Use of the AS800 device in exstrophy and epispadias

Initial experience with ACT™ periurethral adjustable balloons to treat urinary incontinence due to intrinsic sphincter deficiency in the pediatric population

PURPOSE

To present our initial experience with periurethral adjustable continence therapy (ACT™) for urinary incontinence due to intrinsic sphincter deficiency (ISD) in children.

METHODS

This is an approved prospective non-randomized pilot study (NCT03351634) aiming to treat children born with spinal dysraphism (SD) or exstrophy epispadias complex (EEC) with ACT™. Endpoints were patient-reported changes in daily pad count, 24-h Pad test and complications.

RESULTS

Since April 2018, 13 children (six girls, seven boys) were implanted at the median age of 12 years (5-16). The etiology of incontinence was neurogenic ISD (7/13, 54%) and EEC (6/13, 46%). After ACT™ implantation, continence (no pad or 1 security pad/day) was achieved in 9(69%) patients (5/7 SD, 4/6 EEC). Additionally, two (15%) patients had a significant improvement (decreasing Pad test from 1049 to 310 g at 3 months). One patient (7%) had no improvement. Results were stable at 21 months (6-43) of follow-up. Mean final balloon volume was 2.89 ml (± 0.85) with a median of 3 fillings to obtain continence. We had four revisions due to cutaneous port erosion (n = 3) and balloon migration (n = 1) and two definitive explantations. PinQ score was significantly improved (47 vs 40.5 with balloon, p = ns). Neither degradation of the upper urinary tract nor cystomanometric changes have been observed at 6 and 12 months postoperatively.

CONCLUSION

Urinary incontinence due to ISD owing to EEC or SD can be successfully treated with ACT™ periurethral balloons. Given the minimal invasiveness of this therapy, it might be a first-line option treatment in children with complex stress urinary incontinence.

Outcomes of robot-assisted urinary sphincter implantation for male neurogenic urinary incontinence

OBJECTIVES

To report the functional outcomes of robot-assisted laparoscopic artificial urinary sphincter implantation (R-AUS) in men with neurogenic stress urinary incontinence (SUI).

PATIENTS AND METHODS

A monocentric retrospective study included all consecutive adult male neuro-urological patients who underwent R-AUS for SUI between January 2011 and August 2018. The AUS was implanted via a transperitoneal robot-assisted laparoscopic approach. Intraoperative and early postoperative complications were reported (Clavien-Dindo classification). Continence was defined as no pad usage. Revision and explantation rates were also evaluated.

RESULTS

Overall, 19 men with a median (interquartile range [IQR]) age of 45 (37-54) years were included. No conversion to laparotomy was needed. Three minor (Clavien-Dindo Grade I-II) early postoperative complications occurring in three (15.8%) patients were reported. The median (IQR) follow-up was 58 (36-70) months. At the end of the follow-up, the continence rate was 89.5%. The AUS revision and explantation rates were 5.3% and 0%, respectively.

CONCLUSION

A R-AUS is a safe and efficient procedure for AUS implantation in adult male neuro-urological patients, referring to the challenging open technique.

[Male neurogenic stress urinary incontinence treated by artificial urinary sphincter AMS 800™ (Boston Scientific, Boston, USA): Very long-term results (>25 years)]

OBJECTIVE

The aim of the study was to report the very long-term functional outcomes of artificial urinary sphincter (AUS) in male neurological patients.

MATERIAL AND METHODS

Male neurological patients diagnosed with stress urinary incontinence due to sphincter deficiency and undergoing AUS (AMS 800^®) implantation between 1985 and 1992 were enrolled. Continence, defined by no pad/condom usage, explantation and revision rates were reported.

RESULTS

Fourteen patients with a median age of 27.3 years (IQR: 27.3-40.8) were included: four had a spinal cord injury and ten a spina bifida. Prior continence surgery was reported by 6 patients (42.9 %). Artificial urinary sphincter was implanted in a peribulbar (n=4) or periprostatic position (n=10). Median follow-up was 18.3 years (IQR: 10.1-20.3). At last follow-up, all patients were alive. Three native devices were still in place, eight were revised (four of them were secondarily explanted) and three were explanted due to erosion or infection. The 5-, 10-, 15-, 20-year explantation-free survival rates were respectively 85.7, 62.3, 52.0, 39.0 %. The 5-, 10-, 15-, 20-year revision-free survival rates were respectively 78.6, 42.9, 28.6, 7.1 %. At last follow-up, 50 % patients were continent.

CONCLUSION

In the very long run, AUS provided a 50 % continence rate in male neurological patients but the revision rates were important.

LEVEL OF EVIDENCE

4.

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.

Contemporary outcomes in bladder exstrophy

PURPOSE OF REVIEW

The patient with bladder exstrophy presents complex surgical and clinical management challenges to the pediatric urologist. This review aims to present recent developments in the care of these patients as well as to review contemporary medical outcomes.

RECENT FINDINGS

Most of the early literature pertaining to bladder exstrophy has focused on surgical techniques and management. In the last 10-20 years, however, there has been an increase in the number of publications dealing with long-term outcomes in these patients. Psychosexual development, sexual function and social adaptation have received as much attention as urinary continence status, bladder, and renal function. This review will examine these topics.

SUMMARY

Despite the complex nature of bladder exstrophy, there are no well designed, prospective trials examining clinical outcomes in these patients. Until better trials are planned, executed and published, much of what we know about patients with bladder exstrophy will be based on retrospective observations with significant biases.

Long-term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias

OBJECTIVE

To review the long-term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve 'continence' (which implies active mechanisms) but only 'dryness' (which implies passive mechanisms).

PATIENTS AND METHODS

Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young-Dees-Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow-up of 11 years. All patients were treated and followed in the same institution.

RESULTS

In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty-eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery.

CONCLUSION

We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.

[Treatment of urinary incontinence in epispadias at the beginning of the third millenium]

The treatment of urinary incontinence in epispadias is delicate. Urinary continence is generally obtained after onerous and repetitive surgery. Different publications show a variable results. After the study of the results of our series (nine cases) and the results published in the literature, we propose a clarification on the therapeutic modalities of urinary incontinence associated to this malformation.

10-Year experience with artificial urinary sphincter in children and adolescents

PURPOSE

We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence.

MATERIALS AND METHODS

Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5).

RESULTS

There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent.

CONCLUSIONS

This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

10-Year experience with artificial urinary sphincter in children and adolescents

PURPOSE

We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence.

MATERIALS AND METHODS

Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5).

RESULTS

There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent.

CONCLUSIONS

This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

Initial experience with the transurethral self-detachable balloon system for urinary incontinence in pediatric patients

PURPOSE

A new endoscopic technique to treat urinary incontinence in children using a self-detachable balloon device was studied.

MATERIALS AND METHODS

The study includes 11 patients with a mean age of 14.6 years and all of whom had intrinsic sphincter deficiency due to myelomeningocele in 9, spinal artery bleed in 1 and cloacal exstrophy in 1. All patients were on clean intermittent catheterization preoperatively and postoperatively. Endoscopic balloon treatment was performed on an outpatient basis. A mean of 5 balloons (range 2 to 8) were placed per patient. All patients underwent formal urodynamic study preoperatively and at 6 weeks and 6 months following balloon placement.

RESULTS

Of the 9 patients without prior bladder neck surgery 7 had improvement in urodynamic parameters, including urethral pressure profile in all 7 and functional bladder capacity in 6, 4 were markedly improved clinically and 2 were dry. Two patients with prior bladder neck surgery were clinically unchanged following balloon placement, although 1 had urodynamic improvement.

CONCLUSIONS

Our initial experience with the transurethral self-detachable balloon system as a minimally invasive outpatient procedure to treat urinary incontinence in children has been encouraging. To date this procedure appears most applicable to the patient who has not undergone surgery and has a neurogenic etiology for urinary incontinence.

Female bladder exstrophy

Bladder exstrophy is one of the most challenging congenital urinary tract abnormalities. Apart from the open bladder the patient also has various other abnormalities, including urogenital, musculoskeletal and anorectal defects. The size of the exstrophic bladder varies from patient to patient. In the female the clitoris to bifid and the vagina is anteriorly placed. In this paper various aspects of female bladder exstrophy are reviewed in detail, including incidence, etiology, anatomy and clinical features, together with early, medium-term and long-term surgical management. The aim is to achieve a functional bladder closure, although some patients are better off with a urinary diversion. Considering the complexity of the urogenital problems and the surgical management thereof, all patients require lifelong follow-up.

The application of continent urinary stomas to bladder augmentation or replacement in the failed exstrophy reconstruction

OBJECTIVE

To determine the application and success of continent urinary stomas in the failed bladder exstrophy reconstruction.

PATIENTS AND METHODS

A total of 35 patients underwent construction of a continent urinary stoma during bladder replacement or bladder augmentation between 1987 and 1993. The continent stoma was constructed with appendix (19 patients), tapered ileum (2), Benchekroun (12), Indiana (1) and Mainz type stoma (1).

RESULTS

Three patients required revision of their continent stoma, one for incontinence and two for difficulty in catheterization. Overall, 95% experienced daytime continence on an intermittent catheterization regimen, while 90% were dry at night. The upper tract remained normal in 34 of 35 patients.

CONCLUSIONS

While the Benchekroun technique is reliable in producing continence, difficulty with catheterization has been a chronic problem due to stomal stenosis. Our positive experience with using the appendix as a catheterizable conduit into either the bladder template or bowel segment has led us to prefer this method of continent stoma construction in the patient with a failed exstrophy. In the absence of an appendix, our preference is a tapered ileal segment. The failed exstrophy reconstruction can be salvaged with a continent stoma and substitution or augmentation cystoplasty in most patients, thus avoiding urinary diversion.

Evaluation and treatment of incontinence after bladder neck reconstruction in exstrophy and epispadias

Twenty-five children with exstrophy/epispadias who had had at least one bladder neck operation (but no augmentation) for incontinence underwent cystometrography (CMG) and urethral pressure profile (UPP) studies. The purpose of this study was to examine all components of lower urinary tract function and to determine how the properties of the bladder and the properties of the bladder neck/urethra interacted to achieve continence or to result in incontinence in the individual child. Examination of detrusor function during filling revealed involuntary contractions in 12 children and an end-fill pressure > 10 cm H2O in 8. Of the 21 children in whom voiding could be evaluated only 6 could initiate a detrusor contraction. In the 18 incontinent children leak pressure could be measured and was > or = 15 cm H2O in 12. Five of the 7 continent children also demonstrated at least one abnormality in lower tract function. The maximum pressure of the UPP did not agree with the leak pressure and may not be a valid measure of the closing pressure of the bladder neck/urethra in this patient population. Detailed urodynamic investigation is necessary in these children to guide the next step of management and to evaluate objectively each form of treatment.

Improved results using a modification of the Young-Dees-Leadbetter bladder neck repair

Forty-seven patients with primary total incontinence underwent bladder neck reconstruction (BNR) between 1978 and 1988. This included 31 patients with exstrophy/epispadias, 14 with myelomeningocele and 2 with caecoureteroceles. The patients were divided into 5 groups based on the type of BNR: Group 1--standard Young-Dees-Leadbetter (YDL) BNR; Group 2--YDL+Silastic sheath; Group 3--modified YDL; Group 4--Kropp BNR; Group 5--other BNRs. Group 1 included 18 patients with a 45% primary continence failure rate, a 44% reoperation rate and only a fair ability to void spontaneously after BNR. There were 11 patients in Group 3 with a 9% primary continence failure rate, a 27% reoperation rate and excellent post-operative emptying. None of the 3 patients in Group 4 was incontinent post-operatively, but they all required reoperation and had poor post-operative emptying. We feel that the modified YDL BNR provides better overall voiding and continence with less morbidity than the other bladder neck/urethral reconstructive procedures.

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.

Bladder function and dysfunction in exstrophy and epispadias

Bladder exstrophy and epispadias are congenital abnormalities of the urinary bladder. Evaluation of bladder function before and after bladder-neck reconstruction has not been done in patients with these conditions. We report the preliminary results of a prospective study of lower-urinary-tract function in 36 children (10 girls, 26 boys; age range 1.5-16 years) with bladder exstrophy and epispadias. Children's bladder function was measured by cystometry and cystography, and their upper urinary tracts were examined by ultrasound imaging. Normal bladder function was seen in children with primary epispadias but this was severely impaired in children who had had conventional bladder-neck surgery for continence, implying that this may not be the optimal treatment. Contrary to current assumption, children with closed exstrophy bladders are not capable of normal function, and the abnormalities we identified may be a major cause of upper-urinary-tract damage and may impair development of bladder capacity. Although unrecognised in the past, involuntary bladder contractions are a primary cause of urine leakage persisting in children with exstrophy and epispadias after continence surgery. Detailed functional testing should become a routine part of the evaluation of children with exstrophy and epispadias.