Reconstructive lower urinary tract surgery in incontinent adolescents with exstrophy/epispadias complex

Challenges in pediatric urologic practice: a lifelong view

The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.

Effect of autologous muscle-derived cells in the treatment of urinary incontinence in female patients with intrinsic sphincter deficiency and epispadias: A prospective study

OBJECTIVES

To evaluate the effect of autologous muscle-derived cells injection in the treatment of complicated stress urinary incontinence in female patients.

METHODS

Female patients presenting with severe and complicated stress urinary incontinence secondary to the bladder neck and/or urethral trauma or congenital epispadias (with or without exstrophy) were enrolled in this prospective study. They underwent transurethral injection of autologous muscle-derived cells. In selected cases, another injection was given after 6 months, as per the surgeon's assessment. All patients were monitored for 1 year, and the effect of autologous muscle-derived cells was evaluated by cough stress test, 1-h pad test and Incontinence Impact Questionnaire-short form score. A multichannel urodynamic study and maximum urethral closure pressure were carried out before and 12 months after the last treatment session. Cough stress test, 1-h pad test and uroflowmetry were repeated 36 months after the last injection. Severity and occurrence of complications were recorded at each visit.

RESULTS

All 10 patients who completed the study were monitored for 36 months. Three patients were cured, four had improved and three did not respond to the treatment. There was no major adverse effect related to the treatment.

CONCLUSIONS

Muscle-derived cell therapy might represent a minimally-invasive and a safe procedure in the treatment of patients with severe and complicated stress urinary incontinence.

Bladder exstrophy: reconstructed female patients achieving normal pregnancy and delivering normal babies

PURPOSE

Bladder exstrophy (BE) is an anterior midline defect that causes a series of genitourinary and muscular malformations, which demands surgical intervention for correction. Women with BE are fertile and able to have children without this disease. The purpose of this study is to assess the sexual function and quality of life of women treated for BE.

MATERIALS AND METHODS

All patients in our institution treated for BE from 1987 to 2007 were recruited to answer a questionnaire about their quality of life and pregnancies.

RESULTS

Fourteen women were submitted to surgical treatment for BE and had 22 pregnancies during the studied period. From those, 17 pregnancies (77.2%) resulted in healthy babies, while four patients (18.1%) had a spontaneous abortion due to genital prolapse, and there was one case (4.7%) of death due to a pneumopathy one week after delivery. There was also one case (5.8%) of premature birth without greater repercussions. During pregnancy, three patients (21.4%) had urinary tract infections and one patient (7.14%) presented urinary retention. After delivery, three patients (21.4%) presented temporary urinary incontinence; one patient (7.14%) had a vesicocutaneous fistula and seven patients (50%) had genital prolapsed. All patients confirmed to have achieved urinary continence, a regular sexual life and normal pregnancies. All patients got married and pregnant older than the general population.

CONCLUSIONS

BE is a severe condition that demands medical and family assistance. Nevertheless, it is possible for the bearers of this condition to have a satisfactory and productive lifestyle.

Exstrophy in the adolescent and young adult population

The bladder exstrophy-epispadias-cloacal exstrophy complex is a spectrum of genitourinary malformations requiring multiple major reconstructive operations on each affected child. The need for surgical correction in this condition often continues through adolescence and into adulthood. Experience in caring for individuals with exstrophy-epispadias has taught us a great deal about the long-term functional, psychological, and social outcomes involved. Children undergoing repeated hospital admissions and extensive multiple operations have the potential for long-term adjustment problems with incontinence, ambulatory difficulties, psychological disturbance, sexual dysfunction, and issues surrounding self-esteem and social integration. By examining relevant published works from the world literature over the last 20 years, in this article we address with each of these areas and offers some insight into the ongoing issues.

Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail

PURPOSE

We evaluated the functional outcome of continent catheterizable outlet using the serous lined extramural tunnel technique as a continence mechanism in children and adolescents.

MATERIALS AND METHODS

We retrospectively studied all patients who underwent continent catheterizable stoma using the serous lined extramural technique between May 1993 and March 2008. Patient records were reviewed for age, sex, indication for surgery, surgical details and postoperative course. All patients were evaluated for continence with emphasis on frequency of clean intermittent catheterization. Urodynamic evaluation was done for patients with leaking stoma. Stoma related complications were also recorded.

RESULTS

A total of 37 boys and 23 girls 3 to 18 years old underwent continent catheterizable stoma using the serous lined extramural technique. Total bladder substitution was performed in 13 patients using continent ileal W-shaped reservoir, and 47 patients underwent augmentation ileocystoplasty mounted with serous lined outlet. The outlet channel was appendix in 39 patients (65%), tapered ileal segment in 13 (21.5%) and Monti ileal tube in 8 (13.5%). After a median followup of 43 months (range 10 to 180) 55 patients (91.6%) achieved continence, with catheterization frequency of 3 to 5 times during the daytime and 1 to 2 times at night. Stoma related complications were leaking stoma in 5 patients (8.4%), stomal stenosis in 6 (10%), parastomal hernia in 2 (3.3%) and reservoir stones in 8 (13.3%). Reoperation rate was 18.3% (11 patients).

CONCLUSIONS

The serous lined continent outlet seems to be a durable and efficient technique for treating children with incontinence, with an acceptable complication rate.

Evaluation of need for salvage continence procedures after failed modern staged repair

OBJECTIVES

To assess our experience with salvage continence procedures in patients with bladder exstrophy.

METHODS

We retrospectively reviewed our surgical records of patients with bladder exstrophy who had undergone failed modern staged repair elsewhere and underwent salvage continence operations at our institute from 1996 to 2008.

RESULTS

A total of 16 patients had undergone salvage continence operations. Bladder augmentation was performed in 11 patients (68.8%); 14 children (87.5%) received a continent, catheterizable stoma. In 6 children (37.5%) bladder neck injections were done. Three patients (18.8%) underwent bladder neck closure combined with other reconstructive procedures. A total of 49 continence procedures were performed, with an average of 3.06 per patient. We included all 16 children >5 years. After these operations, 13 of 16 (81.3%) became continent. Two children were able to void spontaneously and were dry day and night (12.5%). Of the remaining 14 patients, all of whom used clean intermittent catheterization, 11 (68.7%) were continent during the day and night with augmentation and/or a catheterizable stoma. Three patients were incontinent (18.7%).

CONCLUSIONS

Although the need to perform salvage continence procedures after failed bladder modern staged repair is high, when patients are appropriately selected, continence can be achieved eventually.

Incontinence Following Bladder Neck Reconstruction—Is There a Role for Endoscopic Management?

PURPOSE

Little has been reported concerning the efficacy of endoscopic injection of dextranomer/hyaluronic acid for the treatment of residual incontinence following bladder neck reconstruction. We present the experience of 2 institutions using endoscopic submucosal injection of dextranomer/hyaluronic acid to correct incontinence in patients who had previously undergone bladder neck reconstruction with or without concomitant enterocystoplasty.

MATERIALS AND METHODS

A retrospective chart review was performed with patient demographics, indications for treatment and outcomes recorded. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. Continence was defined as at least a 3-hour daytime dry interval, while improvement was defined as an increase in the daytime dry interval to at least 2 hours.

RESULTS

A total of 14 patients (10 females and 4 males) underwent 21 injections. At a median followup of 17 months 10 patients had successful results (6 continent, 4 improved).

CONCLUSIONS

Endoscopic injection of dextranomer/hyaluronic acid to correct incontinence following bladder neck reconstruction appears safe and can increase the daytime dry interval in more than 70% of carefully selected patients. Continued followup is necessary to evaluate the long-term effectiveness of this treatment.

Continent cutaneous urinary diversion in children: experience with Charleston pouch I

PURPOSE

Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children.

MATERIALS AND METHODS

A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and long-term functional status.

RESULTS

Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory.

CONCLUSIONS

Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable.

Can a Complete Primary Repair Approach be Applied to Cloacal Exstrophy?

PURPOSE

Surgical reconstruction for children with cloacal exstrophy remains challenging. The operative approach to cloacal exstrophy has expanded with the addition of the complete primary exstrophy repair. We assessed the safety and efficacy of complete primary exstrophy repair for this complex condition.

MATERIALS AND METHODS

We performed a retrospective review of children treated from birth for cloacal exstrophy between March 1, 1994 and January 1, 2003 at our institution. We evaluated associated anomalies, method of closure, complications and urinary continence.

RESULTS

Seven patients with cloacal exstrophy were initially treated at our institution. One mortality occurred before complete primary exstrophy repair was attempted. Six patients were converted to a classic exstrophy appearance and underwent closure using complete primary exstrophy repair principles within 7 to 182 days (mean 68, median 32) postoperatively. Postoperative development of moderate hydronephrosis was seen in 1 patient and severe hydronephrosis in 1. Three of six patients had vesicoureteral reflux. Six patients had dry intervals and spontaneous voids before toilet training. Two patients had stress urinary incontinence. Two patients have been treated with bladder neck injections. One has undergone bladder neck reconstruction and construction of a nonorthotopic channel for clean intermittent catheterization (Mitrofanoff). One patient reported complete dryness after toilet training. One child has undergone bladder augmentation.

CONCLUSIONS

This series represents our initial efforts to use complete primary exstrophy repair for cloacal exstrophy. The application of the principles of complete primary exstrophy repair in a sequential fashion appears to be a viable and safe addition to the surgical armamentarium in this challenging patient population.