Long-Term Efficacy of Artificial Urinary Sphincters in Children

Simultaneous bladder augmentation and artificial urinary sphincter placement in children with neuropathic urinary incontinence. Is it safe to perform? Long-term results

INTRODUCTION

Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial.

OBJECTIVE

The aim of this study is to describe our very long-term results after a median follow-up of 17 years.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups.

RESULTS

A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p = 0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p = 0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups.

DISCUSSION

There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time.

CONCLUSION

Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times.

Long-term results of artificial urinary sphincter implantation for urinary incontinence due to intrinsic sphincter deficiency in children

PURPOSE

To report long-term results of artificial urinary sphincter implantation for urinary incontinence due to intrinsic sphincter deficiency in children.

MATERIALS AND METHODS

This retrospective monocentric study included all patients who underwent artificial urinary sphincter (AMS 800) implantation before 18 years of age between 1986 and October 2018 for intrinsic sphincter deficiency. The primary outcome was the continence rate at the last follow-up, defined by the daily use of 0 pads. The secondary outcome was the overall survival of the device, defined as the absence of any repeated surgery (revision or explantation) during follow-up. Reoperation-free, revision-free, and explantation-free device survival rates were estimated using the Kaplan-Meier method.

RESULTS

Thirty-six patients with a median age of 12 years (interquartile range [IQR]: 10-14) were included (15 females, 21 males). The median follow-up was 18.7 years (IQR: 9-26). The main underlying condition was spinal dysraphism (n = 24; 67%). The median time to the first reoperation was 9 years (IQR: 3.75-14.7). At the last follow-up, survival rates without revision were 84%, 71%, 55%, and 33% at 5, 10, 15, and 20 years, respectively. Survival rates without explantation were 91%, 84%, 80%, and 72% at 5, 10, 15, and 20 years, respectively. At the last follow-up, 29 patients had a functional device. The overall continence rate was 88%. All patients who had their device still in place were continent at the last follow-up.

CONCLUSION

The artificial urinary sphincter is an effective long-term treatment for urinary incontinence related to intrinsic sphincter deficiency in children, providing a high rate of continence, even if associated with a high rate of reoperation.

Artificial urinary sphincter in congenital neuropathic bladder: Very long-term outcomes

OBJECTIVE

Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter.

METHODS

A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected.

RESULTS

An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra.

CONCLUSION

The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients.

Robotic-assisted bladder neck procedures in children with neurogenic bladder

PURPOSE

To review the current status of robotic-assisted laparoscopic surgical techniques for bladder neck procedures in children with incontinence secondary to neurogenic bladder.

METHODS

A comprehensive review of the literature on robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 25 years. These data were subsequently compared to published series of open bladder neck procedures and published results from robotic-assisted bladder neck reconstruction series completed at our institution.

RESULTS

The principle bladder neck procedures for incontinence in pediatric patients with neurogenic bladder 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 interoperative 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 the previous open abdominal surgery.

Robotic-Assisted Bladder Neck Procedures for Incontinence in Pediatric Patients

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.

Managing adult urinary incontinence from the congenitally incompetent bladder outlet

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.

Surgical management of pediatric urinary incontinence

The surgical management of pediatric urinary incontinence secondary to neurogenic bladder and congenital anomalies is challenging, and continues to evolve with new surgical innovations. The goal of these surgical procedures is to achieve complete and socially acceptable urinary dryness, while preserving volitional voiding where possible, without causing damage to the upper tracts. This review focuses on recent studies and highlights the pros and cons of these advances, based on our experience. The short-term success in achieving urinary continence has to be tempered with the long-term implications of these reconstructive procedures, about which our knowledge is limited.

Outcome of the Lima periurethral constrictor in children and adolescents: a European perspective

PURPOSE

The Lima constrictor was described in 1996 as a less complex and less expensive alternative to the artificial urinary sphincter for use in cases of pediatric neuropathic sphincter incontinence. The device provides a fixed periurethral resistance which creates continence, yet allows urethral catheterization without the need to deflate the cuff. We report our multicenter experience, and continence, revision and erosion rates.

MATERIALS AND METHODS

We performed a retrospective review of 14 consecutive patients who underwent insertion of the periurethral constrictor (Silimed, Rio de Janeiro, Brazil) between 2005 and 2011. Data are presented as medians (range).

RESULTS

A total of 14 patients (13 male, 1 female) with spina bifida (10), sacral agenesis (3) and Hirschsprung disease (1) underwent insertion of the constrictor at a median age of 12 years (range 8 to 20). All patients were wet despite clean intermittent catheterization, medical therapy and/or previous surgery. Eleven patients underwent simultaneous bladder augmentation and/or Mitrofanoff formation. The constrictor was activated a median of 8 weeks (range 2 to 99) after the procedure in 11 patients whereas 3 became dry without activation. Complications occurred in 4 patients (29%), including spontaneous bladder perforation and constrictor erosion (1), tubing disconnection requiring revision (2) and wound infection (1). At a median of 23 months of followup (range 7 to 77) 13 patients were dry and 1 was damp. All patients performed urethral or Mitrofanoff clean intermittent catheterization. The continence rate with the device in situ was 92%.

CONCLUSIONS

At a median followup of 23 months the Lima constrictor provided a 92% continence rate with erosion and revision rates of 7% and 14%, respectively. Interim results suggest that the constrictor provides a safe and effective surgical option, particularly in patients who are unable to void to completion.

Total continence reconstruction using the artificial urinary sphincter and the Malone antegrade continence enema

PURPOSE

Surgical management of children with myelomeningocele addresses 2 aspects of the disease, neurogenic bladder and neurogenic bowel. Results of total continence reconstruction using an artificial urinary sphincter and Malone antegrade continence enema are presented.

MATERIALS AND METHODS

We performed a retrospective chart review of patients who underwent simultaneous artificial urinary sphincter placement and a Malone antegrade continence enema procedure. From 1997 to 2007 a total of 21 patients with myelomeningocele underwent total continence reconstruction using the artificial urinary sphincter. Mean patient age was 10.4 years (range 6 to 22) and mean followup was 4.7 years (range 0.66 to 11.7). Artificial urinary sphincter cuff was placed around the bladder neck. A Malone antegrade continence enema was performed using appendix in 19 patients and cecal based flaps in 2. Two patients underwent concomitant augmentation cystoplasty. Six patients had concomitant Mitrofanoff vesicostomy using split appendix in 4 and Monti tube in 2.

RESULTS

Immediate postoperative complications were observed in 5 patients, including prolonged ileus (2), urinary tract infection (2) and superficial wound dehiscence (1). Seventeen patients (81%) achieved complete urinary continence and 5 were voiding with sphincter cycling. Improvement in urinary continence with dry intervals greater than 3 hours was reported in 2 patients. There were 19 patients (90%) who reported fecal continence, with 2 reporting soiling 1 to 2 times a week. Malone antegrade continence enema stoma stenosis occurred in 3 patients and 2 required revisions. Sixteen patients (76%) achieved complete continence of stool and urine. During followup 2 artificial urinary sphincters were explanted and 8 patients (38%) underwent bladder augmentation.

CONCLUSIONS

Urinary and fecal continence in patients with myelomeningocele is achievable with a single total continence reconstruction procedure using the artificial urinary sphincter and the Malone antegrade continence enema with durable results.