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Sager C, Burek C, Gomez YR, Weller S, Ruiz J, Imizcoz FL, Szklarz T, Rosiere N, Monteverde M, Campmany L, Vazquez JA, De Castro F, Bernardez L, Adragna M, Corbetta JP. Nephro-urological outcomes of a proactive management of children with spina bifida in their first 5 Years of life. J Pediatr Urol 2022; 18:181.e1-181.e7. [PMID: 34991991 DOI: 10.1016/j.jpurol.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/14/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The proactive management of spina bifida (SB), especially of its severe form, myelomeningocele (MMC), has contributed to decreasing chronic kidney disease (CKD). The objective of this study is to present the evolution of 5-year-old patient with MMC followed from birth with a proactive approach. MATERIAL AND METHODS This retrospective study included 55 cases with MMC of up to 5 years of age. All of them were admitted at birth and followed by a multidisciplinary group, with a proactive approach: CIC and anticholinergics. In the same group, the variables were compared within the first year and the within the fifth year of life. Chronic kidney disease (CKD) was defined by: alterations on renal DMSA scintigraphy; alterations in microalbuminuria/creatininuria ratio, proteinuria 24 hs and decrease in glomerular filtration rate (GFR) calculated with Schwartz bedside equation. RESULTS Although overactivity, UTI and VUR decreased throughout the first 5 years (49, 9 and 12%), reduced cystometric capacity, DLPP >40 cm of water and end-filling pressure (Pdet) >20 cm of water increased (41, 27 and 61%). All patients at 5 years of age required CIC. Reduced cystometric capacity and VUR were more significant with abnormal DMSA (36%) at 5 years old ( p: 0.03). Proteinuria and CKD increased to 25% and 49%. Similarly, the need for enalapril increased from 10% to 27%. The microalbuminuria/creatininuria ratio was pathological in 27.3%. 48 patients (87%) remained unchanged on DMSA scan and the other 7 underwent modifications (4 new cases with altered DMSA) over time. Of the 32 normal DMSA cases without changes, 81% did not present proteinuria and 88% continued to respond favorably to oxybutynin. GFR <90 ml/min/1.72m 2 was found in only 3 cases with abnormal DMSA. There was a RR 1.91 (IC95% 1.15-3.16) greater of renal compromise in cases that were anticholinergic-resistant compared to non-refractory cases. DISCUSSION Over time, some patients suffered loss of bladder wall compliance, despite the proactive approach. There is an association between abnormal renal DMSA, reduced bladder capacity, and VUR at 5 years of age. Although proteinuria, CKD and enalapril requirement increased over 5 years, almost 90% did not show changes in renal DMSA status. CONCLUSIONS Over time, some patients suffered loss of bladder wall compliance. Hence, even if a proactive approach is followed since birth, it is essential to continue with the ongoing monitoring of the renal status and thus avoid greater renal deterioration.
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Affiliation(s)
- Cristian Sager
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina; Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.
| | - Carol Burek
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina; Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Yesica Ruth Gomez
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina; Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Santiago Weller
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Javier Ruiz
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Felicitas Lopez Imizcoz
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Tatiana Szklarz
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Nicolas Rosiere
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Marta Monteverde
- Nephrology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Liliana Campmany
- Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Jorge Agrimbau Vazquez
- Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Fernanda De Castro
- Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Lorena Bernardez
- Pediatrics Department, Interdisciplinary Group Myelomeningocele, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Marta Adragna
- Nephrology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Juan Pablo Corbetta
- Urology Department, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
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Burgos Lucena L, López Pereira P, Martínez Urrutia MJ, Lobato Romera R, Rivas Vila S. Influence in the outcome of neuropathic pediatric patients after early treatment. Actas Urol Esp 2021; 46:28-34. [PMID: 34844901 DOI: 10.1016/j.acuroe.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 01/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.
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Affiliation(s)
- L Burgos Lucena
- Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - P López Pereira
- Urología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | | | - R Lobato Romera
- Urología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
| | - S Rivas Vila
- Urología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
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Burgos Lucena L, López Pereira P, Martínez Urrutia MJ, Lobato Romera R, Rivas Vila S. Influence in the outcome of neuropathic pediatric patients after early treatment. Actas Urol Esp 2021; 46:S0210-4806(21)00139-X. [PMID: 34563387 DOI: 10.1016/j.acuro.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 11/09/2020] [Accepted: 01/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.
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Affiliation(s)
- L Burgos Lucena
- Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España.
| | - P López Pereira
- Urología Pediátrica, Hospital Universitario La Paz, Madrid, España
| | | | - R Lobato Romera
- Urología Pediátrica, Hospital Universitario La Paz, Madrid, España
| | - S Rivas Vila
- Urología Pediátrica, Hospital Universitario La Paz, Madrid, España
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Hobbs KT, Krischak M, Tejwani R, Purves JT, Wiener JS, Routh JC. The Importance of Early Diagnosis and Management of Pediatric Neurogenic Bladder Dysfunction. Res Rep Urol 2021; 13:647-657. [PMID: 34513742 PMCID: PMC8421253 DOI: 10.2147/rru.s259307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/17/2021] [Indexed: 11/23/2022] Open
Abstract
Neurogenic bladder dysfunction is a major source of urologic morbidity in children, especially in those with spina bifida (SB). Complications from progression of bladder dysfunction can include urinary tract infections (UTIs), urinary incontinence, upper tract deterioration, and renal dysfunction or failure. In these children, there has been a recent trend toward proactive rather than expectant management of neurogenic bladder. However, there is a lack of consensus on how to best achieve the three main goals of neurogenic bladder management: 1) preserving kidney function, 2) achieving continence (if desired by the family/individual), and 3) achieving social and functional urologic independence (if appropriate). Hence, our objective was to perform a narrative literature review to evaluate the approaches to diagnosis and management of pediatric neurogenic bladder dysfunction, with special focus on children with SB. The approach strategies vary across a spectrum, with a proactive strategy on one end of the spectrum and an expectant strategy at the other end. The proactive management strategy is characterized by early and frequent labs, imaging, and urodynamic (UDS) evaluation, with early initiation of clean intermittent catheterization (CIC) and proceeding with pharmacotherapy, or surgery if indicated. The expectant management strategy prioritizes surveillance labs and imaging prior to proceeding with invasive assessments and interventions such as UDS or pharmacotherapy. Both treatment strategies are currently utilized and data have historically been inconclusive in demonstrating efficacy of one regimen over the other. We performed a narrative literature evaluating proactive and expectant treatment strategies as they relate to diagnostics and management of Spina Bifida. From the available literature and our practice, a proactive strategy favors greater benefit in preventative management and may decrease risk of renal dysfunction compared with expectant management.
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Affiliation(s)
- K Tyler Hobbs
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
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Comparison of risk of anticholinergic utilization for treatment of neurogenic bladder between in utero or postnatal myelomeningocele repair. J Pediatr Urol 2021; 17:525.e1-525.e7. [PMID: 34074608 DOI: 10.1016/j.jpurol.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/05/2021] [Accepted: 04/30/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION In utero myelomeningocele (MMC) repair has resulted in significant decrease in need for shunt-dependent hydrocephalus, however its impact on bladder function remains less clear. Neurogenic detrusor overactivity (NDO) due to MMC can be addressed with combination of clean intermittent catheterization (CIC) and anticholinergic (AC) therapy to minimize its effect on bladder function and upper urinary tract. The aim of this study was to compare the risk of postnatal AC utilization for in patients that underwent either postnatal or in utero MMC repair related to neurogenic bladder (NGB) management. We hypothesized that postnatal MMC repair would be associated with increased risk of postnatal AC utilization compared to in utero MMC repair. MATERIAL AND METHODS All newborns with MMC in our hospital undergo prospective surveillance radiographic and urodynamic testing as part of institutional MMC protocol. Those MMC patients born between 2013 and 2018 at our institution, who underwent in utero or postnatal MMC repair were retrospectively analyzed. We identified postnatal AC utilization from electronic medical records and recorded indications for AC therapy according to the urodynamic, radiographic and clinical findings related to NGB management. RESULTS 97 patients fulfilled the inclusion criteria. 56 patients underwent a postnatal and 41 an in utero repair. Median follow-up for the in utero and postnatal MMC repair groups was the same at 37 months (p = 0.53). More newborns from the postnatal group were discharged from birth hospital performing CIC (91.1% vs. 58.5%, p < 0.0001), however upon last follow up no difference existed between the groups on use of CIC (83.9% postnatal group % vs. 82.9% in utero group, p = 0.78). At last follow up, postnatal AC utilization was observed in 75% of postnatal MMC group compared to 78.1% of the in utero MMC repair group, p = 0.81 (Figure). The median time to AC utilization was 6.9 months and 8.8 months in the in utero and postnatal groups, respectively (p = 0.28). DISCUSSION We observed no reduction in risk of AC utilization with in utero repair which refuted the hypothesis of our study. Indications for AC utilization were urodynamic abnormalities such as NDO (81.3% in utero vs. 81% postnatal) or impaired bladder compliance (53.1% in utero vs. 64.3% postnatal). CONCLUSIONS We found no difference in risk of postnatal AC utilization between in utero or postnatal MMC repair. CIC rates were higher at birth hospital discharge in the postnatal repair group, however at last follow up CIC rates did not differ between groups.
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Wishahi M. Lower urinary tract dysfunction in pediatrics progress to kidney disease in adolescents: Toward precision medicine in treatment. World J Nephrol 2021; 10:37-46. [PMID: 34430383 PMCID: PMC8353602 DOI: 10.5527/wjn.v10.i4.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/16/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
Newborn infants who had neurogenic bladder dysfunction (NBD) have a normal upper urinary tract at birth. Most of them will develop deterioration of renal function and chronic kidney disease if they do not receive proper management. Children with NBD can develop renal damage at adolescence or earlier, which is due to high detrusor pressures resulted from poor compliance of the bladder, detrusor overactivity against a closed sphincter or detrusor sphincter dyssynergia. To preserve renal function and prevent deterioration of the kidneys, NBD must be treated immediately after being diagnosed. Over the last few years there was great progress in the treatment of children with the NBD. We searched PubMed and the Cochrane Library for peer-reviewed articles published in any language up to March 10, 2021, using the search term “neurogenic bladder children.” Our search excluded diagnosis, pathophysiology, surgical treatment of spinal cord injury and spina bifida. The research identified the effectiveness of treatment regimens targeting prevention of chronic kidney disease and the indications of kidney transplantation. The results of the research showed that NBD in children should be diagnosed early in life, and the child should receive the proper management. The literature search concluded that the management of NBD in children would be personalized for every case and could be changed according to response to treatment, side effects, child compliance, availability of treatment modality and costs of treatment. The objectives of the study are to present the different options of management of NBD in children and the selection of the proper method in a personalized manner.
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Affiliation(s)
- Mohamed Wishahi
- Department of Urology, Theodor Bilharz Research Institute, Cairo 12411, Egypt
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Sager C, Barroso U, Bastos JM, Retamal G, Ormaechea E. Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment. Int Braz J Urol 2021; 48:31-51. [PMID: 33861059 PMCID: PMC8691255 DOI: 10.1590/s1677-5538.ibju.2020.0989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Defective closure of the neural tube affects different systems and generates sequelae, such as neurogenic bladder (NB). Myelomeningocele (MMC) represents the most frequent and most severe cause of NB in children. Damage of the renal parenchyma in children with NB acquired in postnatal stages is preventable given adequate evaluation, follow-up and proactive management. The aim of this document is to update issues on medical management of neurogenic bladder in children. MATERIALS AND METHODS Five Pediatric Urologists joined a group of experts and reviewed all important issues on "Spina Bifida, Neurogenic Bladder in Children" and elaborated a draft of the document. All the members of the group focused on the same system of classification of the levels of evidence (GRADE system) in order to assess the literature and the recommendations. During the year 2020 the panel of experts has met virtually to review, discuss and write a consensus document. RESULTS AND DISCUSSION The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies. Clean intermittent catheterization (CIC) should be implemented during the first days of life, and antimuscarinic drugs should be indicated upon results of urodynamic studies. When the patient becomes refractory to first-line therapy, receptor-selective pharmacotherapy is available nowadays, which leads to a reduction in reconstructive procedures, such as augmentation cystoplasty.
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Affiliation(s)
- Cristian Sager
- Service of Urology, National Hospital of Pediatrics Prof. Dr. P. J. Garrahan, Buenos Aires, Argentina
| | - Ubirajara Barroso
- Departamento de Urologia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil.,Escola Bahiana de Medicina (BAHIANA), Salvador, BA, Brasil
| | - José Murillo Bastos
- Universidade Federal de Juiz de Fora - UFJF, Juiz de Fora, MG, Brasil.,Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (HMTJ-SUPREMA), Juiz de Fora, MG, Brasil
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Le HK, Cardona-Grau D, Chiang G. Evaluation and Long-term Management of Neurogenic Bladder in Spinal Dysraphism. Neoreviews 2020; 20:e711-e724. [PMID: 31792158 DOI: 10.1542/neo.20-12-e711] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Spinal dysraphism, which includes conditions such as myelomeningocele and sacral agenesis, is one of the most common causes of congenital lower urinary tract dysfunction. Early evaluation of the neurogenic bladder serves to minimize renal damage, and the main goals of management include preserving renal function, achieving acceptable continence, and optimizing quality of life. The survival of patients with such conditions has improved to greater than 80% reaching adulthood, owing to advances in diagnostic and therapeutic modalities. The result is a real, and unfortunately often unmet, need for successful transitional care in this complex patient population. Clinicians must be able to identify the unique challenges encountered by patients with neurogenic bladder as they shift through different stages of their life.
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Affiliation(s)
- Hoang-Kim Le
- Division of Pediatric Urology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA
| | | | - George Chiang
- Division of Pediatric Urology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA
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Wiener JS, Huck N, Blais AS, Rickard M, Lorenzo A, Di Carlo HNM, Mueller MG, Stein R. Challenges in pediatric urologic practice: a lifelong view. World J Urol 2020; 39:981-991. [PMID: 32328778 DOI: 10.1007/s00345-020-03203-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
Abstract
The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.
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Affiliation(s)
- John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Nina Huck
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne-Sophie Blais
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada
| | - Mandy Rickard
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada
| | - Armando Lorenzo
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Heather N McCaffrey Di Carlo
- The James Buchanan Brady Urologic Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Margaret G Mueller
- Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Obstetrics & Gynecology and Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Corona LE, Lee T, Marchetti K, S Streur C, Ivancic V, Kraft KH, Bloom DA, Wan J, Park JM. Urodynamic and imaging findings in infants with myelomeningocele may predict need for future augmentation cystoplasty. J Pediatr Urol 2019; 15:644.e1-644.e5. [PMID: 31653462 PMCID: PMC7086486 DOI: 10.1016/j.jpurol.2019.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/15/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Urologic issues are persistent and important causes of morbidity and mortality in patients with myelomeningocele. Classically, patients with elevated bladder pressures despite adherence to clean intermittent catheterization (CIC) and pharmacotherapy undergo augmentation cystoplasty (AC). Currently, there is little understanding of which infants are more likely to require AC later. OBJECTIVE In this context, the authors studied whether unfavorable urodynamic or imaging findings in patients with myelomeningocele during infancy could predict future AC. The authors hypothesized that infants born with elevated bladder pressures, vesicoureteral reflux (VUR), and/or hydronephrosis would be more likely to undergo AC. STUDY DESIGN The authors retrospectively identified patients with myelomeningocele at their institution who were followed-up since infancy (<1 year of age), with a minimum of eight continuous years of follow-up. Standard care protocol included cystometrogram, voiding cystourethrogram (VCUG), and renal ultrasound during infancy. The primary outcome was AC for elevated bladder pressures despite attempts at more conservative management with medical therapy and CIC. Specifically, the authors evaluated for differences in augmentation rates based on gender, level of lesion, presence of detrusor leak point pressure (DLPP) or end-fill pressure (EFP) greater than 40 cm H2O, presence of hydronephrosis, VUR, initiation of CIC, and initiation of antimuscarinics in infancy. The authors excluded patients who underwent surgical intervention for urinary incontinence. RESULTS A total of 97 patients met the inclusion criteria. The median follow-up time was 13.8 years. Augmentation cystoplasty was performed for 17 patients (17.5%) at a median age of 114 months (9.5 years). Detrusor leak point pressure/EFP was greater than 40 cm H2O in 34.0% (33/97) of infant cystometrogram studies, while 30.9% (30/97) had VUR on infant VCUG and 20.6% (20/97) had hydronephrosis on infant renal ultrasound. Patients with DLPP/EFP greater than 40 cm H2O or VUR during infancy were more likely to undergo AC (P = 0.02 and P = 0.03, respectively). Binomial logistic regression revealed that DLPP/EFP greater than 40 cm H2O (odds ratio [OR]: 4.28, 95% confidence interval [CI]: 1.34-13.62) and VUR (OR: 3.73, 95% CI: 1.18-11.77) were independent risk factors for future AC. DISCUSSION Infants with myelomeningocele and elevated bladder pressures and VUR should be closely monitored by urodynamic testing and imaging studies. Parents can be counseled regarding the potentially higher risk for future AC in these patients. Nonetheless, the majority of high-risk infants will safely avoid AC with conservative management.
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Affiliation(s)
- Lauren E Corona
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA.
| | - Ted Lee
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - Kathryn Marchetti
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - Courtney S Streur
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - Vesna Ivancic
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - Kate H Kraft
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - David A Bloom
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - Julian Wan
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
| | - John M Park
- University of Michigan, Department of Urology, 1500 E Medical Center Drive, SPC 5330, Ann Arbor, MI, USA
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Early Vs. Expectant Management of Spina Bifida Patients-Are We All Talking About a Risk Stratified Approach? Curr Urol Rep 2019; 20:76. [PMID: 31734847 DOI: 10.1007/s11934-019-0943-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Radiographic abnormalities, bladder interventions, and bladder surgery in the first decade of life in children with spina bifida. Pediatr Nephrol 2019; 34:1277-1282. [PMID: 30826869 DOI: 10.1007/s00467-019-04222-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/06/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spina bifida (SB) patients are at increased risk for hydronephrosis, bladder storage and emptying problems, and renal failure that may require multiple bladder surgeries. METHODS We retrospectively reviewed patients born with SB 2005-2009, presenting to our institution within 1 year of birth. Outcomes at 8-11 years old included final renal/bladder ultrasound (RBUS) results, clean intermittent catheterization (CIC) use, anticholinergic use, surgical interventions, and final renal function. We excluded those without follow-up past age 8 and/or no RBUS or fluoroscopic urodynamic images (FUI) within the first year of life. Imaging was independently reviewed by four pediatric urologists blinded to radiologists' interpretation and initial findings compared with final outcomes. RESULTS Of 98 children, 62 met inclusion criteria (48% male, 76% shunted). Median age at last follow-up was 9.6 years. Upon initial imaging, 74% had hydronephrosis (≥ SFU grade 1), decreasing to 5% at 10 years (p < 0.0001). Initially, 9% had ≥ SFU grade 3 hydronephrosis, decreasing to 2% (p = 0.13). CIC and anticholinergic use increased from 61% and 37% to 87% and 86%, respectively (p = 0.001 and p < 0.0001, respectively). With follow-up, 55% had surgical intervention and 23% had an augmentation. Of children with a serum creatinine/cystatin-C at 8-11 years old, one had confirmed chronic kidney disease (stage 2). CONCLUSIONS Despite initial high incidence of hydronephrosis, this was low grade and resolved in the first decade of life. Additionally, the 8-11-year incidence of kidney disease and upper tract changes was low due to aggressive medical management.
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Stein R, Zahn K, Huck N. Current Indications and Techniques for the Use of Bowel Segments in Pediatric Urinary Tract Reconstruction. Front Pediatr 2019; 7:236. [PMID: 31245339 PMCID: PMC6581750 DOI: 10.3389/fped.2019.00236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/24/2019] [Indexed: 01/28/2023] Open
Abstract
Today, there are few indications for the use of bowel in pediatric urology. This is in large extent due to the successful conservative therapy in patients with neurogenic bladder and the improved success of primary reconstruction in patients with the bladder exstrophy-epispadias complex. Only after the failure of the maximum of conservative therapy or after failure of primary reconstruction, bladder augmentation, or urinary diversion should be considered. Malignant tumors of the lower urinary tract (e.g., rhabdomyosarcomas of the bladder/prostate) are other rare indications for urinary diversion. Replacement or reconstruction of the ureter with a bowel segment is also a quite rarely performed procedure. In this review, the advantages and disadvantages of the different options for the use of bowel segments for bladder augmentation, bladder substitution, urinary diversion, or ureter replacement during childhood and adolescence are discussed.
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Affiliation(s)
- Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Katrin Zahn
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Nina Huck
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Metcalfe P, De S, Bailly G. Augmented bladders and urinary diversions. Can Urol Assoc J 2018; 12:S24-S26. [PMID: 29681270 DOI: 10.5489/cuaj.5226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Shuba De
- University of Alberta, Edmonton, AB
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15
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Atchley TJ, Dangle PP, Hopson BD, Graham A, Arynchyna AA, Rocque BG, Joseph DB, Wilson TS. Age and factors associated with self-clean intermittent catheterization in patients with spina bifida. J Pediatr Rehabil Med 2018; 11:283-291. [PMID: 30507589 PMCID: PMC6944289 DOI: 10.3233/prm-170518] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study is twofold: 1) to determine the age when a child with spina bifida (SB) will most likely transition from caregiver clean intermittent catheterization (CIC) to self-CIC, and 2) to identify factors associated with self-CIC in children older than that age. METHODS This is a retrospective, single-institution cohort study of individuals with SB. Data were collected prospectively as part of the National Spina Bifida Patient Registry. For Aim 1, we identified all individuals who perform self-CIC and who had a documented transition from caregiver-CIC. We then determined the age of transition to self-CIC. For Aim 2, we compared individuals over age 10 years (age cutoff determined by Aim 1) who use self-CIC to those who use caregiver-CIC to determine what variables were associated with self-CIC. RESULTS From our SB population, 206 individuals used self-CIC. Of these, 64 patients had documented ages of transition from caregiver- to self-CIC. 46 (71.9%) and 56 (87.5%) patients had transitioned to self-CIC by 10 and 14 years, respectively. For Aim 2, we used age 10 as a cutoff, based on the findings from Aim 1, and found that 287/696 patients were ⩾ 10 years and using CIC. Factors independently associated with lower likelihood of self-CIC were thoracic spinal lesions (odds ratio (OR) 0.45) and Medicaid insurance (OR 0.24). CONCLUSIONS The ages at self-CIC transition vary, although most patients transition by age 10. Thoracic-level spinal lesions and Medicaid insurance are associated with lower odds of self-CIC.
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Affiliation(s)
- T J Atchley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - P P Dangle
- Department of Pediatric Urology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - B D Hopson
- Department of Pediatric Urology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A Graham
- Department of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A A Arynchyna
- Department of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - B G Rocque
- Department of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - D B Joseph
- Department of Pediatric Urology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - T S Wilson
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
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16
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Wu CQ, Franco I. Management of vesicoureteral reflux in neurogenic bladder. Investig Clin Urol 2017; 58:S54-S58. [PMID: 28612061 PMCID: PMC5468266 DOI: 10.4111/icu.2017.58.s1.s54] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/06/2017] [Indexed: 11/18/2022] Open
Abstract
Vesicoureteral reflux (VUR) is a significant risk factor for pyelonephritis and renal scarring. VUR can occur through a defective ureterovesical junction (UVJ) or an overwhelmed normal UVJ mechanism such as in bladder dysfunction of congenital, acquired, or behavioral etiology. There are numerous causes for the development of a neurogenic bladder from spinal dysraphisms to spinal cord trauma and even centrally based abnormalities in children with apparently normal motor function (inappropriately termed nonneurogenic neurogenic bladder). The foundation of managing reflux in these neurogenic bladders is to maintain low bladder pressures which will commonly mean that compliance will be normal as well. There have been several publications that have shown that if bladder pressures are lowered simply with clean intermittent catheterization and medications that the reflux can resolve spontaneously. Alternatively, the patients that are in need of bladder augmentation can have spontaneous resolution of their reflux with the resulting increase in capacity. Surgical intervention is called for when bladder capacity is adequate and the reflux persists or if it is part of a larger operation to increase capacity and to manage outlet resistance. In some instances, reimplantation is necessary because the ureters interfere with the bladder neck procedure. Aside from open and robotic surgical intervention the use of endoscopic injectable agents is beginning to become more popular especially when combined with intravesical botulinum toxin A injections. Great strides are being made in the management of patients with neurogenic bladders and we are seeing more choices for the urologist to be able to manage these patients.
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Affiliation(s)
- Charlotte Q Wu
- Department of Urology, Section of Pediatric Urology, Yale School of Medicine, New Haven, CT, USA
| | - Israel Franco
- Department of Urology, Section of Pediatric Urology, Yale School of Medicine, New Haven, CT, USA
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17
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Metcalfe PD. Neuropathic bladders: Investigation and treatment through their lifetime. Can Urol Assoc J 2017; 11:S81-S86. [PMID: 28265327 DOI: 10.5489/cuaj.4276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The child with a neuropathic bladder requires lifelong dedicated care. Just as each patient presents with unique physiology, each phase of their life presents varying challenges. The primary concern for our patients is their renal health, but continence and independence also play significant roles. Most patients can be managed conservatively, but a myriad of surgical options are also available, reinforcing our emphasis on individualized care. Appropriate pre-surgical planning is required to ensure the right patient receives the best operation for his/her wants and needs. Furthermore, the numerous potential complications must be understood and long-term followup and surveillance is required. This review outlines the basic pathophysiology, investigations, and treatments, with a focus on the changing needs throughout their lives.
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Affiliation(s)
- Peter D Metcalfe
- University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
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18
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Routh JC, Cheng EY, Austin JC, Baum MA, Gargollo PC, Grady RW, Herron AR, Kim SS, King SJ, Koh CJ, Paramsothy P, Raman L, Schechter MS, Smith KA, Tanaka ST, Thibadeau JK, Walker WO, Wallis MC, Wiener JS, Joseph DB. Design and Methodological Considerations of the Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida. J Urol 2016; 196:1728-1734. [PMID: 27475969 PMCID: PMC5201100 DOI: 10.1016/j.juro.2016.07.081] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Care of children with spina bifida has significantly advanced in the last half century, resulting in gains in longevity and quality of life for affected children and caregivers. Bladder dysfunction is the norm in patients with spina bifida and may result in infection, renal scarring and chronic kidney disease. However, the optimal urological management for spina bifida related bladder dysfunction is unknown. MATERIALS AND METHODS In 2012 the Centers for Disease Control and Prevention convened a working group composed of pediatric urologists, nephrologists, epidemiologists, methodologists, community advocates and Centers for Disease Control and Prevention personnel to develop a protocol to optimize urological care of children with spina bifida from the newborn period through age 5 years. RESULTS An iterative quality improvement protocol was selected. In this model participating institutions agree to prospectively treat all newborns with spina bifida using a single consensus based protocol. During the 5-year study period outcomes will be routinely assessed and the protocol adjusted as needed to optimize patient and process outcomes. Primary study outcomes include urinary tract infections, renal scarring, renal function and bladder characteristics. The protocol specifies the timing and use of testing (eg ultrasonography, urodynamics) and interventions (eg intermittent catheterization, prophylactic antibiotics, antimuscarinic medications). Starting in 2014 the Centers for Disease Control and Prevention began funding 9 study sites to implement and evaluate the protocol. CONCLUSIONS The Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida began accruing patients in 2015. Assessment in the first 5 years will focus on urinary tract infections, renal function, renal scarring and clinical process improvements.
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Affiliation(s)
- Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, North Carolina.
| | - Earl Y Cheng
- Division of Urology, Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Michelle A Baum
- Division of Nephrology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Richard W Grady
- Department of Urology, Seattle Children's Hospital, Seattle, Washington
| | - Adrienne R Herron
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Steven S Kim
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, California
| | - Shelly J King
- Department of Urology, Riley Hospital for Children, Indianapolis, Indiana
| | - Chester J Koh
- Division of Urology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Pangaja Paramsothy
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa Raman
- Spina Bifida Association, Arlington, Virginia
| | - Michael S Schechter
- Division of Pediatric Pulmonary Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Kathryn A Smith
- Division of General Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Stacy T Tanaka
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Judy K Thibadeau
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - William O Walker
- Division of Developmental Medicine, Seattle Children's Hospital, Seattle, Washington
| | - M Chad Wallis
- Division of Urology, Primary Children's Hospital, Salt Lake City, Utah
| | - John S Wiener
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - David B Joseph
- Department of Urology, University of Alabama-Birmingham, Birmingham, Alabama
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Abstract
Urologic tissue engineering efforts have been largely focused on bladder and urethral defect repair. The current surgical gold standard for treatment of poorly compliant pathological bladders and severe urethral stricture disease is enterocystoplasty and onlay urethroplasty with autologous tissue, respectively. The complications associated with autologous tissue use and harvesting have led to efforts to develop tissue-engineered alternatives. Natural and synthetic materials have been used with varying degrees of success, but none has proved consistently reliable for urologic tissue defect repair in humans. Silk fibroin (SF) scaffolds have been tested in bladder and urethral repair because of their favorable biomechanical properties including structural strength, elasticity, biodegradability, and biocompatibility. SF scaffolds have been used in multiple animal models and have demonstrated robust regeneration of smooth muscle and urothelium. The pre-clinical data involving SF scaffolds in urologic defect repair are encouraging and suggest that they hold potential for future clinical use.
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Affiliation(s)
- Bryan S Sack
- Urological Diseases Research Center, Boston Children's Hospital, Boston, MA, 02115, USA. .,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA.
| | - Joshua R Mauney
- Urological Diseases Research Center, Boston Children's Hospital, Boston, MA, 02115, USA. .,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA. .,Department of Urology, John F. Enders Research Laboratories, Boston Children's Hospital, 300 Longwood Ave., Rm. 1009, Boston, MA, 02115, USA.
| | - Carlos R Estrada
- Urological Diseases Research Center, Boston Children's Hospital, Boston, MA, 02115, USA. .,Department of Surgery, Harvard Medical School, Boston, MA, 02115, USA. .,Department of Urology, Boston Children's Hospital, 300 Longwood Ave., Hunnewell 3, Boston, MA, 02115, USA.
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20
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Brock JW, Carr MC, Adzick NS, Burrows PK, Thomas JC, Thom EA, Howell LJ, Farrell JA, Dabrowiak ME, Farmer DL, Cheng EY, Kropp BP, Caldamone AA, Bulas DI, Tolivaisa S, Baskin LS. Bladder Function After Fetal Surgery for Myelomeningocele. Pediatrics 2015; 136:e906-13. [PMID: 26416930 PMCID: PMC4586733 DOI: 10.1542/peds.2015-2114] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A substudy of the Management of Myelomeningocele Study evaluating urological outcomes was conducted. METHODS Pregnant women diagnosed with fetal myelomeningocele were randomly assigned to either prenatal or standard postnatal surgical repair. The substudy included patients randomly assigned after April 18, 2005. The primary outcome was defined in their children as death or the need for clean intermittent catheterization (CIC) by 30 months of age characterized by prespecified criteria. Secondary outcomes included bladder and kidney abnormalities observed by urodynamics and renal/bladder ultrasound at 12 and 30 months, which were analyzed as repeated measures. RESULTS Of the 115 women enrolled in the substudy, the primary outcome occurred in 52% of children in the prenatal surgery group and 66% in the postnatal surgery group (relative risk [RR]: 0.78; 95% confidence interval [CI]: 0.57-1.07). Actual rates of CIC use were 38% and 51% in the prenatal and postnatal surgery groups, respectively (RR: 0.74; 95% CI: 0.48-1.12). Prenatal surgery resulted in less trabeculation (RR: 0.39; 95% CI: 0.19-0.79) and fewer cases of open bladder neck on urodynamics (RR: 0.61; 95% CI: 0.40-0.92) after adjustment by child's gender and lesion level. The difference in trabeculation was confirmed by ultrasound. CONCLUSIONS Prenatal surgery did not significantly reduce the need for CIC by 30 months of age but was associated with less bladder trabeculation and open bladder neck. The implications of these findings are unclear now, but support the need for long-term urologic follow-up of patients with myelomeningocele regardless of type of surgical repair.
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Affiliation(s)
| | - Michael C. Carr
- Division of Pediatric Urology, and,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - N. Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela K. Burrows
- The Biostatistics Center, George Washington University, Washington, District of Columbia
| | | | - Elizabeth A. Thom
- The Biostatistics Center, George Washington University, Washington, District of Columbia
| | - Lori J. Howell
- Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Mary E. Dabrowiak
- Pediatric Surgery/Fetal Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Earl Y. Cheng
- Lurie Children’s Hospital and Northwestern University, Chicago, Illinois
| | - Bradley P. Kropp
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Anthony A. Caldamone
- Division of Urology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dorothy I. Bulas
- Department of Diagnostic Imaging and Radiology, Children’s National Medical Center, Washington, District of Columbia; and
| | - Susan Tolivaisa
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Laurence S. Baskin
- Department of Urology, University of California, San Francisco, San Francisco, California
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21
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Chowdhary SK, Kandpal DK, Agarwal D, Sibal A, Srivastava RN. Robotic augmentation ileocystoplasty with bilateral ureteric reimplantation in a young child with neuropathic bladder. J Indian Assoc Pediatr Surg 2014; 19:162-5. [PMID: 25197195 PMCID: PMC4155634 DOI: 10.4103/0971-9261.136473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Neuropathic bladder in children is most commonly secondary to spina bifida. The management starts early in life. The modalities of treatment vary depending on the severity of the symptoms. A proportion of children inspite of adequate medical management need augmentation ileocystoplasty later in life. The open surgery has proven safety and success over many decades. Earlier attempts to perform augmentation cystoplasty by the laparoscopic approach were limited by steep learning curve, long operating times, and technical difficulties in intracorporeal anastomosis. The emergence of robotic technology has revived the interest in minimally invasive approach for complex pediatric urological reconstructions. In the recent times, there has been only one reported case report and small series of pediatric robotic augmentation cystoplasty from Chicago. We report the first minimally invasive robotic reconstruction in a child with neuropathic bladder and early renal decompensation despite appropriate medical treatment, from our country.
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Affiliation(s)
- Sujit K Chowdhary
- Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Deepak K Kandpal
- Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Deepak Agarwal
- Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Anupam Sibal
- Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Rajendra N Srivastava
- Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India
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22
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Guerra L, Leonard M, Castagnetti M. Best practice in the assessment of bladder function in infants. Ther Adv Urol 2014; 6:148-64. [PMID: 25083164 PMCID: PMC4054507 DOI: 10.1177/1756287214528745] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be 'reflexive' or 'uninhibited', with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic 'detrusor sphincter dyssynergy' seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of 'early prophylactic treatment (clean intermittent catheterization and anticholinergics)' versus initial 'watchful waiting and treatment as needed' is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.
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Affiliation(s)
- Luis Guerra
- Division of Urology, Children's Hospital of Eastern Ontario (CHEO), 401 Smyth Rd, Ottawa, ON, Canada K1H 8L1
| | - Michael Leonard
- Department of Surgery, Division of Pediatric Urology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Marco Castagnetti
- Section of Paediatric Urology, Urology Unit, University Hospital of Padova, Padua, Italy
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23
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Nerli RB, Patil SM, Hiremath MB, Reddy M. Yang-Monti's Catheterizable Stoma in Children. Nephrourol Mon 2013; 5:801-5. [PMID: 24282789 PMCID: PMC3830905 DOI: 10.5812/numonthly.9443] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 12/25/2012] [Indexed: 11/21/2022] Open
Abstract
Background In 1981, Mitrofanoff described a procedure to create a continent urinary stoma for clean intermittent catheterization. Since then several procedures have been described including Yang-Monti ileovesicostomy for effective catheterization. Objectives We report on our experience from the use of Monti’s procedure in children at our center. Patients and Methods Children < 18 years of age undergoing urinary diversion/reconstruction with Yang-Monti’s procedure for congenital conditions or neuropathic bladder formed the study group. All these children, post-operatively were taught clean intermittent catheterization (CIC) and put on a regime using a 14/16 Fr catheter every 3 hours. The children were followed regularly at 3, 6, 12, 18 and 24months post-operatively, with special attention paid to any problems with catheterization and incontinence. Results During the period from Jan 2000 to Dec 2011, at our center, 19 children less than eighteen years of age underwent urinary diversion with Yang-Monti’s catheterizable stoma. The indications for urinary diversion was neuropathic bladder in eight, exstrophy bladder in seven , valve bladder syndrome in three and persistent urethral stricture in one. None of the children found CIC difficult during the post-operative period and there was no hindrance to the passage of the catheter. Conclusions Although the appendix remains the tissue of choice for creation of catherterizable stoma, the Yang-Monti ileovesicostomy is effective, convenient conduit for children. Long-term complications are minimal and children find this comfortable to do CIC.
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Affiliation(s)
- Rajendra Bapusaheb Nerli
- Department of Urology, KLES Kidney Foundation, JN Medical College, KLE University, Belgaum, India
- Corresponding author: Rajendra Bapusaheb Nerli, Department of Urology, KLES Kidney Foundation, JN Medical College, KLE University, 590010, Belgaum, India. Tel: +91-8312473777; Ext: 1394, Fax: +91-8312470732, E-mail: , .
| | | | | | - Mallikarjun Reddy
- Department of Urology, KLES Kidney Foundation, JN Medical College, KLE University, Belgaum, India
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Baek M, Kang JY, Jeong J, Kim DK, Kim KM. Treatment outcomes according to neuropathic bladder sphincter dysfunction type after treatment of oxybutynin chloride in children with myelodysplasia. Int Urol Nephrol 2013; 45:703-9. [PMID: 23543139 DOI: 10.1007/s11255-013-0423-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 03/15/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE We investigated the treatment outcomes according to neuropathic bladder sphincter dysfunction (NBSD) type after oral oxybutynin (OBT) treatment in children with NBSD caused by myelodysplasia. METHODS Among 334 pediatric patients who were diagnosed with NBSD caused by myelodysplasia, only children treated with oral OBT for more than 1 year with pre- and post-treatment urodynamic studies and dimercaptosuccinic acid (DMSA) were retrospectively reviewed. We compared pre- and post-treatment urodynamic parameters including maximum cystometric capacity (MCC), MCC/estimated bladder capacity (EBC), and compliance by NBSD type in children. We also compared renal scarring on pre- and post-treatment DMSA by NBSD type in children. RESULTS Our study population was comprised of 81 children (45 boys and 36 girls), with a mean age of 4.2 ± 3.4 years. The mean follow-up duration was 4.5 (range 1.0-15.1) years. After OBT treatment, MCC was increased significantly in all types of NBSD from 110.3 ± 62.2 to 202.3 ± 103.9 ml (p < 0.05), compliance was significantly improved from 6.4 ± 6.1 to 11.1 ± 9.6 ml/cmH2O (p < 0.05), but MCC/EBC was slightly decreased from 75.2 ± 46.9 to 69.8 ± 33.3 % (p = 0.40). Sub-analyzed by NBSD type, the pre-treatment compliance of children with acontractile detrusor with spastic sphincter (n = 16) was markedly decreased compared with other types of NBSD. Acontractile detrusor with spastic sphincter demonstrated the worst renal deterioration on DMSA. CONCLUSIONS Although increases in MCC/EBC were limited, oral OBT treatment markedly improved MCC and compliance in all NBSD types. Children who had acontractile detrusor with spastic sphincter had a relatively high probability of renal deterioration and required specific attention.
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Affiliation(s)
- Minki Baek
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Filler G, Gharib M, Casier S, Lödige P, Ehrich JHH, Dave S. Prevention of chronic kidney disease in spina bifida. Int Urol Nephrol 2011; 44:817-27. [PMID: 21229390 DOI: 10.1007/s11255-010-9894-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 12/24/2010] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The prevalence of progressive chronic kidney disease (CKD) in children and adults with spina bifida is considerable, rising, and entirely preventable. REMOVING THE CAUSE PREVENTION OF SPINA BIFIDA: The best prevention of CKD in spina bifida is prevention of spina bifida itself through strategies that include folate supplementation, ideally before pregnancy. THE CAUSE OF CKD Dysfunctional bladder outlet causes febrile Urinary Tract Infections (UTI), even with clean intermittent catheterization (CIC), and subsequent renal scarring. The development of secondary vesicoureteric reflux (VUR) increases the risk of renal scarring and CKD. FINDING THE IDEAL MARKER FOR MEASUREMENT OF RENAL FUNCTION IN SPINA BIFIDA Creatinine-based methods are insensitive because of low muscle mass and underdeveloped musculature in the legs. Only Cystatin C-based eGFR can reliably assess global renal function in these patients. However, unilateral renal damage requires nuclear medicine scans, such as (99m)Tc DMSA. (VIDEO)URODYNAMICS STUDIES (UDS): Early treatment is recommended based on UDS with anticholinergics, CIC, and antibiotic prophylaxis when indicated. Overnight catheter drainage, Botox, and eventually augmentation cystoplasty are required for poorly compliant bladders. A continent child or one rendered continent following surgery is at a higher risk of renal damage. CONCLUSION A multidisciplinary approach is required to reduce the burden of CKD in patients with spina bifida. The right tools have to be utilized to monitor these patients, particularly if recurrent UTIs occur. Cystatin C eGFR is preferred for monitoring renal damage in these patients, and (99m)Tc DMSA scans have to be used to detect unilateral renal scarring.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Children's Hospital at London Health Science Centre, University of Western Ontario, 800 Commissioners Road East, London, ON N6A 5W9, Canada.
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Verpoorten C, Buyse GM. The neurogenic bladder: medical treatment. Pediatr Nephrol 2008; 23:717-25. [PMID: 18095004 PMCID: PMC2275777 DOI: 10.1007/s00467-007-0691-z] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 10/19/2007] [Accepted: 10/25/2007] [Indexed: 11/03/2022]
Abstract
Neurogenic bladder sphincter dysfunction (NBSD) can cause severe and irreversible renal damage and bladder-wall destruction years before incontinence becomes an issue. Therefore, the first step in adequate management is to recognize early the bladder at risk for upper- and lower-tract deterioration and to start adequate medical treatment proactively. Clean intermittent catheterization combined with anticholinergics (oral or intravesical) is the standard therapy for NBSD. Early institution of such treatment can prevent both renal damage and secondary bladder-wall changes, thereby potentially improving long-term outcomes. In children with severe side effects or with insufficient suppression of detrusor overactivity despite maximal dosage of oral oxybutynin, intravesical instillation is an effective alternative. Intravesical instillation eliminates systemic side effects by reducing the first-pass metabolism and, compared with oral oxybutynin, intravesical oxybutynin is a more potent and long-acting detrusor suppressor. There is growing evidence that with early adequate treatment, kidneys are saved and normal bladder growth can be achieved in children so they will no longer need surgical bladder augmentation to achieve safe urinary continence in adolescence and adulthood.
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Affiliation(s)
- Carla Verpoorten
- Department of Child Neurology, University Hospitals K.U. Leuven, Herestraat 49, Leuven, Belgium.
| | - Gunnar M. Buyse
- grid.410569.f0000000406263338Department of Child Neurology, University Hospitals K.U. Leuven, Herestraat 49, B-3000 Leuven, Belgium
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Abstract
A review of the various causes of neurologic impairment to the lower urinary tract in children was the aim of this presentation. The emphasis was on diagnosis, pathophysiology, and treatment that strive to maintain as normal a function as possible in order to achieve eventual urinary continence and health of the upper urinary tract. The latest principles based on the most up to date evidence are promulgated but with an eye towards historical prospective. The reader should gain an adequate understanding of various disorders that comprise this condition and feel comfortable with proposing options for management when faced with the responsibility of caring for an affected child.
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Kapoor R, Agrawal S. Meningomylocele: An update. Indian J Urol 2007; 23:181-6. [PMID: 19675798 PMCID: PMC2721530 DOI: 10.4103/0970-1591.32072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Therapy-resistant overactivity of detrusor or small capacity and poor compliance, will usually need to be treated by bladder augmentation. Ileal or colonic patches are used frequently for augmenting the bladder, with either intestinal segment appearing to be equally useful. Stomach is rarely used because of the associated complications, but it is the only available intestinal segment for patients with impaired renal function. Concerns regarding long-term effects of associated metabolic acidosis, including abnormalities in linear growth and bone metabolism are misplaced. Ureterocystoplasty offers an attractive urothelium-preserving alternative, avoiding the metabolic complications, mucus production and cancer risk of heterotopic epithelium associated with enterocystoplasty. Though ideal for patients with dilated ureter and nonfunctioning kidney, in patients with functioning kidney it carries added risks associated with transuretero-ureterostomy, mainly obstruction. Ureteral dilatation in meningomyelocele patients is avoidable with proper follow-up and treatment. Therefore they rarely should be candidates for this operation. Alternative urothelium-preserving techniques, such as auto augmentation and seromuscular cystoplasty, have not proven to be as successful as standard augmentation with intestinal segment. Work is in progress on various bioengineering techniques to culture and combine bladder cells in tissue culture for regeneration. Early efforts are exciting, but preliminary.
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Affiliation(s)
- R. Kapoor
- Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow - 226 014, UP, India
| | - S. Agrawal
- Department of Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow - 226 014, UP, India
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Abstract
BACKGROUND [corrected] Urological complications are the major cause of ill health during childhood and adult life of patients with spina bifida but the significance of urinary tract disease on the individual and the healthcare services is underemphasised. AIM To assess the effects of spina bifida on the individual and the healthcare services. METHODS A retrospective review was performed to assess the frequency and significance of urological conditions requiring hospital attendance in patients with spina bifida currently attending a specialised multidisciplinary clinic over a period of six months. RESULTS Urinary sepsis accounted for the majority of admissions (62%), while 38 of 62 patients required 60 surgical procedures. Targeting the primary urological abnormality (the dysfunctional and usually poorly compliant bladder) allows implementation of effective treatments, including regular intermittent bladder catherisation (52%) in order to preserve upper renal tract function. Associated postural abnormalities complicated both conservative and interventional therapies. CONCLUSION This study highlights the surgical commitment for units caring for patients with spina bifida, the important considerations for the future healthcare services, and the range and severity of urological diseases encountered by these patients.
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Affiliation(s)
- R A Cahill
- Department of Urology, Cork University Hospital, Ireland.
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