LONG-TERM OUTCOME ANALYSIS OF LOW PRESSURE RECTAL RESERVOIRS IN 33 CHILDREN WITH BLADDER EXSTROPHY

[Surgical urinary diversion in children from war and crisis areas-20-year experience report]

BACKGROUND

Because sick and injured children from war and crisis areas can often only be helped to a limited extent in their countries of origin, those children with the most complex diseases often receive medical treatment in Europe.

MATERIALS AND METHODS

To evaluate the postoperative outcome of reconstructive interventions in children from war and crisis areas, an evaluation of the clinic's internal database between 1997 and 2017 was carried out. The operative indication, the surgical procedure, any revisions or conversions and the overall mortality were analyzed.

RESULTS

During the above-mentioned period a total of 44 (male: 32, female: 12) children aged 3-14 years from Afghanistan, Angola, Central Asia and the Caucasus were treated. Indications for the reconstructive procedures were bladder exstrophy (n = 23), neurogenic bladder dysfunction (n = 9), penile partial amputation (n = 1) and traumatic bladder dysfunction (n = 11). In 26 children, a conduit was created, 11 children received a sigma rectum pouch and 1 child an ileocecal pouch, while 5 other children received bladder augmentation and 1 child an oral mucosal urethroplasty. In total, 7 revisions or conversions due to ureteral implantation stenoses and recurrent acidosis had to be performed. Five children died in their home country due to acidosis, sepsis, end stage renal failure, accident and social exclusion.

CONCLUSION

In the long term 39 of the 44 (88.6%) children live socially integrated in their home country and are regularly monitored by local aid organizations. When choosing the reconstructive intervention, the local conditions must be considered.

[Metabolic long-term complications after urinary diversion]

Metabolic long-term complications and consequences after urinary diversion are somewhat neglected. Subclinical metabolic disturbances are quite common; however, complications are rare. The absorptive surface of the bowel segment is lost for the physiological function of the gastrointestinal tract. Some studies demonstrated that at least some of the absorbent and secreting properties of the bowel are preserved if exposed to urine. For each bowel segment typical complications are reported. Using ileal and/or colon segments, hyperchloremic metabolic acidosis may occur. Studies demonstrated that metabolic effects are not as severe as suspected and could be prevented if a prophylactic treatment is started early.The resection of ileal segments is responsible for malabsorption of vitamin B(12) and bile acid; when using colonic segments, electrolyte disturbances are more common. Careful patient selection, meticulous follow-up and prophylactic treatment are crucial to prevent metabolic complications.

[The history of ureterosigmoidostomy]

Congenital anomalies like bladder exstrophy were the indication in 1821 to implant the ureters into the sigmoid colon for the first time. In 1894 the Maydl technique was used more frequently with a postoperative mortality rate of 31%. The most important impact for ureterosigmoidostomy came from Robert Coffey in 1911. Obstruction at the ureterocolic anastomosis, inflammatory complications together with severe acidosis, renal insufficiency, and high mortality rates however gave way in 1950 to the worldwide success of Bricker's ileal conduit although at the same time the technique of ureterosigmoidostomy was perfected by Leadbetter, Goodwin, and Hohenfellner. About 25 years later, when the high late complication rate of ileal conduits was obvious, the advantages of ureterosigmoidostomy were reconsidered and the technique was refined using valuable principles of pouch surgery. Today modified ureterosigmoidostomy has a strong place among the possibilities of urinary diversion.

[Perspectives in urinary diversion]

"Perspectives in Urinary Diversion" was the title of a presentation held during the opening session of the 56th annual meeting of the German Urological Association in Hamburg on September 21, 2006. It focused on the balance between obstruction and reflux of ureters implanted in diverted intestinal segments, the choice of intestinal segments for orthotopic pouches, orthotopic diversion in the female, the status of rectal diversions, and alternatives to the use of intestinal segments.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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