Experience with non-cycled artificial urinary sphincters

Adolescent urology: A challenge for adult urologists

The medical care of adolescents has become a growth area in many disciplines. There are two major aspects. Firstly, adolescents have specific medical and emotional needs which are not fulfilled either by paediatric or by adult specialists. Secondly, some childhood problems, particularly the congenital deformities, have no equivalent in adult life and so lifelong care is mandatory. Renal damage, especially dysplasia and scarring, leads to a substantial risk of early onset hypertension and, occasionally, to renal failure. Bladder outlet obstruction in utero, such as from a posterior urethral valve, causes irreversible changes to the wall that will act adversely on the kidneys in adolescence or early adulthood. The incidence of renal failure in early adulthood is about 36%. Bladder reconstruction with bowel has been very beneficial in preventing renal failure and improving continence. Life long follow-up is needed because of the high incidence of complications. These include stones, hyperchloraemic acidosis, perforation, anastomotic stenosis and, possibly, cancer. Patients have a normal expectation of sexuality and fertility. Their desires cannot always be achieved but they require considerable emotional and surgical support.

The urologist's role in the management of spina bifida: a continuum of care

Caring for the child with spina bifida necessitates lifelong care by a coordinated team of health care providers, and the urologist plays a vital role in this team. The most important management goal of the urologist is the early establishment and consistent maintenance of a lower pressure urinary reservoir. Ensuring social continence along with its attendant social independence provides some of the greatest management challenges. In those patients who fail medical therapy, surgeons, caregivers, and patients must understand the scope of lower urinary tract reconstruction, the need for strict compliance, and the possibility of future surgery. In this article, we review the recent advances in spina bifida management.

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.

Long-Term Continence Outcomes After Immediate Repair of Pediatric Bladder Neck Lacerations Extending Into the Urethra

PURPOSE

Traumatic bladder neck lacerations extending into the urethra are devastating injuries that occur more commonly in children than in adults. It is unclear whether immediate repair of these injuries decreases long-term complications, such as urinary incontinence. We report our long-term results with immediate operative repair of these injuries.

MATERIALS AND METHODS

Since 1986, we have primarily repaired all individuals sustaining traumatic longitudinal bladder neck lacerations extending into the urethra within 24 hours of injury. All patients were followed a minimum of 2 years.

RESULTS

A total of 12 patients 2 to 16 years old sustained longitudinal bladder neck lacerations extending into the proximal urethra. Median followup was 7 years (range 2 to 13). Postoperatively none of the 12 patients recovered complete urinary continence. Periurethral bulking agents were attempted in all 12 patients with no long-term improvement. Eight patients (75%) pursued additional surgery. Three boys underwent artificial urinary sphincter placement, of which all subsequently eroded. Three girls underwent bladder neck reconstruction with fascial sling procedures, of whom 2 became continent but experienced urinary retention, while 1 became partially continent. Five patients, including the 3 boys with artificial urinary sphincter erosion, ultimately underwent bladder neck closure and continent diversion.

CONCLUSIONS

Traumatic longitudinal bladder neck and proximal urethral lacerations are devastating injuries fraught with long-term complications and the need for additional surgery despite immediate surgical repair. Bladder neck closure and continent diversion should be considered in girls with substantial traumatic urethral loss and in boys with persistent urinary incontinence following primary repair.

14 years of experience with the artificial urinary sphincter in children and adolescents without spina bifida

PURPOSE

The efficacy of the artificial urinary sphincter to treat sphincteric incontinence in pediatric patients with spina bifida has been clearly reported. The possibility of maintaining spontaneous voiding has usually been the main reason for prosthetic device surgery. We reviewed our experience with the artificial urinary sphincter in patients without spina bifida who had had previous surgery of the bladder neck or proximal urethra.

MATERIALS AND METHODS

From 1990 to 2004, 112 children and adolescents underwent implantation of an AMS 800 artificial urinary sphincter. Of the patients 19 males and 4 females (20.5%) between ages 4 and 17 years (mean 8.1) had no spina bifida. Instead there were bladder exstrophy in 12 patients, anorectal malformation with a rectourethral or vesical fistula in 7 and epispadias in 4. A bladder neck cuff between 5.5 and 7.5 cm, and a 61-70 balloon were used in all patients.

RESULTS

Only 1 patient was lost to followup. In 22 patients (95.6%) mean followup was 80 months (range 4 to 155). Three sphincters in patients with exstrophy were removed because of erosion and/or infection 5, 49 and 60 months after initial surgery, respectively. A total of 19 sphincters remained in place (86.3% survival rate) with 5 revisions (26.3%) because of the pump (2), the cuff (2) or balloon fluid leakage. In this group 13 patients (68.4%) voided spontaneously and 6 (31.6%) performed clean intermittent catheterization, although 3 also voided spontaneously. Overall continence was good in 87% of patients because 2 were still incontinent at night.

CONCLUSIONS

The artificial urinary sphincter is a good long-term solution to urinary incontinence secondary to sphincter incompetence despite multiple previous surgeries of the bladder neck or proximal urethra. Patients with bladder exstrophy and many previous bladder procedures are more exposed to complications such as erosion compared with patients with epispadias or anorectal malformation. The high percent of patients maintaining spontaneous voiding and the good rate of continence are the most important benefits of this type of surgical option for sphincter incompetence.