Progression of Renal Insufficiency in Children and Adolescents With Neuropathic Bladder is Not Accelerated by Lower Urinary Tract Reconstruction

Augmentation Uretero-enterocystoplasty Is an Effective Procedure in Protecting the Upper Urinary Tract Without Accelerating Deterioration of Renal Function

Background

Augmentation uretero-enterocystoplasty (AUEC) provides a low-pressure urinary storage capsule that can preserve renal function in patients with lower urinary tract dysfunction for whom conservative treatments have failed.

Objective

To summarize the effectiveness and safety of augmentation uretero-enterocystoplasty (AUEC) and evaluate whether it aggravates renal function deterioration in patients with renal insufficiency.

Design setting and participants

This was a retrospective cohort study of patients who underwent AUEC from 2006 to 2021. Patients were grouped according to whether they had normal renal function (NRF) or renal dysfunction (serum creatinine >1.5 mg/dl).

Outcome measurements and statistical analysis

Follow-up of upper and lower urinary tract function was assessed via review of clinical records, urodynamic data, and laboratory results.

Results and limitations

We included 156 patients in the NRF group and 68 in the renal dysfunction group. We confirmed that urodynamic parameters and upper urinary tract dilation were significantly improved for patients after AUEC. Serum creatinine declined during the first 10 mo in both groups and remained stable thereafter. The reduction in serum creatine was significantly greater in the renal dysfunction group than in the NRF group in the first 10 mo (difference in reduction 4.19 units; p < 0.05). A multivariable regression model showed that baseline renal dysfunction was not a significant risk factor for deterioration of renal function in patients who had undergone AUEC (odds ratio 2.15; p = 0.11). The main limitations are selection bias because of the retrospective design, loss to follow-up, and missing data.

Conclusions

AUEC is a safe and effective procedure to protect the upper urinary tract and will not hasten deterioration of renal function in patients with lower urinary tract dysfunction. In addition, AUEC improved and stabilized residual renal function in patients with renal insufficiency, which is important in preparation for renal transplantation.

Patient summary

Bladder dysfunction is usually treated with medication or Botox injections. If these treatments fail, surgery to increase the bladder size using a portion of the patient's intestine is a possible option. Our study shows that this procedure was safe and feasible and improved bladder function. It did not lead to a further decrease in function in patients who already had impaired kidney function.

Bladder Reconstruction with Bowel: Robot-Assisted Laparoscopic Ileocystoplasty with Mitrofanoff Appendicovesicostomy in Pediatric Patients

Neurogenic bladder occur as a consequence of several conditions, most commonly posterior urethral valves syndrome, spina bifida, tethered cord, sacral agenesis, and Arnold-Chiari malformation. It is characterized by diminished bladder capacity and/or reduced compliance, associated with high-pressure voiding that can lead to deterioration of renal function if left untreated. When medical management fails, bladder reconstruction with bowel (aumentation ileocystoplasty) becomes the treatment of choice for these patients. In most cases, it is accompanied by the creation of a continent catheterizable channel, with the appendix being the most commonly used conduit (Mitrofanoff appendicovesicostomy). Conventional open surgery has proven to be an efficient and safe approach in these patients. However, robot-assisted surgery not only offers a cosmetic advantage, but also results in a shorter hospital stay, less postoperative pain, and even decreased number of adhesions (as shown in porcine models). Nevertheless, the complexity of this technique has limited the wide adoption of this approach. We seek to provide a technical guide to robot-assisted laparoscopic ileocystoplasty and Mitrofanoff appendicovesicostomy in pediatric patients, as well as a critical review of literature about the perioperative care of these patients.

Factors Predicting Renal Function Outcome after Augmentation Cystoplasty

We determined the cause of renal deterioration after augmentation cystoplasty (AC). Twenty-nine adult patients with refractory bladder dysfunction and who underwent ileocystoplasty from 2004 to 2015 were studied. Patients with a decline in glomerular filtration rate (GFR) after augmentation were reviewed. The primary outcome was to determine the factors that might lead to deterioration of estimated GFR. Median follow-up was 7.0 ± 2.6 years. Significant bladder capacity, end filling pressure, and bladder compliance were achieved from median 114 ± 53.6 to 342.1 ± 68.3 ml (p = .0001), 68.5 ± 19.9 to 28.2 ± 6.9 cm H₂O (p = .0001), and 3.0 ± 2.1 to 12.8 ± 3.9 (p = .0001), respectively. Renal function remained stable and improved in 22 (76%) patients from median eGFR 135 ± 81.98 to 142.82 ± 94.4 ml/min/1.73 m² (p = .160). Significant deterioration was found in 7 (24%) patients from median eGFR 68.25 ± 42 to 36.57 ± 35.33 (p = .001). The causes of renal deterioration were noncompliance to self-catheterization (2 patients), posterior urethral valve/dysplastic kidneys (2 patients), and reflux/infection (2 patients). On multivariate analysis, recurrent pyelonephritis (OR 3.87, p = 0.0155) and noncompliance (OR 30.78, p = 0.0156) were significant. We concluded that AC is not the cause of progression to end-stage renal disease in patients with renal insufficiency.

Augmentation cystoplasty: Urodynamic and metabolic outcomes at 10-year follow-up

OBJECTIVE

To review the urodynamic outcomes, renal function and metabolic complications after augmentation cystoplasty with at least 10 years of follow-up.

METHODS

Augmentation cystoplasty performed in two tertiary referral centers from 1995 to 2004 were reviewed. Ten years or more postoperative course was studied by review of the clinical notes, urodynamic reports and laboratory results.

RESULTS

A total of 40 patients were included in this study. The mean age at surgery was 43 years, and 47.5% of patients were female. Median follow up was 13 years. Bladder capacity significantly increased from 283 ± 151 to 492 ± 123 mL (P < 0.01), with a percentage change of +130%. The compliance of the bladder was increased by 87%, and detrusor overactivity decreased by 54.2%. There were no significant changes in preoperative and postoperative estimated glomerular filtration rate (68.3 mL/min vs. 76.6 mL/min, P = 0.798). Three patients (7.5%) had more than one episode of symptomatic urinary tract infection per year.

CONCLUSION

The present study confirms the effectiveness of augmentation cystoplasty in increasing bladder capacity, improving bladder compliance and reducing detrusor overactivity. The preservation of renal function and low metabolic complication rate provide solid evidence for carrying out this time-honored procedure in patients with neurogenic or non-neurogenic bladder dysfunction.

Bricker Conduit for Pediatric Urinary Diversion--Should we Still Offer It?

PURPOSE

We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children.

MATERIALS AND METHODS

We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure.

RESULTS

We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean ± SD baseline (64.5 ± 46 ml/minute/1.73 m(2)) and last followup estimated glomerular filtration rate (54.1 ± 44.9 ml/minute/1.73 m(2)), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications.

CONCLUSIONS

The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population.

Midterm outcomes of protection for upper urinary tract function by augmentation enterocystoplasty in patients with neurogenic bladder

PURPOSE

To evaluate the midterm outcomes of protection for upper urinary tract (UUT) function by augmentation enterocystoplasty (AE) using a grading system for upper urinary tract dilation (UUTD) and a descriptive system for all urinary tract dysfunction (AUTD) in patients with neurogenic bladder.

METHODS

We retrospectively reviewed 120 cases of AE from our database, which was collected between 2005 and 2013. UUTD grading system was developed by magnetic resonance urography (MRU), and AUTD system was described by video-urodynamics, MRU, isotope renography, etc. UUT function was evaluated by these systems before operation, and at 6, 12, 24 and 36 months postoperatively. The indication, midterm outcomes and complications were evaluated.

RESULTS

All patients had significant improvement for urodynamic parameters at 6 months postoperatively. Comparing the grades of UUTD and vesicoureteral reflux (VUR) before and after operation, the median grade of 95 UUTD ureters decreased from 3 to 0, and the percentage of 0 grade UUTD increased from 0 to 90.9 % at 36 months. The median grade of 96 VUR ureters decreased from 3 to 0, and the percentage of 0 grade VUR increased from 0 to 98.6 % at 36 months. The glomerular filtration rate of kidneys and serum creatinine level of patients had an increasing improvement after surgery.

CONCLUSIONS

The midterm follow-up using UUTD and AUTD systems indicates that AE is effective and safe for UUT protection. The patients with moderate and severe UUT deteriorations and renal function impairment resulting from VUR and UUTD have undergone the increasing improvement.

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.

Sigmoidocolocystoplasty with ureteral reimplantation for treatment of neurogenic bladder

OBJECTIVE

To assess the clinical and urodynamic results of sigmoidocolocystoplasty in patients with neurogenic bladder dysfunction.

METHODS

We retrospectively reviewed 78 augmentation enterocystoplasty cases in our database from 2005 to 2011 to identify 47 patients who had undergone sigmoidocolocystoplasty alone or combined with ureter reimplantation. The indications for surgery and postoperative complications were evaluated. Renal function preservation, increased postoperative bladder capacity, decreased maximal detrusor pressure, and overall patient satisfaction were deemed successful outcomes.

RESULTS

The mean follow-up period was 24 months. The mean bladder capacity increased from 160.6 ± 128.3 to 468.5 ± 60.6 mL (P < .001) and the maximal detrusor pressure decreased from 31.1 ± 26.4 to 10.9 ± 4.5 cm H(2)O (P = .002). The serum creatinine level decreased from 270.3 ± 113.6 to 174.4 ± 81.3 μmol/L (P = .001). Most patients resolved the urinary incontinence using clean self-intermittent catheterization. The decrease in the mean number of incontinence episodes and pads used daily indicated a marked improvement in patients' quality of life. Postoperative complications included bowel dysfunction in 5 patients (10.6%), adhesive intestinal obstruction in 4 (8.5%), deteriorating renal function in 3 (6.4%), and vesicoureteral reflux recurrence in 2 patients (4.3%). Nearly all patients expressed satisfaction with the urologic management.

CONCLUSION

Our results suggest that sigmoidocolocystoplasty is safe and effective in treating patients with neurogenic bladder dysfunction. Concomitant ureter reimplantation will be beneficial for patients with a long history of illness.

The past, present and future of augmentation cystoplasty

What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.

CKD and bladder problems in children

Approximately 35% of children with CKD who require renal replacement therapy have a significant urological abnormality, including posterior urethral valves, a neuropathic bladder, prune belly syndrome, Hinman syndrome, or severe vesicoureteral reflux. In such children, abnormal bladder function can have a significant deleterious effect on the renal function. In children with bladder outlet obstruction, bladder compliance and capacity often are abnormal, and a sustained intravesical pressure of >40 cm H(2)O impedes drainage from the upper urinary tract. Consequently, in these conditions, regular evaluation with renal sonography, urodynamics, urine culture, and serum chemistry needs to be performed. Pediatric urological care needs to be coordinated with pediatric nephrologists. Many boys with posterior urethral valves have severe polyuria, resulting in chronic bladder overdistension, which is termed as valve bladder. In addition to behavioral modification during the day, such patients may benefit from overnight continuous bladder drainage, which has been shown to reduce hydronephrosis and stabilize or improve renal function in most cases. In children with a neuropathic bladder, detrusor-sphincter-dyssynergia is the most likely cause for upper tract deterioration due to secondary vesicoureteral reflux, hydronephrosis, and recurrent urinary tract infection (UTI). Pharmacologic bladder management and frequent intermittent catheterization are necessary. In some cases, augmentation cystoplasty is recommended; however, this procedure has many long-term risks, including UTI, metabolic acidosis, bladder calculi, spontaneous perforation, and malignancy. Nearly half of children with prune belly syndrome require renal replacement therapy. Hinman syndrome is a rare condition with severe detrusor-sphincter discoordination that results in urinary incontinence, encopresis, poor bladder emptying, and UTI, often resulting in renal impairment. Children undergoing evaluation for renal transplantation need a thorough evaluation of the lower urinary tract, mostly including a voiding cystourethrogram and urodynamic studies.