent metabolic complications, careful patient selection and meticulous and lifelong follow up, as well as prophylactic treatment, are mandatory. Endoscopy for early detection has been recommended, starting 10 years postoperatively for patients who underwent surgery for a benign condition.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: surgical considerations

In patients with a neurogenic bladder, the primary goal is preservation of renal function and prevention of urinary tract infection, with urinary continence as the secondary goal. After failure of conservative treatment (clean intermittent catheterisation and pharmacotherapy) urinary diversion should be considered. In this review, the surgical options with their advantages and disadvantages are discussed. In patients with a hyper-reflexive, small-capacity and/or low-compliance bladder with normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. To those who are unable to perform clean intermittent catheterisation via urethra, a continent cutaneous stoma can be offered. In patients with irreparable sphincter defects a continent cutaneous diversion is an option. For patients who are not suitable for a continent diversion (incompliant±chronic renal failure), a colonic conduit for incontinent diversion is preferred. Surgical complications specific to urinary diversion include: ureterointestinal stenosis, stomal stenosis, stone formation, bladder perforation, and shunt infection and obstruction. Surgical revision is required in around one third of patients. Careful lifelong follow-up of these patients is necessary, as some of these complications can occur late.

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

PURPOSE

In children with bladder augmentation and particularly in those with bladder neck repair (BNR), urinary tract infections (UTI) and bladder calculi are a recognised problem. Bladder irrigation potentially prevents these complications. Our aim was to investigate the efficacy of bladder irrigation supported by a surveillance program in prevention of UTI and bladder calculi in these children.

METHODS

A cohort of children subjected to ileocystoplasty with a stoma for clean intermittent self catheterisation with or without BNR was retrospectively analysed. The children were subjected to bladder irrigation and monitored by Clinical Nurse Specialists (CNS) according to a protocol. Patients' demographics, treatment methods and postoperative management were reviewed. Compliance to bladder irrigation was assessed with questionnaires. UTI recurrence and bladder calculi during follow-up were assessed.

RESULTS

28 children were included in this study. The median follow-up was 48 months (range 6-87). Compliance could be assessed in all children, except in one child (3.5%). There was no recurrent UTI reported, bladder calculi occurred in two children (7%).

CONCLUSION

Our bladder irrigation regime resulted in a low incidence of calculi by preventing recurrent UTI. The surveillance program resulted in high compliance rates in children with an augmented bladder with or without BNR.

[Continent cutaneous urinary diversion in neurourology]

The management of some neurological patients can require urinary diversion. Continent cystostomy is one of the treatment options proposed in young patients, usually for cosmetic reasons. In this article, the authors describe the main techniques used in this particular indication and then review the literature to define the results of the various techniques used, as well as the modalities of follow-up in these patients in view of the potential complications.

Long-Term Multi-Institutional Evaluation of Charleston Pouch I Continent Cutaneous Urinary Diversion

PURPOSE

Charleston pouch I continent cutaneous urinary diversion has been used since 1989. We evaluated the long-term results of this procedure in 201 consecutive patients.

MATERIALS AND METHODS

The records of patients treated with the Charleston pouch I between 1989 and 2005 at 3 university hospitals were reviewed. Available data on age, sex, indications for diversion, comorbidity, followup duration, continence status, short-term and long-term complications, quality of life issues, and laboratory, radiological and urodynamic data were recorded. Patients were followed at 6-month intervals.

RESULTS

Followup was 14 to 136 months. Seven adults died in the 90-day postoperative period, and 21 (10.8%) and 51 (26%) patients had early and late complications, respectively. The interval between clean intermittent catheterizations was 2 to 8 hours. Mean capacity was 470 ml (range 250 to 1,300). At 12 months diurnal continence was achieved in 98% of the patients. A total of 98 patients (50.5%) needed night catheterization to stay dry. Of 342 ureters 17 (5%) became obstructed, requiring open or endoscopic management. Urolithiasis developed in 16 patients (8%). Vesicoureteral reflux was noted in 15 renal units (4.4%). Stomal complications developed in 8.2% of cases. Modest vitamin B12 supplementation was empirically used to avoid long-term deficiency. No detrimental effects on vitamin B12 concentrations were noted for up to 10 years.

CONCLUSIONS

Long-term multi-institutional followup of the classic Charleston pouch I reveals that it provides adequate continence with an acceptable complication rate and satisfactory patient acceptance.

Chapitre A - Lithiase et vessie neurogène

Stones of the upper and lower urinary tract are frequently observed in spinal cord injury patients. In this article, the authors reviewed the literature to identify the most reliable tools for diagnosis and follow-up. A review of recently published series demonstrated an excess risk of kidney and bladder stones in this population. The authors discuss the possible measures of prevention and identification of high-risk groups likely to benefit from more intensive follow-up.

Continent cutaneous urinary diversion in children: experience with Charleston pouch I

PURPOSE

Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children.

MATERIALS AND METHODS

A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and long-term functional status.

RESULTS

Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory.

CONCLUSIONS

Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable.

The Mitrofanoff procedure in the management of intractable incontinence: a critical appraisal

PURPOSE OF REVIEW

The term intractable urinary incontinence can be applied to urinary incontinence that cannot be managed using conventional treatments like drug therapy for detrusor overactivity or sling procedures for female stress incontinence. This review considers the role of the Mitrofanoff procedure in extending the range of options for the patient who might otherwise consider using an indwelling catheter or an ileal conduit diversion to overcome incontinence. Clinicians use the label 'Mitrofanoff procedure' quite loosely to describe any continent catheterizable abdominal stoma. For the purposes of this review, we will use the term in this generic sense while acknowledging our imprecision.

RECENT FINDINGS

Reviews confirm that the Mitrofanoff procedure has stood the test of time. Quality-of-life benefits, however, need a conclusive demonstration in scientific terms. Enthusiasts of laparoscopic surgery show that this type of lower urinary tract reconstruction can be carried out using minimally invasive methods.

SUMMARY

Reconstructive options using a catheterizable abdominal stoma should be discussed with patients with intractable urinary incontinence. Reliable surgical techniques are established; though complications are frequent, most can be dealt without recourse to major surgical intervention. Unfortunately, authoritative data on the impact of the Mitrofanoff procedure on patients' qualities of life are still lacking.