Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience

Methods of prolonging the effect of caudal block in children

Caudal epidural blockade is one of the most frequently administered regional anesthesia techniques in children. It is a supplement during general anesthesia and for providing postoperative analgesia in pediatrics for sub-umbilical surgeries, especially for genitourinary surgeries. However, the duration of the analgesic effect is occasionally unsatisfactory. In this review, we discuss the main advantages and disadvantages of different techniques to prolong postoperative analgesia for single-injection caudal blockade in children. A literature search of the keywords "caudal", "analgesia", "pediatric", and "children" was performed using PubMed and Web of Science databases. We highlight that analgesic quality correlates substantially with the local anesthetic's type, dose, the timing relationship between caudal block and surgery, caudal catheterization, and administration of epidural opioids or other adjuvant drugs.

Perioperative management of primary classic bladder exstrophy: A single institutional pathway to success

PURPOSE

Appropriate perioperative management is crucial in patients undergoing classic bladder exstrophy closure (CBE). Therefore, the authors sought to review their intra and postoperative management of patients with CBE undergoing primary closure and examine the impact of this pathway on patient outcomes.

METHOD

A prospectively maintained institutional approved exstrophy-epispadias complex database was reviewed for patients with CBE who had undergone primary closure between 2016 and 2022 and whose closure was performed within one year of age. Electronic medical records for eligible patients were retrospectively reviewed to examine patient demographics, use of pelvic osteotomy, immobilization status, pediatric intensive care unit (PICU) admission and management, perioperative analgesia and sedation, nutritional support, drainage tubes, blood transfusions, antibiotic coverage, hospital length of stay, postoperative complications, and closure failure.

RESULTS

A total of 25 patients were identified, 22 with CBE and 3 with variant CBE. Closure was performed at a median age of 84 days with patients ranging in age from 9 to 351 days. All patients underwent osteotomy and immobilization with modified Buck's traction and external fixation for a median duration of 41 days. A suprapubic tube was placed in all patients for a median duration of 46.5 days. All patients underwent PICU admission following closure for a median duration of 8 days. Ventilator support was required in 68 % of patients for a median of 3 days. Epidural analgesia was used in all patients and catheters were maintained for a median duration of 19 days. All patients received a blood transfusion over the course of their admission. Patient-controlled analgesia was used in most patients as an adjunct for a median duration of 38.5 days. Other commonly used analgesic adjuncts included acetaminophen, diazepam, clonidine, and dexmedetomidine. TPN was used in 80 % of patients for a median of 7 days with a return of oral feeding thereafter. Overall, the closure success rate in this cohort of patients was 100 %.

DISCUSSION

The outcome of primary bladder closure can have inauspicious consequences that can affect a child's continence for years. The incidence of failed bladder closure can be minimized with the implementation of a detailed plan for immobilization, analgesia, and nutrition guided by an experienced multi-disciplinary team.

CONCLUSION

We have identified several guiding principles for perioperative success in exstrophy patients at our center including Buck's traction with external fixation, provision of adequate postoperative analgesia and sedation, aggressive nutritional support, renal and bladder drainage, and robust antibacterial support. Our high success rate in managing this complex pathology demonstrates its validity and use as a pathway to success.

Long term evaluation of continence after complete primary bladder exstrophy repair

INTRODUCTION

Continence after bladder exstrophy (BE) repair remains a major debatable challenge to pediatric urologists, together with the lack of standard definitions and long-term results in large series.

OBJECTIVE

We assessed the long-term urinary continence in 142 toilet-trained cases after one (1-) stage of complete primary repair of bladder exstrophy (CPRE) and consequent procedures to achieve this goal in a single tertiary referral center.

STUDY DESIGN

The current retrospective study included 123 boys and 19 girls with BE that were repaired by (1-) stage CPRE. The Mean age at (BE) repair was 9.5 ± 2.6 weeks. Complete penile disassembly (CPD) was used for epispadias repair in 42 (34.1%) and modified Cantwell-Ransley repair (MCR) was used in 81 (65.9%) boys. Bilateral anterior transverse innominate osteotomies (ATIO) were applied in all. Urinary continence was expressed in terms of the dry interval (DI). Continence procedures were afforded if CPRE failed to achieve DI ≥ 3 h (hrs.), those were in the form of endoscopic bladder neck injection (BNI), bladder neck reconstruction (BNR), and bladder neck closure (BNC) with catheterizable stoma.

RESULTS

The mean age at follow up was 12.1 ± 5.2 years. DI ≥ 3 h was gained in 23 (16.2%) after CPRE alone, while complementary post-CPRE continence procedures were required to reach this goal in the remaining patients. Deflux injection was reported in 10 (7%), CIC in 8 (5.6%), BNR in 32 (22.5), and BNC with catheterizable stoma alone in 37 (26.1%), or with Charleston pouch in 32 (22.5%).

DISCUSSION

We think that ≥3 h DI with voiding represents an appropriate definition of continence after BE repair. According to the results in the current series, we think that successful anatomical closure of BE is achievable, but the functional outcome in terms of continence and its evaluation is tricky. Results of continence were reported to change with age of the child, and it is difficult to evaluate both before toilet training age and long-term follow up.

CONCLUSIONS

Long-term follow up of CPRE with bilateral ATIO alone or with BNI results in ≥3 h DI in a few cases; BNR after CPRE can provide a good chance for continence; otherwise, BNC with catheterizable stoma is a valid option.

Prevalence of opioid and benzodiazepine use in adult patients with the exstrophy-epispadias complex

INTRODUCTION

Bladder exstrophy (BE), cloacal exstrophy (CE), and epispadias (E) are variants of the exstrophy-epispadias complex (EEC). These children require opioids and benzodiazepines to achieve pain management and immobilization for a lifetime of surgeries. It is hypothesized that these children would be sensitized to opiates and benzodiazepines as adults. The objective was to identify incidence of opiate and benzodiazepine use in adult EEC patients.

METHODS

A US Health network, TriNetX Diamond was queried from 2009 to 2022. Incidence of prescriptions for benzodiazepines and opioids were calculated for adults aged 18-60 years with a diagnosis of BE, CE, or E.

RESULTS

A total of 2627 patients were identified: 337 with CE, 1854 patients with BE, and 436 with E. Of these, 55.5% of CE, 56.4% of BE, and 41.1% of E had received any opioid prescription. Non-EEC controls had lower rates of opioids at 0.3%. E had a lower likelihood than BE or CE of receiving opioids (p < 0.0001, p < 0.0001). Benzodiazepines were prescribed in 30.3% of CE, 24.4% of BE, 18.3% of E, and 0.1% of controls. CE had a higher likelihood of benzodiazepines than both BE and E (p = 0.022, p < 0.001, respectively). E group had the lowest likelihood of benzodiazepine prescription (p = 0.007 when compared to BE) and all groups were significantly higher than controls (p < 0.0001 for all comparisons). For BE, females were more likely to be prescribed opioids (p = 0.039) and benzodiazepines (p = 0.027) than males. Sub-analyses revealed BE females had higher rates of surgical procedures (general, cardiac, gastrointestinal, and maternity) and chronic diagnoses (generalized anxiety disorder, major depressive disorder, chronic pain) compared to males with BE. Older age was associated with higher likelihood of opioid or benzodiazepine prescriptions in BE (p < 0.001), CE (p = 0.004), and E (p = 0.002).

DISCUSSION

Across the EEC, adult patients with the most severe anomalies of CE were more likely to have received opioids and benzodiazepines. Females with BE were prescribed more opioid and benzodiazepines than males with BE. Mirroring the US population, female sex and increasing age were associated with higher rates of prescriptions, chronic diagnoses, and surgical procedures. Limitations include the lack of granular data and ability to correlate results with childhood surgeries.

CONCLUSION

Adult EEC patients have higher rates of opioid and benzodiazepine prescriptions, with a high percentage of co-prescribing when compared to healthy controls. Across the spectrum, those with more severe anomalies, female sex, and increasing age were more likely to have received prescriptions.

Application of Continuous Sacral Block Guided by Ultrasound After Comprehensive Sacral Canal Scanning in Children Undergoing Laparoscopic Surgery: A Prospective, Randomized, Double-Blind Study

Purpose

The present study aimed to explore the effects of continuous sacral block on the postoperative pain of children and the satisfaction of the nurses in post-anesthesia care unit (PACU). Also, the influence of the modified protocol of continuous sacral block was investigated.

Patients and Methods

A total of 60 children undergoing laparoscopic surgery were randomly divided into two groups: GI and GC groups. The general anesthesia was induced with midazolam, propofol, sufentanil and succinylcholine in both groups. In addition, the patients were subjected to continuous sacral block with levobupivacaine in group GC. The modified protocol of continuous sacral block was divided into three steps: comprehensive lumbar and sacral vertebral canal scanning by ultrasound, catheterization and administration. The EVENDOL pain scales and pediatric anesthesia emergence delirium scales of the children were evaluated at 5 min after extubation (T₃), 90 min (T₄), and 4 h (T₅) after the operation. The nurses' satisfaction scores at T₃ -T₄ and adverse events, such as nausea and vomiting, were also recorded, after the operation.

Results

After ultrasonic scanning, one patient in group GC was excluded due to the sacral hiatus atresia, which might lead to failure of catheterization. Data of 59 patients were collected for statistical analysis. Compared to the GI group, the EVENDOL scores and the pediatric anesthesia emergence delirium scales were reduced at T₃, T₄, and T₅ (P < 0.05) in group GC. Furthermore, there was a higher rank of PACU nurses' satisfaction in the GC group compared to the GI group (P < 0.05).

Conclusion

Based on the modified protocol, continuous sacral block provides reliable and safety analgesia for children undergoing laparoscopic surgery, thereby improving the satisfaction of PACU nurses.

Intraoperative laser angiography in bladder exstrophy closure: A simple technique to monitor penile perfusion

BACKGROUND

The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach.

OBJECTIVE

We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition. This will reduce the risk of tissue compression and potential loss of penile tissue that has been reported to occur as a complication of the procedure.

STUDY DESIGN

Consecutive patients presenting with bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (ICG) at a dose of 1 mg per 10 kg body weight. Measurements were taken at 80 s post infusion and the medial thigh served as the reference control. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure.

RESULTS

Eight consecutive patients were included in this study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion increased slightly following bladder dissection. Internal rotation of the hips with apposition of the symphysis pubis resulted in an average 50% reduction in penile blood flow. Patients undergoing CPRE experienced an additional mean 33% drop in blood flow. In all eight cases the penis was symmetric and healthy with no sign of tissue loss at three months follow up.

CONCLUSIONS

This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion is markedly reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair. Future correlation with measures of penile viability and function are needed to define the clinical utility of this modality.

Delayed primary closure of bladder exstrophy without osteotomy: 12 year experience in a safe and gentle alternative to neonatal surgery

BACKGROUND

Successful primary closure of bladder exstrophy is of utmost importance for bladder capacity and urinary continence. We evaluated our concept of delayed primary closure that challenges the role of neonatal surgery, pelvic osteotomy, and perioperative pain management.

MATERIAL AND METHODS

We reviewed the medical records of patients with classic bladder exstrophy (CBE) who had undergone delayed primary closure without osteotomy at our institution between January 2008 and May 2020. Data to be analyzed included patient demographics, intraoperative pelvic laxity, blood transfusion, postoperative ventilation time, requirement of pain medication, time to full feeds, length of ICU stay, postoperative complications, and total hospital stay.

RESULTS

66 patients (44 boys) met the inclusion criteria. Mean age at surgery was 64.8 days (SD±24.7). Pelvic approximation < 5 mm was possible in 66 (100%) patients. Blood transfusion was required by 31 (47%) patients. 14 (21.2%) patients needed postoperative ventilation for a mean time of 2.7 h. 45 (68.2%) children required intravenous opioids in addition to an epidural catheter. Oral feeding started on average 17.6 h after surgery. Mean ICU stay was 1.3 day. The initial success rate of delayed closure was 93.9%. None of the patients had bladder dehiscence. Girls developed more often minor postoperative complications than boys (m/f: 12 [27.3%] vs. 8 [36.4%]. Mean overall time of hospitalization was 19 days (13-34 d).

CONCLUSION

Delayed primary closure of CBE without osteotomy but with continuous epidural blockage is a safe and promising procedure that has crucial advantages in the pre- and postoperative management of CBE.

LEVEL OF EVIDENCE

Level III.

Expression of Low Affinity Nerve Growth Factor Receptor p75 in Classic Bladder Exstrophy

Successful primary closure of classic bladder exstrophy (BE) is crucial for development of bladder capacity and voided continence. It is universally agreed that an intensive pain management including the use of caudal epidural anesthesia is an essential cornerstone for the outcome of this complex surgery. Whether and to what extent pain is caused by structural or functional changes is not yet known. The nerve growth factor (NGF) is regarded as a marker for pain in different bladder disorders. This prospective study investigated the role of histological alterations and NGF in patients with BE including 34 patients with BE and 6 patients with congenital vesicoureterorenal reflux (VUR) who served as controls. Between January 2015 and April 2020 transmural bladder biopsies were taken from the posterior bladder wall during delayed primary bladder closure. The samples were stained for histological evaluation and subjected to immunohistochemistry to analyze NGFR p75. Differences in histological alterations were examined with Fisher's exact test, and Mann-Whitney-U-test was used to compare the NGFR p75 staining intensity between patients with BE and controls. Patients with BE showed significantly more often acute inflammation (p < 0.001), squamous metaplasia (p = 0.002), and cystitis glandularis (p = 0.005) as well as NGFR p75 in the urothelium (p = 0.003) than patients with VUR. A limitation of this study is the small number of participants due to the rare disease entity. Similar to other painful bladder disorders, pain transmission in BE after intitial closure may in part be facilitated by elevated NGF signaling through its receptor.

Recent Trends in the Management of Bladder Exstrophy: The Gordian Knot Has Not Yet Been Cut

Although enormous effort has been made to further improve the operative techniques worldwide, the management of bladder exstrophy (BE) remains one of the most significant challenges in pediatric urology. Today it is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome with regard to bladder capacity, renal function and continence. Due to a number of reasons, including a lack of comparable multicenter studies, a range of concepts is currently used to achieve successful primary closure. We review the literature of the last 15 years on the current concepts of bladder exstrophy repair with regard to the time of primary closure (initial vs. delayed closure), the concepts of primary closure (single-stage vs. staged approach; without osteotomy vs. osteotomy) and their outcomes. There is a worldwide lack of multicenter outcome studies with adequate patient numbers and precisely defined outcome parameters, based on the use of validated instruments. The modern staged repair (MRSE) in different variations, the complete primary reconstruction of exstrophy (CPRE), and the radical soft-tissue mobilization (RSTM) had been the most extensively studied and reported procedures. These major concepts are obligatory stable now for more than 20 years. Nevertheless, there are still a lot of open-ended questions e.g., on the potential for development of the bladder template, on continence, on long-term orthopedic outcome, on sexuality and fertility and on quality of life. Management of BE remains difficult and controversial. Further, clinical research should focus on multi-institutional collaborative trials to determine the optimal approach.