Enterocystoplasty vs Detrusorectomy: Outcome in the Adult with Spina Bifida

Outcomes of detrusorectomy in neurogenic bladders: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aims to assess the outcomes of detrusorectomy in children with neurogenic bladder (NB).

MATERIALS AND METHODS

A search was performed in PUBMED, EMBASE and the Cochrane Library database in August 2023. The following search terms were used: "detrusorectomy", "detrusorotomy", "auto-augmentation". The two main primary outcomes were improvement in bladder capacity and bladder compliance after intervention. Outcomes were dichotomized into favorable and unfavorable. The secondary outcomes were the effect of postoperative bladder cycling on bladder compliance and bladder capacity and complications.

RESULTS

258 references were screened for inclusion, of these 242 were excluded. 8 of the remaining 16 studies were included for the qualitative and quantitative analysis. All studies were retrospective case series studies (165 patients). Median follow-up time varied between studies (1.75-11.1 years), while two studies reported a mean follow-up time of 8.1 years. Using a random effects meta-analysis, the overall rate for unchanged or improved bladder capacity was 95% (Proportion[CI]: 0.95 [0.61; 1.00]). The overall rate for improved bladder compliance after detrusorectomy was 67% (Proportion[CI]: 0.67 [0.26; 0.92)) (Summary Fig). In the bladder cycling group improved compliance was found in 89% of patients (Proportion[CI]: 0.89 [0.41; 0.99]), whereas it was 21% in the non-cycling group (Proportion[CI]: 0.21 [0.04; 0.61]) (p = 0.0552). Bladder cycling did not affect bladder capacity as the overall rate for unchanged or improved bladder capacity was 98% (Proportion[CI]: 0.98 [0.35; 0.92]) in the cycling and 73% (Proportion[CI]: 0.73 [0.46; 0.90]) in the non-cycling group (p > 0.05). Overall complications were encountered in 16 (9.7%) patients, with major complications (stones, bladder perforations) detected only in 5(3%) patients.

DISCUSSION

Detrusorectomy leads to an improved bladder compliance in 67% of children. As such, detrusorectomy proves to be a viable procedure to enhance bladder compliance or to cure overactivity. Importantly, the beneficial effect of detrusorectomy on bladder compliance seems to be long-lasting. Bladder capacity remained unchanged or improved in almost all patients undergoing detrusorectomy. Postoperative bladder cycling was effective in improving bladder compliance outcome compared to the non-cycling group. Proper patient selection is the key to good postoperative outcomes.

CONCLUSIONS

Detrusorectomy enhances bladder compliance in pediatric neurogenic bladders. Postoperative bladder cycling improves bladder compliance and the overall complication rate of the procedure is low. Therefore, detrusorectomy should be considered a valuable therapeutic option in the comprehensive management of neurogenic bladders in children.

Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury

This study aimed to present a comprehensive literature review of the efforts of a spinal cord injury workgroup in Taiwan regarding urologic surgery for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI). Surgical procedures should be viewed as a final option for managing patients with SCI who have persistent symptoms and complications that cannot be resolved by other means. Surgeries can be grouped according to their purpose: reducing bladder pressures, reducing urethra resistance, increasing urethra resistance, and urinary diversion. The choice of surgery depends on the type of LUTD based on urodynamic tests. Additionally, cognitive function, hand motility, comorbidities, efficacy of surgery, and related complications should be considered.

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.

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.

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.