Strategies in urological reconstruction in myelomeningocele

Long-term follow-up of bladder outlet procedures in children with neurogenic urinary incontinence

INTRODUCTION

Achieving continence in children with neurogenic sphincteric incompetence is a challenge. Awareness of the long-term outcome in this young patient population is important. In the past 25 years, the study institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstructions.

OBJECTIVE

The objective of this study was to evaluate the long-term outcome on continence and re-intervention rate of bladder outlet procedures in children with neurogenic urinary incontinence at the study institution.

DESIGN

All children who underwent a bladder neck procedure between 1992 and 2017 at the study institution were retrospectively reviewed. Continence at the end of follow-up was the primary endpoint, defined as 'dry' when there was an interval of a minimum of 4 h without urinary leakage. Non-parametric tests were used for statistical analysis.

RESULTS

During this 25-year period, a total of 60 children underwent a bladder outlet procedure, either a bladder neck sling (n = 43) or a bladder neck reconstruction (n = 17). The median age at surgery was 11.6 years (interquartile range [IQR] 7.8-13.9). Concomitant surgery consisted of bladder augmentation in 80% and continent catheterizable urinary channel in 97% of children. Dry rate within 1 year was 38%. After a median follow-up of 10.4 years (IQR 6.5-15.5), 77% of all children were dry. Twenty-five children (42%) needed one or more re-interventions, including redo of the bladder outlet procedure, other type of outlet procedure, bulking agents, bladder augmentation, and bladder neck closure.

DISCUSSION

This study confirms that achieving continence is a challenge. The inconsistent use of the definition of urinary continence creates confusion in the literature and makes comparison of outcome with other studies difficult. Openness of (long-term) results in achieving urinary continence is important and helpful for future patients.

CONCLUSION

On the long term, the majority of children with neurogenic urinary incontinence were dry after a bladder outlet procedure, but a considerable number of patients had a re-intervention. The initial outcome on continence was slightly disappointing. Reporting long-term results is essential and helpful for patient counseling.

Management of urological dysfunction in pediatric patients with spinal dysraphism: review of the literature

An intact, fully functional spine is the result of a complex sequence of embryological events involving both nervous and musculoskeletal system precursors. Deviations from this highly ordered system can result in congenital abnormalities ranging from clinically insignificant cosmetic changes to CNS malformations that are incompatible with life. Closure of the neural tube, which is believed to be the embryological event gone awry in these cases, is complete by just 28 days' gestation, often before pregnancy is detected. Although progress has been made to help prevent neural tube defects in the children of those attempting to conceive, these congenital deformities unfortunately continue to affect a startling number of infants worldwide each year. Furthermore, the precise mechanisms governing closure of the neural tube and how they might be interrupted remain elusive. What is known is that there are a large number of individuals who must deal with congenital spine dysraphism and the clinical sequelae on a daily basis. Bladder and urinary dysfunction are frequently encountered, and urological care is a critical, often neglected, component in the lifelong multidisciplinary approach to treatment. Although many treatment strategies have been devised, a need remains for evidence-based interventions, analysis of quality of life, and preemptive education of both caregivers and patients as they grow older. Pediatric neurosurgeons in particular have the unique opportunity to address these issues, often in the first few days of life and throughout pre- and postoperative evaluation. With proper management instituted at birth, many patients could potentially delay or avoid the potential urological complications resulting from congenital neurogenic bladder.

Urinary continence across the life course

Spina bifida is the most common defect of the central nervous system. It is a congenital malformation of the spine with abnormal neural tube closure occurring between the third and fourth weeks of gestation, and most frequently affecting the lumbar and sacral regions. Most children with spina bifida have a normal urinary tract at birth, although renal damage and renal failure are among the most severe complications of spina bifida. Before ventricular shunting, survival rates for children with spina bifida were low, but most patients can now be expected to live into adulthood, thus prevention of urologic complications and promotion of continence have become critical. This article reviews the literature regarding urinary continence, and discusses issues across the lifespan, and implications for clinical practice and the pediatrician's role in the urologic care of children with spina bifida.

Urologischer Erkrankungen bei Patienten mit Meningomyelozele

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

Myelomeningocele: a review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals

Although the use of folic acid before conception decreases the chance that a fetus will have an open neural tube defect, this condition still affects 0.5-1.0/1000 pregnancies in the United States. Results of a recent survey suggest that there are gaps in obstetrician-gynecologists' knowledge of risk factors for conception, strategies for prenatal diagnosis, and prognosis for affected individuals. To address these gaps this paper reviews the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals, presents current information, and makes suggestions for expanding obstetrician-gynecologists' knowledge of myelomeningocele.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that despite a large amount of professional and public education on the use of folic acid in prevention of open neural tube defects (ONTDs) the incidence still affects 0.5-1.0/1000 pregnancies and recall that a recent survey conducted by the ACOG shows substantial misunderstanding and misinformation on major categories of neural tube birth defects.

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

OBJECTIVE

Continent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang-Monti) and site of implantation (augmentation vs. native bladder) on outcome.

PATIENTS AND METHODS

A retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon).

RESULTS

There were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang-Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang-Monti CCC (P=0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder (P=0.3). The majority of revisions were at skin level.

CONCLUSIONS

Although there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.

Effectiveness of implanting catheterizable channels into intestinal segments

OBJECTIVE

To assess the effectiveness of implanting continent catheterizable channels (CCCs) into bowel segments used for bladder augmentation or substitution.

METHODS

The records of patients operated on between 2000 and 2003 were reviewed. CCCs were created using the appendix or a transverse tubularized bowel, and were implanted either in the intestinal segment of an augmentation or into an intestinal continent reservoir. Implantation into the intestinal segment was preferred over the native bladder, when it allowed the stoma to be placed at the umbilicus, creating the shortest possible channel. Ease of catheterization and continence through the stoma were evaluated by clinic interviews or record review.

RESULTS

Thirty-two patients (16 males) were 11.6 years old (mean) at the time of operation. Mean follow-up was 26 months. The CCCs were implanted in colon (24), ileum (six) and into a seromuscular colocystoplasty (two). At the last follow up all patients had satisfactory continence through the catheterizable stoma, but the continence rate after the initial procedure was 87.5% (28/32). Three patients required revision because of a short tunnel and became continent. One patient experiences occasional incontinent episodes when the bladder is full, but has not been re-operated on. Three patients experienced difficulties with catheterization attributed to a skin-level stenosis and have been revised. The overall revision rate was 18%.

CONCLUSION

CCCs constructed with either appendix or transverse tubularized bowel implanted into intestinal segments had a success rate comparable to that reported by others when implanted in the native bladder. The umbilical location of the stoma had significant cosmetic advantages and no apparent disadvantages.

Surgical treatment of neuropathic urinary incontinence in 2005. When, what, and how?

We present our current opinions on the surgical treatment of urinary incontinence in children with spina bifida. The age of treatment, preferred treatment modalities and results are discussed. We emphasize the importance of initiating treatment for incontinence at an early age as well as the use of effective surgical techniques.

Colpo-wrap: a new continence procedure

OBJECTIVE

To present a new surgical method to increase bladder outlet resistance for the treatment of urinary incontinence in girls and women.

PATIENTS AND METHODS

Six patients (mean age 9.6 years), with urinary incontinence were operated using the new technique within the last 3 years. The principle of the procedure is tightening of the bladder neck by mobilizing the anterior vaginal wall and wrapping it around the bladder neck and proximal urethra, in the sense of a vaginoplication (colpoplication). The underlying conditions and causes for urinary incontinence was neurogenic bladder-sphincter dysfunction caused by myelodysplasia in three girls and anorectal malformation combined with a tethered spinal cord in one. In one case incontinence was caused by a cloacal anomaly and one girl had intrinsic sphincter insufficiency after repetitive Otis urethrotomies. The colpo-wrap was combined with a bladder augmentation and Mitrofanoff in three patients, the three other girls undergoing isolated procedures.

RESULTS

The result of the method is a constant increase in outlet resistance and coaptation of the urethra, comparable with the effect of a vaginal sling procedure. Five patients are completely dry after surgery, one girl with cloaca needed an additional bladder neck injection with hyaluranon/dextranomer copolymer. Transurethral catheterization was possible after surgery with no problems in all patients who required intermittent catheterization.

CONCLUSION

Considering the feasibility of this technique the colpo-wrap is a reasonable alternative for treating urinary incontinence in females.

Evaluation of urinary and faecal continent stomas

OBJECTIVES

To evaluate the outcome and complications of urinary and faecal continent catheterizable stomas.

PATIENTS AND METHODS

Retrospective record review of all patients operated on in our institution within the last 6 years.

RESULTS

Fifty-five children received 63 stomas. The mean age at operation was 9.2 years and the mean follow-up period was 2.8 years. The diagnoses were: neurogenic bladder (n=22), bladder or cloacal exstrophy (n=20), anorectal malformation (n=6), persistent cloaca (n=3), Hirschsprung's disease (n=2), posterior urethral valves (n=1) and prune belly syndrome (n=1). There were 35 urinary stomas and 28 faecal stomas. Eight patients received both stomas. Both the appendix and a transverse tubularized intestinal segment (Yang-Monti technique) were used; in some cases a caecal flap was created. In three patients the appendix was divided and used to construct two stomas. The implantation of urinary stomas was into the native bladder in 24 patients and into the intestinal segment of an augmented bladder in 11 cases. The location of the stoma was umbilical in 20 cases, right lower quadrant of the abdomen in 35, neo-umbilicus in five and left lower quadrant in three. When an extra-umbilical location was chosen skin flaps were used. Excellent cosmetic and functional results were achieved in 53 (84.2%) of the 63 stomas, which are continent and easy to catheterize. Two had acceptable results with minor problems. There were eight re-operations (12.6% of stomas, 14.5% of patients). The reasons for the re-operations were difficult catheterization in two, incontinence in three, and mucosal prolapse in three patients in whom skin flaps were not used. Of the eight re-operations, seven were in urinary stomas and one in a faecal stoma. Urinary incontinence was attributed to shortening of the intravesical tunnel. No difference in results was observed between the different techniques used, with the exception that cutaneous anastomosis without skin flaps had to be revised because of prolapse, and two out of three incontinent channels had been constructed with tubularized ileum.

CONCLUSIONS

Catheterizable continent urinary and faecal stomas achieve the objectives of urinary and faecal continence and independence in most patients with a low complication rate.

The ureter as a pedicle for construction of a ureteral urethra: the double tunnel

PURPOSE

Clean intermittent self-catheterization has been shown to be an effective method for the prevention of upper tract urinary disease in patients who are unable to void efficiently. When the urethra is not available for catheterization surgeons can construct a catheterizable channel from the appendix or retubularized bowel. However, for patients without an appendix and limited bowel segments we have reimplanted the ureter to prevent reflux and tunneled the distal portion of the same ureter to construct a catheterizable stoma, the "double tunnel."

MATERIALS AND METHODS

We retrospectively reviewed our 10-year experience with the double tunnel ureteral pedicle. A total of 10 patients (8 girls and 2 boys) were included in this study. The left ureter was used in 7 cases and the right ureter was used in 3. Mean followup for these patients was 4.1 years, with a range of 0.5 to 8.5 years. Outcome measures included intraoperative complications, reoperation rates, postoperative complications and upper urinary tract deterioration.

RESULTS

There were no intraoperative complications. Furthermore, there were no cases of stomal stenosis or strictures that required reoperation or excision of the ureteral pedicle in the followup period. In our cohort the renal function associated with the ipsilateral double tunnel ureteral pedicle remained stable or improved. All patients reported that their catheterizable stoma is still functional.

CONCLUSIONS

The double tunnel ureteral pedicle provides another option in the urological armamentarium when there are minimal resources with which to construct a catheterizable stoma.

Children With Chronic Continence Problems

For families who are raising children with myelomeningocele, bowel and bladder incontinence presents unique challenges for everyday life. The Parenting and Childhood Chronicity model is used to describe the work of raising a child with a chronic condition in 6 areas, including medical care, adapted parenting, dealing with the systems, caring for siblings, maintaining relationships, and personal coping (keeping yourself going). This article provides an overview of the physiologic and developmental challenges inherent in this neural tube defect and illustrates the work that is involved in the child's care and the challenges of maintaining a balance in family life. Clinical implications are discussed, including the setting of appropriate expectations, providing parents with accurate information, ensuring that a focus on continence is not at the expense of other important aspects of the child's functioning, and supporting parents in their interaction with the school system. The medical team, consisting of nursing, urology, nephrology, and psychology working together, can be a strong support for families.