Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty

Simultaneous bladder augmentation and artificial urinary sphincter placement in children with neuropathic urinary incontinence. Is it safe to perform? Long-term results

INTRODUCTION

Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial.

OBJECTIVE

The aim of this study is to describe our very long-term results after a median follow-up of 17 years.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups.

RESULTS

A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p = 0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p = 0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups.

DISCUSSION

There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time.

CONCLUSION

Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times.

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.

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

PURPOSE

The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision.

MATERIALS AND METHODS

Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible.

RESULTS

A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs.

CONCLUSION

These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.

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.

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.

Entérocystoplastie d'agrandissement

Augmentation enterocystoplasty refers to a technique that consists in removing a bowel segment in order to suture it onto the bladder. This technique is indicated in case of reduced bladder capacity and/or compliance, in case of failure of conservative treatments. The goal is to improve the patient's urination comfort, but above all to ensure long-term protection of the upper urinary tract. All bowel segments may be utilized but the ileum is the segment of choice. The selected digestive segment must be detubulized in order to better decrease its peristaltic contractions and obtain low-pressure urine storage. Bi-valving the bladder while preserving the detrusor usually performs augmentation enterocystoplasty. However, in case of very fibrous and thickened detrusor, a supra-trigonal cystectomy should be considered. The digestive segment is removed and detubulized, then it is sutured on to the bladder as a patch at the incision level. Following such surgery, over 90% of the patients report significantly improved quality of life. Nocturnal bladder competence is obtained in more than 90% of the patients, while 91 to 100% report diurnal bladder competence. Long-term complications may be observed, such as chronic infections with asymptomatic bacteruria (70% of the cases) not necessitating any treatment. Within the two first years, there is a 10% to 15% risk for stone formation following intestinal mucus development. Enterocystoplasty perforation may occur at a frequency estimated to range from 5 to 13%, which is a very serious and life-threatening complication. Similarly, a risk of enterocystoplasty cancer may be observed after five to ten years, in 1% of the cases.

Strategies in urological reconstruction in myelomeningocele

PURPOSE OF REVIEW

This paper reviews recent advances in the strategies for urinary tract reconstruction in children with spina bifida. The aims of reconstruction are the preservation of renal function and achievement of urinary continence. Considerable controversy exists on the subjects of bladder augmentation, procedures to increase outlet resistance, and continent stomas. The authors put the most recently published information in perspective in the light of their own personal experience.

RECENT FINDINGS

Thirty-seven papers covering the above-mentioned subjects published in the past 5 years (25 of them published since 2000) have been selected. Seven relevant older references are included. There is persistent interest in developing methods to enlarge the urinary bladder that avoid bringing the urine in contact with the intestinal mucosa. The artificial urinary sphincter and fascial slings are the most frequently reported methods to increase outlet resistance. The Mitrofanoff principle continues to be regarded as an effective method to construct a continent catheterizable channel, either with the appendix or reconfigured intestinal segments. The achievement of fecal continence has to be pursued in parallel with urinary continence. Incontinent diversions continue to be best for a small group of patients. The role of continent urinary diversion requires reassessment.

SUMMARY

Progress in this area continues to be made. Periodic, critical and objective reviews on the subject should help the practitioner to arrive at sound decisions.

Neurogenic and non-neurogenic bladder dysfunction

Children with a neurological defect have a clear cause for their bladder dysfunction; however, in neurologically normal children the cause of their incontinence is usually unclear. When no anatomical abnormalities seem to be present a functional problem is generally the cause. This type of incontinence is referred to as 'functional incontinence'. The different forms of bladder and sphincter dysfunction will be discussed and treatment modalities described. As the treatment modalities in children with neuropathic bladders focus on medical and especially surgical options, special attention is paid to new developments in surgical treatment. For those with functional incontinence treatment options are more variable and the new developments are described.