The Indiana Experience With Artificial Urinary Sphincters in Children and Young Adults

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.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management

BACKGROUND

Treatment in children and adolescents with a neurogenic bladder is primarily conservative with the goal of preserving the upper urinary tract combined with a good reservoir function of the bladder. However, sometimes-even in childhood-conservative management does not prevent the development of a low-compliant bladder or overactive detrusor.

MATERIAL & METHODS

After a systematic literature review covering the period 2000-2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update.

RESULTS

In these patients, surgical interventions such as botulinum toxin A injections into the detrusor muscle, bladder augmentation, and even urinary diversion may become necessary to preserve the function of the upper (and lower) urinary tracts. The creation of a continent catheterizable channel should be offered to patients with difficulties performing transurethral clean intermittent catheterization. However, a revision rate of up to 50% needs to be considered. With increasing age continence of urine and stool becomes progressively more important. In patients with persistent weak bladder outlets, complete continence can be achieved only by surgical interventions creating a higher resistance/obstruction at the level of the bladder outlet with a success rate of up to 80%. In some patients, bladder neck closure and the creation of a continent catheterizable stoma is an option.

CONCLUSION

In all these patients close follow-up is mandatory to detect surgical complications and metabolic consequences early.

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.

Surgical Management of Neurogenic Sphincter Incompetence in Children

We report on the results of a literature review regarding the indications and results of operations to increase bladder outlet resistance to achieve dryness in children with neurogenic sphincter incompetence (NSBD). The relative advantages and disadvantages of injection of bulking agents, periurethral slings, bladder neck reconfiguration, artificial sphincters, and bladder neck closure based on a literature review and our combined clinical experience are discussed. Based on this review and our experience, we propose that periurethral injection of bulking agents is not justified as a primary treatment. Likewise, operations that reconfigure the bladder neck are not very useful since most patients also require bladder augmentation and an abdominal catheterizable channel. Bladder neck slings with autologous tissues are effective, mostly in females bur in the majority of patients a bladder augmentation is necessary. There is a role also for implantation of artificial urinary sphincters but when done as an isolated procedure, close monitoring to detect possible detrusor changes is needed. Bladder neck closure is an effective measure when other methods have failed.

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.

Perioperative Complications following Artificial Urinary Sphincter Placement

PURPOSE

We evaluated perioperative complications in patients undergoing primary artificial urinary sphincter placement and the potential impact of these complications on device outcomes.

MATERIALS AND METHODS

During the 2-year period from 2012 to 2014 we retrospectively evaluated the outcomes of 197 consecutive artificial urinary sphincter implantation procedures performed at our institution for post-prostatectomy incontinence. Of these cases 100 that were primary implantations comprise the study cohort. Perioperative complications, defined as those occurring within 6 weeks postoperatively, were classified by the Clavien-Dindo classification. After office evaluation at 6 weeks patients were followed for symptoms. Patient followup was obtained through office examination and telephone correspondence.

RESULTS

Patients undergoing primary artificial urinary sphincter implantation had a median age of 71.5 years (IQR 66, 76). The overall rate of any complication (Clavien I-V) within 6 weeks of surgery was 35%, including urinary retention in 31% of cases, cellulitis in 1%, device infection in 2% and urethral erosion in 2%. No significant differences in pertinent clinical comorbidities such as age (p = 0.69), hypertension (p = 0.95), coronary artery disease (p = 0.57), diabetes mellitus (p = 0.17), body mass index (p = 0.47), prior pelvic radiation therapy (p = 0.45), prior urethral sling placement (p = 0.91) or transcorporeal urethral cuff placement (p = 0.22) were found between patients with and without complications. Median followup was similar between those with and without postoperative urinary retention (p = 0.14). Postoperative urinary retention was associated with adverse 6-month device survival (76% vs 89%, p = 0.04).

CONCLUSIONS

The most common complication of artificial urinary sphincter placement is urinary retention. Serious adverse events following artificial urinary sphincter placement are rare. Postoperative urinary retention is associated with adverse short-term device survival rates.

Retropubic bulbourethral sling in incontinence post-exstrophy repair: 2-year minimal follow up of a salvage procedure

AIMS

Post-exstrophy incontinence is a challenge because continence is difficult to achieve and more difficult to maintain. Feasibility and outcomes of a bulbourethral sling to treat post-exstrophy incontinence is shown in this report.

METHODS

A retropubic bulbourethral sling was applied to male patients with incontinence post-exstrophy-epispadius repair. The study included children with total (continuous) incontinence who underwent multiple previous anti-incontinence procedures, ranging from bladder neck injection to bladder neck reconstruction. Preoperative assessment includes urinalysis, renal US, VCUG, 1-hr pad test and urodynamics. The bulbourethral sling applied is made of polypropylene and is suspended by 4 pairs of nylon sutures, to support the bulbar urethra within its covering muscles with the sutures tied on the rectus muscles. Continence was evaluated as well as adverse events.

RESULTS

Seventeen children, (median age 8.7 years) completed 24-month of follow up. All had CPRE. Five children (29.27%) were dry. Four micturated through the urethra and one by catheterizing his cutaneous stoma every 3-4 hr. In none, PVR exceeded 10% of expected capacity. Four children underwent re-tightening 1-4 weeks after removal of urethral catheter. Perineal wound dehiscence occurred in one, perineal/suprapubic pain in seven and epididymo-orchitis in one child.

CONCLUSION

The current technique is promising for difficult cases of incontinence after CPRE. It is safe, as no serious adverse events occurred during follow up period. It is economic and re-tightening is easy to perform. Neurourol. Urodynam. 35:497-502, 2016. © 2015 Wiley Periodicals, Inc.

Long-term fate of the bladder after isolated bladder neck procedure

OBJECTIVE

Recent and historical studies suggest that bladder neck procedures (BNPs) without augmentation are safe and effective. In select patients we have performed BNPs without concomitant augmentation. We sought to determine long-term outcomes of this approach and attempt to identify risk factors for bladder deterioration.

PATIENTS AND METHODS

A retrospective chart review was conducted to identify patients who underwent a BNP without bladder augmentation and followed for at least 4 years. BNPs were only performed in patients with favorable preoperative urodynamics (UDS). The charts were analyzed for long-term outcomes with the primary endpoint of bladder augmentation.

RESULTS

Twenty-nine patients (21 females) with poor bladder outlet resistance underwent a BNP without augmentation (mean follow-up 8 years). Thirteen patients (45%) were augmented at an average of 2.6 years. No predictive UDS parameters were identified; however, exploratory analysis suggested detrusor pressure at 100 mL bladder volume prior to BNP (p = 0.009) was predictive of delayed augmentation.

CONCLUSION

We report a 45% augmentation rate after isolated BNP in patients with favorable preoperative UDS parameters. We recommend close observation of this patient population with serial UDS, routine ultrasounds, and appropriate preoperative counseling prior to undertaking this approach, as this represents a life-long risk to the upper tracts.

Newer and novel artificial urinary sphincters (AUS): the development of alternatives to the current AUS device

INTRODUCTION

The current artificial urinary sphincter (AUS), AMS 800 (American Medical Systems, Minnesota, MN, USA) is considered the standard of care for the treatment of urinary incontinence (UI). While the long-term effectiveness, safety, and durability of the current model of the AMS 800 are well documented, it is not without its limitations and complications. Over the last few years, improvements in design and innovative research into AUS devices have increased the treatment arsenal in male UI.

METHODS

Articles from peer-reviewed journals, abstracts from scientific meetings and electronic literature searches formed the basis of this review.

RESULTS

Newer AUS models, e.g. FlowSecure, Zephyr, Pro-ACT and other novel experimental AUS devices, are designed to simulate a healthy human sphincter and address the limitation of the existing AMS 800 device.

CONCLUSIONS

Newer and novel AUS models are innovative and showed promising outcomes in short- to intermediate-term follow-up. However, there exists the need for prospective randomised clinical trials and complete reporting of adverse and long-term results before these AUS models can replace the existing AMS 800 device.

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.

The efferent segment in continent cutaneous urinary diversion: a comprehensive review of the literature

OBJECTIVE

To critically assess the biophysical properties and current status of outlet formation in heterotopic intestinal urinary diversion. As despite three decades of clinical experience with continent cutaneous urinary diversion through bowel segments, no consensus has been reached for the optimal efferent segment although its function largely determines patient satisfaction.

METHODS

A comprehensive Medline literature search using the Medical Subject Headings database (search terms: continent urinary diversion followed by either efferent segment, nipple, Mitrofanoff, Yang-Monti, Benchekroun, tapered ileum, intussuscepted ileum, Kock pouch, T-valve, or Ghonheim) was conducted to identify all full-length original articles addressing the various principles and techniques of outlet formation as well as their outcomes and complications. Examined series were published in English between 1966 and 2010. All studies were systematically evaluated using a checklist (study design, number of patients, etc.) and rated according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence (LoE).

RESULTS

While there was a continuous flow of publications over the last three decades, the vast majority of studies were retrospective case series with numerous confounding factors and poorly defined, non-standardized outcomes (LoE, 3). Only a few investigations compare different efferent segments (LoE, 2a). No randomized studies exist. The major biophysical principles are based on the use of flap, nipple, and hydraulic valves. Vermiform appendix, intussuscepted ileal nipple, and the Yang-Monti tube are the most popular techniques and have well-established data on outcomes, complications, and failure rates. Artificial sphincter systems and tissue engineering have provided disappointing results thus far. Most reconstructive strategies are subject to a process of on-going improvement.

CONCLUSIONS

The continuous quest for optimization has not led to a single universally applicable efferent segment in continent cutaneous urinary diversion. While all techniques have their unique set of advantages and disadvantages, they will always remain a compromise. Success depends on selecting the optimal strategy for individual patients. A major change in principles in the near future is unlikely.

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.

U2B-dry: preliminary results of a new vesicoscopic technique for bladder neck repair in children

INTRODUCTION

The aim of this work was to present a new vesicoscopic technique for treatment of sphincter insufficiency and to evaluate the short-term results.

MATERIALS AND METHODS

Eight children (mean age, 11.7 years), 4 with non-neurologic and 4 with neurologic sphincter incontinence, were operated on. All had previously failed open surgery. In all, leak-point pressure was below 30 cm H(2)O. Mean follow-up was 5.2 months. In the supine position, three ports were inserted into the bladder under direct visual control. A U-shaped incision was made in the mucosa around the bladder neck, leaving a strip of mucosa on the anterior bladder wall that was tubularized. One lateral mucosal flap was used to cover the tube. A transurethral catheter was left in for 3 weeks.

RESULTS

One conversion to open procedure was necessary because of leakage. Mean operation time was 161 minutes (range, 150-194). Postoperative hospital stay was between 2 and 4 days (mean, 2.7). Transurethral clean intermittent catheterization has been resumed in 4 children without complications. Four patients are dry, 2 are sporadically wet but satisfied with the result, and 2 patients are wet.

CONCLUSIONS

Vesicoscopic U-bladder neck plasty is a promising procedure. A major advantage of the technique is the fact that it is a relatively minor surgery with excellent cosmetic outcome and quick recovery.

Sling suspension of the bladder neck for pediatric urinary incontinence

OBJECTIVE

Surgery for urinary incontinence in childhood is in the process of an ongoing search for better results because a procedure that guarantees dryness still does not exist. This study has been conducted to assess the overall results of the fascia sling procedure for incontinence in children.

MATERIAL AND METHODS

Eighty-nine patients with neurogenic lower urinary tract dysfunction and follow-up of more than 2 years have been included in the study (46 boys and 43 girls aged 2-17 years). All patients underwent U-type sling suspension of the bladder neck. In 59 patients detrusorectomy and in 11 patients bladder augmentation was performed. Sphincter incompetence was defined as low-pressure (<30 cm H(2)O) leakage observed during urodynamic studies. The results of surgery were assessed clinically (dryness intervals).

RESULTS

Forty-two (47%) patients were completely dry, and 23 (26%) considerably improved. The success rate was higher in males (35) than in females (30) (76% vs 70%). Detrusorectomy did not improve the success rate of the sling procedure (68% vs 79% sling only), but bladder augmentation did (90%). Higher success rates have been observed in adolescents compared to prepubertal children (83% vs 56%). No serious complications were observed.

CONCLUSIONS

Rectus fascia sling suspension is a safe procedure and could be considered a good option for the treatment of neurogenic sphincter incompetence in children.

Bulbar urethral ligation for managing persistent urinary incontinence in young men with myelomeningocele

OBJECTIVE

To report our experience with ligation of the bulbar urethra for treating refractory stress incontinence in a selected group of young men with neuropathic bladders secondary to myelomeningocele (MM), in whom primary anti-incontinence procedures had failed.

PATIENTS AND METHODS

Persistent urethral incontinence leading to chronic perineal skin ulceration can occur in these patients, despite aggressive medical and surgical efforts to decrease wetting by increasing bladder capacity, compliance and outlet resistance. Four young men with MM had bulbar urethral ligation; all had undergone a previous ileocystoplasty and functioning continent catheterizable channels (CCC, three appendicovesicostomies, one Monti procedure). Three patients had primary bladder neck procedures using rectus fascia slings, and secondary attempts were made at urethral bulking in two patients. All patients had persistent incontinence through their native urethra, with dry intervals of <2 h.

RESULTS

The bulbar urethra was ligated through a small midline perineal incision at 1 year after augmentation, and successfully resolved incontinence in all four patients. All reported satisfaction with their bladder regimen at a mean (range) follow-up of 49 (20-93) months. There were no perineal wound infections. While one patient developed bladder calculi, no patient developed urethral stones, febrile urinary tract infections, fistulae or bladder perforations.

CONCLUSIONS

We report the results of bulbar urethral ligation for resolution of incontinence in patients with MM in whom anti-incontinence bladder neck procedures had failed. Ligation of the urethra is effective, and can be considered an alternative treatment for refractory urinary incontinence in patients with a functional CCC in whom previous bladder neck-supporting procedures have failed.

Severe bladder trabeculation obviates the need for bladder outlet procedures during augmentation cystoplasty in incontinent patients with neurogenic bladder

OBJECTIVE

To evaluate whether the degree of preoperative bladder trabeculation in neurogenic bladder (NB) patients is a marker of significant outlet resistance. If so, severe trabeculation may obviate the need for concomitant bladder outlet procedure (BOP) during augmentation cystoplasty (AC).

PATIENTS AND METHODS

We retrospectively reviewed 48 incontinent patients with NB who had surgery. The patients were divided into two groups: group 1 (23 patients) had AC alone; group 2 (10) had AC with BOP. Children who had a BOP alone (15) were excluded from the study. Success was defined as a dry period of > or = 4 h. Preoperative bladder trabeculation was classified as mild or severe. Data collected included continence status, imaging and urodynamic findings.

RESULTS

In group 1 patients before surgery, there was severe bladder trabeculation in 14 (61%), hydronephrosis in 13 (57%) and associated vesico-ureteric reflux (VUR) in 16 (70%). The mean detrusor leak-point pressure (DLPP) was 49.7 cmH2O and the bladder neck was open in nine (39%). Dryness with AC alone was achieved in 91% of group 1 patients. In group 2 patients (10 patients), there was severe bladder trabeculation in five, hydronephrosis in three, and VUR in two. The mean DLPP was 42.8 cmH2O and the bladder neck was open in eight. After surgery, eight of 10 patients achieved a dry period of 4 h. There was no significant difference between group 1 and 2 patients for age at surgery, gender, ambulatory status, hydronephrosis, degree of trabeculation, detrusor overactivity, DLPP and eventual outcome. The incidence of VUR was higher in group 1 patients (P = 0.009) and more patients in group 2 had an open bladder neck (P = 0.031).

CONCLUSION

Severe bladder trabeculation in incontinent patients with NB might predict an element of intrinsic outlet resistance. In this subset of patients, dryness was achieved by AC alone without further BOP. The degree of bladder trabeculation should be considered in the surgical decision-making process for incontinent children with NB.

Artificial urinary sphincters placed after posterior urethral distraction injuries in children are at risk for erosion

PURPOSE

Management for posterior urethral disruption and concurrent bladder neck incompetence is controversial. Some groups recommend treatment with a Mitrofanoff catheterizable stoma, while others advocate urethral reconstruction with delayed placement of an artificial urinary sphincter. We report our experience with the latter strategy.

MATERIALS AND METHODS

We reviewed the records of all patients with the above injury who were treated with end-to-end urethroplasty followed by delayed bladder neck artificial urinary sphincter placement from 1986 to 2006.

RESULTS

Five patients had videourodynamic evidence of bladder neck incompetence coexisting with traumatic posterior urethral disruption. The etiology of bladder neck incompetence in all 5 patients was a known longitudinal tear through the bladder neck that occurred at the time of trauma. Each patient underwent end-to-end urethroplasty. Six to 12 months later the patients had persistent incontinence. Bladder function and urethral patency were documented by urodynamic, radiographic and endoscopic studies. A bladder neck artificial urinary sphincter was subsequently placed. Each operation was technically demanding due to fibrosis in the pelvis and around the bladder neck. All patients were initially continent but erosion of the artificial urinary sphincter into the bladder neck in 4, and the bladder neck and rectum in 1 occurred at a mean of 3 years (range 6 months to 8 years).

CONCLUSIONS

Placement of a bladder neck artificial urinary sphincter for managing urinary incontinence due to concurrent posterior urethral disruption and bladder neck incompetence is difficult and it risks delayed erosion. In this patient population we would strongly consider urinary diversion with a Mitrofanoff catheterizable stoma.

Artificial Urinary Sphincter: 11-Year Experience in Adolescents with Congenital Neuropathic Bladder

OBJECTIVE

We assess our experience over the last 11 years in the use of an artificial urinary sphincter (AUS) to treat urinary incontinence in children with neuropathic bladders.

MATERIALS AND METHODS

Between 1994 and 2005 an AUS was implanted in 35 patients (mean age 14.4; range 11.5-18). Upper urinary tract (UUT) evaluations and urodynamic studies were performed in all patients pre- and post-AUS implantation. Thirteen patients underwent enterocystoplasty combined with AUS placement and 22 underwent AUS implantation alone.

RESULTS

An AUS was implanted in 35 patients. Mean follow-up is 5.5 years (range 0.4-11 years). Nine mechanical malfunctions occurred in seven patients (20%). Of the 22 patients who underwent AUS implantation alone, seven (31.2%) eventually required an enterocystoplasty because of unexpected bladder behaviour changes, usually within three years of AUS implantation. In seven patients (20%), a continent catheterisable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterisation (CIC) through the urethra. Three AUS (8.6%) were removed because of sphincter erosion at the bladder neck. All 32 patients (91.4%) with the AUS currently in place are dry, three void their bladders spontaneously, and 29 need CIC.

CONCLUSIONS

AUS must be considered as an elective treatment in the surgical management of these patients because it produces better continence rates than other methods. However, these patients need long-term follow-up because their bladder behaviour may undergo unexpected clinically asymptomatic changes that could negatively affect their UUT and require bladder augmentation.

Can urodynamic studies predict bladder behaviour changes after artificial urinary sphincter implantation?

OBJECTIVE

To assess whether preoperative urodynamic studies can predict bladder behaviour changes that will necessitate bladder augmentation in patients with neuropathic incontinence after undergoing artificial urinary sphincter (AUS) implantation.

PATIENTS AND METHODS

We analysed 17 patients, with a mean age of 14.4 years at AUS implantation, who did not undergo bladder augmentation either before or at implantation. All patients were followed at regular intervals before and after implantation. Urodynamic studies were done at least three times before implantation and yearly thereafter. Bladder capacity and compliance were evaluated preoperatively and during the follow up, in order to determine whether these urodynamic measurements could predict the eventual need for bladder augmentation.

RESULTS

After a mean follow up of 7.5 years bladder behaviour was unchanged in 11 patients while six required augmentation. In these six patients, normal bladder capacity and compliance decreased from 67 to 39.6% of age expected capacity (AEC) (P=0.004) and from 31.6 to 13.5 ml/cm of water (P=0.001), respectively. Four of the six had no clinical symptoms to suggest the change in bladder behaviour. The differences in the average preoperative and follow up values for both normal bladder capacity (72.4 vs 83.5% of AEC) and compliance (30 vs 33.7 ml/cm of water) were not significant in the non-augmented patients (P=0.2 and P=0.3, respectively). Preoperative normal bladder capacity and compliance were 72% of AEC and 30 ml/cm of water, respectively, in the 11 non-augmented patients and 67% and 31 ml/cm of water in the six patients with augmentation. These differences between the two groups were not significant (P=0.06; P=0.1).

CONCLUSION

Preoperative urodynamic studies do not predict bladder function outcome after AUS implantation. These patients require long-term careful observation to detect any asymptomatic change in detrusor behaviour.

SIMULTANEOUS AUGMENTATION CYSTOPLASTY IS ASSOCIATED WITH EARLIER RATHER THAN INCREASED ARTIFICIAL URINARY SPHINCTER INFECTION

PURPOSE

While artificial urinary sphincter infection or erosion occurs in 20% of implantations, the risk factors are poorly understood. One of the most contentious factors reported to increase prosthesis infection is simultaneous sphincter implantation and augmentation cystoplasty. In contrast to some reports, to date our results have not shown an increased infective risk with the simultaneous procedure. We reviewed the long-term infective complications of 195 sphincters to investigate for predisposing infective factors and review the role of augmentation cystoplasty.

MATERIALS AND METHODS

We performed a retrospective case note review of 144 patients with a median followup of 112 months. Augmentation cystoplasty performed in 86 patients (60%) and was simultaneous in 56. All patients were reviewed within the last year or followed until death or sphincter failure. Patient, surgical and treatment factors were statistically analyzed for associations with prosthesis infection.

RESULTS

A total of 108 sphincters failed from infection (25%), tissue atrophy (5%) or mechanical reasons (25%). The overall infective failure rate was similar in patients who underwent simultaneous augmentation (30%) compared with the other patients (23%), although there was a statistically significant difference within the first 3 postoperative years (log rank p = 0.009). While no other variables were significantly associated with sphincter infection, intermittent self-catheterization did not increase sphincter infection and females appeared to have more prosthesis infections.

CONCLUSIONS

Our results suggest that, while simultaneous augmentation cystoplasty and artificial urinary sphincter implantation lead to an initial increase in prosthesis infection, this difference disappears after 3 years.

PERIURETHRAL CONSTRICTOR IN PEDIATRIC UROLOGY: LONG-TERM FOLLOWUP

PURPOSE

We report long-term followup of a new device for the treatment of urinary incontinence in children.

MATERIALS AND METHODS

A periurethral constrictor was implanted in 29 boys and 13 girls 3 to 17 years old (mean age 10.2, median age 10) during the last 9 years. Of the patients 29 had neurogenic bladder, 12 had bladder exstrophy and 1 had megalourethra. Bladder augmentation was done simultaneously in 34 patients. The device was implanted around the bladder neck in 41 cases and at the bulbous urethra in 1. Continence was achieved in all cases when the device remained in situ.

RESULTS

Followup ranged from 4 to 104 months (mean 63, median 75). In 23 patients (82.1%) in the neurogenic group and the patient with megalourethra the device remains in situ and continence is preserved. Clean intermittent catheterization is performed without difficulty. In 4 patients the device was extracted due to erosion or infection. The device was extracted due to erosion and urine extravasation in 10 exstrophy group patients. Two patients have the device and perform post-void catheterization.

CONCLUSIONS

Based on the data from this long-term study we conclude that the periurethral constrictor is a safe alternative for the treatment of urinary incontinence in children. Like other devices it must be used with caution in cases of bladder exstrophy.

Experience with non-cycled artificial urinary sphincters

OBJECTIVE

To report our experience in children and adolescents with a non-cycled artificial urinary sphincter. While some children with the AUS can void, others require clean intermittent catheterization (CIC) through the sphincter or an alternative site for catheterization; in some of the latter we have either not cycled (pumped) an activated AUS or the AUS has failed, and there is concern about ischaemia in some adults with a non-cycled AUS.

PATIENTS AND METHODS

In all, 143 patients who had an AUS placed between 1980 and 2002 were reviewed retrospectively; 15 (10 boys and five girls) no longer cycled (pumped) their AUS. The mean age at AUS insertion was 11 years and the mean (range) follow-up after insertion was 10.4 (1.64-22.2) years. The diagnoses included myelomeningocele in 11, sacral agenesis in three and cloaca in one. Nine patients have an activated functioning AUS and in six the AUS does not function; in the first nine the sphincter has not routinely been cycled (pumped) for a mean (range) of 1.6 (0.6-2.9) years. In the other six with a nonfunctioning AUS the mean (range) observation period is 6.4 (1.5-10) years since the system has not functioned.

RESULTS

All patients were completely continent, including the six with a nonfunctioning AUS. After inserting the AUS, two patients voided in combination with CIC (one each urethral and abdominal stoma) and 13 emptied by CIC (nine abdominal stoma, four urethral). There was a mechanical complication in eight patients; three had the AUS repaired and are dry, and five are dry with no repair. In one patient the AUS was never activated. To date there has been no erosion of the cuff in any of the 15 patients with a non-cycled AUS.

CONCLUSION

The AUS remains an extremely reliable procedure to achieve continence in children and young adults. It is versatile and can be combined with other procedures that provide an alternative means for catheterization. While some have noted the need to routinely cycle the AUS to prevent erosion, this has not been our experience in these 15 patients.