Shunt Conversion Before Bladder Augmentation Can Prevent Shunt Infection

Urinary perforation in spina bifida: Neurosurgical and infectious consequences

As the number of medically complex children increases, pediatricians and emergency physicians face challenges in evaluating complications from devices placed to treat their underlying conditions. We present a child with spina bifida who developed a perforation of his vesicostomy leading to peritonitis, septic shock, and urgent externalization of his ventriculoperitoneal shunt. Multiple consultants may need to be promptly involved in the management of children with underlying medical problems. Because procedural complications are often reported only in the surgical specialty literature, pediatricians and emergency physicians should seek information from their patients’ specialists about potential problems.

Effect of bladder augmentation on VP shunt failure rates in spina bifida

PURPOSE

Most patients with spina bifida require ventriculoperitoneal (VP) shunt placement. Some also require bladder augmentation, which may increase the risk of VP shunt malfunction and/or failure. The aim of this study was to assess whether bladder augmentation affects the rate of VP shunt failure in this population.

METHODS

Using the Pediatric Health Information System, we studied patients with spina bifida born between 1992 and 2014 who underwent VP shunt placement. Using conditional logistic regression, we compared age- and hospital-matched patients who did and did not undergo a bladder augmentation to determine their difference in rates of VP shunt failure.

RESULTS

There were 4192 patients with spina bifida who underwent both surgical closure and VP shunt placement. Of these, 203 patients with bladder augmentation could be matched to 593 patients without bladder augmentation. VP shunt failure occurred within 2 years in 7.7% of patients, the majority of whom were in the group who underwent bladder augmentation (87%). After adjusting for confounders, undergoing bladder augmentation was independently associated with VP shunt failure (HR: 33.5, 95% CI: 13.15-85.44, p< 0.001).

CONCLUSION

Bladder augmentation appears to be associated with VP shunt failure. Additional studies are necessary to better define this relationship and identify risk-reduction techniques.

Establishing a Multidisciplinary Approach to the Management of Neurologic Disease Affecting the Urinary Tract

Neurologic diseases often affect the urinary tract and may be congential or acquired. The progressive nature of many neurologic diseases necessitates routine surveillance and treatment with a multidisciplinary approach. Urologic treatments may interact with pharmacologic or procedural interventions planned by other specialists, mandating close coordination of care and communication among providers. Primary care and nursing often can serve as the quarterbacks of the multidisciplinary team by identifying when a slowly progressive condition warrants further investigation and management by specialists.

Prevention of ventriculoperitoneal shunt complications after intraperitoneal urological surgeries

PURPOSE

To evaluate perioperative management for the prevention of postoperative shunt infection and malfunction after intraperitoneal urological surgery in patients with myelodysplasia and a ventriculoperitoneal shunt.

METHODS

From 2005 to 2015, 20 consecutive patients with myelodysplasia and a ventriculoperitoneal shunt who underwent intraperitoneal urological surgeries were managed with the same perioperative regimen. Intraperitoneal surgeries involved opening gastrointestinal tracts, including bladder augmentation by enterocystoplasty, creating continent catheterizable channels and Malone antegrade continent enema. We compared results with those from seven previous reports regarding postoperative shunt complications, surgical histories of previous shunt revisions, management of bacteriuria before surgery preoperative bowel preparation, antibiotic regimens, and duration of indwelling drain.

RESULTS

Of 20 patients, 18 received prior shunt revisions, and 14 had positive urine culture before surgery that was managed with oral antibiotics. Thirteen patients underwent bladder augmentation with ileum, and one underwent augmentation with sigmoid colon. Nineteen patients underwent Malone antegrade continent enema using the appendix. All parenteral antibiotics were stopped on postoperative day 2.5. Mean duration of indwelling peritoneal drain was 2.7days. Mean follow-up period was 59.8months. Neither postoperative shunt infections nor intraperitoneal shunt malfunctions were recognized during follow-up period.

CONCLUSIONS

This is the first study to evaluate postoperative ventriculoperitoneal shunt complications in patients with myelodysplasia who underwent intraperitoneal urological surgeries with a specific perioperative regimen. Shunt complications are greatly reduced by rigorous perioperative management, including preoperative control of bacteriuria, appropriate administration of prophylactic antibiotics, and early removal of intraperitoneal drains.

LEVELS OF EVIDENCE

The type of study: Case series with no comparison group, IV.

Augmentation cystoplasty in children without preoperative mechanical bowel preparation

OBJECTIVE

To retrospectively assess early postoperative complications in augmentation cystoplasty without preoperative mechanical bowel preparation (MBP).

MATERIAL AND METHODS

Between May 1987 and May 2006, 162 cystoplasties were performed in 158 children. The segments used were: sigmoid colon (81.5%), ileum (13%), and ileocecum (5.5%). The mean age was 8.65 years (range 2.1-22.7 years). No preoperative MBP of any kind was used in any of the patients and all of them received antibiotics preoperatively and postoperatively.

RESULTS

No intraoperative complications related to the procedure were reported. The mean hospital stay was 9.48 days (range 4-30 days). The mean time to intake of oral fluids was 94.77 h (range 48-288 h). Postoperative complications occurred in 9.87%: urinary fistula was the most common (2.4%); only 3 patients presented wound infection (1.85%); 5 patients required reoperative surgery (hemoperitoneum, patch necrosis and 3 cases of urinary peritonitis); 1 patient presented an intra-abdominal abscess that resolved with antibiotic treatment.

CONCLUSIONS

Preoperative MBP can be omitted in children that require augmentation cystoplasty without an increased risk of infectious or anastomotic complications. Further prospective, randomized clinical trials should be carried out in order to validate our findings in the pediatric population.