Urinary tract re-functionalization after long-term diversion. A 20-year experience with 177 patients

Medullary pyramids opacification in high-grade vesicoureteral reflux associated with posterior urethral valve

Posterior urethral valve (PUV) is a common cause of obstructive uropathy in children, leading to renal failure and frequently associated with vesicoureteral reflux (VUR), which can rapidly progress to end-stage renal disease (ESRD). We describe a rare presentation of high-grade VUR opacifying the renal pyramids in a 5-month-old child with sepsis and renal failure.

Bladder salvage in children with congenital lower urinary tract malformations undergoing renal transplant

INTRODUCTION

Patients with Congenital Lower Urinary Tract Malformations (CLUTM) have increased risk of post-transplant complications if bladder dysfunction is not addressed. Pretransplant assessment may be difficult if urinary diversion has been previously applied. In case of low capacity and/or low compliance and/or high-pressure overactive bladder, transplantation into a diverted or augmented system may be required. We hypothesised that a bladder optimization pathway may help identify potentially salvageable bladders and prevent unnecessary bladder diversion or augmentation. We propose a structured bladder optimisation and assessment programme for safe transplant and native bladder salvage.

MATERIAL AND METHODS

Data of 130 children who underwent renal transplant between 2007 and 2018 were retrospectively collected and analysed. All patients with CLUTM were assessed by urodynamic study. Bladder optimisation: Low compliance bladders were managed with anticholinergics and/or Botulinum toxin A (BtA) injections. Those who had urinary diversion for their pathology underwent a structured assessment and optimisation process with undiversion/anticholinergics/BtA/bladder cycling/Clean Intermittent Catheterisation (CIC)/Suprapubic catheter (SPC) as indicated. Details of medical and surgical management were collected (Figure 1).

RESULTS

Between 2007 and 2018, 130 renal transplants were done. Of these, 35 (27%) had associated CLUTM (PUV in 15, neurogenic bladder dysfunction in 16, other pathology in 4) which was managed in our centre. Ten patients needed initial diversion in the form of vesicostomy (2) or ureterostomy (8) to manage primary bladder dysfunction. The median age at transplant was 7.8 years (range 2.5-19.6). After bladder assessment and optimisation, a safe bladder was demonstrated in 5 of 10 with initial diversion leading to transplant into native bladder (without augmentation). Overall, of the 35 patients, 20 (57%) had transplant into native bladder, 11 patients had ileal conduits and 4 had bladder augmentation. Eight required help with drainage: three with CIC, four with Mitrofanoff, and one had reduction cystoplasty.

CONCLUSION

With a structured bladder optimisation and assessment programme, safe transplant and 57% native bladder salvage is achievable in children with CLUTM.

Functional and Objective Results of Urinary Undiversions in Oncologic Patients

OBJECTIVE

To review surgical outcomes in urinary undiversions and describe short and long-term complications.

METHODS

Retrospective review of patients who underwent urinary undiversion in our institution between May 2010 and May 2016. Complications were graded according to the Clavien classification. All patients completed the Patient Global Impression of Improvement questionnaire to indicate overall satisfaction with urinary undiversion.

RESULTS

Median time from the cystectomy to undiversion was 29 months (range 11-53 months). Five patients (55%) reported significant distress related to the ileal conduit and were undiverted into an orthotopic neobladder. A female patient with an orthotopic neobladder and severe urinary incontinence received neobladder neck closure and catheterizable channel. Another female patient with an orthotopic neobladder was undiverted into an Indiana Pouch. Complications during the first 60 days were mostly minor, Clavien I (1 patient), 5 patients Clavien II, and a patient with Clavien IIIb. Patient Global Impression of Improvement questionnaire scores showed that 6 patients (67%) felt "Very much better" and 3 patients (33%) felt "Much better" after urinary undiversion 60%.

CONCLUSION

After urinary undiversions, minor complication rate is high, and major complication rate is considerable. Urinary undiversions are a highly complex, yet feasible procedure, which requires experienced multidisciplinary teams and demands appropriate patient selection. Patients, after undiversions show a high degree of satisfaction with long-term satisfactory outcomes, which points out the need for consideration for these procedures once the oncologic disease is controlled.

Externally removable stents in the treatment of benign recalcitrant strictures and esophageal perforations in pediatric patients with esophageal atresia

BACKGROUND

We investigated whether removable stents, such as self-expandable plastic stents (SEPSs) and fully covered self-expandable metal stents (FCSEMSs) could provide an alternative treatment for recalcitrant strictures and esophageal perforations after esophageal atresia (EA) repair.

OBJECTIVE

The primary aim of our study was to evaluate technical feasibility. Secondary aims were to evaluate safety and procedural success.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral center.

PATIENTS

A total of 24 children with EA.

INTERVENTIONS

Retrospective review of all children with EA who underwent dilation and esophageal stent placement from January 2010 to February 2013 at our institution.

MAIN OUTCOME MEASUREMENTS

Healing of perforation and stricture resolution at 30 and 90 days.

RESULTS

A total of 41 stents (SEPSs 14, FCSEMSs 27) were placed in 24 patients with EA during the study period, including 14 who had developed esophageal leaks. Procedural success of esophageal stent placement in the treatment of refractory strictures was 39% at 30 days and 26% at 90 days. The success rate was 80% for closure of esophageal perforations with stent therapy after dilation and 25% for perforations associated with surgical repair. Adverse events of stent placement included migration (21% of SEPSs and 7% of FCSEMSs), granulation tissue (37% of FCSEMSs), and deep ulcerations (22% of FCSEMSs).

LIMITATIONS

Retrospective study with small sample size.

CONCLUSION

SEPSs and FCSEMSs can be placed successfully in small infants and children with a history of EA repair. The stents appear to be safe and beneficial in closing esophageal perforations, especially post-dilation. However, a high stricture recurrence rate after stent removal may limit their usefulness in treating recalcitrant esophageal anastomotic strictures.

Laparoscopic undiversion in a child with sacral agenesis into augmentation cystoplasty

INTRODUCTION

In neurogenic bladder with compromised renal function or when complex reconstruction is not preferred, ileal conduit is considered. Undiversion is performed when the patient prefers the procedure, once the renal function improves, or when complications resulting from diversion are present.

CASE DESCRIPTION

We present the case of a 10-y-old boy with sacral agenesis, who underwent laparoscopic-assisted ileal conduit diversion in 2006, because he had a grossly unstable, small-capacity bladder and was not compliant with intermittent self-catheterization. At present, he preferred not to have a conduit.

DISCUSSION

Laparoscopic undiversion with ileal augmentation cystoplasty was performed. The postoperative course was uneventful, and he is now on intermittent self-catheterization with healthy renal function. Laparoscopic undiversion is technically challenging, yet feasible, and is an effective option in children. To our knowledge, this is the first such case reported.

Case report: Laparoscopy-assisted urinary undiversion: transforming an ileal conduit into an orthotopic continent neobladder

PURPOSE

To describe the technique of laparoscopy-assisted undiversion of an ileal conduit into a continent orthotopic ileal neobladder performed on a patient with a previous radical cystoprostatectomy and ileal conduit.

CASE REPORT

A 57-year-old man presented with a prolapsed stoma and a history of a right radical nephroureterectomy for grade 3 ureteral transitional-cell carcinoma and a radical cystoprostatectomy and ileal conduit urinary diversion for in-situ bladder carcinoma, performed 12 and 8 years ago, respectively. After the ileal stoma was resected, five trocars were placed transperitoneally. Partial resection of the distal ileal conduit was performed, leaving in place the proximal segment with its left ureteroileal anastomosis. Flexible urethroscopy revealed a contracting external sphincter, and random urethral frozen-section biopsies ruled out tumor. A 45-cm segment of ileum was isolated and exteriorized through the stoma site, and an ileal neobladder was created extracorporeally, suturing the proximal ileal-conduit segment, with its ureteroileal anastomosis, to it. The ileal neobladder was reintroduced into the abdomen and anastomosed laparoscopically to the urethral stump with six 2-0 polyglactin sutures. The total operative time was 7 hours with a blood loss of 100 mL. There were no intraoperative complications. The hospital stay was 7 days. At a follow-up of 24 months, the patient had total daytime continence and normal renal function, and intravenous urography revealed an unobstructed urinary tract.

CONCLUSION

Laparoscopy-assisted ileal-conduit undiversion into an orthotopic ileal neobladder is technically feasible. It can be considered an alternative to open surgery for patients who have undergone urinary diversion.

LONG-TERM FOLLOWUP OF BILATERAL HIGH (SOBER) URINARY DIVERSION IN PATIENTS WITH POSTERIOR URETHRAL VALVES AND ITS EFFECT ON BLADDER FUNCTION

PURPOSE

Although valve ablation is the treatment of choice in patients with posterior urethral valves (PUV), temporary high (ureterostomy) diversion remains controversial. In this study we evaluated the effect of bilateral Sober high urinary diversion on renal and bladder function.

MATERIALS AND METHODS

We retrospectively reviewed the records of 36 patients with PUV who underwent bilateral Sober-type diversion. Following valve ablation urodynamic studies were done in all patients after diversion and repeated after ureterostomy closure. The mean duration of diversion was 55 months. Vesicoureteral reflux (VUR), renal dysplasia, serum creatinine during followup and urodynamic parameters were recorded.

RESULTS

All patients underwent endoscopic valve ablation. Renal function impairment at the end of followup was present in 15 patients. Renal dysplasia was found in 10 patients, while VUR was present in 16 at the time of the first urodynamic studies. Urodynamic studies after ureterostomy closure showed well preserved bladder capacity or compliance in 80% and 69% of cases, respectively. About a third of patients showed increased capacity and normal compliance. Univariate analysis showed that VUR, urinary tract infection and renal dysplasia significantly correlated with impaired renal function. On multivariate analysis renal dysplasia was an independent prognostic factor for poor prognosis.

CONCLUSIONS

In patients with PUV temporary high diversion of the Sober type does not have a negative influence on bladder function. It immediately releases high intrarenal pressures but only improves renal function temporarily and may contribute to postpone the time of end stage renal failure. Renal dysplasia dictates long-term renal outcomes in this group.

Use of small and large bowel in renal transplantation

The continued success of renal transplantation has provided a higher quality of life for properly selected patients with ESRD. It is also a much more cost-effective and efficient treatment of ESRD compared with chronic dialysis. Innovative urologic reconstructive surgery using enteric segments for both continent and incontinent urinary diversions has permitted this therapeutic modality to be offered to the recipient with lower urinary tract disease not previously amenable to renal transplantation. These same reconstructive techniques using ileal segments have also permitted preservation of renal allografts with previously nonreconstructable renal pelvic or ureteral disease.

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.

Continent urinary pouches in pediatric age

– To make a new urinary reservoir which can be catheterised either through an external stoma or transurethrally, is the only way to achieve continence in quite a large number of irreversible structural and functional disorders of the bladder wall, also in pediatric age. Orthotopic are usually preferred to heterotopic pouches in pediatric patients, indications for the latter being few. Bladder exstrophy, neurogenic bladder from spina bifida, severe fibrosis of the bladder walls as a consequence of congenital outlet obstruction in prenatal age, such as posterior urethral valves and bilateral ectopic ureterocele, are the most frequent clinical indications, while bladder tumours are uncommon. Over the last 10 years we have perfomed 31 partial or total bladder substitutions in pediatric patients, 7 of which were continent urinary pouches with 2 in an ectopic position in the iliac fossa (Indiana pouch and Kock pouch). The 7 pouches were made in 4 bladder exstrophies (Indiana Pouch), 1 neurogenic bladder (gastric pouch with continent appendico-vesicostomy), 2 bladder tumours (Kock pouch). Results, in terms of continence and major or minor complications, are presented and discussed with particular reference to pediatric patients.

Ileal nipple for continence in cloacal exstrophy

Since 1985, 7 children 2 to 17 years old with urinary incontinence from cloacal exstrophy underwent bladder augmentation and creation of a small bowel nipple at the bladder outlet. There were 3 genetic female and 4 genetic male patients being reared in the female role. In 3 early cases augmentation was done with small bowel, while gastric augmentation was used in 3 later cases and 1 had both types. Six patients became completely dry and they empty by intermittent self-catheterization. In the youngest patient the operation failed because the nipple became infarcted and disappeared. Reoperation will be performed after at least 1 year has passed. In cloacal exstrophy if there is insufficient local tissue to create a bladder neck and urethra, a reversed, catheterizable bowel nipple may be an option to consider.