Teapot Ureterocystoplasty and Ureteral Mitrofanoff Channel for Bilateral Megaureters: Technical Points and Surgical Results of Neurogenic Bladder

Simultaneous Renal Transplantation With Bilateral Nephrectomy and Ureterocystoplasty

Bladder augmentation (BA) may be required before renal transplantation in children with end stage renal disease (ESRD). Herein we report a case of a 7-year-old boy with ESRD, contracted bladder and severe bilateral reflux secondary to posterior urethral valve (PUV), successfully managed by simultaneous bilateral nephrectomy, bilateral ureterocystoplasty and renal transplantation.

Revascularized Pyelo-Uretero-Cystoplasty in Patients with Chronic Bladder Outlet Obstruction Due to Ectopic Ureterocele: A Safe Surgical Technique with Superior Continence Outcomes

PURPOSE

To present the outcomes of revascularized pyeloureterocystoplasty with ureterocele unroofing in end stage bladder patients with duplex system and ureterocele.

METHODS

Thirteen patients with obstruction of intrauterine outlet from an ectopic obstructive ureterocele were included. Fourteen units of duplex systems underwent upper pole partial nephrectomy in conjunction with augmentation revascularized pyeloureterocystoplaty and ureterocele unroofing. The anterior and lateral walls of the ureterocele were excised before cystoplasty, and the resultant edges of the posterior wall were sutured to the bladder epithelium. Anastomosis of the upper pole vein and artery to the inferior iliac artery and the common iliac vein was performed. Detubularization of the whole ureter was performed with exception of the intramural ureteric part that kept tubularized for 'jet/turbulent' occurrence. Five patients (control group) underwent pyeloureterocystoplasty without revascularization. Patients underwent several evaluations in long-term follow-up.

RESULTS

Patients were all dry by day and night in our long-term follow-up. Urinary incontinence improved in patients with no need for re-augmentation technique. Vesicoureteral reflux subsided in all patients postoperatively except one, who was asymptomatic. After five years, median bladder capacity rose from 128.5 ml to 395 ml and bladder compliance showed significant improvement from 15 ml/cm H₂O to 29 ml/cm H₂O, in experimental group and remained stable for 24-36 months. Median bladder capacity did not rise significantly in control group.

CONCLUSION

Pyeloureterocystoplasty is an efficient choice in this type of patients, which may prevent the recurrence of hypocompliant bladders and prevent ischemia and subsequent fibrosis.

What do we know about neurogenic bladder prevalence and management in developing countries and emerging regions of the world?

OBJECTIVE

To summarize information on Neurogenic Bladder (NB) epidemiology, management and access to patient treatment in developing countries and emerging regions of the world in order to propose future interventions and help governmental as well as non-governmental organizations design their action plans.

METHODS

Different search methods were used to gather the maximum available data. They included strategic searches; reference checks; grey literature searches (reports, working papers, government documents, civil society information); contacting professional societies, registries, and authors; requesting unpublished data from organizations; and browsing related websites and journals.

RESULTS

The incidence and prevalence rates of NB in developing countries are difficult to establish because epidemiological reports are few and far between. The frequency of bladder dysfunction in neurologically impaired populations can be approximately estimated in some of these countries. Similar information paucity affects diagnostic and therapeutic approaches to NB patients living in less-developed regions of the world. The assessment and management of NB seems to vary markedly between countries, and care of patients from emerging regions of the world is often inadequate.

CONCLUSION

Strong concerted efforts are needed on the part of international scientific societies, non-governmental organizations and local governments to work together to change the prognosis for these patients and to improve their quality of life.

British Association of Paediatric Urologists consensus statement on the management of the neuropathic bladder

INTRODUCTION

A large number of children with spina bifida develop a neuropathic bladder and this group of patients still forms the largest group of children who require urological management. Although there are published guidelines on the management of the neuropathic bladder, they are not specific to children. It is unsurprising, therefore, that the initial investigation, assessment and management of children with spina bifida vary considerably. The 2014 British Association of Paediatric Urologists (BAPU) meeting was devoted to the management of the neuropathic bladder. The aim was to produce a consensus on the appropriate investigation and management of a child with a neuropathic bladder.

METHODS AND MATERIALS

A questionnaire was devised and the members were polled on their current practice. Six paediatric urology fellows presented an evidence-based literature review on different aspects of the neuropathic bladder. At the end of the session, the members of the organisation present were polled again using the same questions.

RESULTS

The BAPU felt that the use of urodynamics in the neuropathic bladder should be selectively determined by clinical parameters. Regarding CIC, the group was evenly split between universal use or only when poor emptying was established. Oxybutinin was the first-line anticholinergic of choice. Most paediatric urologists routinely used Botox and were happy to use it repeatedly. The surgical intervention most frequently employed was determined to be an ileocystoplasty, with most surgeons deferring the need for surveillance cystoscopy until at least 10 years after surgery.

CONCLUSION

It was felt that a consensus statement is not a guideline or a way to establish best practice; however, it serves as a way of surveying current practice and providing a benchmark for clinicians involved in the management of these patients.

Ureterocystoplasty in pediatric patients with unilateral nonfunctioning kidney

OBJECTIVE

Bladder augmentation with uroepithelium lined material yields an absence of mucus production, with reduced possibility of urinary infection and lithiasis. The utilization of the ureter in augmentation cystoplasty results in a uroepithelium-lined neobladder with all of the appropriate histologic layers. The purpose of this study was to assess the efficacy and safety of ureterocystoplasty in children with a small bladder capacity and low bladder compliance.

MATERIAL AND METHODS

Between January 1992 and August 2011, six females and eight males who were 3 to 13 years old (median age 6 years) and had a low-capacity, poorly compliant bladder underwent augmentation cystoplasty using dilated ureters. Unilateral non-functioning renal moiety draining into a massively dilated ureter was present in every patient. The etiology of hydroureteronephrosis was a neurogenic bladder secondary to meningomyelocele in five patients, a posterior urethral valve in four patients, an obstructive megaureter in three patients and ectopic obstructive ureterocele in two patients.

RESULTS

Mean age was 6 years (3-13 y). Clinical improvement regarding the resolution of reflux, a better bladder capacity and improved compliance was achieved in every patient. The increase in bladder capacity ranged from 84 cc (30 to 200) to 235 cc (150 to 420), with a mean increase of 318% (210 to 500). Marked improvement in compliance was also observed (from 1.2 to 5.1 mL/cm H2O, mean 2.4, to 22 to 50 mL/cm H2O, mean 41). No uninhibited bladder contractions were detected during a urodynamic study at 12 months postoperatively.

CONCLUSION

In patients with a low-capacity, poorly compliant bladder, augmentation cystoplasty using the ureter seems to be a viable alternative. Ureterocystoplasty results in a large-capacity, high-compliance bladder, without metabolic and infective complications, compared with other techniques of augmentation cystoplasty.

Tissue-engineered cholecyst-derived extracellular matrix: a biomaterial for in vivo autologous bladder muscular wall regeneration

PURPOSE

To compare the biocompatibility and histological aspects of cholecyst-derived extra cellular matrix (CDECM) graft, either alone or with application of autologous detrusor muscles small fragments (ADMSF) on rabbit bladder mucosa for bladder augmentation.

METHODS

The gallbladders were acellularized and evaluated for preserved acellular matrix scaffold and biophysical properties. Thirty rabbits were divided into five groups. Rabbits in the control group underwent partial detrusorectomy followed by perivesical fat coverage. Groups I and II underwent the same procedure and bladder mucosa was covered either by acellular rabbit gallbladder (ARG) (group I) or acellular sheep gallbladder (ASG) (group II). Groups III and IV underwent detrusorectomy and the bladder mucosal was seeded by ADMSF and covered by ARG (group III), or ASG (group IV). Biopsies were taken at 4, 12, and 24 weeks postoperatively.

RESULTS

Higher expression of CD34 endothelial progenitor cells, CD31 microvessels, α-smooth muscle actin, S100, and cytokeratin with more organized muscular wall generation was demonstrated in groups III and IV. Expression of IHC markers was higher in groups III and IV compared with groups I and II in all the time points.

CONCLUSION

The current study confirmed that autologous fragment-seeded CDECM can be considered as a reliable natural collagen scaffold for bladder augmentation.

Augmentation cystoplasty using decellularized vermiform appendix in rabbit model

PURPOSE

The aim of this study was to produce a decellularized rabbit vermiform appendix (sacculus rotundus) and investigate its feasibility in bladder augmentation or appendicovesicostomy. The superiority of sacculus rotundus over other tissues is its unique mechanical properties as well as its abundant collagen content.

MATERIALS AND METHODS

The acellular matrix of vermiform appendix underwent different laboratory investigations prior to transplantation. We divided 12 rabbits into 3 groups: group I underwent bladder augmentation cystoplasty by detubularized acellular matrix. Group II underwent implantation of the tapered (tubularized) acellular matrix just beneath the seromuscular part of the bladder without connection to the bladder urothelium. Group III underwent the same procedure as group II plus reimplantation of tapered and tubularized acellular matrix (simulating an appendicovesicostomy). The distal end of the transplanted graft was connected to the bladder mucosal opening and was intubated by a 5Fr double blind ended feeding tube catheter. Biopsies were taken 3, 12, and 36months post-operatively for further histological and immunohistochemical analyses.

RESULTS

The results of the examinations performed prior to transplantation, revealed a decellularized structure resembling the native tissue with intact extracellular matrix, normal pits and appropriate gaps that will be suitable for further cell seeding. Histopathology examination of the biopsies after transplantations confirmed successful cell seeding with urothelial lining in groups I and III, while the inner lumen in group II showed no urothelial lining.

CONCLUSION

The results suggest that we can prospect to perform bladder reconstruction by the application of this method without complications of previously reported augmentation cystoplasty. In the current study we used the bladder as a natural bioreactor for autologous recellularization which may pave the road for clinical application in acellular matrix augmentation cystoplasty.

The evolution of bladder augmentation: from creating a reservoir to reconstituting an organ

Bladder augmentation was first described in 1899. The goal at the time was to establish the ideal method to create a simple capacious reservoir for the safe storage of urine. That simple idea has over the last 100 years grown into one of the most dynamic areas in Pediatric Urology. Creative minds and hands from individuals in multiple disciplines have led us from creating a reservoir to the threshold of recreating a functional organ. In this review, we look at the historical evolution of bladder augmentation and how it exponentially grew in scope from those initial descriptions of intestinocystoplasty to the work being reported today in the field of tissue engineering.

Alternatives to conventional enterocystoplasty in children: a critical review of urodynamic outcomes

Alternatives to conventional enterocystoplasty have been developed in order to avoid the most common complications derived from contact of the urine with intestinal mucosa. In this article critically we review the literature on the topics: ureterocystoplasty, detrusorectomy, detrusorotomy, seromuscular gastroenterocystoplasty, use of off the shelf biomaterials, and bladder augmentation by bioengineering. Recognizing the difficulty of deciding when a child with a history of posterior urethral valves requires and augmentation and that the development of a large megaureter in cases of neurogenic dysfunction represents a failure of initial treatment, we conclude that ureterocystoplasty can be useful in selected cases when a large dilated ureter is available. Seromuscular colocystoplasty lined with urothelium (SCLU) has been urodynamically effective in several series when the outlet resistance is high and no additional intravesical procedures are necessary. Seromuscular gastrocystoplasty lined with urothelium seems to offer no distinct advantages and involves a much more involved operation. The use of seromuscular segments without urothelial preservation, with or without the use of an intravesical balloon has been reported as successful in two centers but strict urodynamic evidence of its effectiveness is lacking. The published evidence argues strongly against the use of detrusorectomy or detrusorotomy alone because of the lack of significant urodynamic benefits. Two recent reports discourage the use of small intestinal submucosa patches because of a high failure rate. Finally, research into the development of a bioengineered bladder constructed with cell harvested from the same patient continues but is fraught with technical and conceptual problems. In conclusion of the methods reviewed, only ureterocystoplasty and SCLU have been proven urodynamically effective and reproducible.

Bladder augmentation: Distal ureterocystoplasty with proximal ureteric reimplantation: A novel technique

A novel technique of bladder augmentation is reported, wherein the distal dilated ends of tortuous ureters were used for ureterocystoplasty while proximal remaining ureters reimplanted back into the native bladder.

Bladder augmentation and urinary diversion for neurogenic LUTS: current indications

Augmentation cystoplasty and urinary diversion are no longer commonplace in the management of patients with neurogenic bladder, but remain an important surgical treatment for those with refractory LUTS who have failed neuromodulation and onabotulinum toxin treatment or who are not candidates for those treatments. Augmentation is an option in patients who can perform intermittent catheterization and is usually performed with ileum or large intestine. Some patients benefit from continent cutaneous catherizable channels. Supravesical urinary diversion may be necessary in more severe cases. Ileovesicostomies are being supplanted by indwelling suprapubic catheters, and when catheters fail conduits may be a better option. When feasible, the diverted bladder should be excised to avoid pyocystis.