1
|
Reppucci ML, Harris KT, Wilcox DT, Peycelon M, Bischoff A. Adult urological outcomes for patients with anorectal malformation. J Pediatr Urol 2024; 20:193-199. [PMID: 38184446 DOI: 10.1016/j.jpurol.2023.12.015] [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: 06/13/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/08/2024]
Abstract
Anorectal malformations (ARM) are rare congenital anomalies characterized by a spectrum of defects resulting in the absence of a normal anal opening with or without fistula. Urogenital involvement is common, and the fistulous tract may terminate in the genitourinary system in males or within gynecological structures in females. Surgical reconstruction occurs early in life and survival of these patients to adulthood is the norm. There has, therefore, been increased focus on their long-term outcomes to better anticipate and treat the sequelae that may impact their health and well-being as this population ages. For urologists, urinary health, sexual function, and fertility outcomes are of particular interest among this population. This article aims to provide a review of urological, sexual, and fertility outcomes for individuals born with ARM with a focus on key issues that may occur later in life to ensure adequate counseling, screening, and treatment.
Collapse
Affiliation(s)
- Marina L Reppucci
- Department of General Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Kelly T Harris
- Division of Pediatric Urology, Children's Hospital of Colorado, Aurora, CO, USA
| | - Duncan T Wilcox
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, National Reference Center for Rare Urinary Tract Malformations (MARVU), Robert-Debré University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), INSERM, UMR NeuroDev 1141, Université Paris Cité, Paris, France
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.
| |
Collapse
|
2
|
de Beaufort CMC, Boom DT, Mackay TM, Dekker JJML, Arguedas Flores OE, de Jong JR, Kuijper CF, Gorter RR. Potential benefits of routine cystoscopy and vaginoscopy prior to reconstructive surgery in patients with an anorectal malformation. Pediatr Surg Int 2023; 39:284. [PMID: 37889354 PMCID: PMC10611826 DOI: 10.1007/s00383-023-05565-0] [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: 10/07/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE First, to assess the number of patients with anorectal malformations (ARM) in whom additional urological and/or gynecological anomalies were identified through routine screening with cysto- or vaginoscopy prior to reconstructive surgery. Second, to assess potential procedure-related complications. METHODS Retrospective mono-center cohort study, including all ARM patients born between January 2019 and December 2022. Routine screening consisted of cystoscopy for male patients, with the addition of vaginoscopy for female patients. Chi-square was used to compare the screening percentages over time. RESULTS In total, 38 patients were included, of whom 27 (71.1%) underwent cystoscopy ± vaginoscopy, without the occurrence of complications. Nine of 13 females (69.2%) underwent cysto- and vaginoscopy and 18 of 25 males (72.0%) underwent a cystoscopy. The percentage of patients that underwent these procedures improved over the 2 time periods (50.0% in 2019-2020 vs 90.0% in 2021-2022, p = 0.011). In 15 of 27 patients (55.6%) that underwent cystoscopy ± vaginoscopy, additional anomalies were found that were not identified through physical examination or US-kidney. CONCLUSIONS In 56% of the patients that underwent cysto- ± vaginoscopy, additional anomalies were identified that were not with imaging studies or physical examination. This study emphasizes the potential benefit of routine cysto- and vaginoscopy in the diagnostic work-up of children with ARM. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Cunera M C de Beaufort
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam UMC, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Daphne T Boom
- Department of Pediatric Urology, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tara M Mackay
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Judith J M L Dekker
- Amsterdam UMC, Department of Gynecology, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Olga E Arguedas Flores
- Department of Pediatric Urology, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Justin R de Jong
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Caroline F Kuijper
- Department of Pediatric Urology, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Kennedy U, Daugherty M, Frischer J, DeFoor W, Strine AC, Reddy PP, Sheldon C, Minevich E, VanderBrink BA. Reoperative Anorectal Procedures in Patients with Anorectal Malformations - Is Bladder Function Affected? J Pediatr Surg 2023; 58:1910-1915. [PMID: 37217362 DOI: 10.1016/j.jpedsurg.2023.04.015] [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: 12/24/2022] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Anorectal malformations (ARM) are associated with neurogenic bladder. The traditional surgical ARM repair is a posterior sagittal anorectoplasty (PSARP), which is believed to have a minimal effect on bladder dynamics. However, little is known about the effects of reoperative PSARP (rPSARP) on bladder function. We hypothesized that a high rate of bladder dysfunction existed in this cohort. METHODS We performed a retrospective review of ARM patients undergoing rPSARP at a single institution from 2008 to 2015. Only patients with Urology follow-up were included in our analysis. Data was collected regarding original level of ARM, coexisting spinal anomalies and indications for reoperation. We assessed urodynamic variables and bladder management (voiding, CIC or diverted) before and after rPSARP. RESULTS A total of 172 patients were identified, of which 85 met inclusion criteria with a median follow-up of 23.9 months (IQR, 5.9-43.8 months). Thirty-six patients had spinal cord anomalies. Indications for rPSARP included mislocation (n = 42), posterior urethral diverticulum (PUD; n = 16), stricture (n = 19) and rectal prolapse (n = 8). Within 1 year following rPSARP, 11 patients (12.9%) had a negative change in bladder management, defined as need for beginning intermittent catheterization or undergoing urinary diversion, which increased to 16 patients (18.8%) at last follow-up. Postoperative bladder management changed in rPSARP patients with mislocation (p < 0.0001) and stricture (p 0.005) but not for rectal prolapse (p 0.143). CONCLUSIONS Patients who undergo rPSARP warrant especially close attention for bladder dysfunction as we observed a negative postoperative change in bladder management in 18.8% of our series. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Uchenna Kennedy
- University Children's Hospital of Zurich, University of Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Michael Daugherty
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jason Frischer
- Cincinnati Children's Hospital Medical Center, Department of Pediatric Surgery, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - William DeFoor
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Andrew C Strine
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Pramod P Reddy
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Curtis Sheldon
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Eugene Minevich
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Brian A VanderBrink
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| |
Collapse
|
4
|
Harris KT, Wilcox DT. Management of the urological tract in children with anorectal malformations - a contemporary review. Ther Adv Urol 2023; 15:17562872231161468. [PMID: 36969498 PMCID: PMC10034273 DOI: 10.1177/17562872231161468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
Anorectal malformations (ARMs) consist of a broad spectrum of congenital anomalies that are associated with an equally wide variety of urological abnormalities, often with increasing incidence as the severity of the ARM increases. The importance of urologic involvement in the care of ARM patients has been noted for decades and is critical from birth to adulthood. Urology must be involved in the initial evaluation and operative care of the child as well as in monitoring and managing issues such as neurogenic bladder, renal disease, and eventually sexual function and fertility. Care of the ARM patient must be done through a multidisciplinary lens, with the urologist as a key player. This review will serve as an update on the management of the urologic tract in children with ARM.
Collapse
Affiliation(s)
| | - Duncan T. Wilcox
- Division of Urology, Department of Surgery,
Children’s Hospital Colorado, University of Colorado Anschutz Medical
Campus, Aurora, CO, USA
| |
Collapse
|
5
|
Reppucci ML, Wehrli LA, Wilcox D, Ketzer J, Pena A, de la Torre L, Bischoff A, Wood D. Patient-reported urinary outcomes in adult males with congenital colorectal conditions. Pediatr Surg Int 2022; 38:1709-1716. [PMID: 36151341 DOI: 10.1007/s00383-022-05215-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Long-term urinary outcomes for patients born with Hirschsprung disease (HD) and anorectal malformations (ARM) may impact their health and wellbeing into adulthood. This study describes self-reported long-term urinary outcomes in males with HD and ARM. METHODS This was a prospective study of male patients in the Adult Colorectal Research Registry who completed surveys on urinary function between October 2019 and March 2022. Self-reported health and functional outcomes were summarized, and differences based on type of condition were compared. RESULTS Sixty-seven patients completed the questionnaire (response rate: 59.1%), of which 17.9% (12) had HD and 82.1% (55) had an ARM. Rates of urinary incontinence and stress urinary incontinence were 16.4% (11) and 4.5% (3), respectively. On sub-analysis of patients with ARM, patients with sacral ratio (SR) of 0.4-0.69 reported higher UTI rates compared to those with SR ≥ 0.7 (57.9 vs 25.8%, p = 0.023). Renal failure rates were highest among patients with recto-bladder neck fistulas (66.0%, p = 0.012). CONCLUSION Patients with HD and ARM report a variety of urological sequelae in adulthood. Outcomes appear to be more common in patients with ARM and may be impacted by both anatomy and sacral ratios. Transitional care to monitor and manage renal and urological function is imperative.
Collapse
Affiliation(s)
- Marina L Reppucci
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Lea A Wehrli
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Duncan Wilcox
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Jill Ketzer
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Alberto Pena
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Luis de la Torre
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Dan Wood
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA.
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave Anschutz Medical Campus, Box 323, Aurora, CO, 80045, USA.
| |
Collapse
|
6
|
Anatomic factors predict urinary continence in patient with anorectal malformation. J Pediatr Urol 2020; 16:545.e1-545.e7. [PMID: 32798105 DOI: 10.1016/j.jpurol.2020.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 11/21/2022]
Abstract
It has been described that patients with more complex anorectal malformations (ARM), lower sacral ratios and spinal anomalies have poorer rates of fecal and urinary continence. While the ARM subtype has been shown to be an independent predictor of fecal continence, it is not well understood how each of these anatomic factors impact urinary continence. The purpose of this study was to identify anatomic factors associated with urinary continence in children born with ARM. We performed a retrospective review of a large prospectively collected database of children with ARM. Inclusion criteria included diagnosis of ARM, age >4 years, available lateral sacral ratio measurement and presence of spinal MRI. Any child with incomplete or absent continence data was excluded. Continence was defined as voiding per urethra volitionally, dry between voids and ≤1 urinary accident per week. Bivariable tests of association and log-binomial regression models were used to examine association between anatomic factors and urinary continence. A total of 434 patients were included in the study. 57.8% (n = 251) were male. Median age was 8.4 years (IQR 6.0-12.3). With regards to severity of ARM, 20.3% (n = 88) were complex, 23.3% (n = 101) were moderate and 56.5% (n = 245) were simple. Lateral sacral ratio included 11.1% (n = 48) that were <0.4, 36.2% (n = 157) 0.4-0.7 and 52.8% (n = 229) > 0.7. Spine status was found to be myelomeningocele in 4.4% (n = 19), low conus or tethered cord in 34.8% (n = 151) and normal or fatty filum in 60.8% (n = 264). Overall 62.2% were continent. ARM severity, lateral sacral ratio and spine status were each independent predictors of urinary continence on univariate and multivariable analysis. We conclude that in children born with ARM, the severity of ARM, lateral sacral ratio and spine status each independently predict urinary continence. These results allow us to better understand these complex patients and their ability to develop urinary continence. This is crucial in enabling proper patient and family counseling and thus, setting appropriate expectations.
Collapse
|
7
|
Ahmed H, Almomani M, Strine AC, Reddy PP, Sheldon C, Frischer J, Breech L, Minevich E, Noh PH, VanderBrink BA. Clinical urologic and urodynamic outcomes in patients with anorectal malformation and absent vagina after vaginal replacement. J Pediatr Surg 2020; 55:1834-1838. [PMID: 32087935 DOI: 10.1016/j.jpedsurg.2020.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/17/2019] [Accepted: 01/27/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES Anorectal malformations (ARMs) represent a complex spectrum of anorectal and genitourinary anomalies and a paucity of evidence is available on long-term urologic outcomes in all ARM subtypes. It was our subjective bias from being a referral center for ARM patients that the subtype of rectovestibular fistula and absent vagina had higher risk of renal and bladder abnormalities than typical rectovestibular fistula patients. Therefore, to confirm or refute our clinical suspicions, the purpose of this study was to review this specific cohort of ARM patients and describe both the clinical urological and urodynamic outcomes. METHODS A retrospective cohort study was performed for 120 patients who were treated for ARM and vaginal replacement at our institution between 1991 and 2017. Fifteen patients with rectovestibular fistula and absent vagina were included in our review. Demographic and clinical data were abstracted from their medical records, including urodynamic findings, need for clean intermittent catheterization (CIC), urinary continence, and renal function. RESULTS Vaginal replacement surgery was undertaken concomitantly with ARM repair in 10 of the 15 patients (67%). One patient was lost to follow up, and mean follow up postoperatively was 39 months. In all but one patient, rectum or colon was used as the substrate for vaginal replacement. Of the 15 patients, 13 had continence data available. A total of 10 patients (77%) were able to achieve social continence. Overall six patients used CIC to manage their bladder and 40% of continent patients used CIC. Urinary continence outcomes in patients who had partial vaginal replacement compared to those with total vaginal replacement did not reveal a clinically significant difference. Continence was achieved in 3/4 patients (75%) with a history of tethered cord compared to 7/9 patients (78%) without a history of tethered cord release. Urodynamics were performed postoperatively in 7 of the 157 patients (47%). Uninhibited detrusor contractions (UDCs) were present in 3 out of 7 patients, and a cystometric capacity greater than expected was noted in 4 patients. Additionally, 2 patients had end filling detrusor pressure greater than 40 cm H2O. GFR data were available for 13 of the 15 patients and (85%) were classified as chronic kidney disease (CKD) stage I or not having any significant loss of renal function. CONCLUSIONS In this cohort of rectovestibular fistula and absent vagina, 77% reported achieving urinary continence. However CIC was employed in 40% of the patients which is higher than prior published noncloaca female ARM patient population. Urodynamic abnormalities were noted when performed and led to change in bladder management. Renal function measured with GFR was normal in 85%. Patients with rectovestibular fistula and absent vagina benefit from urologic screening given higher rates of lower urinary tract dysfunction that can require CIC to protect the upper urinary tract and achieve urinary continence. TYPE OF STUDY Case series. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Haris Ahmed
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Mosab Almomani
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Andrew C Strine
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Pramod P Reddy
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Curtis Sheldon
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Jason Frischer
- Cincinnati Children's Hospital Medical Center, Department of Pediatric Surgery, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Lesley Breech
- Cincinnati Children's Hospital Medical Center, Division of Pediatric and Adolescent Gynecology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Eugene Minevich
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Paul H Noh
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229
| | - Brian A VanderBrink
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Urology, 3333 Burnet Avenue, Cincinnati, OH 45229.
| |
Collapse
|
8
|
Ball JN, Pimpalwar A, Vachharajani A. Infant of a Diabetic Mother With an Anomaly. Neoreviews 2020; 21:e361-e366. [PMID: 32358151 DOI: 10.1542/neo.21-5-e361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jamie N Ball
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO, Women's and Children's Hospital, Columbia, MO
| | - Ashwin Pimpalwar
- Department of Pediatric Surgery, University of Missouri School of Medicine, Columbia, MO, Women's and Children's Hospital, Columbia, MO
| | - Akshaya Vachharajani
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO, Women's and Children's Hospital, Columbia, MO
| |
Collapse
|