The urological care and outcome of pregnancy after urinary tract reconstruction

Long-term risks of childhood surgery

INTRODUCTION

Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery.

MATERIAL AND METHODS

Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery.

RESULTS

Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up.

CONCLUSION

Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.

Pregnancy and delivery after augmentation cystoplasty: A case report and review of literature

BACKGROUND

Augmentation cystoplasty, first described by Mikulicz in 1899 involves segments of bowel, stomach or mega-ureter to increase bladder capacity in those with inadequate bladder function or lack of detrusor compliance. The most widely used bowel segment is a detubularised patch of ileum. When ileum is not suitable for augmentation, sigmoid colon is the alternative. However, only eight pregnancies after sigmoidocystoplasty have been reported without detail and clinicians may be uncertain about the effects of sigmoidocystoplasty on reproductive health and pregnancy.

CASE SUMMARY

We followed the patient from gestational week 32+3 until 6 wk after delivery. During pregnancy, our patient suffered urinary tract infection twice and had to undergo percutaneous nephrostomy drainage due to progressive hydronephrosis. Despite a dense adhesion between the uterus and neobladder, we were able to deliver a healthy baby by cesarian section in the presence of the attending urologist.

CONCLUSION

Augmentation cystoplasty-afflicted women can have a healthy reproductive life. Certain perioperative measures may be advisable to avoid serious surgical complications.

A qualitative interview study on successful pregnancies in women with spina bifida

BACKGROUND

Improvements in antenatal medicine and surgical management for conditions associated with spina bifida such as hydrocephalus have extended the lifespan for individuals with spina bifida (SB) into adulthood. Decisions and education regarding reproductive care and pregnancies for patients with spina bifida are increasingly important. Pregnancy in these patients can be particularly challenging due to physical limitations, previous abdominal surgery for urinary or bowel management and presence of a ventriculoperitoneal shunt. To date, little research has examined the unique challenges that women with spina bifida face during pregnancy.

OBJECTIVE

The purpose of this descriptive study is to characterize the successful pregnancy histories of SB women and describe how pregnancy affected their mobility as well as bladder and bowel management.

STUDY DESIGN

We conducted semi-structured interviews with women followed in our adult multidisciplinary SB clinic who previously had successful pregnancies. Questions regarding perinatal issues, obstetrical complications, urinary tract infections (UTI) and neurological changes were asked. Baseline mobility, bladder and bowel management were compared with changes during and after pregnancy.

RESULTS

121 women of childbearing age were followed per year by our adult multidisciplinary spina bifida clinic between 2009 and 2016. We identified 6 women who successfully carried 8 pregnancies to term. There were no miscarriages. Four women had ventriculoperitoneal (VP) shunts. No children were born with neural tube defects. Mean age at first pregnancy was 23.5 years. Average gestational age at delivery was 37 weeks. 50% of the women had a spontaneous vaginal delivery. Five of six women intended to get pregnant; only one patient consumed folic acid regularly prior to pregnancy. Two of six women had bladder augmentation surgery, one of whom had urologic changes during pregnancy that persisted after childbirth. The other patient had a concomitant bladder neck sling procedure and did not have urologic issues during pregnancy. 50% of the patients experienced bladder-bowel dysfunction during their pregnancy. While 67% patients had full baseline ambulatory function, 4 patients had decreased mobility and required additional assistance during pregnancy. All returned to their baseline functionality afterwards.

CONCLUSION

Six of our patients had eight successful pregnancies, with no children born with neural tube defects. New changes to mobility, bladder and bowel management were experienced by over half of the women during their pregnancies. Future studies should focus on the role of multidisciplinary teams in reproductive health education and perinatal management of changes to activities of daily living during pregnancy in this population.

Women's health guidelines for the care of people with spina bifida

Women and girls with spina bifida have specific health care concerns. It is essential that they, and their health care providers have access to information to help them make healthy choices throughout their lifespan. This article aims to address key aspects of health pertinent to girls and women with spina bifida and outlines the SB Women's Health Guidelines for the Care of People with Spina Bifida. Further research into this area is needed.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature

INTRODUCTION AND HYPOTHESIS

The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR).

METHODS

We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies).

RESULTS

Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section.

CONCLUSIONS

Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Bladder Augmentation (Enterocystoplasty): the Current State of a Historic Operation

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of enterocystoplasty, a historical operation for bladder dysfunction but with continued and increasing modern relevance.

RECENT FINDINGS

Since the advent of third line neuromodulation techniques for neurogenic and idiopathic overactive bladder (OAB), the usage of enterocystoplasty has decreased. However, this procedure continues to be utilized in pediatric urology patients and the most refractory OAB patients. Adult urologist should be familiar with this operative technique in an effort to manage pediatric patients transitioning to adulthood. Minimally invasive techniques for this surgical procedure have been described with very limited outcome data. It is important for all urologists to be familiar with enterocystoplasty, both technically and with the unique needs of these patients postoperatively. Further studies evaluating the outcomes of this procedure in idiopathic overactive bladder patients and efforts to standardize recommendations for neurogenic bladder patients will help guide care in the future.

Pregnancy following urinary tract reconstruction using bowel segments: a review of published literature

PURPOSE

To provide a literature review of the urological and obstetric outcomes during and after pregnancy following urinary diversion using bowel segments.

METHODS

A systematic literature research by specific keywords was performed in February 2017. Relevant articles were assessed and available parameters such as, e.g., number of included patients, indication for and type of urinary diversion, birth mode and complications during and after pregnancy were evaluated.

RESULTS

We found 61 relevant articles published between 1961 and 2017. Overall, data of 282 females carrying 330 babies within 395 pregnancies were listed. Birth was via vaginal delivery in 132 cases, while 183 females delivered via elective or emergency cesarean. The main urological complications during pregnancy were urinary tract infections, pyelonephritis and dilatation of the upper urinary tract. In total, 155 episodes of pyelonephritis (39.2%) were reported, but no major or persisting complications occurred.

CONCLUSION

After urinary diversion, pregnancy is possible without major complications. Due to an increased risk of pyelonephritis and dilatation of the upper urinary tract requiring intervention, these pregnancies should be considered high risk. Vaginal delivery as well as delivery by cesarean is feasible, but should be carried out in centers of expertise with urological stand-by.

Pelvic Organ Prolapse and Pregnancy in the Female Bladder Exstrophy Patient

PURPOSE OF REVIEW

Classic bladder exstrophy (BE) remains one of the most demanding reconstructive challenges encountered in urology. In female BE patients, the long-term sequela of both primary and revision genitoplasty, as well as intrinsic pelvic floor deficits, predispose adult women to significant issues with sexual function, pelvic organ prolapse (POP), and complexities with reproductive health.

RECENT FINDINGS

Contemporary data suggest 30-50% of women with BE develop prolapse at a mean age of 16 years. Most women will require revision genitoplasty for successful sexual function, although in some series over 40% report dyspareunia. Current management for pregnancy includes elective cesarean section with involvement of high-risk obstetrics and urologic surgery. This review encapsulates contemporary concepts of etiology, prevalence, and management of POP and pregnancy in the adult female BE patient.

Pregnancy among mothers with spina bifida

INTRODUCTION

Recognizing the importance of sexual and reproductive health to patients with spina bifida (SB), pediatric urologists have taken responsibility for initiating conversations regarding this topic with adolescent and young adult SB patients. However, the sexual and reproductive health of women with SB remains under-investigated. It is unknown how many women are having babies, what mode of delivery is used, and if this has changed over time with the increasing life expectancy of these patients. A better understanding of pregnancy and delivery among young women with SB will enable urologists to provide more informed, comprehensive counseling to patients.

OBJECTIVE

We sought to compare hospitalizations for delivery in women with and without SB to determine differences in the mode of delivery used and changes in the rate of deliveries over time.

STUDY DESIGN

Using the Healthcare Cost and Utilization's National Inpatient Sample, we identified all hospitalizations for delivery in 2003-2013. After distinguishing between hospitalizations among women with and without SB, temporal trends analysis and bivariate comparison were performed to determine differences in patient and hospital characteristics and mode of deliveries.

RESULTS

We identified 10,147 hospitalizations for deliveries among women with SB and 42,197,763 among women without. Of all hospitalizations for deliveries, the percentage of deliveries by women with SB increased by 56% between 2003 and 2013 (629-925 deliveries per year, p < 0.001). Women with SB hospitalized for a delivery differed from those without SB. They had a higher number of comorbidities and were more likely to be white, have Medicare or private insurance, live outside a city, and deliver at an urban teaching hospital (all p < 0.001). Women with SB were significantly more likely to undergo a caesarean section (see Figure, 52.4% of women with SB vs. 31.9% of those without, p < 0.001), although nearly half were able to undergo vaginal delivery. For women with SB, 25.9% of all deliveries occurred by age 22, which did not differ significantly from women without SB (24.7% of all deliveries).

DISCUSSION

There are significant differences in the characteristics and mode of delivery between women with and without SB who are hospitalized for a delivery. The number of deliveries among these women are significantly increasing and over a quarter of the deliveries occur by age 22.

CONCLUSION

With increasing rates of deliveries and young age at delivery for women with SB, it is imperative that pediatric and transitional urologists initiate discussions on sexual and reproductive health beginning in adolescence.

Complications and Outcomes of Pregnancy and Cesarean Delivery in Women With Neuropathic Bladder and Lower Urinary Tract Reconstruction

OBJECTIVE

To determine the outcomes of pregnancy and cesarean delivery (CD) in women with neuropathic bladder (NB) and pediatric lower urinary tract reconstruction (LUTR) as these women often have normal fertility and may become pregnant.

METHODS

We reviewed consecutive patients with NB due to spinal dysraphism who underwent LUTR, became pregnant, and had a CD at our institution from July 2001 to June 2016. We collected data on demographics, hydronephrosis, symptomatic urinary tract infection, continence, and catheterization during pregnancy. CD data included gestational age, abdominal or uterine incisions, and complications.

RESULTS

We identified 18 pregnancies in 11 women. Fifteen live newborns were delivered via CD (53.3% term births). Thirteen of 15 patients (86.7%) developed new (10) or worsening (3) hydronephrosis. Six of 13 patients (46.2%) underwent nephrostomy tube placement. Eight of 15 patients (53.3%) developed difficulty catheterizing (66.7% via native urethra, 44.4% via catheterizable channel); 50.0% of patients required an indwelling catheter. Five of 15 patients (33.3%) developed urinary incontinence during pregnancy. Ten of 15 patients (66.7%) had a urinary tract infection (30.0% febrile). A urologist was present for all CDs: 5 were scheduled, 10 occurred emergently. Complications occurred in 40.0% (5 cystotomies, 1 bowel deserosalization, 1 vaginal laceration). All cystotomies occurred during emergent CD. Three patients (20.0%) developed urinary fistulae after emergent CD.

CONCLUSIONS

Women with NB and LUTR have high rates of complications during pregnancy and CD, despite routine involvement of urologists. Women with prolonged labor, previous CD, or those with a history of noncompliance developed the worst complications. Based on our experience, a urologist should always be present and participate in the CD.

Pregnancy After Urinary Diversion at Young Ages-Risks and Outcome

OBJECTIVE

To assess the urologic and obstetric outcomes during and after pregnancy following urinary diversion (UD) performed during childhood or adolescence.

MATERIALS AND METHODS

From our UD database, we identified 25 women who became pregnant between 1981 and 2013. Reasons for UD were neurogenic bladder, exstrophy, trauma, sinus urogenitalis, and interstitial cystitis. Seventeen had continent cutaneous diversion, 4 had continent anal diversion, and 4 had colonic conduit.

RESULTS

The average age at delivery was 27.8 (18-39) years. Thirty-seven pregnancies occurred; 1 patient decided for an induced abortion. Thirty-two healthy children were born. Five patients had a spontaneous abortion before the 12th week. Main urologic complications were urinary tract infections in 11 of 32 successful pregnancies. Twelve patients presented with dilatation of the upper urinary tract; 3 of them required a temporary nephrostomy tube. Four of 25 patients required an indwelling catheter because of difficulties of clean intermittent catheterization. One small bowel injury occurred during cesarean section. One patient with exstrophy developed uterine prolapse; 1 nipple prolapse was surgically repaired in the same anesthesia after the cesarean section. Two patients had 3 vaginal deliveries, whereas 28 had a cesarean section. All children were healthy, without malformation, and with mean Apgar scores of 7.8, 8.9, and 9.7 for the 1st, 5th, and 10th minutes of life, respectively. No persistent urologic complications were observed.

CONCLUSION

After UD, pregnancy is possible without major complications. Because of an increased risk of pyelonephritis and dilatation of the upper urinary tract requiring intervention, these pregnancies should be considered high-risk pregnancies. Delivery should be carried out in a center of expertise with urologic standby.

Control Cross-sectional Study Evaluating an Antibiotic Prevention Strategy in 30 Pregnancies Under Clean Intermittent Self-catheterization and Review of Literature

OBJECTIVE

To assess the efficacy and safety of a weekly oral cycling antibiotic (WOCA) strategy to prevent UTI in women.

MATERIALS AND METHODS

We performed a monocentric, comparative, retrospective, cross-sectional study on pregnant women under clean intermittent self catheterization between January 2008 and December 2014. WOCA consisted the administration of a single-dose antibiotic, alternating antibiotic A and B once every 2 weeks, according to previous urine cultures.

RESULTS

Twenty-five women carried out 30 pregnancies. Thirteen pregnancies (43.3%) were in the WOCA group (WCG) strategy and 17 were in the non-WOCA group (NWCG) (56.7%). In the 19 (63.3%) pregnancies with urinary tract infection (UTI), 5 (38.4%) were in WCG, 14 (82.3%) were not (P = .023). There were more cystitis in NWCG (76.5% vs 23.1% P = .009) but more colonization in WCG (46.2% vs 5.8% P = .025). UTIs were due to Escherichia coli, Enterobacter cloacae, and Klebsiella pneumoniae. There was a nonsignificant increase in preterm birth in NWCG (35.3% vs 7.7% P = .10), no small for gestational age neonates, and no significant difference for the mode of delivery, birthweight, and neonatal outcome.

CONCLUSION

According to our result, WOCA seems safe and effective on symptomatic UTI frequency and could be promoted to help physicians to manage specific risks in pregnancy.

Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience

INTRODUCTION

With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy.

OBJECTIVES

We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC.

STUDY DESIGN/RESULTS

This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects.

DISCUSSION

Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.

Successful Pregnancy and Neobladder Subsequent to Muscle Invasive Bladder Cancer and Fertility Preserving Surgery: Case Report and Review of the Literature

We report a successful pregnancy and birth subsequent to fertility-preserving cystectomy and neobladder formation in a muscle-invasive sarcomatoid urothelial carcinoma.

[Ileocystoplasty, pregnancy and delivery]

INTRODUCTION

Bladder augmentation is commonly used in neurological and other congenital anomalies of the lower urinary tract. In pregnant women, this reconstructive surgery may affect pregnancy and delivery. The obstetrical consequences of these urological procedures are scarcely reported in literature.

MATERIAL AND METHOD

Eight pregnancies in 6 pregnant women with ileocystoplasty were followed in our institution between 1998 and 2014.

RESULTS

Urinary tract infections were the most frequent undesirable record event (5 patients, 7 pregnancies). Obstetrical complications were not more frequent compared to common pregnancies. Delivery was programmed at 37WA. Cesarean section was favoured in this group although natural delivery is possible.

CONCLUSION

Urological complications were the major problem in this series. The type of delivery depends on the past surgical history and the obstetrical prognosis.

Management of pregnancy after augmentation cystoplasty

We report a case of successful pregnancy following augmentation ileocystoplasty in a patient with a neurogenic bladder dysfunction. A review of the literature reveals incidences of premature delivery and renal dysfunction. Careful urological monitoring of such patients should result in a successful pregnancy. Nevertheless, the unique clinical challenges and management options published to date are limited.

Caesarean bladder and ureteric injuries in the UK

Lower segment caesarean section (LSCS)-related lower urinary tract injuries are rare. The incidence is rising because of the increasing number of LCSCs being performed. In this review, we classify such injuries into three types and outline their management.

Pregnancy and urinary diversion

In most children or premenopausal women who need urinary diversion, the underlying disease is benign. After the problems associated with urinary incontinence have been resolved, and patients have reached puberty, sexuality and fertility become more significant. In women with urinary diversion, numerous influencing factors exist, including, but not limited to, the underlying disease and form of urinary diversion. The authors' center has a large expertise in urinary diversion, although the number of cases with pregnancies is limited. This article uses this prior experience and data from a literature review to provide guidance for urologists, obstetricians, general practitioners, and patients to aid decision making in pregnancies after urinary diversion.

Management of the neurogenic bladder in the female patient

Management of the female patient with neurogenic bladder requires special considerations that are not seen with many male neurogenic bladder patients. Because of the unique challenges that certain women present, a disproportionate number of women end up with an indwelling catheter or continuously leak urine into a diaper. Other options for bladder management include intermittent catheterization and reconstruction, which, when used appropriately, can lead to significant improvements in urinary continence, quality of life, and patient independence. This article reviews the various options available today as well as several potential therapies that may be available in the future.

Quality of life for adult women born with bladder and cloacal exstrophy: a long-term follow up

OBJECTIVE

To assess the quality of life of 23 female patients over 18 years of age treated and followed in the same institution.

METHODS

Fifty questions were sent to this group of patients covering their uro-gynaecological history, education and profession, social life and related psychological issues, sexual life and fertility. All replies were kept anonymous.

RESULTS

Seventeen patients (74%) replied. Urine incontinence at various degrees was found in 65%. Genital prolapse was reported in 29.5%. Students accounted for 41%; 59% were actively working with a satisfactory professional life in 82% of cases. Seventy-six per cent did not consider that exstrophy affected their professional life, and 76% were happy with their social life. Psychological distress was reported by 41%, and the symptoms are detailed. Sixty-four per cent were married or had a stable partner. Seventy-six per cent were active sexually, all declaring heterosexual relations. Eighty-eight per cent had periods. Four pregnancies were reported and morbidity during gestation is described. All children were born by Caesarean section and were normal. These results are discussed and compared with the literature.

CONCLUSION

Despite many hurdles, this group of patients can expect a subnormal social, family and professional life. Urinary incontinence and poor body image were the most important factors altering quality of life.