Compatibility of enterocystoplasty and the artificial urinary sphincter

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.

The Asia-Pacific AMS800 artificial urinary sphincter consensus statement

This Asia-Pacific (AP) AMS 800™ artificial urinary sphincter (AUS) consensus statement aims to provide a set of practical recommendations to assist surgeons with the AMS 800 device surgery. The AP consensus committee consisted of key opinion leaders with extensive experience with AMS 800 surgery across several AP countries. The panel reviewed and discussed relevant findings with emphasis on locoregional and specific clinical challenges relevant to the AP region. Recommendations were made in key areas namely (1) patient selection and informed consent process; (2) preoperative assessment; (3) dealing with co-existing urological disorders; (4) surgical principles and intraoperative troubleshooting; (5) postoperative care; (6) special populations; and (7) cost analysis and comparative review. The AMS 800 device should be offered to males with moderate to severe stress urinary incontinence (SUI). Full informed consent should be undertaken, and emphasis is placed on surgical contraindications and high-risk candidates. The presence of a surgical mentor or referral to experts is recommended in complex AUS candidates. Preoperative cystoscopy with or without multichannel urodynamic study is necessary and patients with pre-existing urological disorders should be treated adequately and clinically stable before surgery. Adherence to strict patient selection and safe surgical principles are critical to ensure excellent clinical outcomes and minimize complications. Given that InhibiZone-coated device is not available in many AP countries, the use of prophylactic antibiotics pre-and post-operatively are recommended. The AMS 800 device should be prepared according to the manufacturer's guidelines and remains a cost-effective treatment for male SUI. The AMS 800 device remains the surgical benchmark for male SUI but is associated with certain mechanical limitations and a unique set of complications.

Artificial urinary sphincter surgery in the special populations: neurological, revision, concurrent penile prosthesis and female stress urinary incontinence groups

The artificial urinary sphincter (AUS) remains the standard of care in men with severe stress urinary incontinence (SUI) following prostate surgery and radiation. While the current AUS provides an effective, safe, and durable treatment option, it is not without its limitations and complications, especially with regard to its utility in some “high-risk” populations. This article provides a critical review of relevant publications pertaining to AUS surgery in specific high-risk groups such as men with spinal cord injury, revision cases, concurrent penile prosthesis implant, and female SUI. The discussion of each category includes a brief review of surgical challenge and a practical action-based set of recommendations. Our increased understandings of the pathophysiology of various SUI cases coupled with effective therapeutic strategies to enhance AUS surgery continue to improve clinical outcomes of many patients with SUI.

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.

Neurogenic bladder in spinal cord injury patients

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction

AIMS

To investigate the functional outcome after supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

Retrospective follow-up investigation in a single spinal cord injury rehabilitation center. In 29 patients, urodynamic data before and after supratrigonal cystectomy and augmentation ileocystoplasty, clinical outcome and post-operative complications were evaluated.

RESULTS

The median age of the 29 patients at the time of surgery was 31 years, a median 14 years after NLUTD had occurred. At the last follow-up visit (median 2.4, range 0.4-9.0 years post-operatively), 20/29 patients (69%) were continent compared to 2/29 pre-operatively (P = 0.001). Furthermore, 16 patients required no or less detrusor relaxation therapy after augmentation ileocystoplasty. Augmentation cystoplasty resulted in a significant (P = 0.001) increase in the median bladder capacity (from 240 ml to 500 ml) and compliance (from 13 ml/cm H2 O to 50 ml/cm H2 O). The median maximum detrusor pressure had decreased significantly (P = 0.001) from 38 cm H2 O to 15 cm H2 O. Significantly (P = 0.001) fewer patients presented with a risk for renal damage (1 vs. 15 with maximum detrusor pressure >40 cm H2 O and 1 vs. 12 with detrusor compliance <20 ml/cm H2 O) at the last follow-up. The following complications were observed in 11/29 (38%) patients: paralytic and obstructive ileus, impaired bowel function, bladder stones, dehiscence, metabolic acidosis and autonomic dysreflexia.

CONCLUSIONS

Protection of renal function, adequate bladder capacity and low detrusor pressure can be achieved using supratrigonal cystectomy and augmentation ileocystoplasty in patients suffering from refractory NLUTD.

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.

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.

Surgical treatment of neuropathic urinary incontinence in 2005. When, what, and how?

We present our current opinions on the surgical treatment of urinary incontinence in children with spina bifida. The age of treatment, preferred treatment modalities and results are discussed. We emphasize the importance of initiating treatment for incontinence at an early age as well as the use of effective surgical techniques.

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.

Gastrocystoplasty in patients with an areflexic low compliant bladder

AIM

This study was performed with the aim of evaluating gastrocystoplasty as a method of management of patients with an areflexic low compliant bladder.

PATIENTS AND METHODS

We performed gastrocystoplasty in 30 patients (19 males and 11 females) with an areflexic low compliant bladder. The mean age of the patients was 23.4+/-11 years (range 4-32). The etiology of lower urinary tract dysfunction was myelodysplasia in 26 patients and spinal cord injury in 4. Twenty-three patients had normal renal function and 7 had impaired renal function (creatinine 2.0-5.0mg%). Additionally, 4 patients had an artificial urinary sphincter implanted and seven had an antireflux procedure performed.

RESULTS

Renal function remained stable or improved in 29 patients. Postoperatively, there was a 225% increase from mean preoperative capacity and a 52% decrease from the preoperative end filling pressure. Nineteen patients voided spontaneously and 11 used clean intermittent catheterization to empty the bladder. Twenty-five patients were continent with augmentation alone, four with augmentation and artificial sphincter implantation while one remained incontinent, as sphincter implantation could not be performed due to the young age of the patient. Five patients (17%) had transient hematuria and dysuria after augmentation. There were no mortalities and complications included prolonged urinary leakage in one patient and mild gastric bleeding in another two.

CONCLUSION

The use of the stomach for augmenting the areflexic low compliant bladder is clearly advantageous over other tissues as it increases bladder capacity and compliance with consequent achievement of continence and preservation of upper tracts. An artificial urinary sphincter can be safely implanted in the same session. Because of its inherent fibromuscular properties, the gastric patch contributes to the force of urination resulting in better bladder emptying. Patients with impaired renal function are protected from hyperchloremic metabolic acidosis.

Treating neuropathic incontinence in children with seromuscular colocystoplasty and an artificial urinary sphincter

PURPOSE

To review the results of artificial urinary sphincter (AUS) implantation combined with seromuscular colocystoplasty (SCLU) in the treatment of mixed neurogenic urinary incontinence in children.

PATIENTS AND METHODS

Patients (27, six females) who had undergone SCLU were interviewed, and their charts and imaging studies reviewed retrospectively. Their urodynamic data were analysed and bladder capacity, end-filling pressure, safe capacity and percentage of expected capacity for age compared before and after surgery. Continence was defined as dryness between catheterizations or voiding with no need for protective pads.

RESULTS

The mean (sd) follow-up since the SCLU was 1.7 (1.1) years; continence was achieved in 24 of the 27 (89%) patients with no additional procedures. No significant upper tract changes developed. Bladder capacity, safe capacity for age and end-filling pressure were all improved significantly. There were two AUS erosions necessitating removal and in one patient the augmentation failed. Six patients early in the series developed an 'hourglass' deformity that required correction. Modifications to the technique to avoid this complication are discussed.

CONCLUSIONS

For children with neuropathic incontinence who require both augmentation of outlet resistance and bladder storage capacity, the combination of the AUS and SCLU effectively achieves continence with no upper tract deterioration. SCLU is also the preferred method of augmentation when adverse bladder changes occur after implanting the AUS.

Bladder dysfunction in children with bilateral single ectopic ureters

BACKGROUND

Single ectopic ureters are a rare malformation in children. Therapy consists of ureteral reimplantation. However, in case of bilateral single ectopic ureters, subsequent malformation of the bladder trigone and bladder neck may result in additional voiding dysfunction, and ureteral reimplantation alone may not solve the urologic problems.

METHODS

The authors report their experience with 2 girls, in whom bilateral single ectopic ureters were treated by ureteral reimplantation in early childhood and who did not gain adequate bladder control during following years.

RESULTS

Videourodynamic evaluation was done in both girls. No bladder overactivity was found during the urodynamic studies. However, cystography showed a widely open bladder neck during filling with no sufficient bladder neck closure shown by urethral pressure profile studies. When blocking the bladder outlet by balloon catheters, adequate bladder filling volume was achieved. Incontinence was cured by implantation of an AMS 800 artificial sphincter system in a 10-year-old girl. A 7-year-old girl was regarded to be too young for sphincter implantation and is waiting for surgery within the next years.

CONCLUSION

Insufficient development of trigone and bladder neck with subsequent urinary incontinence has to be kept in mind when deciding on surgical procedures in children with bilateral single ectopic ureters.

Artificial urinary sphincter placement in men after cystectomy with orthotopic ileal neobladder: continence, complications, and quality of life

OBJECTIVES

To review our experience regarding the overall efficacy and safety of an artificial urinary sphincter (AUS) in men with stress urinary incontinence (SUI) after cystoprostatectomy with an orthotopic ileal neobladder.

METHODS

We performed a retrospective review of 5 men who underwent placement of an AUS (AMS 800) for severe SUI after radical cystectomy with an orthotopic ileal neobladder. Incontinence symptoms and quality of life were quantified using two validated continence questionnaires (Urogenital Distress Inventory Short Form and Incontinence Impact Questionnaire Short Form) and a brief addendum questionnaire. The degree of continence, perioperative and postoperative complications and infections, symptom distress, quality of life, and patient satisfaction were compared before and after AUS placement.

RESULTS

Complete (0 pads per day) or social (1 pad or less per day) continence was reported in 5 of 5 patients after AUS placement. The average pad usage significantly decreased from 6.2 to 0.6 per day (P <0.001). No significant perioperative or postoperative complications or infections were noted. Symptom distress, quality of life, and patient satisfaction were significantly improved after AUS placement (P < 0.01, < 0.0001, and < 0.001, respectively).

CONCLUSIONS

With short-term follow-up and a limited number of patients, the placement of an AUS for treatment of SUI after bladder substitution is well tolerated and reliable and has a positive impact on patients' quality of life.

Bladder augmentation: does it predispose to prosthetic infection of simultaneously placed artificial genitourinary sphincters or in situ ventriculoperitoneal shunts?

OBJECTIVE

To review previous reports and our experience in assessing the risk of prosthetic infections in patients undergoing bladder augmentation simultaneously with artificial genitourinary sphincter (AGUS) implantation, and in patients with in situ ventriculoperitoneal (VP) shunts, implicated as a cause of shunt infection.

PATIENTS AND METHODS

The literature was searched to identify the number of prosthetic infections (AGUS or VP shunt) reported in patients who have undergone bladder augmentation. Additionally, the records of 53 myelodysplastic patients at our institution who had undergone bladder augmentation were reviewed to determine the incidence of AGUS and/or VP shunt infections. An AGUS was placed in 17 of these patients, who were then divided into three groups based upon the timing of their AGUS placement relative to bladder augmentation. Of the 53 patients, 47 had an in situ VP shunt at the time of their augmentation. All patients were followed for at least 12 months.

RESULTS

The reported rate of AGUS infection at the time of simultaneous bladder augmentation was not significantly different from that when these procedures were staged. In the present series, the AGUS became infected in two patients (12%); one infection occurred in each of 10 patients undergoing simultaneous procedures (10%) and one developed in each of the seven patients undergoing staged procedures (14%). Although VP shunt infections have been reported after bladder augmentation, none of the present patients had a VP shunt infection after bladder augmentation.

CONCLUSION

These results suggest that bladder augmentation is not associated with an increased risk of prosthetic infection in patients undergoing simultaneous placement of an artificial sphincter or in those who have an in situ VP shunt.

Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder

OBJECTIVES

Although the urologic outcomes of augmentation cystoplasty for neurogenic bladder dysfunction are well known, additional information about the patient perspective is needed. The aim of this study was to assess patient perspective using a standardized questionnaire.

METHODS

Fifty-nine patients, who had undergone augmentation enterocystoplasty as part of reconstruction mainly to correct hyperactive bladders and incontinence, were subjected to a questionnaire after a median of 76.1 postoperative months. The questionnaire addressed medications, catheterization, incontinence, bowel dysfunction, and satisfaction with urinary tract management. The urologic outcomes regarding upper and lower tract changes, complications, and reinterventions were documented as well.

RESULTS

The patients experienced a significant increase in bladder capacity and decrease in pressure at capacity (P < 0.0001). Normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Twenty-four patients (40.6%) had one or more complications, with 21 requiring reinterventions. Twenty-five percent of patients required the reintervention within the first 25 months, and the median time to reintervention was almost 10 years. Thirty-five patients took medications such as anticholinergics, antidiarrheals, or antibiotics. Fifty-six patients were treated with clean intermittent catheterization (CIC) at a mean interval of 4.6 hours. Seven patients had some difficulty with CIC. Thirty-nine patients (67%) were dry, and 17 had mild and 3 severe incontinence. Eleven patients (18.6%) reported bowel dysfunction, although 7 had it preoperatively. Almost all patients were very satisfied with their urologic management.

CONCLUSIONS

The high degree of patient satisfaction attests to the value of the procedure. The complication and reintervention rates underscore the importance of long-term follow-up.

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement: infection rates and voiding mechanisms

PURPOSE

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement have recently been reported to be associated with a high incidence of infection. We reviewed our results to define the infection rate and outline the mechanisms of voiding in our patient population.

MATERIALS AND METHODS

A total of 29 patients underwent a simultaneous procedure. The etiology of lower urinary tract disease was exstrophy in 14 patients, myelomeningocele in 10, lipomeningocele in 3, spinal cord injury in 1 and radical retropubic prostatectomy in 1. We used 19 gastric, 5 ileal and 5 colonic intestinal segments. Average followup was 33 months. All patients were followed for a minimum of 2 years. Preoperatively all cases had mechanical bowel preparation and documented sterile urine cultures or treated bacteriuria.

RESULTS

Infection developed in 2 patients (6.9%) necessitating artificial urinary sphincter removal at 1 week and 9 months. There were no infections associated with gastrocystoplasty. Clean intermittent catheterization was required in 21 patients, while the remaining 8 voided spontaneously. Of the 8 patients 4 were catheterized at least once daily to monitor residual urine volumes. Of all patients 5 were catheterized with a gastric tube, 5 with an appendicovesicostomy and 14 per urethra.

CONCLUSIONS

A simultaneous procedure was associated with an acceptable prosthetic infection rate and gastric segments were associated with the lowest incidence of infection. The minority of patients voided spontaneously. The combination procedure was effective in achieving continence. However, in the future a nonprosthetic means of providing urethral resistance may provide better treatment.

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement: infection rates and voiding mechanisms

PURPOSE

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement have recently been reported to be associated with a high incidence of infection. We reviewed our results to define the infection rate and outline the mechanisms of voiding in our patient population.

MATERIALS AND METHODS

A total of 29 patients underwent a simultaneous procedure. The etiology of lower urinary tract disease was exstrophy in 14 patients, myelomeningocele in 10, lipomeningocele in 3, spinal cord injury in 1 and radical retropubic prostatectomy in 1. We used 19 gastric, 5 ileal and 5 colonic intestinal segments. Average followup was 33 months. All patients were followed for a minimum of 2 years. Preoperatively all cases had mechanical bowel preparation and documented sterile urine cultures or treated bacteriuria.

RESULTS

Infection developed in 2 patients (6.9%) necessitating artificial urinary sphincter removal at 1 week and 9 months. There were no infections associated with gastrocystoplasty. Clean intermittent catheterization was required in 21 patients, while the remaining 8 voided spontaneously. Of the 8 patients 4 were catheterized at least once daily to monitor residual urine volumes. Of all patients 5 were catheterized with a gastric tube, 5 with an appendicovesicostomy and 14 per urethra.

CONCLUSIONS

A simultaneous procedure was associated with an acceptable prosthetic infection rate and gastric segments were associated with the lowest incidence of infection. The minority of patients voided spontaneously. The combination procedure was effective in achieving continence. However, in the future a nonprosthetic means of providing urethral resistance may provide better treatment.

Upsizing of the artificial urinary sphincter cuff to facilitate spontaneous voiding

OBJECTIVES

Following placement of an artificial urinary sphincter (AUS) in the male child, functional and mechanical alterations can ensue, resulting in an inability to void spontaneously. One possible mechanical etiology in the patient entering puberty is prostatic growth within the fixed mechanical confines of the AUS cuff, resulting in progressive bladder outlet obstruction. Unrecognized infravesical obstruction can, in turn, lead to upper urinary tract deterioration, sepsis, or renal failure. We evaluated the effect of somatic growth and maturation of the male urethra on voiding dynamics in boys with an AUS to specifically determine whether revision of the sphincter cuff (ie, upsizing) is beneficial in restoring the ability to void spontaneously.

METHODS

A retrospective review of 124 children with an AUS was performed. Eleven boys were identified whose bladder neck cuffs were later upsized in an attempt to improve bladder emptying. All boys were prepubertal at the time of original cuff placement. The average interval between the initial operation and cuff upsizing was 5 years.

RESULTS

Following original sphincter placement, 8 patients emptied to completion spontaneously and 3 patients emptied by intermittent catheterization. All eight of the spontaneous voiders experienced progressive difficulty emptying after they entered puberty and ultimately had to rely on clean intermittent catheterization to empty completely. Follow-up subsequent to cuff exchange averaged more than 5 years (range 1 to 10 years). Despite an average increase of 10 mm in cuff size, all patients continued to depend on intermittent catheterization to empty completely.

CONCLUSIONS

Upsizing the bladder cuff in the maturing male who experiences difficulty with bladder emptying does not restore the ability to void spontaneously.

Ten-year experience with the artificial urinary sphincter in children

PURPOSE

To assess the efficacy of the artificial urinary sphincter survival and continence were first evaluated 5 years ago. We now evaluated the effects of the artificial urinary sphincter more than a decade after implantation.

MATERIALS AND METHODS

Before 1985 an artificial urinary sphincter was implanted in 22 male and 14 female consecutive patients 4 to 30 years old (median age 12). In addition, between 1985 and 1990, 18 other children underwent artificial urinary sphincter implantation. Results of both series were compared.

RESULTS

Of the 25 sphincters in the original series that were functioning after 5 years 1 was removed and 2 patients were lost to followup, resulting in 22 functioning implants (61% of the patients). Mean survival time of the prostheses was 12.1 years and average followup for functioning sphincters was 13.7 years. There was no statistically significant difference in artificial urinary sphincter survival between the original group at 5 years and the second group treated after 1985. Of the patients in both groups with sphincters in place 32 of 39 (82%) were dry. Augmentation cystoplasty was performed in 9 of 18 patients (50%) in the second series (5 preoperatively and 4 postoperatively) compared to 10 of 36 (28%) in the original series at 5 years (3 preoperatively and 7 postoperatively). Renal failure developed in 6 patients from both series.

CONCLUSIONS

The artificial urinary sphincter is a durable long-term solution for children with intractable incontinence. Long-term surveillance of the urinary tract is mandatory because of the potential for renal failure in patients who have bladder hypertonicity after placement of the device.

Combined use of bowel and the artificial urinary sphincter in reconstruction of the lower urinary tract: infectious complications

Combined use of the artificial urinary sphincter and bowel in reconstruction of the lower urinary tract is currently being performed with increasing frequency. We reviewed our experience with 31 patients undergoing augmentation cystoplasty and insertion of the artificial urinary sphincter with respect to device infections to determine if a single operation was associated with increased morbidity compared to staged procedures. Of the patients who underwent simultaneous reconstruction 50% had prosthetic infections as opposed to 9.5% when the procedure was staged. More than half of the infections presented longer than 1 year after placement of the artificial urinary sphincter. The lowest incidence of device infection occurred in patients who underwent a staged procedure with implantation of the artificial urinary sphincter initially followed by augmentation cystoplasty. The discrepancy in infection rates between single and staged procedures is dramatic in this series and, therefore, a staged approach is recommended to decrease infectious complications.

The use of the AMS800 artificial urinary sphincter in combination with the gastric tube for continence in the canine model

An experimental canine model was designed to examine the potential use of the artificial urinary sphincter around a gastric tube. The artificial urinary sphincter was placed around a tubularized gastric flap as part of a continent gastric reservoir in 4 dogs and in 2 additional dogs the gastric tube was anastomosed to the native bladder. Two dogs underwent placement of the artificial urinary sphincter around the gastric tube 4 weeks postoperatively and the remainder had the sphincter placed simultaneously with creation of the gastric tube. All dogs with the gastric reservoir underwent urodynamics before and after activation of the sphincter. Only 61 to 70 cm. water pressure balloons were used. All dogs were continent postoperatively on clean intermittent catheterization every 8 hours. There were no erosions or problems with catheterization. Urodynamics confirmed a complaint system and an average increase of capacity of 410% after artificial urinary sphincter activation (4 dogs). There was no leakage at capacity. Histology of the artificial urinary sphincter and neighboring (control) regions, and of the reservoir at 1 (2 dogs), 3 (3 dogs) and 6 months (1 dog) was obtained. Microscopic examination of the cuff site showed mild serosal hyperplasia and fibrosis, a well preserved muscularis and mild to moderate focal mucosal atrophy. These changes were slightly more evident at 6 months. Mucosal folds were well preserved with normal submucosa and lamina propria. In the control region histology was well preserved and similar to native stomach. We conclude that the artificial urinary sphincter around a gastric tube can provide urinary continence. The minimal changes in histology under the cuff are encouraging and support the potential for use of the gastric tube with the artificial urinary sphincter, although longer term effects are unknown.

Lower urinary tract reconstruction using stomach and the artificial sphincter

We implanted the artificial urinary sphincter at gastrocystoplasty in 13 male and 5 female patients. The diagnoses were classical bladder exstrophy (8 patients), myelodysplasia (8), cloacal exstrophy (1) and bilateral ectopic ureters (1). Mean patient age was 14.3 years (range 7 to 32.5). Six patients (5 with bladder exstrophy and 1 with clocal exstrophy) had failed bladder neck continence procedures, 3 myelodysplastic patients had failed artificial urinary sphincter placement, and 1 exstrophy patient had failed a Young-Dees bladder neck repair and artificial urinary sphincter placement. The sphincter cuff was placed around the reconstructed bladder neck in these patients, while in the remainder the artificial urinary sphincter was placed around the intact bladder neck. Mean followup was 20.3 months (range 1 to 5). Of the patients 16 (88%) are continent day and night, while 2 are wet. A total of 11 patients (61%) use Valsalva's maneuver alone for voiding and the remainder use Valsalva's maneuver and/or clean intermittent catheterization for bladder evacuation. Complications related to the artificial urinary sphincter were recurrent pump erosion requiring conversion to a Mitrofanoff continent stoma in 1 patient, and mechanical dysfunction requiring pump cuff and reservoir replacement in 3. There were no complications due to infection. Our report demonstrates that the combination of augmentation gastrocystoplasty and an artificial urinary sphincter leads to urinary continence and can allow for spontaneous urination. The rate of infectious complications is not increased when the 2 procedures are combined simultaneously.

Experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma

We describe our experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma as an alternative to an indwelling catheter or supravesical diversion in 14 women and 4 men with various problems who could not perform intermittent urethral self-catheterization. The aim of management was also to provide, if possible, a competent urethra for additional access. Mean patient age was 37 years (range 22 to 75) and mean followup was 26 months (range 5 to 58). Preoperative management in the 11 wheelchair dependent women with neurological disease was an indwelling catheter in 7, urethral intermittent catheterization with the patient in the supine position in 3 and diapers in 1. Two women with a nonneurogenic bladder and a grossly incompetent urethra (1 after multiple incontinence and fistula repairs, and 1 after severe obstetrical trauma) wore diapers, while 1 with urinary retention and inability to perform self-catheterization had an indwelling catheter. The 4 men included 2 wheelchair dependent incontinent spinal cord injury patients who could not be managed with condom drainage, 1 with multiple anomalies who had trouble with self-catheterization, and 1 with an impassable postoperative stricture and a suprapubic tube. Surgery included anti-incontinence procedures in 10 patients and bladder neck closure in 3. A total of 15 patients required bladder augmentation in addition to the stoma and 3 had a stoma alone. Postoperative intervention was necessary in 4 women for stomal incontinence and in 2 of these bladder stones were removed simultaneously. One of these women was later treated for recurrent stones cystoscopically through the stoma. Overall, 17 of 18 patients are dry on intermittent stomal catheterization, with 1 lost to followup. We conclude that this procedure is a good alternative in patients with an end stage urethra or who cannot perform urethral catheterization because of physical disability. Establishing urethral continence and maintaining patency leaves a safety valve should the stoma fail. Since the bladder remains as a reservoir no ureteral surgery is necessary.

Influence of preoperative bladder capacity and compliance on the outcome of artificial sphincter implantation in patients with neurogenic sphincter incompetence

We performed a retrospective study of 23 patients with neurogenic sphincteric incompetence who had undergone implantation of an artificial urinary sphincter to determine if bladder capacity and compliance as determined by cystometrography could predict the need for enterocystoplasty. Study criteria were neurogenic sphincteric incompetence, no previous operations on the lower urinary tract, and performance of preoperative and postoperative cystometrography. Patients were 5 to 17 years old at implantation. Incontinence was caused by myelomeningocele (18 patients), sacral agenesis (3) and spinal cord tumor (2). The 8 patients for whom preoperative cystometric bladder capacity was greater than 60% of the expected capacity for age have been followed for a mean of 60 months. All 8 patients are continent and none required enterocystoplasty. Preoperative bladder compliance exceeded 2 ml./cm. water in all patients (group 1). Of the 15 patients for whom preoperative cystometric bladder capacity was less than 60% of the expected value (group 2, small bladders) 8 followed an average of 72 months had a compliance greater than 2 ml./cm. water and have done well without bladder augmentation. In contrast, 7 patients in this group (46%) required enterocystoplasty: 6 for persistent or recurrent incontinence and 1 for upper tract changes. The average interval between artificial sphincter placement and enterocystoplasty was 14 months. Patients with a small bladder that required augmentation had a preoperative bladder compliance of less than 2 ml./cm. water. We conclude that small bladder capacity, as determined by cystometrography in patients with neurogenic sphincteric incompetence but a bladder compliance of less than 2 ml./cm. water predicts the future need for bladder augmentation. In all other patients, with good medical treatment and followup, the possible adverse effects of a small capacity bladder can be prevented or corrected. With this strategy we have been able to avoid enterocystoplasty with its attending potential complications in 70% of our patients with neurogenic incontinence and favorable urodynamics regardless of preoperative cystometric bladder capacity.

Management of the bladder outlet in patients requiring enterocystoplasty

We reviewed 30 patients who required augmentation enterocystoplasty and a procedure to modify the bladder outlet for the treatment of intractable incontinence. Of the 30 patients 16 were treated with simultaneous cystoplasty and an outlet procedure, 6 initially underwent an outlet procedure followed by cystoplasty and in 8 cystoplasty was performed first with a subsequent operation to modify the bladder outlet. Continence was achieved in 29 patients. The current methods for evaluation of the bladder and its outlet are reviewed, focusing on the predictive value of preoperative testing to determine which patients require cystoplasty and an outlet modifying procedure.

Success of the artificial urinary sphincter after failed surgery for incontinence

We implanted the artificial urinary sphincter in 15 incontinent patients for whom multiple urethral and bladder neck operations, including sphincter placement, had been unsuccessful. The 5 male and 10 female patients ranged from 3 to 26 years old (mean age 11 years). The etiology of incontinence was neurogenic bladder in 10 patients, epispadias in 2, exstrophy in 1, ectopic ureters in 1 and traumatic urethral disruption in 1. Of the 15 patients 13 required augmentation enterocystoplasty and clean intermittent catheterization. The initial anti-incontinence procedures were Young-Dees-Leadbetter bladder neck reconstruction in 10 patients, artificial urinary sphincter placement in 4 and bladder neck suspension in 1. Causes of failure of the primary treatment were erosion (artificial urinary sphincter), and incontinence and/or difficult catheterization (Young-Dees-Leadbetter). Followup from the last salvage operation averaged 21 months (range 6 to 37 months). A total of 58 operations was performed. Among the 4 patients in whom the artificial urinary sphincter eroded the bladder neck repeated attempts to place the cuff at the same site were unsuccessful and erosion occurred in all 4 within 1 year. Sphincter placement was more successful among the 11 patients who initially underwent Young-Dees-Leadbetter bladder neck reconstruction or bladder neck suspension; acceptable continence was attained in 8 patients (73%). We conclude that placement of the sphincter cuff around a previously eroded bladder neck probably will result in erosion. Sphincter implantation should be attempted in patients in whom bladder neck reconstruction has failed. Persistence in the treatment of these patients is essential because multiple operations often are necessary to achieve continence.

Augmentation enterocystoplasty for the management of voiding dysfunction in spinal cord injury patients

A total of 12 spinal cord injury adults underwent augmentation enterocystoplasty for treatment of a high pressure neurogenic bladder. These patients suffered from urinary incontinence, recurrent urinary tract infection, upper tract deterioration and severe autonomic dysreflexia. A sigmoid colon segment fashioned into a cup-patch was used in 11 patients and detubularized cecum was used in 1. The artificial urinary sphincter was implanted in 3 patients at augmentation enterocystoplasty and in 1 after enterocystoplasty. After a mean followup of 15 months all patients were continent on clean intermittent self-catheterization, the upper tract had remained stable or had improved and the symptoms of autonomic dysreflexia had disappeared. A third of the patients are on maintenance antibiotic therapy to control bacteriuria.

The artificial sphincter AS800 in congenital urinary incontinence

The artificial urinary sphincter AS800 was implanted in 33 male and 13 female patients with congenital urinary tract incontinence. In 15 patients (32 per cent) previous operations to correct incontinence had failed. The sphincter was implanted around the bladder neck in 43 patients and around the bulbous urethra in 3. Mean patient age at the time of sphincter implantation was 13 years. In 40 patients (87 per cent) the sphincter functions well after a mean followup of 25 months and 39 patients (85 per cent) have satisfactory continence. In 6 patients the sphincter was removed because urethral, vulvar or scrotal erosions developed, all of whom had had previous surgical procedures in the area of the erosion. In 1 patient not operated upon previously erosion of the bulbous urethra developed. He did well after a new sphincter was implanted around the bladder neck. Five patients required an enterocystoplasty to achieve continence following the sphincter implantation. Nine patients required surgical revision of the sphincter for mechanical failure, technical errors, trauma and patient growth. We conclude that in patients with neurogenic sphincter failure implantation of an artificial sphincter around the bladder neck should be considered as the initial treatment of choice.