Bladder augmentation: Complications in the pediatric population

Autoaugmentation: A Feasible Option before Ileal Augmentation in Selected Cases

PURPOSE

 To evaluate the long-term outcomes of autoaugmentation (AA) in pediatric population.

MATERIALS AND METHODS

 The data of 59 patients (32 females and 27 males) who underwent AA between 1993 and 2018 were analyzed retrospectively. During postoperative follow-up, deterioration on renal scan and/or nonimproved hydronephrosis (HN) were described as upper urinary tract (UUT) impairment. Incontinence was described as use of diaper or pad. Preoperative urodynamic volume was divided into two as less than 50 and more than or equal to 50% expected bladder capacity (EBC). The effect of preoperative clinical factors on reaugmentation, incontinence, and UUT impairment was evaluated.

RESULTS

 The mean age and the median follow-up were 8.9 ± 3.6 years and 64 (12-218) months, respectively. Ten (16.9%) patients underwent reaugmentation (ureteral or ileal). UUT impairment and incontinence rates were 13.6% (8/59) and 30.5% (18/59), respectively. On multivariate analysis, less than 50% EBC was the only predictor of reaugmentation and incontinence (p = 0.013, odds ratio [OR]: 17.546 and p = 0.035, OR: 3.750, respectively). Preoperative HN was predictor of UUT impairment (p = 0.041, OR: 10.168). After AA, 51 patients used clean intermittent catheter and 27 (45.8%) patients discontinued the use of anticholinergic medication. At follow-up, eight (13.5%) patients underwent surgery after AA due to long-term complications, dissatisfaction, or poor functional results (bladder neck injection, cystolithotripsy, Mitrofanoff revision, dilatation, and injection).

CONCLUSION

 AA is a viable option in selected cases with high pressure and low compliant bladders. Preoperative bladder capacity is significant for reaugmentation rate and continence. UUT impairment is related to preoperative HN.

Augmentation uretero-enterocystoplasty for refractory urinary tract dysfunction: a long-term retrospective study

Objectives

To report the long-term efficacy and complications of the augmentation uretero-enterocystoplasty (AUEC), including augmentation cystoplasty with simultaneous ureteroplasty and ureteral anti-reflux implantation in a single center.

Methods

We retrospectively reviewed clinical records, video-urodynamic data, and magnetic resonance urography of 210 patients who underwent the procedure for refractory lower urinary tract dysfunction (LUTD) from 2003 to 2019. International vesicoureteral reflux (VUR) and upper urinary tract dilatation (UUTD) grading systems were applied to assess upper urinary tract function, and post-operative complications were assessed.

Results

Mean age was 28.1 years, with a mean follow-up time of 57.4 months. A total of 338 ureters were simultaneously re-implanted, and ureteroplasty was performed on all ureters. There was a significant postoperative improvement in the bladder capacity, intravesical pressure, and compliance (P < 0.05). VUR improvement rate was 97.7% and postoperative improvement of UUTD presented in 72.5% ureters. Mean serum creatinine (Scr) level was significantly improved compared to preoperative Scr values (226.0 ± 89.4 μmol/L vs. 217.5 ± 133.9 umol/L, P < 0.05). The 1.0% patients had unacceptably postoperative urinary incontinence and 85.4% preoperative megaureters were improved. Primary complications included metabolic acidosis (9.5%), vesicoureteral anastomosis stenosis (6.2%), persistent VUR (2.7%), urinary calculi (6.6%), and intestinal dysfunction requiring laparotomy (3.3%).

Conclusion

In the study, a large series of patients treated with a complex surgical procedure was reported. It is novel, as this case series represents patients with aggressive surgical correction of VUR, ureteral tortuosity and upper tract dilation at the time of AC. AUEC was shown to have a positive role in treating patients with refractory LUTD associated with hydronephrosis and ureteral dilatation, stenosis or obstruction, with or without high- or low-pressure VUR. It was effective in improving renal function and protecting the UUT function from further deterioration in most patients with renal insufficiency.

Bladder augmentation from an insider's perspective: a review of the literature on microcirculatory studies

Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.

Incidence of nephrolithiasis after bladder augmentation in people with spina bifida

INTRODUCTION

Risks of nephrolithiasis after bladder augmentation in people with spina bifida (SB) remain unclear. Annual incidence of nephrolithiasis in the general population is 0.01% for 10-14 years old, 0.07% for 15-19 years old and 0.2% for 20-24 years old. Our aim was to assess the incidence and risk factors of nephrolithiasis in SB patients after augmentation.

METHODS

Patients with SB and augmentation followed at our institution were retrospectively reviewed (born ≥1972, surgery 1979-2019). Patients were screened annually with renal bladder ultrasound and abdominal radiograph. Main outcome was nephrolithiasis treatment. Kaplan-Meier survival and Cox proportional hazards analysis were used. Possible predictors were assessed using stepwise forward selection (variables with p < 0.1 on univariate analysis included in multivariate analysis).

RESULTS

427 patients with SB and augmentation were included (51.8% female, 74.9% shunted). Median age at augmentation was 8.5 years (median follow-up: 12.4 years, ileum segment: 81.0%, bladder neck procedure: 60.7%, urinary channel: 74.2%) and 28.8% developed bladder stones. Overall, 47 (11.0%) patients were treated for nephrolithiasis. After correction for differential follow-up, nephrolithiasis was treated in 7.3% at 10 years, 13.2% at 15 years, and 18.0% at 20 years (Figure). Patients presented with either a urinary tract infection (46.8%), on screening (44.7%), or pain (8.5%). Stones were treated percutaneously, endoscopically or by ESWL (63.8%/34.0%/10.7%, respectively). Most were calcium stones (58.3%). On multivariate analysis, compared to younger patients, patients augmented at ≥10 years of age had 1.84 times the risk of nephrolithiasis (p = 0.01). Nephrolithiasis was more common in those who developed bladder stones (HR = 3.00, p < 0.0001). Among those with both renal and bladder stones, bladder stones typically preceded nephrolithiasis (55.2%), were treated concurrently (31.0%) and 13.8% occurred after nephrolithiasis. Gender, wheelchair use, bowel segment used, MACE and skeletal fractures were not associated with higher nephrolithiasis risk (p ≥ 0.11).

DISCUSSION

This study of a large cohort of SB patients with long-term follow-up highlights that the risk of nephrolithiasis is cumulative and related to bladder stone formation, age at augmentation and time since augmentation. An association with bladder stones suggests potential shared metabolic causes. The study's retrospective design likely led to underestimating the risk of nephrolithiasis by not capturing spontaneously passed stones.

CONCLUSION

Approximately 1% of patients with SB develop nephrolithiasis annually after augmentation. Close long-term surveillance after augmentation is strongly indicated, as nephrolithiasis incidence in augmented patient with SB is at least 10 times higher than general population. Patients with bladder stones are especially at risk.

Need for botulinum toxin injection and bladder augmentation after isolated bladder outlet procedure in pediatric patients with myelomeningocele

INTRODUCTION

In patients with neurogenic bladder outlet incompetence, a bladder outlet procedure (BOP) may be required to achieve urinary continence. However, when performed in isolation, a BOP can be associated with bladder deterioration and upper-tract injury. In the event of bladder deterioration, additional procedures such as bladder augmentation (BA) or botulinum toxin injection (BTI) may be pursued.

OBJECTIVE

The aim of this study was to assess long-term outcomes after isolated BOP in a pediatric myelomeningocele (MMC) population, including the need for additional surgical intervention in the form of BTI or BA.

MATERIALS AND METHODS

A retrospective cohort study was performed for patients with MMC who underwent an isolated BOP between 2004 and 2017. Primary outcomes included the need for postoperative BTI or BA. Secondary outcomes included the association between preoperative urodynamic parameters and need for BTI or BA.

RESULTS

BTI or BA was performed in 18 of 36 (50%) patients at a median of 17.8 months (IQR 11.2-29.3) after an isolated BOP. A median of 1 (IQR 1-3) BTI was performed in 11 (30.6%) patients. BA was performed in 9 (25%) patients, including 2 patients who previously underwent BTI. Patients who did not undergo BTI or BA after BOP had a slightly increased percentage estimated bladder capacity at the end of follow-up (107% versus 95%, p=0.42). By contrast, patients who underwent BTI or BA had a post-BOP percentage estimated bladder capacity that decreased from 112 to 70% (p < 0.001), increased maximum detrusor leak point pressure from 43 to 67 cm H₂O (p = 0.01), and higher rate of de novo upper-tract changes. Unfortunately, no preoperative clinical, radiographic, or urodynamic factors predicted the need for BTI or BA.

DISCUSSION

On time-to-event analysis, the risk of BTI or BA was 53% at 5 years in our cohort. Risk of these procedures was highest in the first two years after BOP. 9 of 11 (82%) patients who underwent BTI had improvement in bladder dynamics and BA was not pursued. These findings suggest that BTI provides a less-morbid alternative to BA in patients with MMC and de novo adverse bladder storage changes after an isolated BOP.

CONCLUSION

The need for BTI or BA after an isolated BOP is significant in patients with MMC. BTI offers a less-invasive alternative to BA in this population.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management

BACKGROUND

Treatment in children and adolescents with a neurogenic bladder is primarily conservative with the goal of preserving the upper urinary tract combined with a good reservoir function of the bladder. However, sometimes-even in childhood-conservative management does not prevent the development of a low-compliant bladder or overactive detrusor.

MATERIAL & METHODS

After a systematic literature review covering the period 2000-2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update.

RESULTS

In these patients, surgical interventions such as botulinum toxin A injections into the detrusor muscle, bladder augmentation, and even urinary diversion may become necessary to preserve the function of the upper (and lower) urinary tracts. The creation of a continent catheterizable channel should be offered to patients with difficulties performing transurethral clean intermittent catheterization. However, a revision rate of up to 50% needs to be considered. With increasing age continence of urine and stool becomes progressively more important. In patients with persistent weak bladder outlets, complete continence can be achieved only by surgical interventions creating a higher resistance/obstruction at the level of the bladder outlet with a success rate of up to 80%. In some patients, bladder neck closure and the creation of a continent catheterizable stoma is an option.

CONCLUSION

In all these patients close follow-up is mandatory to detect surgical complications and metabolic consequences early.

Advances in Pediatric Urinary Diversion

Pediatric urinary diversion is performed for a unique set of indications with many options to consider. Although surgical intervention has decreased in necessity overall due to advances in expectant management, it remains an important tool. There are many options and various factors to consider in choosing the right type of diversion for an individual and these patients require lifelong follow-up with a pediatric urologist and eventually an adult urologist. This article provides a detailed review of the most relevant techniques used by pediatric urologists for urinary diversion.

Neuropathic bladders: Investigation and treatment through their lifetime

The child with a neuropathic bladder requires lifelong dedicated care. Just as each patient presents with unique physiology, each phase of their life presents varying challenges. The primary concern for our patients is their renal health, but continence and independence also play significant roles. Most patients can be managed conservatively, but a myriad of surgical options are also available, reinforcing our emphasis on individualized care. Appropriate pre-surgical planning is required to ensure the right patient receives the best operation for his/her wants and needs. Furthermore, the numerous potential complications must be understood and long-term followup and surveillance is required. This review outlines the basic pathophysiology, investigations, and treatments, with a focus on the changing needs throughout their lives.

Comparison of morphological and functional restoration between asymmetric bilayer chitosan and bladder acellular matrix graft for bladder augmentation in a rat model

Asymmetric bilayer chitosan promoted bladder reconstruction with enhanced smooth muscle regeneration and angiogenesis, and functional restoration with augmented bladder capacity.

Preoperative Risk Factors Predicting Complication Rates of Augmentation Cystoplasty Using the Modified Clavien Classification System in Pediatric Population

OBJECTIVE

To evaluate preoperative predictive factors for postoperative complications of augmentation cystoplasty in children by using the modified Clavien classification system (MCCS).

PATIENTS AND METHODS

A retrospective review of medical records between 1994 and 2014 identified 117 children (64 males and 53 females) who underwent augmentation cystoplasty. Complications were evaluated according to the MCCS. Univariate and multivariate analyses were used to determine predictive factors affecting complication rates.

RESULTS

The mean (SD) age was 9.3 (1.9) years and the mean (SD) hospitalization time was 9.7 (3.6) days. Patients with an adverse or unexpected event within 30 days of surgery were identified. Complications occurred in 29 (24.7%) children; 13 (11.1%) were MCCS grade I, 8 (5.1%) were grade II, 5 (4.2%) were grade III, and 3 (2.5%) were grade IV. Antireflux surgery, outlet resistance increasing procedures, Society of Fetal Urology (SFU) grades 3-4 hydronephrosis, posterior urethral valves, scoliosis, and serum creatinine greater than 1.0 mg/dL were statistically significant predictors of complications on univariate analysis. In the multivariate analysis, SFU grades 3-4 hydronephrosis, bladder neck reconstruction, and serum creatinine greater than 1.0 mg/dL were statistically significant independent predictors of complications.

CONCLUSION

Augmentation cystoplasty remains a valid method of treating severe bladder dysfunction in children. SFU grades 3-4 hydronephrosis, outlet resistance increasing procedures, and serum creatinine greater than 1.0 mg/dL were the main predictive factors for postoperative complications. Use of a standardized complication grading system, such as the MCCS, should be encouraged to allow the valid comparison of complication rates between series.

Vitamin B12 deficiency in patients after enterocystoplasty

INTRODUCTION

Serum B12 deficiency is a known sequlae of enterocystoplasty. The complications of B12 deficiency include megaloblastic anemia, neuropsychiatric disease, and demyelinating diseases such as peripheral neuropathy. Some studies have suggested that underlying disease states may be more important than enteric absorptive capacity in predicting acquired B12 deficiency. A 38% incidence of low or low-normal serum B12 in patients who have undergone enterocystoplasty has previously been reported, and oral B12 supplementation has been demonstrated to be an effective short-term therapy; however, the long-term results remain unclear.

AIMS

This study hypothesized that oral vitamin B12 supplementation in patients with B12 deficiency following enterocystoplasty is an effective long-term treatment. Additionally, it sought to determine if underlying disease state predicts B12 deficiency following enterocystoplasty.

DESIGN

Children who underwent enterocystoplasty at the present institution prior to August 2007 were reviewed. Patients with non-ileal augment, insufficient follow-up or hematologic disorders were excluded. Patients with low or low-normal B12 levels were included. Treatment consisted of daily oral therapy of 250 mcg or monthly parenteral therapy of 1000 mcg IM. Separately, the institutional database of 898 patients who underwent enterocystoplasty was searched and patients with at least one post-operative B12 level were highlighted. The indication for enterocystoplasty was classified as neuropathic or non-neuropathic.

RESULTS

Twenty-three patients met inclusion criteria. The mean follow-up was 49 months (range 5-85) following initial abnormal B12 level. On the last follow-up, 4/23 (17%) patients had normal serum B12 levels. No patients reported sequelae of long-term B12 deficiency. In the secondary investigation, 113 patients met inclusion criteria. A total of 101 had neuropathic indications for enterocystoplasty, and 12 had non-neuropathic indications. At any time during follow-up, 48/101 (47.5%) neuropathic patients had low or low-normal B12 levels, and 4/12 (33.3%) non-neuropathic patients had low or low-normal B12 levels during follow-up (P = 0.54) (Figure).

DISCUSSION

The initial success of oral B12 deficiency treatment following enterocystoplasty does not persist over time. This contradicts previous results with short duration follow-up. Underlying disease as the indication for enterocystoplasty did not predict B12 deficiency risk. The study was limited by the small number of patients with B12 deficiency who were started on treatment, as well as by the small number of patients with non-neuropathic indications for enterocystoplasty.

CONCLUSION

The aims of the study were met. Further investigation is required to assess predictors of B12 deficiency following enterocystoplasty.

Is CT cystography an accurate study in the evaluation of spontaneous perforation of augmented bladder in children and adolescents?

BACKGROUND

Spontaneous bladder perforation (SBP) is a potentially fatal complication of augmented bladder. Imaging is often used for diagnosis. In this study we present our experience with CT cystography (CTC) in the diagnosis of SBP.

OBJECTIVE

To determine CTC accuracy in the evaluation of SBP in children with an augmented bladder.

STUDY DESIGN

The institutional review board approved this HIPAA-compliant study; informed consent was waived. All patients under 20 years old, who underwent CTC for SBP evaluation from 2003 to 2013, were identified. Two radiologists independently reviewed CTC studies for contrast extravasation, ascites, and pneumoperitoneum. Ascites was graded: small - confined to the rectovesical pouch (RVP); moderate - beyond the RVP; large - beyond the pelvis.

RESULTS

Eighty-nine patients (47 males, age 4.2-19.8 years) had 132 CTCs. SBP was diagnosed in 14% (19/132). Both radiologists found contrast extravasation in 74% (14/19) of patients with SBP; two patients had only pneumoperitoneum, and three had only ascites (large = 2, moderate = 1) (Fig.). SBP was found in 1% of CTCs with no ascites or small ascites (1 of 98 and 92; radiologists 1 and 2, respectively). Findings of extraluminal extravasation, unexplained pneumoperitoneum, or large ascites, yielded a detection rate of 95% for SBP by each radiologist. In eight patients, small bowel obstruction was diagnosed.

DISCUSSION

Contrast extravasation was detected in only 74% of patients with SBP. The use of indirect signs of perforation (unexplained pneumoperitoneum and large ascites) in addition to contrast extravasation, increased the detection rate of SBP to 95%. US screening for SBP and selection of patients with moderate or large ascites for CTC, may eliminate the need for most CT scans. In the absence of SBP, other abdominal abnormalities should be evaluated. Bowel obstruction was the most common non-urological emergency detected in this series. The main limitations of the study are: the small number of SBP cases; the diagnosis of SBP not based on surgical findings in three patients; and inability to completely exclude occult SBP in patients not explored surgically.

CONCLUSION

Extraluminal contrast was seen on CTC in most cases of SBP, but some patients with sealed bladder perforation had only pneumoperitoneum or moderate/large ascites. Therefore, SBP should be suspected in any patient with moderate/large volumes of pelvic fluid or unexplained pneumoperitoneum, even when there is no evidence of contrast extravasation. Patients with no ascites, or small volumes, are unlikely to have SBP; therefore, US can be used to screen low risk patients.

Proteomic profile of an acute partial bladder outlet obstruction

INTRODUCTION

Partial bladder outlet obstruction (pBOO) is a ubiquitous problem in urology. From posterior urethral valves to prostatic hypertrophy, pBOO results in significant morbidity and mortality. However, the pathophysiology is not completely understood. Proteomics uses mass spectrometry to accurately quantify change in tissue protein concentration. Therefore, we have applied proteomic analysis to a rodent model to assess for protein changes after a surgically induced pBOO. We hypothesize that proteomic analysis after an acute obstruction will determine the most prevalent initial protein response and, potentially, novel molecular pathways.

METHODS

Sprague Dawley rats underwent a surgically induced pBOO (n = 3 per group) for 3, 7, or 14 days. Bladders were assessed for weight and urodynamic parameters. Proteomics used liquid-chromatography based mass spectrometry. Polymerase chain reaction (PCR) was performed on tissue samples to confirm increased mRNA transcription.

RESULTS

Bladder weight and capacity increased over the experimental period, but no changes were seen in bladder pressure. Statistically significant increases in protein quantities were seen in 3 proteins related to endoplasmic reticulum stress: GRP-78 (3.66-fold), RhoA (1.90-fold), and RhoA-GDP (1.95-fold), and 2 cytoskeleton molecules: actin (1.7-fold) and tubulin a/b (3.01-fold). Decorin and lumican, members of the small leucine rich proteoglycan (SLRP) family, were also elevated (0.35- and 0.34-fold, respectively). Real-time PCR data confirmed protein elevation.

CONCLUSION

Our experiment confirms that molecular changes occur very soon after the initiation of pBOO, and implicates several molecular pathways. We believe these insights may provide insight into novel prevention and treatment strategies targeted at the pathophysiology of pBOO.

Does augmentation cystoplasty with continent reconstruction at a young age increase the risk of complications or secondary surgeries?

INTRODUCTION AND OBJECTIVE

Lower urinary tract reconstruction with augmentation cystoplasty (AC) is an effective strategy for achieving urinary continence in children with neurogenic or severely compromised bladder. We compared complications and need for secondary surgeries in children 3-5 years of age undergoing AC with continent reconstruction to those ≥ 6 years old.

STUDY DESIGN

Medical charts of children undergoing AC with continent urinary diversion between 2003 and 2011 were reviewed. Complications and secondary surgeries were analyzed according to patient age. Patient demographics, etiology of bladder dysfunction, bowel segment used, and concomitant procedures were also assessed.

RESULTS

One hundred and eight children underwent AC with continent urinary diversion. Mean age at augmentation was 8.5 years (range 3-20). Twenty-eight children (25.9%) were 3-5 years old and 80 (74.1%) were ≥ 6 years. Mean follow-up was 6.93 years (range 1.6-10 years). Bowel segment used included ileum in 59 (54.6%), sigmoid in 33 (30.6%), cecum in 4 (3.7%) and composite in 12 (11.1%). Major complications included bowel obstruction in 6 (5.6%), bladder perforation in 3 (2.8%) and fistula in 2 (1.9%). There was no difference in major complications based on bowel segment utilized (p = 0.804, OR 0.894) or age (p = 0.946, OR 0.969). Fifty children (46.3%) required no additional surgeries; the remaining 58 underwent 137 procedures post-augmentation. Surgeries included urolithiasis management (58/137, 42.3%), appendicovesicostomy revision including stoma revision or redo for persistent leakage between catheterizations in (34/137, 24.8%), bladder neck procedures (26/137, 19%) and revision of MACE (19/137, 13.9%) [Figure]. Incidence of stones in patients 3-5 years (32.1%) was not significantly different than children ≥ 6 years of age (25%, p = 0.463, OR 0.704). Mean number of secondary surgeries for those 3-5 years was 1.21 ± 1.34, which was not statistically different than those ≥ 6 (1.3 ± 1.82, p = 0.154). Children with myelomeningocele (MMC) were statistically more likely to require secondary surgeries than those with other bladder pathology (p = 0.01).

DISCUSSION

Augmentation enterocystoplasty with cutaneous continent catheterizable channel is performed both to protect the upper urinary tract and afford the patient the option of social continence. Continent lower urinary tract reconstruction has been proven technically feasible and safe in preschool-aged children however, the ideal age for augmentation remains unknown. Urolithiasis accounted for over 40% of additional procedures in our series, with 26.9% of patients requiring one or more surgeries for stone disease. The incidence of stone disease in patients 3-5 years of age at the time of augmentation was comparable to that seen in older children. The overall need for additional post-augment procedures was not influenced by patient age or bowel segment utilized, however children with MMC were significantly more likely to require future surgeries than those with a different underlying etiology of bladder dysfunction. Our study has several limitations that warrant mention. Children with neurogenic bladder represent a heterogeneous population, and their surgical outcomes are inherently influenced by underlying disease processes and severity. Complications and secondary surgeries were assessed; however success rates were not evaluated in the current study. Patient and caregiver adherence with CIC and daily bladder irrigation was not assessed; whether noncompliance affected complication rates (i.e. stone formation) is unknown.

CONCLUSION

Whether performed at a young or older age, families must be adequately counseled regarding the daily management responsibilities and potential risks associated with lower urinary tract reconstruction including bladder augmentation. Augmentation with continent urinary diversion in selected patients 3-5 years of age confers complication and secondary surgery risk equal to that observed in their older counterparts.

Lack of improvement: a national assessment of readmission rates after pediatric bladder reconstruction

Background:

Bladder reconstruction in the pediatric population is challenging for many reasons, including perioperative complications and readmissions.

Objectives:

On a national scale, determine readmission rates at 30, 60 and 90 days after bladder reconstruction in a pediatric population over a 7-year period, evaluating the influence of hospital and patient-specific variables.

Patients and Methods:

Using the Pediatric Health Information System database, we identified patients 0-17 years of age, from 2004-2010, undergoing bladder reconstruction using ICD-9 procedure codes. Descriptive statistics characterized demographics, prevalence of surgeries, and readmission rates. Surgery prevalence over time was examined using linear regression. Readmission rates were compared using the Chi2 test. Regression was used to evaluate the influence of variables on readmission risk.

Results:

We identified 1,985 patients for inclusion, of which 52.7% were female. Median age was 9 years. There has been no change in the prevalence of bladder reconstruction surgeries (P = 0.327). There was no change in 30-day (P = 0.272), 60-day (P = 0.788) or 90-day readmission rates (P = 0.924). Despite surgical volume adjustment, 90-day readmission rates did not significantly vary among the majority of hospitals. Initial LOS > 7 days (P < 0.001) and complex chronic condition males (P < 0.001) were significantly associated with 90-day readmission.

Conclusions:

No improvement in readmission rates after pediatric bladder reconstruction was observed during the study period. Nearly all centers have a similar readmission rate despite volume adjustment.

Bladder acellular matrix conjugated with basic fibroblast growth factor for bladder regeneration

Basic fibroblast growth factor (bFGF) plays an important role in wound repair and tissue regeneration. Considerable research has been focused on the exploration of bFGF delivery systems for maintaining efficient local concentration at the injury sites. In this study, bFGF was chemically crosslinked to the bladder acellular matrix (BAM) to create specific binding between bFGF and BAM. The BAM scaffold conjugated with bFGF (CL-BAM/bFGF) could bind more bFGF and achieve controlled release of bFGF, which promoted human fibroblasts to proliferate in vitro and accelerated cellularization and vascularization after subcutaneous implantation. Using the rat bladder reconstruction model, the CL-BAM/bFGF group showed better tissue regeneration compared with the other groups. In summary, CL-BAM/bFGF could prevent the diffusion of bFGF from BAM and maintain its activity. Thus, the scaffold conjugated with growth factor systems could be an effective way for maintaining local therapy dosage at the target site in wound repair and tissue regeneration.

Rapid construction of sigmoid bladder augmentation using absorbable staples: long-term results and comparison to standard colocystoplasty in children with neurogenic bladder

OBJECTIVE

Absorbable staples facilitate detubularization and reconfiguration of the bowel when performing augmentation colocystoplasty. We compared the outcomes of stapled sigmoid augmentation with standard sutured colocystoplasty.

MATERIALS AND METHODS

Between 2003 and 2011, 108 children underwent bladder augmentation at our institution. Colocystoplasty was used in 30 patients (27.8%). Medical charts of children who underwent stapled (n = 8) or sutured (n = 22) sigmoid augmentation were compared with regard to patient demographics and surgical complications, including anastomotic leak and urolithiasis.

RESULTS

Eight children with underwent stapled sigmoid colocystoplasty. Average age at surgery was 8 years (range 4-17 years). Time to detubularize and refashion the bowel segment prior to augmentation was consistently under 5 min. Average length of follow-up was 44 months (range 12-80 months). One patient experienced anastomotic leak. Two of eight children (25%) in the stapled anastomosis cohort developed bladder stones. Twenty-two patients underwent standard sigmoid augmentation during the same time period (average age 8.2 years; range 4-16 years). One of 22 (4.5%) experienced anastomotic leak. Seven of 22 (31.8%) developed cystolithiasis.

CONCLUSIONS

Complications from stapled sigmoid anastomosis are similar to those from standard colocystoplasty. Use of absorbable staples decreases operating time by avoiding bowel spatulation and suturing, and should be considered in pediatric patients undergoing colocystoplasty.

Neurogenic bladder in children: basic principles, new therapeutic trends

Diagnosis of neurogenic bladder is straightforward in children with myelomeningocele. However, recognition is more difficult in patients with occult dysraphism or central nervous system disorders since clinico-anatomical correlations are poor. Careful clinical examination and urodynamic exploration are mandatory for diagnosis and follow-up. Even if urinary leak is the first symptom, the main goal of the pediatric surgeon must be to preserve the upper urinary tract. The ideal protection strategy consists of ensuring that micturition is voluntary and complete and that the bladder capacity is sufficient with adequate compliance and sphincter outlet resistances. Balancing these functions requires a combination of medical and surgical treatment. A variety of techniques can be used depending on gender and age of the patient and social environment. In most cases, intermittent bladder catheterization is necessary to obtain complete evacuation of the bladder. Bladder capacity can be increased by anticholinergic drugs, injection of botulinum toxin into the bladder, and augmentation cystoplasty. Augmentation of bladder outlet resistances requires endoscopic injection of bulking agents, surgical bladder neck reconstruction and urethral lengthening, bladder neck suspension, and artificial urinary sphincter. In difficult cases, continent cystostomy with closure of the bladder neck can achieve definitive continence. At the beginning endoscopic treatment combining anti reflux procedure, injection of the bladder neck and botulinum toxin can be considered as a "total endoscopic management" and should be our first line. Other techniques are under evaluation. Sacral neuro-modulation has given promising results. Artificial tissue engineering will probably be used in the next future. Management of neurogenic bladder is not limited to urological considerations. Orthopedic, digestive, and sexual problems must also be taken into account in order to obtain an "acceptable quality of life".

Urinary diversion in early childhood: indications and outcomes in the exstrophy patients

OBJECTIVE

To evaluate indications and applicability of continent and incontinent urinary diversion (CUD and IUD, respectively) in early childhood in patients with classic bladder exstrophy (CBE).

METHODS

Using an institutionally approved exstrophy database, patients with CBE born after 1980 who underwent CUD or IUD by 2 surgeons within the first 5 years of life were identified. All aspects of their care and clinical outcomes were studied.

RESULTS

In the CUD group (n = 14), only 21% had successful primary closure. Indications were desire to be dry (7), persistent hydronephrosis (4), urinary tract infections (UTIs) (1), repeat CUD (1), and inaccessible proper follow-up (1). Three patients had neobladder creation, 10 had bladder augmentation with continent stomas, and 2 underwent ureterosigmoidostomy. Currently, all patients are dry with clean intermittent catheterization (CIC). In the IUD group (n = 5), only 1 had successful primary closure. In addition to small, noncontractile bladders, the indications for IUD were severe hydronephrosis (2), recurrent UTIs (2), and noncompliance with catheterization (1). Four patients were re-diverted to CUD after a mean of 9.4 years and 1 has colon conduit. All are socially dry via catheterization. There was no case of renal function loss or malignant transformation.

CONCLUSION

The need for early diversion in CBE is primarily driven by upper tract changes after secondary closure and social factors. Urinary diversion can be safe in younger children with a favorable continence outcome.

A nonhuman primate model for urinary bladder regeneration using autologous sources of bone marrow-derived mesenchymal stem cells

Animal models that have been used to examine the regenerative capacity of cell-seeded scaffolds in a urinary bladder augmentation model have ultimately translated poorly in the clinical setting. This may be due to a number of factors including cell types used for regeneration and anatomical/physiological differences between lower primate species and their human counterparts. We postulated that mesenchymal stem cells (MSCs) could provide a cell source for partial bladder regeneration in a newly described nonhuman primate bladder (baboon) augmentation model. Cell-sorted CD105(+) /CD73(+) /CD34(-) /CD45(-) baboon MSCs transduced with green fluorescent protein (GFP) were seeded onto small intestinal submucosa (SIS) scaffolds. Baboons underwent an approximate 40%-50% cystectomy followed by augmentation cystoplasty with the aforementioned scaffolds or controls and finally enveloped with omentum. Bladders from sham, unseeded SIS, and MSC/SIS scaffolds were subjected to trichrome, H&E, and immunofluorescent staining 10 weeks postaugmentation. Immunofluorescence staining for muscle markers combined with an anti-GFP antibody revealed that >90% of the cells were GFP(+) /muscle marker(+) and >70% were GFP(+) /Ki-67(+) demonstrating grafted cells were present and actively proliferating within the grafted region. Trichrome staining of MSC/SIS-augmented bladders exhibited typical bladder architecture and quantitative morphometry analyses revealed an approximate 32% and 52% muscle to collagen ratio in unseeded versus seeded animals, respectively. H&E staining revealed a lack of infiltration of inflammatory cells in grafted animals and in corresponding kidneys and ureters. Simple cystometry indicated recovery between 28% and 40% of native bladder capacity. Data demonstrate MSC/SIS composites support regeneration of bladder tissue and validate this new bladder augmentation model.

Detrusor wraparound for bladder neck reconstruction in cohort of children with bladder exstrophy

OBJECTIVE

To evaluate the outcome of the detrusor wraparound bladder neck technique of bladder neck reconstruction in 28 children with bladder exstrophy.

METHODS

The records of all patients with bladder exstrophy who underwent detrusor wraparound bladder neck were reviewed. A total of 28 consecutive patients were identified and included 21 boys and 7 girls, with a mean age at surgery of 8.3 years. All patients had undergone previous exstrophy closure (17 staged and 11 complete). Of the 28 patients, 8 (29%) had undergone previous endoscopic injection of a bulking agent at the bladder neck. At surgery, 13 patients (46%) required concomitant ileocystoplasty and a continent outlet. Continence was defined as complete dryness with no urine leakage either through the urethra or the continent outlet.

RESULTS

The mean follow-up duration was 31 months (range 13-48). All augmented patients were continent using clean intermittent catheterization through the outlet. Complete dryness was achieved in 20 (71%) of 28 patients. However, the continence rate was only 47% in the nonaugmented group compared with 100% in the augmented group. Six of the incontinent children underwent bladder neck injection using a bulking agent but dryness was achieved in only 1 (17%).

CONCLUSION

The detrusor wraparound bladder neck technique is a viable option for bladder neck reconstruction for incontinent children after exstrophy closure. However, bladder augmentation and continent outlet construction are the pillars of optimal success. Injection of bulking agent at the bladder neck for failure has had poor success.

The molecular pathways behind bladder stretch injury

Stretch injury is a non-reversible process that changes the cellular and extracellular characteristics of the bladder wall, leading to bladder dysfunction. Posterior urethral valve and neurogenic bladder are examples of disorders that may lead to stretch injury. There is a lack of understanding of the molecular processes leading to stretch injury. The current literature is reviewed in this paper, with the aim of giving some insight into the molecular and genetic pathways of bladder stretch injury.

Neurogenic bladder: etiology and assessment

A review of the various causes of neurologic impairment to the lower urinary tract in children was the aim of this presentation. The emphasis was on diagnosis, pathophysiology, and treatment that strive to maintain as normal a function as possible in order to achieve eventual urinary continence and health of the upper urinary tract. The latest principles based on the most up to date evidence are promulgated but with an eye towards historical prospective. The reader should gain an adequate understanding of various disorders that comprise this condition and feel comfortable with proposing options for management when faced with the responsibility of caring for an affected child.