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Eke H, Hunt H, Ball S, Rogers M, Whear R, Allinson A, Melluish J, Lindsay C, Richardson D, Rogers J, Hutton E, Madden N, Wright A, Anderson R, Logan S, Thompson Coon J, Morris C. Improving continence in children and young people with neurodisability: a systematic review and survey. Health Technol Assess 2021; 25:1-258. [PMID: 34866570 DOI: 10.3310/hta25730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Children and young people with neurodisability often need help to achieve socially acceptable bladder and bowel control. Approaches vary depending on whether or not the impairment results from spinal cord pathology that impairs motor control and sensation of the bladder and bowel. Currently, there is uncertainty about which interventions are effective. OBJECTIVE The objective was to summarise the available evidence on and current practice for improving continence in children and young people with neurodisability. DESIGN A systematic review of the effectiveness, cost-effectiveness and factors that modify intervention implementation, alongside a cross-sectional, online survey of current practice with health professionals, parent carers, school and care staff and young people with neurodisability. RESULTS Twelve databases were searched in the review, resulting in 5756 references; 71 studies (72 papers) were included in the analyses. Most of the evidence was for children with spinal cord pathology, which involved evaluations of pharmacological approaches and surgical techniques, whereas the evidence pertaining to those with non-spinal-cord-related pathology tended to be for behavioural interventions. The methodological quality of studies was rated as being moderate to poor. There were three robust qualitative studies about the experience of continence among children with spinal cord pathology. We found substantial heterogeneity across the interventions that we evaluated in terms of quality, study design and outcomes measured. No economic studies were found. The results were synthesised narratively and reported in text and tables. We did not find any eligible studies evaluating interventions using toilet and clothing adaptations in the review, although the survey highlighted that these types of interventions are frequently used and considered. In total, 949 people responded to the survey: 202 health professionals, 605 parent carers, 122 school and social care staff, and 20 young people. The survey results illustrated the different roles that professionals have in improving continence, highlighting the importance of a multidisciplinary approach to supporting children and young people and their families. Clinicians employ a range of assessments and interventions to improve continence or independent toileting, depending on the needs of the child. LIMITATIONS Quantitative studies in the review were not methodologically robust. The survey had a risk of response bias. CONCLUSIONS Our research found a dearth of good-quality evidence for many of the interventions currently in use, and no evidence of experiences of implementing interventions for children with non-spinal-cord-related pathology. There was also no evidence of cost-effectiveness of any of the interventions. FUTURE WORK There is a need to involve young people and families in the design of high-quality evaluative research for interventions that aim to improve continence. This is especially the case for children with autism and learning disability, who have been neglected in previous evaluative and qualitative research. We recommend better training for health, education and care professionals about toileting, informed by evidence and the lived experiences of children and their families. We recommend a joined-up multidisciplinary and holistic approach to improving continence to maximise independence, dignity and comfort. It is vital that children and young people with neurodisability have early access to regular, integrated assessment of their bladder and bowel health, and are fully supported with appropriate personalised treatment. STUDY REGISTRATION This study is registered as PROSPERO CRD42018100572. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Helen Eke
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Harriet Hunt
- Evidence Synthesis & Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Susan Ball
- Health Statistics Group, University of Exeter Medical School, University of Exeter, Exeter, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Morwenna Rogers
- Evidence Synthesis & Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, Exeter, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Rebecca Whear
- Evidence Synthesis & Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, Exeter, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Annette Allinson
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Julia Melluish
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Claire Lindsay
- Paediatric Bladder and Bowel Care Team, Northern Devon Healthcare NHS Trust, Exeter, UK
| | | | - June Rogers
- Bladder & Bowel UK, Disabled Living, Manchester, UK
| | - Eve Hutton
- School of Allied Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Nicholas Madden
- Children's Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Anne Wright
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rob Anderson
- Evidence Synthesis & Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Stuart Logan
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Jo Thompson Coon
- Evidence Synthesis & Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, Exeter, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
| | - Christopher Morris
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Exeter, UK
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Use of the extracellular matrix from the porcine esophagus as a graft for bladder enlargement. J Pediatr Urol 2019; 15:531-545. [PMID: 31542362 DOI: 10.1016/j.jpurol.2019.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 03/08/2019] [Accepted: 07/15/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Some patients with diseases that involve increased bladder pressure or low-capacity bladders may need bladder enlargement surgery. In current techniques for bladder enlargement, autologous tissue such as small intestine or colon tissue is used to perform cystoplasties, which is far from ideal for these patients. In search of biomaterials with appropriate regeneration and safety profiles, tissue engineering has resulted in preclinical studies with acellular matrices in animal models that have yielded positive preliminary results with respect to the urothelial cell and smooth muscle repopulation; these studies have primarily been performed with matrices originating from the bladder or intestinal submucosa. OBJECTIVE The aim of the study was to assess an extracellular matrix device derived from the porcine esophagus for augmentation cystoplasty in an animal model. STUDY DESIGN Seven male Wistar rats weighing 357-390 g were subjected to augmentation cystoplasty with a circular segment of the acellular matrix from the porcine esophagus. Daily postoperative follow-up was performed with evaluation of changes in body weight, behavior, and wound status. RESULTS During follow-up, there were no complications associated with the process. Three specimens were sacrificed at day 30, and three, at day 60. Necropsy was performed, with a description of the macroscopic findings and a morphological study. Epithelialization was observed, with different stages of mucosal development in all specimens analyzed. Repopulation of smooth muscle cells, mixed inflammatory infiltrate, and vascular neoformation were identified in the matrices. DISCUSSION The urothelium and fibers of the smooth muscle were observed inside the implanted matrix. Additional investigations in larger animal models that allow urodynamic evaluation of the bladder with the matrix implanted are needed. However, to compare the results of this study model with those reported in the literature, a matrix derived from an organ different from the bladder was used because it could prevent the use of an intestinal segment in augmentation cystoplasty. CONCLUSION The acellular porcine esophagus matrix offers positive results regarding the repopulation of the urothelium and smooth muscle when used in augmentation cystoplasty in a murine model.
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Sinha S. Follow-up urodynamics in patients with neurogenic bladder. Indian J Urol 2017; 33:267-275. [PMID: 29021649 PMCID: PMC5635666 DOI: 10.4103/iju.iju_358_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/24/2017] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Neurogenic bladder patients are at long-term risk of secondary upper urinary tract damage. Symptoms are unreliable and follow-up urodynamics is the only method of ascertaining safety of bladder pressures. This review examines the recommendations, shortcomings and utilization of existing guidelines. The evidence with regard to follow-up urodynamics in different settings relevant to neurogenic bladder is evaluated and an algorithm is proposed. METHODS A pubmed search was conducted for studies on follow-up urodynamics in patients with neurogenic bladder. Additional search was made of secondary sources including reviews and guidelines. RESULTS The need for follow-up urodynamics should be considered in all patients undergoing an initial assessment and weighed against the risks. Existing guidelines, while unanimous in their recommendation of its utilization, give scant details regarding its incorporation in clinical management. Follow-up urodynamics can document efficacy and identify the need for escalation of therapy in patients on intermittent catheterization and antimuscarinics. Patients with spinal injury, spinal dysraphism and anorectal malformations are at higher risk for upper tract damage. Follow-up urodynamics can help identify patients suitable for intravesical botulinum and mark those destined for failure. Patients undergoing augmentation cystoplasty may be candidates for less aggressive urodynamic follow-up. CONCLUSIONS Neurogenic bladder is managed by a broad cross-section of physicians. Clear recommendations and a management algorithm are important for improving patient care. Follow-up urodynamics can identify patients at risk, prevent renal dysfunction and improve the quality of life. There is an urgent need for more evidence on this important subject.
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Affiliation(s)
- Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, Telangana, India
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Abstract
Neurogenic bladder is a heterogeneous entity that may result from a variety of conditions affecting the central or peripheral nervous systems. Regardless of etiology, the overall goals of management are primarily twofold. As a neurogenic bladder may affect the ability to store urine safely and to empty the bladder efficiently, early management is focused on optimization of bladder storage function to prevent irreversible injury to either the upper or lower urinary tracts. In older children, this goal is added to the challenge of maximizing quality of life through achievement of urinary continence and independence in bladder management that continues into the transition to adulthood. In this review, we seek to bring the reader up-to-date regarding management of the pediatric neurogenic bladder with a focus on literature published in the past year. We discuss key contributions related to fetal intervention for myelomeningocele, monitoring and medical management of the neurogenic bladder and prediction of postoperative outcomes. Put together, these studies highlight the continued need for further research to improve evidence-based medical and surgical decision-making strategies for children affected by neurogenic bladder.
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Affiliation(s)
- Renea M. Sturm
- Division of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Box 24, Chicago, IL 60611 USA
- Department of Urology, Feinberg School of Medicine at Northwestern University, 303 E. Chicago Ave, Chicago, IL 60611 USA
| | - Earl Y. Cheng
- Division of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Box 24, Chicago, IL 60611 USA
- Department of Urology, Feinberg School of Medicine at Northwestern University, 303 E. Chicago Ave, Chicago, IL 60611 USA
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