Urinary diversion and undiversion in children

Early Vs. Expectant Management of Spina Bifida Patients-Are We All Talking About a Risk Stratified Approach?

PURPOSE OF REVIEW

Advancements in the care of patients affected by myelomeningocele have flourished in recent years especially with respect to renal preservation and continence. Involvement of urologists both prenatally and early in life has driven many developments in preventative care and early intervention. As of yet, however, the ideal management algorithm that offers these patients the least invasive diagnostic testing and interventions while still preserving renal and bladder function remains ill defined.

RECENT FINDINGS

In a shift from prior years where the use of surgical intervention and intermittent catheterization were more liberally employed, some providers have more recently advocated for monitoring patients in a more conservative manner with a variety of diagnostic tests until radiographic or clinical changes are discovered. The criteria used to define the need for catheterization and the timing to initiate CIC or more invasive interventions is disparate across pediatric urology and there is published data to support several approaches. This review presents some of these criteria for use of CIC and some newer evidence to support different approaches along with supporting the trend toward individualized medicine and use of risk stratification in developing clinical treatment algorithms.

Transureteroureterostomy revisited: long-term surgical outcomes

PURPOSE

Transureteroureterostomy is a treatment alternative for ureteral obstruction when more conventionally reconstructive techniques are not feasible. We report on long-term outcomes of patients treated with transureteroureterostomy.

MATERIALS AND METHODS

A retrospective chart review of all patients treated with transureteroureterostomy from January of 1985 to February of 2007 was performed.

RESULTS

We identified 63 patients who underwent transureteroureterostomy at our institution. Average treatment age was 31.5 years (range 1 to 83). Transureteroureterostomy was performed for 21 (33%) malignant and 42 (67%) benign indications. Reconstructions were 30 right-to-left (47.6%) and 33 left-to-right (52.4%) with 21 concurrent urinary diversions. There were 16 patients (25.4%) who received radiation before transureteroureterostomy. Postoperative complications occurred in 15 (23.8%) patients and were more common in those undergoing diversion for malignancy. Mean followup was 5.8 years (range 0.1 to 22.2) and 5 patients were lost to followup. Of the 56 patients with followup imaging the transureteroureterostomy was patent in 54 (96.4%) and obstructed in 2 (3.6%). Mean preoperative and recent calculated glomerular filtration rate for this cohort were 62.8 (range 13 to 154) and 71.8 (range 22 to 141) ml per minute, respectively (p = 0.04). Stone disease developed in 8 patients, and was treated with percutaneous nephrolithotomy (2), spontaneous passage (2), ureteroscopy (1) and surveillance (3). Subsequent urological intervention was required for obstruction or revision in 6 (10.3%) patients.

CONCLUSIONS

We demonstrated the long-term safety and effectiveness of transureteroureterostomy with sustained improvement of renal function compared to preoperative status. Recurrent stricture, distal obstruction and stone disease occur in a small percentage of patients, and can be treated in most with minimal intervention.

Historical perspective of the use of bowel in urology

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.

Ileocecal ureterosigmoidostomy: an alternative to conventional ureterosigmoidostomy

We describe a 1-stage procedure that involves use of the ileocecal segment as an intervening urine conduit to the large bowel to achieve a continent diversion. The ureters are anastomosed end to end to the terminal ileum that is intussuscepted into the cecum. The cecum then is joined to the lower sigmoid by an end-to-side anastomosis. Mixed urine and feces are eliminated through the rectum. The results in 5 patients with exstrophy and 1 with epispadias between 5 months and 13 years old are reported. Ureteral reflux was not observed. Urinary tract infection developed in 2 patients. Ileocecal ureterosigmoidostomy is a reasonable alternative to intact ureterosigmoidostomy that may reduce the risk of development of cancer.

Urinary undiversion in young adults

Eighteen patients who underwent urinary diversion in childhood were undiverted. There were three main groups: the neurologically intact bladder, the neuropathic bladder and the "occult" neuropathic bladder. The simplest procedure of anastomosing the proximal ureters to the distal ureters was preferred. The neuropathic group required excision of the bladder remnant and substitution with detubularised bowel. In four patients the renal function was progressively deteriorating pre-operatively and two have required transplants. Renal failure in one of these patients was accelerated by a post-operative anastomotic stenosis and infection, although his early post-operative anastomotic stenosis and infection, although his early post-operative course was uneventful.

Experiences with bladder reconstruction in children

The results in 56 children (28 with neurogenic bladder dysfunction) undergoing enterocystoplasty between 1981 and 1985 are presented. Ileal, ileocecal, right colon and sigmoid segments were used in tubular and opened configurations. Our experience leads us to recommend opened ileal segment reconstruction in neurogenic bladder patients and those with weak anal sphincters generally, and open ileocecal or open right colon segments in patients with other etiologies. Continence was achieved in 53 patients, although secondary procedures, particularly at the bladder outlet, were required in 13. When ureteral reimplantation was required we achieved excellent success with normal-sized or mildly dilated ureters regardless of the operative technique used. Initial failures to prevent reflux in the face of marked ureterectasis using the ileocecal valve have been resolved by a modified technique of intussusception and fixation. An over-all favorable experience is reported, which we believe permits us to formulate certain rules that will improve the acceptability and success of bladder reconstruction in general.

Sexuality after urinary undiversion

We report on the sexuality of 2 young men following urinary undiversion. One patient reported improved sexual experience due to loss of the appliance and improved self-image. Urine leakage during sexual activity can be prevented only by catheterization before intercourse. The other patient has undergone rediversion after a technically satisfactory undiversion because of urine leakage during intercourse that did not respond to intense pharmacologic therapy and bladder emptying before sexual activity. Sexuality following undiversion has not been studied previously. Additional guidelines in preoperative evaluation and patient education are suggested.

Radiology of urinary undiversion

Many patients with urinary diversions are now considered candidates for "undiversion". Radiographic evaluation prior to undiversion of the urinary tract includes cystography to determine bladder capacity and sensation, urinary continence, and the presence of reflux. Urography, loopography, and/or ureterography (antegrade and/or retrograde) are necessary to completely visualize the remaining urinary structures. Surgical techniques involved in the reconstruction are briefly discussed to facilitate an understanding of the often unusual radiographic appearance of the undiverted urinary tract. Stentograms and cystography are recommended for early postoperative evaluation to exclude urinary leakage or significant obstruction. Percutaneous ureteral perfusion studies are often useful in the long-term follow-up of these patients.

Urinary undiversion in patients with myelodysplasia and neurogenic bladder dysfunction. Report of a workshop

This workshop was conducted in an attempt to analyze critically the role of reconstruction of the myelodysplastic patient who had undergone urinary diversion and to develop guidelines for selecting those patients in whom urinary undiversion might be undertaken safely. The collective experience initially seems to be acceptable; however, the authors emphasize the gravity of the decision and the complexity of the evaluation which must be undertaken prior to embarking on such reconstructive surgery. Contrary to some reports, we believe that the defunctionalized bladder frequently can be evaluated. Further, many of the contraindications to urinary undiversion have been identified and several of the hazards involved therein can be avoided. We believe that the neurogenic bladder is no longer an absolute contraindication to undiversion. Our experience suggests that undiversion is a reasonable surgical treatment in select patient with neurogenic bladder dysfunction. But, the decision to remove a satisfactorily functioning conduit must not be undertaken lightly. Patients should be selected only after a thorough, detailed, and properly conducted evaluation. A protocol has been developed which will hopefully assist in this evaluation. Perhaps additional shared experience will further refine and delineate the circumstances appropriate for reconstruction of these patients.

Undiverting the ileal conduit

The experience described herein reinforces the belief that it is worthwhile to consider undiversion of the urinary tract in any patient in whom the indication for diversion initially was, upon re-examination, questionable. In children the optimum time for this appears to as the candidate approaches adolescence, since by then he has outgrown most of the incoordination of childhood and is likely to be highly motivated toward the idea of being freed from the external appliance. Evaluation of such patients requires consideration of many factors but the best guide to bladder potential is probably provided by the placement of a suprapubic catheter followed by bladder filling and voiding exercises. Finally, a careful analysis of the anatomy of the urinary tract is essential if the operation is to be undertaken safely and effectively. None of these steps is easy but the potential rewards are so great as to make them well worth the effort expended.

Ileal conduit undiversion: experience with tunneled vesical implantation of tapered conduit

Reconstruction of the urinary tract after ileal conduit diversion was done in 9 patients by antirefluxing vesical implantation of the tapered conduit. Of the patients 5 required prior operative rehabilitation of the lower tracts, while 4 had urodynamically normal lower tracts. Reoperation for post-undiversion reflux was necessary in 2 patients; reimplantation was satisfactory in 1 but ileocecocystoplasty was required in the other. Followup showed a stable or improved upper tracts and renal function in the remaining patients.

Urinary tract undiversion in a patient with an areflexic neurogenic bladder: management with intermittent catheterization

Neurogenic bladder disease generally is though to be a contraindication to urinary undiversion. We describe a teenage boy who received an ileal conduit for an areflexic neurogenic bladder. He had a poor emotional reaction to the diversion and requested reconstruction. After extensive studies undiversion was done. The neurogenic bladder has been managed with intermittent catheterization. Thus far, the result has been quite satisfactory.

Non-refluxing colon conduit: experience with 70 cases

From 1969 through 1976, 70 non-refluxing colon conduit urinary diversions were performed on 30 adults and 40 children at the Massachusetts General Hospital. Although this is a longer and more complex operation to perform the rate of complications appears significantly less than that seen previously in patients with ileal loop diversions.

Technique and results of the colonic conduit, continent by means of a new magnetic stoma seal an experimental study

On the basis of satisfactory results with a new magnetic stoma seal in colostomy patients this seal, consisting of a magnetic ring and cap, was used in an experimental study to convert the colonic conduit into a continent reservoir. Complete continence was obtained in all of the 12 animals which survived the operation. All rings were well accepted by the tissue when the procedure was staged by implanting the ring transperitoneally several weeks prior to fashioning of the conduit. Residual urine was low, owing to an ideal energy-balance pattern. Coloureteric reflux was successfully prevented in all cases where a long-tunnel-modification of the Leadbetter-Clarke technique was used. Hyperchloraemic acidosis and deterioration in renal function were not observed. All conduits were infected.

Ureterosigmoidostomy

Some historical aspects of ureterosigmoidostomy are described, and various techniques are discussed and illustrated. Our own satisfaction with the results when the procedure is done through the open sigmoid colon is expressed. Ureterosigmoidostomy, which has in some surgeons' hands fallen into disuse, will continue to be used and probably should be used more than it is at present. When ureterosigmoidostomy is done meticulous care is important in producing a long submucosal tunnel with direct anastomosis of the ureter to the bowel. Preoperative bowel preparation is mandatory. Patients who have undergone ureterosigmoidostomy should remain on a low chloride diet indefinitely with an adequate supplement of sodium potassium citrate to diminish the dangers of electrolyte imbalance and hyperchloremic acidosis. Careful postoperative management and followup care are vital to success.