The outcome of bladder neck closure in children with severe urinary incontinence

The impact of repeated bladder surgery on successful bladder neck closure in classic bladder exstrophy: The role of mucosal violations

INTRODUCTION

Restoration of genitourinary anatomy with functional urinary continence is the reconstruction aim is the exstrophy-epispadias complex (EEC). In patients who do not achieve urinary continence or those who are not a candidate for bladder neck reconstruction (BNR), bladder neck closure (BNC) is considered. Interposing layers including human acellular dermis (HAD) and pedicled adipose tissue are routinely placed between the transected bladder neck and distal urethral stump to reinforce the BNC and minimize failure due to fistula development from the bladder.

OBJECTIVE

The aim of this study was to review classic bladder exstrophy (CBE) patients who underwent BNC to identify predictors of BNC failure. Specifically, we hypothesize that increased operations on the bladder urothelium leads to a higher rate of urinary fistula.

STUDY DESIGN

CBE patients who underwent BNC were reviewed for predictors of failed BNC which was defined as bladder fistula development. Predictors included prior osteotomy, interposing tissue layer use and number of previous bladder mucosal violations (MV). A MV was defined as a procedure when the bladder mucosa was opened or closed for: exstrophy closure(s), BNR, augmentation cystoplasty or ureteral re-implantation. Predictors were evaluated using multivariate logistic regression.

RESULTS

A total of 192 patients underwent BNC of which 23 failed. Patients were more likely to develop a fistula with a wider pubic diastasis at time of primary exstrophy closure (4.4 vs 4.0 cm, p=0.0016), have failed exstrophy closure (p=0.0084), or have 3 or more MVs before BNC (p=0.0002). Kaplan-Meier analysis of fistula-free survival after BNC, demonstrated an increased fistula rate with additional MVs (p=0.0004, Figure 1). MVs remained significant on multivariate logistic regression analysis with a per-violation odds ratio of 5.1 (p<0.0001). Of the 23 failed BNC's, 16 were surgically closed including 9 using a pedicled rectus abdominis muscle flap which was secured to the bladder and pelvic floor.

CONCLUSION

This study conceptualized MVs and their role in bladder viability. Increased MVs confer an increased risk of failed BNC. When considering BNC, CBE patients with 3 or more prior MVs may benefit from a pedicled muscle flap, in addition to HAD and pedicled adipose tissue, to prevent fistula development by providing wellvascularized coverage to further reinforce the BNC.

Continence outcomes following a modification of the Mitchell bladder neck reconstruction in myelomeningocele: A single institution experience

BACKGROUND

Many surgical procedures have been developed to improve continence in myelomeningocele patients. Our modification of the Mitchell bladder neck reconstruction involves removal of a diamond-shaped wedge of the anterior bladder neck, tubularization of the bladder neck and urethra to increase outlet resistance, and addition of a bladder neck autologous fascial sling.

OBJECTIVE

We aimed to evaluate rates of continence and re-operation in children with myelomeningocele undergoing this Modified Mitchell bladder neck reconstruction.

STUDY DESIGN

We retrospectively identified children with myelomeningocele having undergone bladder neck reconstruction at our tertiary care referral center from 2012 to 2016.

RESULTS

We identified twelve patients with myelomeningocele undergoing this modified bladder neck reconstruction with sling, four female and eight male, median age at the time of surgery was 7 years old. After initial bladder neck reconstruction with sling only 33% were dry. All patients with bothersome leakage after reconstruction underwent bladder neck bulking. Two patients of twelve (17%) ultimately underwent bladder neck closure and achieved dryness. 58% of patients ultimately achieved continence (Summary Figure).

DISCUSSION

Our modification of the bladder neck reconstruction with autologous fascial sling showed midterm rates of incontinence near 60%, with initial post-operative continence at 33%. Our patients, however, required higher rates of reoperation (43%) than previous results would suggest (27%). The first line of re-treatment was bladder neck bulking, but this showed low success. While this procedure is minimally invasive and safe, reasonable expectations of efficacy should be established with families when offering this option. Two patients (17%) required bladder neck closure to achieve dryness. While bladder neck closure is often considered a procedure of last resort, both of these patients were immediately dry. Perhaps bladder neck closure should be considered earlier in our algorithm of surgical continence.

CONCLUSION

Our rates of continence with the Modified Mitchell bladder neck reconstruction with a fascial sling were similar to prior bladder neck reconstructions. We did find higher rates of reoperation, and further modifications are warranted to continue to improve continence after surgical procedures in the myelomeningocele population. Select cases may warrant early consideration of bladder neck closure.

Efficacy and security of continent catheterizable channels at short and middle term for adult neurogenic bladder dysfunction

AIMS

The objective of this study was to assess the effectiveness and the complications rate following continent cutaneous channels (CCC) procedures, at short and medium term follow-up (FU).

MATERIALS & METHODS

A continuous retrospective case series (2008-2018): all patients who have undergone a CCC for neurogenic bladder were included in our department. The primary outcome was the effectiveness of CCC defined by the status of catheterizability (by the patient or a care-giver), continence of the tube, and absence of reintervention at 3 and 12 months FU. The secondary outcome was the prevalence of postoperative complications at 3 and 12 months FU.

RESULTS

Fifty-three patients were included during the study period in our department. Median follow up was 3,3 years (1.5-6.1). The overall effectiveness of CCC was 67.9% (n=36/53) at 3 months FU and 45,3% (n=24) at 12 months FU. The global rate of complications was 60.4% (n=32/53) at 3 months, and 73.6% (n=39/73) at 12 months FU. The statistical analysis showed no statistical differences on efficacy and complications in the different subgroups of CCC.

CONCLUSIONS

In the current series, the effectiveness and the complications rates following CCC were comparable across the procedure types.

LEVEL OF EVIDENCE

4.

The Role of Human Acellular Dermis in Preventing Fistulas After Bladder Neck Transection in the Exstrophy-epispadias Complex

OBJECTIVE

To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition.

METHODS

A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas.

RESULTS

In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716).

CONCLUSION

Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.

Continent urinary diversion in the epispadias-exstrophy complex

Despite improvements in modern surgical reconstructive techniques, many patients with epispadias-exstrophy continue to experience urinary incontinence. Continent diversion is commonly performed to achieve urinary continence and improve quality of life. In this work we describe the population that can be considered for continent urinary diversion, consider the benefits and implications of concurrent augmentation and bladder neck closure, and review recent literature regarding continence outcomes and common complications. Even in this complex patient population, urinary continence can be reliably achieved by bladder augmentation and the use of intermittent catheterization via a catheterizable cutaneous stoma with or without closure of the bladder neck.

A comparative study between continent diversion and bladder neck closure versus continent diversion and bladder neck reconstruction in children

OBJECTIVE

To assess the long-term outcome of continent diversion in children with structural or neurogenic cause of incontinence, with special interest in differences between closed and open bladder neck procedures.

PATIENTS AND METHODS

A cohort of 63 children with intractable incontinence treated with continent diversion between January 1998 and January 2008 were reviewed for underlying disease, type of surgery, complications and outcome.

RESULTS

Forty patients had a continent diversion with open bladder neck (group 1) and 23 patients had their bladder neck closed (group 2: 11 primarily closed; 12 secondarily closed). There was no difference between the two groups in terms of patient characteristics, surgical re-interventions and stone formation. The continence rate however was significantly better in group 2 (95.6% vs 77.5%).

CONCLUSION

Bladder neck closure with continent diversion as primary or salvage procedure in children with intractable incontinence does not result in extra morbidity and has a high success rate. Thorough urodynamic evaluation of bladder function is the key to success in therapy planning for these children, to minimize the need for re-intervention.

Bladder neck closure and suprapubic tube placement in a debilitated patient population

AIMS

Bladder neck closure (BNC) with suprapubic tube (SPT) placement is a method of bladder management for patients with neurogenic bladders (NGB). We evaluated our experience at one institution.

METHODS

We conducted a retrospective chart review of patients who received BNC with SPT placement from 1999 to 2008.

RESULTS

Twenty-nine patients (24 females and 5 males, average age 53.4 +/- 9.6 years) underwent BNC with SPT placement. Cause of NGB was multiple sclerosis (48%), spinal injury (28%), or myelodysplasia (17%). All but one were dependent on caregivers for activities of daily living. Preoperative urodynamics studies were performed on 23 patients. Retropubic BNC was performed in 26 of 29 patients. Two females had a transvaginal approach, and one male had a perineal approach. Early (<90 days) postoperative complication rate was 52%. Persistent urine leakage was present in eight patients: two peristomal leakage and six urethral leakage. All three non-retropubic BNC had postoperative fistulas (P = 0.01). Catheter complications were associated with seven of the eight urinary leaks (P = 0.01).

CONCLUSIONS

BNC with SPT is a method of bladder management in the NGB population, particularly suited to those with a low functional status. Fistula rates are significantly higher with non-retropubic BNC (P = 0.01). Poor catheter care in the postoperative period is associated with postoperative urinary leakage (P = 0.01).

Use of rectus abdominis muscle flap as adjunct to bladder neck closure in patients with neurogenic incontinence: preliminary experience

PURPOSE

Vesicoureteral fistula is a well-known potential complication following bladder neck closure for neurogenic incontinence. Various maneuvers, including omental interposition, have been described to prevent this problem. Unfortunately omentum is not always available or feasible for use. We describe the surgical anatomy and use of a rectus abdominis muscle flap as an adjunctive maneuver during bladder neck closure to correct or prevent development of bladder neck fistula.

MATERIALS AND METHODS

We performed a retrospective chart review of all patients at our institution undergoing rectus abdominis muscle flap by a single surgeon (EAS). Patient demographics, indications for surgery, intraoperative and postoperative complications, and long-term efficacy were assessed. Cadaveric dissection was also performed to gain a greater understanding of the surgical anatomy relevant to this procedure.

RESULTS

In 6 patients with neurogenic bladder dysfunction a rectus abdominis muscle flap was interposed between the bladder neck and urethral stump at bladder neck closure. There were no intraoperative or postoperative complications associated with this procedure. At a mean followup of 45.5 months (range 18 to 120) all 6 patients were continent of urine. There have been no urinary fistulas related to use of the rectus abdominis muscle flap. Cadaveric dissections confirmed the inferior epigastric artery to be the dominant and readily mobile blood supply of the rectus abdominis muscle flap.

CONCLUSIONS

The rectus abdominis muscle flap is easily harvested without significant risk of morbidity and offers a well vascularized tissue for coverage of a bladder neck closure when an omental flap is not available.

Sling suspension of the bladder neck for pediatric urinary incontinence

OBJECTIVE

Surgery for urinary incontinence in childhood is in the process of an ongoing search for better results because a procedure that guarantees dryness still does not exist. This study has been conducted to assess the overall results of the fascia sling procedure for incontinence in children.

MATERIAL AND METHODS

Eighty-nine patients with neurogenic lower urinary tract dysfunction and follow-up of more than 2 years have been included in the study (46 boys and 43 girls aged 2-17 years). All patients underwent U-type sling suspension of the bladder neck. In 59 patients detrusorectomy and in 11 patients bladder augmentation was performed. Sphincter incompetence was defined as low-pressure (<30 cm H(2)O) leakage observed during urodynamic studies. The results of surgery were assessed clinically (dryness intervals).

RESULTS

Forty-two (47%) patients were completely dry, and 23 (26%) considerably improved. The success rate was higher in males (35) than in females (30) (76% vs 70%). Detrusorectomy did not improve the success rate of the sling procedure (68% vs 79% sling only), but bladder augmentation did (90%). Higher success rates have been observed in adolescents compared to prepubertal children (83% vs 56%). No serious complications were observed.

CONCLUSIONS

Rectus fascia sling suspension is a safe procedure and could be considered a good option for the treatment of neurogenic sphincter incompetence in children.

Bulbar urethral ligation for managing persistent urinary incontinence in young men with myelomeningocele

OBJECTIVE

To report our experience with ligation of the bulbar urethra for treating refractory stress incontinence in a selected group of young men with neuropathic bladders secondary to myelomeningocele (MM), in whom primary anti-incontinence procedures had failed.

PATIENTS AND METHODS

Persistent urethral incontinence leading to chronic perineal skin ulceration can occur in these patients, despite aggressive medical and surgical efforts to decrease wetting by increasing bladder capacity, compliance and outlet resistance. Four young men with MM had bulbar urethral ligation; all had undergone a previous ileocystoplasty and functioning continent catheterizable channels (CCC, three appendicovesicostomies, one Monti procedure). Three patients had primary bladder neck procedures using rectus fascia slings, and secondary attempts were made at urethral bulking in two patients. All patients had persistent incontinence through their native urethra, with dry intervals of <2 h.

RESULTS

The bulbar urethra was ligated through a small midline perineal incision at 1 year after augmentation, and successfully resolved incontinence in all four patients. All reported satisfaction with their bladder regimen at a mean (range) follow-up of 49 (20-93) months. There were no perineal wound infections. While one patient developed bladder calculi, no patient developed urethral stones, febrile urinary tract infections, fistulae or bladder perforations.

CONCLUSIONS

We report the results of bulbar urethral ligation for resolution of incontinence in patients with MM in whom anti-incontinence bladder neck procedures had failed. Ligation of the urethra is effective, and can be considered an alternative treatment for refractory urinary incontinence in patients with a functional CCC in whom previous bladder neck-supporting procedures have failed.

Outcomes of bladder neck closure for intractable urinary incontinence in patients with neurogenic bladders

OBJECTIVE

Recent reports of outcomes of bladder neck closure for neurogenic urinary incontinence reveal poor initial continence and high vesicourethral fistula rates. We evaluated a large series of patients who underwent complete transection and closure of the bladder neck with modified abdominal stoma creation.

MATERIALS AND METHODS

The medical records of 52 consecutive patients (23 males and 29 females) undergoing bladder neck closure by a single surgeon between July 1996 and January 2003 were reviewed. Mean follow up was 20 months (range 2-68 months) and mean age was 13.9 years (range 1.5-58 years). Forty-two patients (81%) underwent concomitant bladder augmentation. Catheterizable stomas included 46 appendicovesicostomies (88%) and six Monti tubes (12%). Of the 52 patients, 22 were confined to wheelchairs (42%), and the majority of patients had spinal cord pathology (40/52, 77%). Mean preoperative vesical leak point pressure was 25 cm/H(2)O (range 4-69 cm/H(2)O).

RESULTS

Complete postoperative urinary continence was achieved in 44 patients (88%) after one procedure. Of the six patients who were incontinent (12%), one had a vesicourethral fistula (2%) and five had incontinence at the urinary diversion stoma (10%). Twelve of 50 patients had urinary stomal stenosis (24%), with six requiring urgent evaluation (12%) and six requiring surgical revision (12%). Postoperative urinary continence was unknown in two patients due to inadequate follow-up data.

CONCLUSIONS

Our findings suggest that bladder neck closure is a safe and effective method of achieving urinary continence in children with neurogenic voiding dysfunction. While there are risks of stomal stenosis and fistula formation, modifications in surgical technique may reduce them to acceptable levels.

The challenge of pediatric continent urinary diversion

OBJECTIVE

Continent urinary diversion (CUD) may be required for refractory incontinence in children with various malformations. We review our experience with CUD to identify determinants of success and ongoing challenges.

METHODS

Retrospective chart review of 43 consecutive patients undergoing CUD since 1991 at British Columbia Children's Hospital.

RESULTS

Our preferred surgery was intestinal cystoplasty and either appendicovesicostomy (77%) or ileal-vesicostomy. Concomitant bladder neck surgery was performed in 67%. Mean follow-up was 2.5 years. There was a 16% revision rate for persistent leakage, the most common being cystoscopic injection of bulking agents. Continence was ultimately achieved in 88%. Early major and minor postoperative complications each occurred in 21% of cases. Delayed minor complications requiring surgical intervention occurred in 30% including stomal stenosis in 6 patients and stomal prolapse in 2. Urolithiasis required intervention in 5 patients.

CONCLUSIONS

Pediatric CUD is a challenging endeavor. Most patients achieve continence although many require additional minor procedures to do so. Early major and minor complications are common. A significant minority of patients require reoperation for delayed minor complications. Patients and families should be informed of these frustrations as part of their preoperative counseling. A high degree of family motivation and commitment is essential.

Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet

OBJECTIVES

To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets.

METHODS

A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications.

RESULTS

With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively.

CONCLUSIONS

High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.