Evaluation of augmentation cystoplasty in childhood with reference to vesico-ureteric reflux and urinary infection

Management of vesicoureteral reflux in neurogenic bladder

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.

Risk Factors Associated With Recurrent Urinary Tract Infection in Neurogenic Bladders Managed by Clean Intermittent Catheterization

OBJECTIVE

To identify risk factors for recurrent urinary tract infection (UTI) in patients who perform clean intermittent catheterization (CIC).

METHODS

A 6-year retrospective chart review of patients with spina bifida or tethered cord who perform clean intermittent catheterization (8 months to 58 years) was conducted. A strict case definition for UTI was applied, and per-subject UTI events, demographic, and clinical data were abstracted. Data were compared between groups defined by no or infrequent UTI (≤1.0 UTI/study year) and frequent UTI (>1.0 UTI/study year).

RESULTS

Of 194 total patients, 146 (75%) had no UTIs or infrequent UTIs, and 48 (25%) patients had frequent UTIs. On univariate analysis, only younger age and suprasacral cord lesions were associated with frequent UTIs (P = .002 and P = .007, respectively). Among the 128 patients with urodynamic studies, bladder capacity, compliance, detrusor overactivity, and detrusor leak point pressure were not associated with frequent UTI on univariate analysis. On multivariate analysis, increasing age was found to be associated with decreased odds of UTI by 7% per year (odds ratio 0.93, P = .016).

CONCLUSION

The risk of UTI among individuals with spina bifida or tethered cord declines with increasing age. Bladder function based on urodynamic parameters did not correlate with frequent UTIs.

Augmentation enterocystoplasty without reimplantation for patients with neurogenic bladder and vesicoureteral reflux

The objective of this study was to assess the clinical outcome of vesicoureteral reflux (VUR) after augmentation cystoplasty alone in patients with a hypocompliant neurogenic bladder. Between January 2009 and December 2014, 29 patients with a hypocompliant bladder associated with VUR confirmed by videourodynamics (VUD) preoperatively were recruited in this study. All patients had undergone bladder augmentation with a generous detubularized segment of bowel at our institution. No effort had been made to correct the existing reflux. Preoperative assessment included urinalysis, kidney function tests, ultrasonography, and videourodynamic evaluation. All patients had various degrees of VUR. The status of VUR and bladder function were studied by VUD. The mean follow-up period was 2.2 years (range 0.5-5.5 years). The VUD manifested a significant improvement of bladder capacity, diminution of intravesical pressure, and resolution of reflux after bladder augmentation. After the surgery, 24/29 (83%) no longer had reflux, 3/29 (10%) showed improvement in reflux, and 2/29 (7%) demonstrated no change in reflux. In addition, 16/21 (76%) patients had reflux Grades I-III; 100% patients with reflux Grades IV and V had complete cessation of reflux. Only one patient had symptomatic urinary infection after the surgery. Augmentation enterocystoplasty without ureteral reimplantation is thus effective and adequate for patients with high-pressure and hypocompliant neurogenic bladder. Therefore, ureteral reimplantation is not necessary when augmentation enterocystoplasty is recommended for patients with high-pressure, low-compliant bladder and VUR.

Enterocistoplastia de ampliación laparoscópica: experiencia inicial

OBJECTIVE

To analyze the initial experience of our group in the realization of the augmentation enterocystoplasty by laparoscopyc approach.

METHODS AND PATIENTS

We describe the augmentation enterocystoplasty technique with ileal segment completely achieved by laparoscopyc approach. We present the cases of two patients suffering from hyperreflexic bladder refractory to medical treatment who underwent this surgery. In both cases the technique was realized without intraoperative complications although it was needed a surgical time of 6 and 4.5 hours respectively. The results after 12 and 5 months were satisfactory in both patients, obtaining a low pressure bladder with a good continence.

CONCLUSIONS

Laparoscopyc augmentation enterocystoplasty is a complicated technique that requires a great experience, mainly in laparoscopyc suture. It reproduces completely the open surgery and it offers all the advantages inherent to the laparoscopyc surgery.

Changing composition of renal calculi in patients with neurogenic bladder

PURPOSE

Renal calculi are a significant source of morbidity for patients with neurogenic bladder. Calculi from patients with NB have traditionally been composed primarily of struvite and carbonate apatite secondary to chronic urea-splitting bacteriuria. In the current era there have been great improvements in the urological rehabilitation of patients with NB. We defined the composition of renal calculi in a contemporary cohort of patients with NB due to spinal cord injury or myelomeningocele who underwent percutaneous nephrolithotomy.

MATERIALS AND METHODS

We performed a retrospective evaluation of all patients with NB due to SCI or MM who underwent PNL between January 2002 and January 2005.

RESULTS

A total of 32 patients with NB (14 with SCI, 18 with MM) underwent PNL in this period. Stones were infectious in etiology in 37.5% (12 struvite/carbonate apatite) and metabolic in 62.5% (1 uric acid, 2 calcium oxalate monohydrate, 2 brushite, 6 hydroxyapatite, 9 mixed hydroxyapatite/calcium oxalate). All patients with struvite calculi were infected with urea-splitting bacteria on preoperative urine culture.

CONCLUSIONS

Patients with neurogenic bladder are traditionally thought to harbor infection related calculi. These data demonstrate that many contemporary patients will be found to have calculi of a metabolic etiology. Although patients with NB still have renal calculi, advances in urological treatment may have affected the composition of their calculi, as metabolic stones are becoming more commonly identified. When metabolic components are identified, stone activity may be attenuated with appropriate metabolic evaluation, pharmacological therapies and dietary modifications.

Is ureteral reimplantation necessary during augmentation cystoplasty in patients with neurogenic bladder and vesicoureteral reflux?

PURPOSE

We assessed the outcome of vesicoureteral reflux after augmentation cystoplasty in patients with neurogenic bladder.

MATERIALS AND METHODS

Since May 1992, 112 male and 18 female patients with neurogenic bladder have undergone augmentation cystoplasty with a generous detubularized segment of bowel and no effort to correct existing reflux. Patients were treated conservatively at the beginning but the response was unsatisfactory. All patients had various degrees of vesicoureteral reflux (197 refluxing units). Mean age at operation was 21.6 years (range 1.5 to 57). Preoperatively assessment included urinalysis, urine culture, kidney function tests, voiding cystourethrography, urodynamic evaluation, ultrasonography or excretory urography and cystoscopy when indicated. The status of vesicoureteral reflux, renal hydronephrosis and clinical pyelonephritis were studied during an average followup of 44.5 months.

RESULTS

Of the 130 patients 111 (85.4%) no longer had reflux, 14 (10.8%) had improvement, 4 (3%) had no change and 1 (0.8%) had worsening reflux. All refluxing units with grades I to III, 105 of 120 with grade IV (87.5%) and 8 of 13 with grade V (61.5%) showed complete cessation of reflux. Renal hydronephrosis improved in 127 renal units (97.7%). In 8 individuals (6.2%) without reflux after cystoplasty episodes of clinical pyelonephritis occurred.

CONCLUSIONS

Augmentation cystoplasty without ureteral reimplantation is effective and adequate treatment for high pressure, noncompliant neurogenic bladder when conservative management fails.

Enterocystoplasty

Despite the problems of augmentation cystoplasty, on balance it has been a much better form of management of the lower urinary tract in patients with bladder neuropathy or high pressure detrusor contractions than the alternatives of rectal diversion, indwelling catheter or external urinary diversion. The metabolic consequences do not seem to interfere with general health in the medium term. The risk of perforation appears to be present with other forms of augmentation cystoplasty or bladder replacement. However, the results are far from perfect and the ideal technique will be one that: removes the need for intraperitoneal surgery and prevents the risk of intestinal adhesions; stops the development of intestinal mucus and stone formation; prevents the metabolic complications and potential bony complications during adolescence; at the same time improves the patient's resistance to UTI; maintains the same degree of long-term, good, low-pressure urine storage and the consequent improvement and stability of the upper urinary tract.

SHOULD WE TREAT VESICOURETERAL REFLUX IN PATIENTS WHO SIMULTANEOUSLY UNDERGO BLADDER AUGMENTATION FOR NEUROPATHIC BLADDER?

PURPOSE

If high pressure is responsible for vesicoureteral reflux in neurogenic bladders, eliminating the high pressure should resolve reflux in noncompliant bladders. Nevertheless, the need for simultaneous ureteral reimplantation and bladder augmentation remains controversial in patients with a noncompliant bladder and vesicoureteral reflux.

MATERIALS AND METHODS

Bladder augmentation was performed in 8 boys and 8 girls with a noncompliant bladder and vesicoureteral reflux at a mean age of 10 years (range 2 to 17) because they had not responded satisfactorily to clean intermittent catheterization and anticholinergic therapy alone. No effort had been made to correct reflux surgically in these patients. Before bladder augmentation reflux was grade II to III in 4 ureters (3 patients) and IV to V in 18 (13). The bladder was augmented with intestine in 14 patients and with ureter in 2. Mean followup was 5.2 years (range 2.8 to 7.5).

RESULTS

After bladder augmentation bladder compliance improved in all patients. Of the 18 ureters with high grade reflux 2 were used for bladder augmentation, and reflux resolved in 13, was downgraded in 1 and persisted in 2. Of the 4 ureters with low grade reflux, reflux disappeared in 2 and was down graded in 2. The rate of high and low grade vesicoureteral reflux resolution or improvement was 87.5% and 100%, respectively. At the end of the study only 3 patients had persistent reflux, which was downgraded in 2. No urinary tract infections developed in any patient and none was receiving chemoprophylaxis 6 months postoperatively.

CONCLUSIONS

Our experience indicates that antireflux procedures are not routinely needed in patients with a noncompliant bladder and associated vesicoureteral reflux who undergo bladder augmentation.

THE MITROFANOFF PROCEDURE: 20 YEARS LATER

PURPOSE

We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup.

MATERIALS AND METHODS

Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux.

RESULTS

One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion.

CONCLUSIONS

The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency.

The Mitrofanoff procedure: 20 years later

PURPOSE

We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup.

MATERIALS AND METHODS

Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux.

RESULTS

One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion.

CONCLUSIONS

The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency.

Should we treat vesicoureteral reflux in patients who simultaneously undergo bladder augmentation for neuropathic bladder?

PURPOSE

If high pressure is responsible for vesicoureteral reflux in neurogenic bladders, eliminating the high pressure should resolve reflux in noncompliant bladders. Nevertheless, the need for simultaneous ureteral reimplantation and bladder augmentation remains controversial in patients with a noncompliant bladder and vesicoureteral reflux.

MATERIALS AND METHODS

Bladder augmentation was performed in 8 boys and 8 girls with a noncompliant bladder and vesicoureteral reflux at a mean age of 10 years (range 2 to 17) because they had not responded satisfactorily to clean intermittent catheterization and anticholinergic therapy alone. No effort had been made to correct reflux surgically in these patients. Before bladder augmentation reflux was grade II to III in 4 ureters (3 patients) and IV to V in 18 (13). The bladder was augmented with intestine in 14 patients and with ureter in 2. Mean followup was 5.2 years (range 2.8 to 7.5).

RESULTS

After bladder augmentation bladder compliance improved in all patients. Of the 18 ureters with high grade reflux 2 were used for bladder augmentation, and reflux resolved in 13, was downgraded in 1 and persisted in 2. Of the 4 ureters with low grade reflux, reflux disappeared in 2 and was down graded in 2. The rate of high and low grade vesicoureteral reflux resolution or improvement was 87.5% and 100%, respectively. At the end of the study only 3 patients had persistent reflux, which was downgraded in 2. No urinary tract infections developed in any patient and none was receiving chemoprophylaxis 6 months postoperatively.

CONCLUSIONS

Our experience indicates that antireflux procedures are not routinely needed in patients with a noncompliant bladder and associated vesicoureteral reflux who undergo bladder augmentation.

Pediatric urinary tract reconstruction using intestine

OBJECTIVE

To analyse the outcome of urinary tract reconstruction in children.

MATERIAL AND METHODS

Fifteen children with bladder exstrophy or neurogenic bladder, 4-18 years old, were followed in accordance with a predetermined program for bladder augmentation (13 pat) or continent urinary reservoir (2 pat). The follow-up time was 1.7-6.3 years, median 3.7 years.

RESULTS

All were dry, though one case had occasional leaks. Three bladder neck reconstructions, two artificial sphincters, one sling plasty and one fistula closure with subsequent bladder neck injection were required. Bladder volumes were adequate for age at low pressures. Reflux resolved in 12/13 ureters. A boy with preoperative renal insufficiency was transplanted. Total renal function remained otherwise stable despite acidosis in one case and some glomerular impairment in all. Progressive parenchymal lesions were seen in combination with abundant mucus, infections and calculi only. Growth and bowel function was unaffected. Bone mineral density showed overall increase; some low values were not consistent between investigations.

CONCLUSIONS

Urinary tract reconstruction in children results in continence and regression of reflux. Growth, bone mineralization and renal function are unimpaired during the first years, but irrigation of the bladder is essential to minimize the risk of urinary tract infection. However, glomerular function might be affected and the possible risk of metabolic complications in later life can only be determined by continuous close monitoring over an extended period of time.

ABBREVIATIONS

Voiding cystourethrogram (VCUG), dimercapto-succinic acid (DMSA), Chrome51-Ethylenediaminetetraacetic acid (Cr-EDTA), single photon absorption (SPA), bone mineral content (BMC), bone mineral density (BMD), dual photon x-ray absorption (DEXA), glomerular filtration rate (GFR), urinary tract infection (UTI), immunoglobulin G (IgG), clean intermittent catheterization (CIC) and subureteral teflon injection (STING).

Augmented enterocystoplasty for neurogenic bladder associated with renal transplantation: appearance on Tc-99m MAG3 renal transplant scan

Enterocystoplasty (bladder augmentation) is a method of increasing bladder capacity in patients with small or neurogenic bladders in order to prevent vesicoureteral reflux. In patients with poorly compliant bladders, enterocystoplasty, which consists of a segment of detubularized small bowel or a portion of the stomach attached to the bladder, often helps to reduce the intravesicular pressures, thus reducing the likelihood of infection. It is also useful in treating bladder dysfunction in children with end-stage renal disease who require renal transplantation. Radiographic evaluation of patients with a renal transplant and augmented bladder often can be confusing, and may suggest a urine leak or hematoma. We report a patient with a renal transplant, bladder augmentation, and rising serum creatinine who underwent renal scintigraphy and ultrasonography.

Therapy Suggested in the Treatment of 94 Cases of Vesico-Ureteral Reflux in Neurologic Bladder after a Traumatic Spinal Cord Lesion

The Authors present their experience in the treatment of vesico-ureteral reflux in 623 patients, admitted to the “A. Gemelli” Hospital from 1976 to 1995, with neurologic bladder due to traumatic spinal cord lesion. Ninety-four patients with medium-high level reflux were treated; in 71 cases, the reflux was bilateral. The various therapies practised and the medium-long term results achieved are given.

Ureterocystoplasty with renal preservation in young infants

To assess the outcome of ureterocystoplasty (UCP) with renal preservation in infants, three infants had a UCP with preservation of the ipsilateral kidney, including one who had a ureteropyeloplasty and one who had a UCP using a previously reimplanted ureter. All three had complication-free improvement in bladder volume and compliance. UCP thus produces an augmented bladder and can be performed as part of a transureteropyeloplasty and following ureteric reimplantation.