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Yadav PS, Kapoor K, Khanna V, Pant N, Roy Choudhury S, Chadha R. Management of urinary incontinence in girls with congenital pouch colon. Pediatr Surg Int 2024; 40:168. [PMID: 38954013 DOI: 10.1007/s00383-024-05757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE This study describes the management of urinary incontinence (UI) in eight girls with congenital pouch colon (CPC) associated with anorectal malformation (ARM). METHODS From 2013 to 2015, six girls with CPC and UI underwent bladder neck reconstruction (BNR). Four girls had complete UI (CUI) and two girls partial UI (PUI). From 2019 to 2023, four girls, including two with failed BNR, underwent bladder neck closure (BNC) and augmentation cystoplasty (AC) with a continent stoma. Subtypes of CPC were Complete CPC (n = 7) and Incomplete CPC (n = 1). All girls had a double vagina; short, wide urethra; and reduced bladder capacity with an open, incompetent bladder neck (BNI). During BNR, a neourethra was constructed from a 1.5-2 cm-wide and 1.5-3-cm-long trigonal strip. During BNC, AC was performed using a 20 cm ileal segment (n = 3) and by a colonic pouch segment, preserved during earlier colorraphy (n = 1). Continent stoma included a Monti's channel (n = 3) and appendicovesicostomy (n = 1). RESULTS BNR produced moderate improvement of UI (n = 2), while UI was still very severe (n = 4). During BNC, intraoperative complications included iatrogenic vaginal tears (n = 4). Early complications included partial dehiscence of the ileocystoplasty (n = 1), partial adhesive small bowel obstruction (n = 1), and difficulty in stomal catheterization with prolonged drainage from the pelvic drain (n = 1). Late complications included unilateral grade II vesicoureteric reflux (n = 2) and vesicovaginal fistula (VVF) (n = 2) needing trans-vaginal closure in one girl. Urinary stones (n = 2) with stomal leakage of urine in one girl needed open cystolithotomy twice (n = 1), and endoscopic lithotripsy (n = 1). At follow-up, all patients have high overall satisfaction with the procedure and their continence status. CONCLUSIONS BNC with AC and a catheterizable stoma satisfactorily achieves continence in girls with CPC and UI, vastly improving quality of life. If lower urinary tract (LUT) anatomy is favorable, BNR with/without AC can be the initial surgical procedure. BNC should be the primary procedure in girls with unfavorable LUT anatomy and for failed BNR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Partap Singh Yadav
- Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Kanu Kapoor
- Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Vikram Khanna
- Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Nitin Pant
- Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Subhasis Roy Choudhury
- Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, 110001, India
| | - Rajiv Chadha
- Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, 110001, India.
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Koch VH, Lopes M, Furusawa E, Vaz K, Barroso U. Multidisciplinary management of people with spina bifida across the lifespan. Pediatr Nephrol 2024; 39:681-697. [PMID: 37501019 DOI: 10.1007/s00467-023-06067-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Vera H Koch
- Pediatric Nephrology Unit, Department of Pediatrics, University of São Paulo Medical School, Children's Hospital, Hospital das Clinicas, Sau Paulo, Brazil.
| | - MarcosTomasin Lopes
- Pediatric Nephrology Unit, Department of Pediatrics, University of São Paulo Medical School, Children's Hospital, Hospital das Clinicas, Sau Paulo, Brazil
| | - Erika Furusawa
- Pediatric Nephrology Unit, Department of Pediatrics, University of São Paulo Medical School, Children's Hospital, Hospital das Clinicas, Sau Paulo, Brazil
| | - Katharinne Vaz
- Division of Urology, Federal University of Bahia - UFBA, Salvador, BA, Brazil
| | - Ubirajara Barroso
- Division of Urology - Federal University of Bahia, Bahiana School of Medicine, Salvador, BA, Brazil
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Gargollo PC, White LA. Robotic-Assisted Bladder Neck Procedures for Incontinence in Pediatric Patients. Front Pediatr 2019; 7:172. [PMID: 31134167 PMCID: PMC6514215 DOI: 10.3389/fped.2019.00172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/12/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose: To review the current status of bladder neck procedures for incontinence in pediatric patients, focusing on the increasing role of robotic-assisted laparoscopic surgical techniques. Methods: A comprehensive review of the literature on open and robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 20 years. This data was subsequently compared with published results from robotic-assisted bladder neck reconstruction series completed at our institution. Results: The principal bladder neck procedures for incontinence in pediatric patients include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including: low intraoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation. Conclusions: Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with previous open abdominal surgery.
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Affiliation(s)
- Patricio C Gargollo
- Division of Pediatric Urology, The Mayo Clinic and Mayo Medical School, Rochester, MN, United States
| | - Lindsay A White
- The University of Washington School of Medicine, Seattle, WA, United States
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Wyndaele JJ, Birch B, Borau A, Burks F, Castro-Diaz D, Chartier-Kastler E, Drake M, Ishizuka O, Minigawa T, Opisso E, Peters K, Padilla-Fernández B, Reus C, Sekido N. Surgical management of the neurogenic bladder after spinal cord injury. World J Urol 2018; 36:1569-1576. [DOI: 10.1007/s00345-018-2294-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/05/2018] [Indexed: 10/17/2022] Open
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Phé V, Boissier R, Blok BFM, Del Popolo G, Musco S, Castro-Diaz D, Padilla Fernández B, Groen J, Hamid R, 't Hoen L, Ecclestone H, Kessler TM, Gross T, Schneider MP, Pannek J, Karsenty G. Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review. Neurourol Urodyn 2017; 36:1711-1722. [PMID: 28139848 DOI: 10.1002/nau.23213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 11/11/2022]
Abstract
AIMS To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients. METHODS The search strategy and studies selection were performed on Medline, Embase, and Cochrane using the PICOS method according to the PRISMA statement (CRD42015019212; http://www.crd.york.ac.uk/PROSPERO). RESULTS After screening 3,634 abstracts, 11 studies (all retrospective, enrolling 213 patients) were included in a narrative synthesis. Mean follow-up ranged from 21.6 months to 8.7 years (median: 36 months, IQR 28.5-44). At last follow-up, the ability to catheterize rate was ≥84% (except in one study: 58.3%) and the continence rate at stoma was >75%. Data comparing health-related quality-of-life before and after surgery were not available in any study. Overall, 85/213 postoperative events required reoperation: 7 events (7 patients) occurring ≤3 months postoperatively, 22 events (16 patients) >3 months, and 56 events (55 patients) for which the time after surgery was not specified. Sixty additional complications (60 patients) were reported but did not require surgical treatment. Tube stenosis occurred in 4-32% of the cases (median: 14%, IQR 9-24). Complications related to concomitant procedures (augmentation cystoplasty, pouch) included neovesicocutaneous fistulae, bladder stones, and bladder perforations. Risk of bias and confounding was high in all studies. CONCLUSIONS CCS/T appears to be an effective treatment option in adult neuro-urological patients unable to perform intermittent self-catheterization through the urethra. However, the complication rate is meaningful and the quality of evidence is low, especially in terms of long-term outcomes including the impact on the quality-of-life.
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Affiliation(s)
- Véronique Phé
- Department of Urology, Pitié-Salpêtrière Academic Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris, France
| | - Romain Boissier
- Department of Urology, La Conception Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Giulio Del Popolo
- Department of Neuro-Urology, Careggi University Hospital, Florence, Italy
| | - Stefania Musco
- Department of Neuro-Urology, Careggi University Hospital, Florence, Italy
| | - David Castro-Diaz
- Department of Urology, Hospital Universitario de Canario, Universidad de La Laguna, Tenerife, Spain
| | | | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rizwan Hamid
- Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, United Kingdom
| | - Lisette 't Hoen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hazel Ecclestone
- Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, United Kingdom
| | - Thomas M Kessler
- Department of Neuro-Urology, Spinal Cord Injury Center & Research, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | - Tobias Gross
- Department of Urology, University of Bern, Inselspital, Bern, Switzerland
| | - Marc P Schneider
- Department of Neuro-Urology, Spinal Cord Injury Center & Research, University of Zürich, Balgrist University Hospital, Zürich, Switzerland.,Brain Research Institute, University of Zürich, Zürich, Switzerland.,Department of Health Sciences and Technology, Swiss Federal Institute of Technology Zürich, Zürich, Switzerland
| | - Jürgen Pannek
- Department of Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
| | - Gilles Karsenty
- Department of Urology, La Conception Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
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Carrasco A, Vemulakonda VM. Managing adult urinary incontinence from the congenitally incompetent bladder outlet. Curr Opin Urol 2016; 26:351-6. [PMID: 27096718 DOI: 10.1097/mou.0000000000000296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Treatment of urinary incontinence in adult patients with congenital incompetent bladder outlet (exstrophy-epispadias complex, cloacal anomalies, or neurogenic bladder secondary to myelomeningocele) is a challenging surgical problem. In this review article, we summarize and highlight recent studies in the management of incontinence in this patient population. RECENT FINDINGS The literature regarding management of urinary incontinence in this patient population is scarce. Injection of bulking agents to the bladder neck, artificial/autologous slings, artificial urinary sphincters, bladder neck reconstruction, bladder neck closure, or a combination of these are the cornerstone of management. Augmentation cystoplasty is a major adjunct procedure that can help increase continence rate and success of surgery in select patients. The level of evidence on bladder neck procedures for this patient population is low because of significant limitations, including small sample, heterogeneity of primary diagnosis/surgical techniques, variable definitions of continence, and the retrospective nature of most studies in this field. SUMMARY Standard options for treatment of urinary incontinence in the congenitally incompetent bladder outlet procedure remain unchanged. There is no single reproducible procedure to accomplish the goal of renal preservation and continence in these patients, and often patients require multiple procedures to achieve continence. Most importantly, the pediatric and adult urologist should continue to work toward achieving a well tolerated and efficient transition of care. There is a need to standardize data acquisition and reporting of outcomes. Although randomized control studies would be ideal, because of the small number of patients with these conditions, this may not be practical. Collaboration and continued discussion among experts in the field is needed to gain a better understanding of the optimal management strategy in this growing patient population.
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Affiliation(s)
- Alonso Carrasco
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, Colorado, USA
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Snodgrass W, Granberg C. Clinical indications for augmentation in children with neurogenic urinary incontinence following bladder outlet procedures: Results of a 14-year observational study. J Pediatr Urol 2016; 12:46.e1-8. [PMID: 26429598 DOI: 10.1016/j.jpurol.2015.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 06/18/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE We report continence, upper tract changes, and augmentation indications and rates in consecutive patients undergoing bladder outlet surgery without augmentation for neurogenic urinary incontinence. METHODS From 2000 to 2007, 37 patients underwent bladder neck sling (BNS), and from 2007 to 2013, 45 patients had Leadbetter/Mitchell bladder neck revision plus sling (LMS), all without augmentation. Mitrofanoff channels were created in all cases. Twenty children with persistent outlet insufficiency underwent bladder neck closure (BNC). All patients had pre- and postoperative urodynamic testing (UD). RESULTS Mean follow-up was 60 months after BNS, 38 months after LMS, and 29 months after BNC. Continence (dry, no pads) was achieved significantly more often with LMS versus BNS (66% vs. 37%). There were no significant differences between these patients in preoperative UD % capacity, end filling pressure (EFP), or compliance. Those that became dry had a greater % capacity on postoperative UD, but postoperative EFP was similar between dry and wet LMS and BNS patients. BNC resulted in dryness in 65% of patients, with most incontinence occurring from the Mitrofanoff stoma associated with filling pressures > 40 cm. A total of 10 (12%) children had augmentation, seven after BNC. Clinical indications were end filling pressures > 40 cm plus hydronephrosis ≥ grade 3, and/or persistent incontinence. Need for augmentation was not predicted by preoperative urodynamic parameters. Postoperative UD in those who were augmented showed significantly less % capacity and compliance, and significantly greater EFP, than those not augmented. CONCLUSIONS Dryness was achieved in only 33% of BNS versus 66% of LMS and BNC patients. Twelve percent of consecutive children undergoing bladder outlet surgery for neurogenic incontinence developed clinical parameters leading to augmentation. These occurred most often after BNC.
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Affiliation(s)
| | - Candace Granberg
- Division of Pediatric Urology, Department of Urology, Mayo Clinic, USA
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Bladder Neck Closure in Conjunction with Enterocystoplasty and Mitrofanoff Diversion for Complex Incontinence: Closing the Door for Good. J Urol 2012; 188:1561-5. [DOI: 10.1016/j.juro.2012.02.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Indexed: 11/24/2022]
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Abstract
Bladder dysfunction following colorectal surgery may be related to extirpative procedures in the region of the pelvic autonomic plexus. The most common etiology is from autonomic disruption during abdominoperineal or low anterior resections. Contemporary technical modifications have allowed surgeons to achieve oncologic control while preserving the autonomic nerves that innervate the bladder and sexual organs. Although these modifications have resulted in a significant decrease in the incidence of postoperative bladder dysfunction, bladder dysfunction continues to be a source of significant morbidity after surgery. In this patient population, symptoms are not reliable for accurate diagnosis. The use of urodynamics provides objective measurements of bladder and outlet function and are paramount in providing an accurate diagnosis and in recommending treatments. Follow-up and treatment are highly individualized based on urodynamic findings, patient expectations, patient abilities, and family support. This article provides an overview of pertinent neuroanatomy, diagnosis, urodynamic interpretation, and treatment related to bladder dysfunction following pelvic colorectal surgery.
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Affiliation(s)
- Scott E Delacroix
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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De Troyer B, Van Laecke E, Groen LA, Everaert K, Hoebeke P. A comparative study between continent diversion and bladder neck closure versus continent diversion and bladder neck reconstruction in children. J Pediatr Urol 2011; 7:209-12. [PMID: 20488754 DOI: 10.1016/j.jpurol.2010.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess the long-term outcome of continent diversion in children with structural or neurogenic cause of incontinence, with special interest in differences between closed and open bladder neck procedures. PATIENTS AND METHODS A cohort of 63 children with intractable incontinence treated with continent diversion between January 1998 and January 2008 were reviewed for underlying disease, type of surgery, complications and outcome. RESULTS Forty patients had a continent diversion with open bladder neck (group 1) and 23 patients had their bladder neck closed (group 2: 11 primarily closed; 12 secondarily closed). There was no difference between the two groups in terms of patient characteristics, surgical re-interventions and stone formation. The continence rate however was significantly better in group 2 (95.6% vs 77.5%). CONCLUSION Bladder neck closure with continent diversion as primary or salvage procedure in children with intractable incontinence does not result in extra morbidity and has a high success rate. Thorough urodynamic evaluation of bladder function is the key to success in therapy planning for these children, to minimize the need for re-intervention.
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Affiliation(s)
- Bart De Troyer
- Department of Urology & Paediatric Urology, Ghent University Hospital, Ghent 9000, Belgium
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Improved Continence in Patients With Neurogenic Sphincteric Incompetence With Combination Tubularized Posterior Urethroplasty and Fascial Wrap: The Lengthening, Narrowing and Tightening Procedure. J Urol 2010; 184:1763-7. [DOI: 10.1016/j.juro.2010.03.080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Indexed: 11/22/2022]
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Abstract
Initial care of newborns with spina bifida centers on preventing bladder and upper tract damage from detrusor leak point pressure of greater than 40 cm H(2)O. The authors recommend using urodynamic-based management to select patients with elevated pressures for anticholinergic therapy and intermittent catheterization (CIC), using diapers and observation with biannual renal sonography for the remainder. At the age of toilet training, children who have urodynamic evidence of uninhibited contractions or rising pressure during filling are started on anticholinergics and CIC, or have their dosage increased until pressures less than 40 cm H(2)O and areflexia are achieved. Sphincter incompetency is diagnosed in incontinent children with pressures less than 40 cm H(2)O and areflexia or stress incontinence. Augmentation is indicated in patients with hydronephrosis or reflux and end-filling pressures or DLPP less than 40 cm H(2)O despite medical management to the point of patient tolerance. A minority of patients, not yet well-defined, will also need augmentation after bladder outlet surgery for similar postoperative indications.
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Affiliation(s)
- Warren T Snodgrass
- Department of Urology, University of Texas Southwestern Medical Center and Children's Medical Center, Dallas, TX 75207, USA.
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