The past, present and future of augmentation cystoplasty

Long-term Survival of Bladder Augmentation is Influenced by its Shape and Mucosal Lining

INTRODUCTION

Bladder augmentation in the UK has been largely by enterocystoplasty or ureterocystoplasty (UC). Ileocystoplasty can be simple patch placement (SPP), or formation of an ileal cup (IC). Urothelium is the "right" mucosa, whereas intestinal mucosa exhibits absorption, mucus production, malignancy. On videourodynamics it can be shown that SPP fills with a poor conformation (irregular shape), while IC was good, and UC adequate. Our aim was to measure the long-term outcomes of augmentation, comparing UC ("right" mucosa and adequate conformation), to SPP ("wrong" mucosa and poor conformation) to IC ("wrong mucosa" and good conformation).

METHODS

Single-centre retrospective review. Patients were identified from operative logs for the period 2005 to 2022. Registered as an audit (CARMS 31503). Data collected included: demographics, dates: operation, redo-surgery, imaging, stones (renal/bladder) and any intervention. Data were given as numbers (%), median (range) analysed by Fisher exact test where P < 0.05 was taken as significant.

RESULTS

There were 168 bladder augmentations: UC (n = 24), SPP (n = 72), and IC (n = 72). Follow-up was no different for IC 4.23 (0.05-11.50) vs SPP 4.43 (0.15-13) yrs, but was longer for UC at 6.2 (4.1-8.9) yrs. Age at augmentation was 6.7 (2.5-17.1) vs 8.1 (2-17) vs 11.6 (5.9-17) yrs respectively (UC vs IC vs SPP, P = 0.0001). Revision surgery was required in 3/24 (12.5 %) UC, 6/72 (8.3 %) SPP, and 0/72 (0 %) IC. IC had fewer redos than SPP, P = 0.028. Long-term survival was significantly better for IC (100 % at 10 years, vs UC 85 % at 10 years and SPP 96 % at 5 yrs and 75 % at 10 yrs, log-rank P < 0.05). Imaging follow-up was available in SPP (n = 56) IC (n = 62), UC (n = 24) with renal stones identified in 7/56 (%) SPP, 2/62 (%) IC, and 0 in UC. Bladder stones were present in SPP 5/56 (8.9 %) vs IC 2/62 (3.2 %), NS. Stone-free survival was 100 % at 10yrs in UC, 95 % in IC, and 62 % in SPP, P = 0.028. Combining bladder failure leading to reaugmentation and bladder stones requiring surgery, allows comparison between SPP and IC: In SPP bladder stones and augment failure occurred in 15.3 %, vs 2.8 % in IC. There is a 6.3-fold increase in bladder stones and augment redo with SPP [irregular filling bladder (poor conformation) and the "wrong" mucosa] vs IC (good confirmation, but "wrong" mucosa).

CONCLUSION

Augmentation survival is influenced by conformation and presence of the "right" mucosa. UC is only possible in 14 % of cases, and an IC is preferable to SPP when an enterocystoplasty is needed.

Long-term outcomes of "clam" bladder augmentation in a pediatric population with neurogenic refractory bladder dysfunction: A 20-year follow-up experience at single center

PURPOSE

Bladder augmentation (BA) is the gold standard treatment to increase compliance and treat neurological detrusor overactivity (DO) in children with neurological bladder refractory to medical treatment. In pediatrics, bivalve cystoplasty (Clam) is preferred to supratrigonal cystectomy. Our initial aim was to evaluate the re-intervention rate and long-term outcomes of BA in relation to Clam in children. The secondary aim was the evaluation of refractory DO during follow-up after Clam cystoplasty.

METHODS

A retrospective analysis was performed including all patients<18years of age operated for BA with Clam for neurological bladder (01/2004 to 01/2023). Pre- and postoperative urodynamics were performed.

RESULTS

Twenty-six patients (14 girls and 12 boys) underwent surgery for BA. The median age was 8years (IQR: 5-12). The causes of Neurogenic Low Urinary Tract Dysfunction were spina bifida in 8 patients, Hinman syndrome in 8 patients and sacral agenesis in 8 patients. The ileum was used in 100% of cases and 8 children had continent catheterizable channels inserted (29.6%). The overall re-intervention rate was 41% (11/27) for median follow-up of 7years (IQR: 4-12). The rates of early and late complications>Clavien 2 were 11% and 22% respectively. BA resulted in significant postoperative improvements (at 1, 5, 10 and 15years) in compliance (P=0.0332), detrusor overactivity (DO) (P=0.032) and bladder capacity [167mL preoperatively and 425mL at 15years (P<0.0001)]. No refractory DO was identified, and no second augmentation procedure was required during the follow-up period. Two children had a Bricker (7%) due to cognitive impairment preventing self-catheterizing.

CONCLUSION

BA with clam cystoplasty seems a safe and effective treatment for children with neurological bladder. The re-intervention rate is comparable to current literature, and long-term urodynamic parameters demonstrate sustained improvements. The absence of refractory DO and additional augmentation procedures highlight the favorable long-term outcomes of this surgical approach.

LEVEL OF EVIDENCE: 4

Metabolic consequences and tubular function after augmentation cystoplasty in children with neurogenic bladder

BACKGROUND

While many studies have reported the renal outcomes and metabolic consequences of augmentation cystoplasty (AC), few have focused on changes in renal tubular function. This study investigated the prevalence of metabolic disturbances, renal tubular function, and 24-hour urine chemistry, aiming to evaluate the association between metabolic alterations and urolithiasis after AC.

METHODS

We investigated serum biochemistry, blood gas, and 24-hour urinary metabolic profile of children who underwent AC between January 2000 and December 2020. The assessed outcomes included metabolic complications, tubular function, and magnesium status. Associations between 24-hour urinary metabolic parameters and urolithiasis formation were also examined.

RESULTS

A total of 25 patients with a mean follow-up period of 13.8 ± 5.7 years were enrolled. The mean age at AC was 7.5 ± 4.4 years, and 22 and 3 patients underwent AC using the ileum and colon, respectively. There were no abnormalities in serum levels of sodium, potassium, chloride, and calcium. Hypomagnesemia (magnesium <1.7 mg/dL) due to renal loss was observed in one patient (4.0%). Six (24.0%) patients had increased urinary β2-microglobulin levels and normal serum levels. The ratio of the maximum rate of tubular phosphate reabsorption to the glomerular filtration rate was low in three (12.0%) patients. Four (16.0%) patients had normal serum magnesium levels but urinary magnesium excretion <40 mg/d. Urolithiasis occurred in 11 patients (44.0%). The most common 24-hour urine metabolic abnormality was hypomagnesiuria (72.0%). No urinary metabolic parameters or daily protein intake were associated with urolithiasis.

CONCLUSION

AC for children is safe and does not significantly impact the metabolic profile. Excretions of 24-hour urinary calcium, uric acid, magnesium, and the sodium-to-potassium ratio were not associated with urolithiasis. However, a high prevalence of 24-hour urine magnesium excretion <88 mg/1.73 m 2 was noted. Further prospective studies are needed to investigate longitudinal changes in renal tubular function and 24-hour urine metabolic profiles, particularly magnesium status.

A Rocky Road: Bladder Stones in the Augmented Exstrophy-Epispadias Complex Patient

OBJECTIVE

To determine the rate of stone formation amongst patients of the exstrophy-epispadias complex with augmentation cystoplasty. We hypothesize that bowel segment choice influences the rate of stone formation after bladder augmentation and the rate of complications from bladder stone surgery.

METHODS

An IRB-approved institutional database of 1512 exstrophy-epispadias patients was reviewed retrospectively. Patients that had a history of bladder augmentation and were seen at our institution between 2003 and 2023 were included.

RESULTS

Out of 259 patients, bladder stones developed in 21.6% (56), of which the bowel segment used was colon in 147 patients and ileum in 100. Stones formed in 19% of colon augments compared to 29% ileal augments, however, this was not statistically significant (P = .07). The most common primary stone component was dahllite, followed by struvite for all augments (Table 1). The median time to stone treatment after augmentation was 4.14 years (0.75-31). Seventy-four percentage of patients had a recurrence that required a second surgery. The median time from first to second surgery and second to third surgery was 1.4 years and 2.22 years, respectively. Bladder stone surgery complications occurred in 14% of patients, vesicocutaneous fistula being the most common, and complications did not differ by augment type. Median follow-up after first stone intervention was 6.07 years (0-19.5).

CONCLUSION

The treatment of bladder stones in the exstrophy-epispadias complex remains challenging. Interventions to prevent recurrence are crucial as the majority of patients will require 2 or more stone surgeries in their lifetime.

Minimally invasive versus open ileal ureter with ileocystoplasty: comparative outcomes and 5-year experience

PURPOSE

To present the experience of ileal ureter with ileocystoplasty (IUC), and compare the outcomes of IUC in minimally invasive procedures to open procedures.

PATIENTS AND METHODS

From December 2017 to April 2023, twenty patients underwent IUC in open or minimally invasive (including laparoscopic and robotic) procedures. The baseline characteristics, perioperative data and follow-up outcomes were collected. Success was defined as relief of clinical symptoms, stable postoperative serum creatine and absence of radiographic obstruction. The perioperative and follow-up outcomes of open procedures and minimally invasive procedures were compared.

RESULTS

The etiology included pelvic irradiation (14/20), urinary tuberculosis (3/20) and surgical injury (3/20). Bilateral ureter strictures were repaired in 15 cases. The surgeries conducted consisted of open procedures in 9 patients and minimally invasive procedures in 11 patients. Compared to open procedures, minimally invasive surgeries had less median estimated blood loss (EBL) (100 ml vs. 300 min, p = 0.010) and shorter postoperative hospitalization (27 d vs. 13 d, p = 0.004). Two patients in the open group experienced grade 3 complications (sigmoid fistula and acute cholecystitis in one patient, and pulmonary embolism in another patient). Over a median follow-up period of 20.1 months, the median bladder functional capacity was 300 ml, with a 100% success rate of IUC.

CONCLUSION

IUC is feasible in both open and minimally invasive procedures, with acceptable complications and a high success rate. Minimally invasive procedures can have less EBL and shorter postoperative hospitalization than open procedure. However, prospective studies with larger groups and longer follow-up are needed.

OnabotulinumtoxinA is now an important tool for managing pediatric neurogenic lower urinary tract dysfunction

Initial urologic management of pediatric neurogenic lower urinary tract dysfunction (NLUTD) includes clean intermittent catheterization (CIC) regimen and use of anticholinergic or beta3 agonist medications. Historically, NLUTD that did not respond to these initial management strategies received open surgical procedures such as augmentation cystoplasty (AC) to increase bladder capacity and create a lower-pressure reservoir. Since its first reported use in 2002, intradetrusor onabotulinumtoxinA (BTX-A) injections has developed an emerging role in management of pediatric NLUTD, culminating in its recent FDA-approval in 2021. In this review, the current evidence regarding the safety, tolerability, and efficacy of BTX-A use in pediatric NLUTD will be summarized. Additionally, we will attempt to define the current role of BTX-A in the management of patients with NLUTD, discuss limitations to the current body of literature, and suggest future avenues of study.

Intradetrusor botox injection and augmentation cystoplasty trends among spina bifida patients at US freestanding children's hospitals

INTRODUCTION

Intra-detrusor botulinum toxin (Botox) injection is a minimally invasive alternative to augmentation cystoplasty in patients with refractory neurogenic bladder. Botox was first used for neurogenic bladder children two decades ago. However, there are no existing guidelines on indications or use among patients with spina bifida. Furthermore, there are little data regarding its use relative to bladder augmentation and patient volume on a national scale.

OBJECTIVE

We sought to investigate the contemporary trends of intra-detrusor Botox injection and augment cystoplasty in free-standing children's hospitals.

STUDY DESIGN

We queried the Pediatric Health Information System database to identify spina bifida patients from 2016 to 2019 who underwent intra-detrusor Botox injection and augment cystoplasty based on CPT and ICD-10 codes. Total spina bifida population under care in the free-standing children's hospitals was estimated by all inpatient and ambulatory surgery encounters as denominators to calculate frequency by time for both intra-detrusor Botox injections and augmentation cystoplasty.

RESULTS

In total, we included 1924 intra-detrusor Botox injections and 842 augmentation cystoplasties. 1413 (51.1%) patients were female. Median age at surgery was 10.0 (interquartile range 6.98-13.5) years. There was a significant increase in intra-detrusor Botox injection frequency (p < 0.001). While there was an overall decreasing, but not significant, trend for augmentation cystoplasty, there was a significant increase in this procedure during the summer months compared to the rest of the year (p < 0.001, Figure 1). Sensitivity analysis using only first intra-detrusor Botox injection per patient demonstrated similarly significant increasing trend.

DISCUSSION

Use of intra-detrusor Botox injection for the management of neurogenic bladder has significantly increased among patients with spina bifida while augmentation cystoplasty has slightly decreased, but not significantly.

CONCLUSIONS

Over time, practice patterns for the treatments of neurogenic bladder among spina bifida children have favored minimally invasive Botox injections while augmentation cystoplasty use has not significantly changed.

Long-term urodynamic findings following colo-, gastro- and ileocystoplasty

PURPOSE

To evaluate the urodynamic changes in patients who have undergone colocystoplasty (CCP), gastrocystoplasty (GCP) and ileocystoplasty (ICP) in a retrospective study. Changes in urinary continence, incidence of pathologic contractions before and after augmentation, alterations of urodynamic parameters were also examined.

METHODS

Eighty-four patients were included in the study who underwent bladder augmentation between 1987 and 2017. Group I: 35 patients with CCP. Group II: 18 patients with GCP. Group III: 31 patients with ICP. Cystometry was performed at 3, 6, and every 12 months, then biannually after augmentation. Pre- and postoperative urodynamic changes were analysed statistically.

RESULTS

In Group I, two patients and in Group III, one patient remained incontinent after CCP and ICP. Bladder capacity increased significantly, maximal intra-vesical pressure decreased and compliance improved in all groups (p < 0.001). Postoperative studies showed pathologic contractions in the augmented bladder in half of the patients with GCP, in 43% of patients after CCP and 26% of patients with ICP.

CONCLUSION

From the urodynamic point of view, ileum is the most adequate option in the long term. Contractions after augmentation might be caused by the remaining peristalsis of the detubularised segment. Further investigations are needed to evaluate pathologic contractions that remained after detubularisation.

A catheterizable serous-lined urinary outlet associated with the ileal bladder augmentation Abol-Enein and Ghoneim procedure: a safe and reliable procedure in children

Purpose

This study aims to evaluate the long-term outcome of the serous-lined extramural continent catheterizable outlet procedure (SLECCOP) associated with ileal bladder augmentation in children.

Methods

This was a monocentric and retrospective study (2002-2021) that included children (<18 years) undergoing the SLECCOP associated with W-shaped ileocystoplasty with a catheterizable channel (Abol-Enein and Ghoneim procedure). Patients who received other types of bladder augmentation or W-shaped ileocystoplasty without a catheterizable channel were excluded. Patient records were reviewed for demographic information, surgical data, and long-term outcomes.

Results

This study included 52 children [33 boys, median age: 8.5 (0.8-18) years]. Pathological conditions included 28 children with the bladder exstrophy and epispadias complex (BEEC), 11 with neurogenic bladders, and 13 with other pathologies. Two patients underwent total bladder substitution. Thirty-four (65%) patients had bladder neck reconstruction (BNR), with 23 undergoing the SLECCOP and ileocystoplasty and 11 having prior BNR. All stomas, except for two, were umbilical, and were associated with omphaloplasty in 28 patients with the BEEC. A total of 40 stomas were created using the appendix (77%) and 12 with a Monti tube (23%). Stoma-related complications included cutaneous strictures (n = 2, 4%) and leaks (n = 10, 19%), all treated by dextranomer/hyaluronic acid copolymer injection (n = 10). A redo surgery was required in three patients: extraserosal wrapping was performed for persistent leakage (n = 2, 4%), and surgical revision was required for the Monti tube procedure (n = 1, 2%). Three patients (6%) underwent dilatation for transient stoma stenosis. Leakage occurred in 20% of appendix channels (n = 8/40) and 17% of Monti tubes (n = 2/12). Strictures were reported in 3% of appendix channels (n = 1/40) and 8% of Monti tubes (n = 1/12). Bladder stones developed in four patients (8%). Channel leakage persisted in one patient (2%) at a median follow-up of 4.4 years (IQR 1.4-9.7).

Conclusion

W-Ileal bladder augmentation with the SLECCOP is an efficient technique for treating children with incontinence caused by different etiologies. The rate of channel complication is very low, specifically for strictures, in this complex population of patients.

Long-term complications and outcomes of augmentation cystoplasty in children with neurogenic bladder

Augmentation cystoplasty (AC) is an effective surgical procedure for patients with neurogenic bladder whenever conservative treatments have failed. The present study aimed to determine the risks of metabolic complications, malignancy, long-term outcomes and histopathologic changes of native bladder and the augmented intestine after AC in children with neurogenic bladder. Pediatric patients < 18 years who underwent AC between 2000 and 2020 were enrolled. Early postoperative complications, long-term outcomes and histopathologic changes in mucosal biopsies of native bladder and the augmented intestine after AC were reviewed. Twenty-two patients with a mean age of 7.6 ± 4.4 years were included. The ileum was used in 19 patients and the sigmoid colon in 3 patients. The length of hospital stay was 14.8 ± 6.8 days. Post-operatively, the urinary continence rate improved from 22.7 to 81.8% (p < 0.001). Hydronephrosis resolved in 17 of 19 patients. Vesicoureteral reflux resolved in 16 (64.0%) of the refluxing ureter units and was downgraded in 7 (28.0%). Grades of hydronephrosis and reflux significantly improved following AC (p < 0.001). The estimated glomerular filtration rate also significantly increased (p = 0.012). Formation of urinary tract stones was the most frequent late complication (in 8 patients, 36.4%). Life-threatening spontaneous bladder perforation occurred in 1 patient. After a mean follow-up of 13.4 ± 5.9 years, there were no cases of mortality, new-onset symptomatic metabolic acidosis, or changes in serum electrolytes. Of the 17 patients who were followed for > 10 years, no cases of malignancy or metaplastic changes were identified in the native bladder or augmented bowel epithelium. AC is a safe and effective procedure with low surgical and metabolic complication rates. In addition, AC provides a satisfactory continence rate and long-term protection of renal function, increases functional capacity, and regresses reflux and hydronephrosis. Individualized surveillance is recommended for the early identification of urolithiasis and metabolic disturbances.

Long-term results of clam enterocystoplasty in non-neurogenic refractory urge incontinence

OBJECTIVES

This study aims to assess the efficacy of Clam enterocystoplasty (CECP) surgery for the treatment of non-neurogenic refractory urgency urinary incontinence (UUI).

METHODS

We conducted a retrospective evaluation of 17 female patients who underwent CECP for non-neurogenic refractory UUI between May 2010 and November 2022.

RESULTS

The median of ICIQ-SF was 19 (15-21) before treatment, which decreased to a median of 0 (0-5) after treatment (p = 0.01). The average preoperative pad use among the participants was 4 (3-6), while it became 0 postoperatively (p < 0.01). The median preoperative cystometric bladder capacity was 251 ml (100-350 ml), increasing to 456 ml (400-650 ml) postoperatively (p < 0.01). According to the Clavien-Dindo classification system, the majority of patients experienced either no complications (66%) or minor complications (CD I/CD II) (33%) within the initial 90 days following surgery.

CONCLUSIONS

"Clam" iliocystoplasty emerges as a secure and successful treatment option in the patient group whose symptoms persist after first, second, and third-line treatments with the diagnosis of urge incontinence.

Autologous Endothelial Progenitor Cells and Bioactive Factors Improve Bladder Regeneration

Insufficient vascularization is still a challenge that impedes bladder tissue engineering and results in unsatisfied smooth muscle regeneration. Since bladder regeneration is a complex articulated process, the aim of this study is to investigate whether combining multiple pathways by exploiting a combination of biomaterials, cells, and bioactive factors, contributes to the improvements of smooth muscle regeneration and vascularization in tissue-engineered bladder. Autologous endothelial progenitor cells (EPCs) and bladder smooth muscle cells (BSMCs) are cultured and incorporated into our previously prepared porcine bladder acellular matrix (BAM) for bladder augmentation in rabbits. Simultaneously, exogenous vascular endothelial growth factor (VEGF) and platelet-derived growth factor BB (PDGF-BB) mixed with Matrigel were injected around the implanted cells-BAM complex. In the results, compared with control rabbits received bladder augmentation with porcine BAM seeded with BSMCs, the experimental animals showed significantly improved smooth muscle regeneration and vascularization, along with more excellent functional recovery of tissue-engineered bladder, due to the additional combination of autologous EPCs and bioactive factors, including VEGF and PDGF-BB. Furthermore, cell tracking suggested that the seeded EPCs could be directly involved in neovascularization. Therefore, it may be an effective method to combine multiple pathways for tissue-engineering urinary bladder.

Negatively charged bladder acellular matrix loaded with positively charged adipose-derived mesenchymal stem cell-derived small extracellular vesicles for bladder tissue engineering

Adipose-derived mesenchymal stem cell-derived small extracellular vesicles (Ad-MSC-sEVs/AMEs) combined with scaffold materials are used in tissue-engineered bladders; however, the lack of retention leads to limited distribution of AMEs in the scaffold areas and low bioavailability of AMEs after bladder reconstruction. To improve retention of AMEs, we developed a novel strategy that modifies the surface charge of the bladder acellular matrix (BAM) via oxidative self-polymerization of dopamine-reducing graphene oxide (GO) and AMEs using ε-polylysine-polyethylene-distearyl phosphatidylethanolamine (PPD). We evaluated two BAM surface modification methods and evaluated the biocompatibility of materials and PPD and electrostatic adherence effects between PPD-modified AMEs and rGO-PDA/BAM in vivo and in vitro. Surface modification increased retention of AMEs, enhanced regeneration of bladder structures, and increased electrical conductivity of rGO-PDA/BAM, thereby improving bladder function recovery. RNA-sequencing revealed 543 miRNAs in human AMEs and 514 miRNAs in rat AMEs. A Venn diagram was used to show target genes of miRNA with the highest proportion predicted by the four databases; related biological processes and pathways were predicted by KEGG and GO analyses. We report a strategy for improving bioavailability of AMEs for bladder reconstruction and reveal that enriched miR-21-5p targets PIK3R1 and activates the PI3K/Akt pathway to promote cell proliferation and migration.

Congenital Anomalies of the Kidney and Urinary Tract: A Continuum of Care

Congenital anomalies of the kidney and urinary tract (CAKUT) are the leading cause of kidney failure in children and adolescents. CAKUT describes a wide spectrum of structural disorders with a prenatal origin. The etiology of CAKUT is multifactorial, including environmental, nongenetic, and genetic causes that impact kidney development as well as upper and lower urinary tract development. Adult nephrologists who treat patients with CAKUT may be challenged by the underlying diseases they are not familiar with and the accumulation of chronic kidney disease complications in childhood. This article discusses CAKUT etiology and presentation, the course during childhood and adolescence, as well as adult issues in CAKUT patients including CKD complications, urologic interventions, and genetic counseling. A smooth transition of CAKUT patients from pediatric to adult care can be challenging. Semin Nephrol 43:x-xx © 2023 Elsevier Inc. All rights reserved.

Cost analysis for mirabegron use in the treatment of children with neurogenic bladder

INTRODUCTION

Mirabegron is a beta-3 adrenergic receptor agonist that received FDA approval in 2021 to treat neurogenic detrusor overactivity (NDO) in children ages three years and older. Despite its safety and efficacy, access to mirabegron frequently remains restricted by payor coverage policies.

OBJECTIVE

This cost minimization study sought to determine the cost implications from a payor perspective of mirabegron use at different points in the treatment pathway for pediatric NDO.

STUDY DESIGN

A Markov decision analytic model was constructed to assess the costs for eight treatment strategies over a 10-year period, using six-month cycles (Table). Five strategies involve mirabegron use as first-, second-, third-, or fourth-line therapy. Two strategies, including the "base case," entail use of anticholinergic medications followed by onabotulinum toxin type A (Botox) injection and augmentation cystoplasty. A strategy involving first-line Botox was also modeled. The effectiveness, adverse event rates, attrition rates, and costs associated with each treatment option were obtained from the clinical literature and adjusted to a six-month cycle. Costs were adjusted to 2021-dollar value. A discount rate of 3% was used. To quantify uncertainty, costs and treatment transition probabilities were modeled as gamma and PERT distributions, respectively. One-way sensitivity analyses were performed. Probabilistic sensitivity analysis (PSA) was conducted using a Monte Carlo simulation with 100,000 iterations. Analyses were performed using Treeage Pro (Healthcare Version).

RESULTS

The least costly strategy involved first-line mirabegron (expected cost $37,954). All strategies involving mirabegron were less costly than the base case ($56,417). On PSA, first-line mirabegron was the least costly strategy in 88.9% of cases (mean $37,604, 95% CI: $37,579-37,628); in 100% of cases, the least costly strategy involved mirabegron use. Cost savings associated with mirabegron use were attributable to decreased use of augmentation cystoplasty and Botox injections.

DISCUSSION

This is the first study to compare costs across multiple strategies involving mirabegron to treat pediatric NDO. Mirabegron use likely yields cost savings for the payor: the least costly strategy involved first-line mirabegron, and all pathways incorporating mirabegron were less costly than those without mirabegron use. These findings provide an updated cost analysis for the treatment of NDO by investigating mirabegron use alongside more established treatment options.

CONCLUSION

Use of mirabegron for the treatment of pediatric NDO is likely associated with cost savings as compared to treatment pathways without mirabegron. Expansion of payor coverage for mirabegron, as well as clinical studies to study first-line mirabegron use, should be considered.

[Bladder augmentation in the era of botulinum toxin: Indications and results]

AIM

To determine the surgical indication and results of bladder augmentation (BA) during the last decade in a neurourology center in the era of intradetrusor botulinum toxin injection.

MATERIAL

We conducted a retrospective study that included patients with BA between January 1, 2012 and December 31, 2022 in our centre. We collected pre-operative demographic, clinical, and urodynamic data, BA indication, and associated procedures. We analyzed early and late complications as well as continence and postoperative voiding mode in patients with first BA in a neurological pathology context.

RESULTS

We performed 77 BA over the study period. The main indication was neurogenic overactive bladder, which was secondarily resistant to botulinum toxin. The main associated procedure was continent cutaneous diversion (n=31, 57.4%). Among patients who had a first BA for neurogenic bladder, 34 patients had early complications (50%) including 12 patients with≥Clavien 3 complications (17.6%). After a median follow-up of 33 [14; 55] months, 23 patients had late complications (33.8%) and 59 patients had complete continence (86.8%).

CONCLUSION

In the era of botulinum toxin, the main indication of BA is the secondary failure of botulinum toxin for overactive neurogenic bladder. The BA provided continence in 86.8% of patients. It remains however an intervention with a significant rate of severe complications whose indication must be discussed by a multidisciplinary team.

LEVEL OF EVIDENCE

Weak.

An evaluation of onobotulinumtoxinA as a therapeutic option for pediatric neurogenic detrusor overactivity

INTRODUCTION

Neurogenic detrusor overactivity (NDO) results in involuntary detrusor contractions during bladder filling or storage risking transmission of pressure to the upper urinary tracts and/or significant incontinence. The goals of bladder management in children with NDO prioritize the preservation of renal function, prevention of UTIs, and optimizing quality of life. First-line measures include intermittent catheterization and anticholinergic medication. However, when conservative measures fail, surgical intervention may be indicated. Historically, the next step was major reconstructive surgery to create a low-pressure urinary reservoir. The introduction of intravesical botulinum neurotoxin A (BoNT/A) for use in children in 2002 offered a less invasive option for management. However, its exact role is still evolving.

AREAS COVERED

This article summarizes the mechanism of action of BoNT/A for management of NDO and evaluates the current literature defining common practice and clinical efficacy in children with NDO. The findings of the recently completed phase III trial for intravesical onabotulinumtoxinA in children are discussed in detail.

EXPERT OPINION

As the first BoNT/A approved for use in children with NDO, onabotulinumtoxinA appears to be a safe and less invasive alternative to major reconstructive surgery. However, data defining appropriate patient selection and its role as a long-term treatment option continue to develop.

Augmentation Uretero-enterocystoplasty Is an Effective Procedure in Protecting the Upper Urinary Tract Without Accelerating Deterioration of Renal Function

Background

Augmentation uretero-enterocystoplasty (AUEC) provides a low-pressure urinary storage capsule that can preserve renal function in patients with lower urinary tract dysfunction for whom conservative treatments have failed.

Objective

To summarize the effectiveness and safety of augmentation uretero-enterocystoplasty (AUEC) and evaluate whether it aggravates renal function deterioration in patients with renal insufficiency.

Design setting and participants

This was a retrospective cohort study of patients who underwent AUEC from 2006 to 2021. Patients were grouped according to whether they had normal renal function (NRF) or renal dysfunction (serum creatinine >1.5 mg/dl).

Outcome measurements and statistical analysis

Follow-up of upper and lower urinary tract function was assessed via review of clinical records, urodynamic data, and laboratory results.

Results and limitations

We included 156 patients in the NRF group and 68 in the renal dysfunction group. We confirmed that urodynamic parameters and upper urinary tract dilation were significantly improved for patients after AUEC. Serum creatinine declined during the first 10 mo in both groups and remained stable thereafter. The reduction in serum creatine was significantly greater in the renal dysfunction group than in the NRF group in the first 10 mo (difference in reduction 4.19 units; p < 0.05). A multivariable regression model showed that baseline renal dysfunction was not a significant risk factor for deterioration of renal function in patients who had undergone AUEC (odds ratio 2.15; p = 0.11). The main limitations are selection bias because of the retrospective design, loss to follow-up, and missing data.

Conclusions

AUEC is a safe and effective procedure to protect the upper urinary tract and will not hasten deterioration of renal function in patients with lower urinary tract dysfunction. In addition, AUEC improved and stabilized residual renal function in patients with renal insufficiency, which is important in preparation for renal transplantation.

Patient summary

Bladder dysfunction is usually treated with medication or Botox injections. If these treatments fail, surgery to increase the bladder size using a portion of the patient's intestine is a possible option. Our study shows that this procedure was safe and feasible and improved bladder function. It did not lead to a further decrease in function in patients who already had impaired kidney function.

[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]

INTRODUCTION

Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population.

MATERIALS AND METHODS

National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached.

RESULTS

Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible).

CONCLUSION

Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury

This study aimed to present a comprehensive literature review of the efforts of a spinal cord injury workgroup in Taiwan regarding urologic surgery for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI). Surgical procedures should be viewed as a final option for managing patients with SCI who have persistent symptoms and complications that cannot be resolved by other means. Surgeries can be grouped according to their purpose: reducing bladder pressures, reducing urethra resistance, increasing urethra resistance, and urinary diversion. The choice of surgery depends on the type of LUTD based on urodynamic tests. Additionally, cognitive function, hand motility, comorbidities, efficacy of surgery, and related complications should be considered.

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach

BACKGROUND

Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed.

OBJECTIVE

The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique.

METHODS

A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed.

RESULTS

A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P = 0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P = 0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P = 0.294, log-rank P = 0.832, and log-rank P = 0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P = 0.236).

DISCUSSION

This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal.

CONCLUSIONS

Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

Long-term outcomes of augmentation cystoplasty: A retrospective view of 54 children

INTRODUCTION AND OBJECTIVES

Throughout the years, clinicians dealing with pediatric urology disorders have resorted to bladder augmentation (BA), a demanding surgical procedure, to preserve renal functions in sundry congenital urinary tract defects. This study aimed to reveal the very long-term outcomes of BA in a large sample of pediatric patients and the role of underlying disease on renal prognosis after BA.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted on 54 children with congenital urinary defects who underwent BA. The utilized augmentation technique, the location of ureter implantation, complications, and ultrasonography findings were analyzed. Data on serum creatinine levels were collected from preoperative records and anniversaries following BA.

RESULTS

Among 54 children, 33 (61.1%) were boys. Diagnoses were spinal dysraphism (SD) (n = 13), posterior urethral valve (PUV) (n = 8), bladder exstrophy (n = 32) and trauma (n = 1). The median follow-up duration was 18 (3-31) years. The comparisons of serum creatinine levels between groups revealed that, despite no meaningful difference was present between bladder exstrophy and PUV group in the preoperative period and postoperative 1st year, cases with PUV had significantly higher levels of serum creatinine levels in the following postoperative years. Therewithal compared with the SD group, subjects with PUV had significantly higher levels at the postoperative 2nd year (P = .035) and 10th year (P = .006).

CONCLUSIONS

In our study, significantly long-term follow-up outcomes could facilitate the pre- and postoperative approach for enterocystoplasty in children. According to our results, it is noteworthy that kidney functions are at high risk of worsening in subjects with PUV and underwent BA.

National Trends and Outcomes in the Use of Intravesical Botulinum Toxin and Enterocystoplasty Among Patients With Myelomeningocele

OBJECTIVE

To compare trends in the treatment of patients with myelomeningocele receiving intravesical Botulinum (IVB) toxin and enterocystoplasty.

METHODS

We identified patients with myelomeningocele in a commercial insurance database from 2008-2017 and stratified them into adult and pediatric samples. Index procedure was identified as either IVB toxin injection or enterocystoplasty. The annual rate of treatments was measured and a change in treatment rate was identified. Time to enterocysplasty was calculated using survival analysis and factors associated with clinical outcomes up to 10 years after index procedure were determined using multivariate Poisson regression.

RESULTS

We identified 60,983 patients with myelomeningocele. Nearly twice as many pediatric patients had an enterocystoplasty (n = 317) compared to IVB (n = 138). Very few adult patients underwent enterocystoplasty (n = 25) compared to IVB (n = 116). We identified a significant increase in the annual rate of IVB use around mid-2010 among pediatric patients and around mid-2009 among adults. Twelve pediatric patients (8.6%) and 5 adults (4.3%) went on to receive an enterocystoplasty. Patients who received IVB as the index procedure experienced significantly lower rates of hospitalization days (RR 0.64; 95% CI 0.53-0.78), emergency department visits (RR 0.72; 95% CI 0.63-0.82), and an increased rate of urologic procedures (RR 1.44; 95% CI 1.28-1.62).

CONCLUSION

The annual rate of IVB use has increased among patients with myelomeningocele. Nearly 1 in 10 pediatric patients and 1 in 20 adults go on to receive enterocystoplasty. Patients who receive IVB experience lower rates of hospitalization and emergency department visits compared to patients who receive enterocystoplasty.

The causes and consequences of paediatric kidney disease on adult nephrology care

Adult nephrologists often look after patients who have been diagnosed with kidney disease in childhood. This does present unique challenges to the adult nephrologist, who may be unfamiliar with the underlying cause of kidney disease as well as the complications of chronic kidney disease (CKD) that may have accumulated during childhood. This review discusses common causes of childhood CKD, in particular congenital anomalies of the kidney and urinary tract (CAKUT), autosomal dominant tubulointerstitial kidney disease (ADTKD), polycystic kidney disease, hereditary stone disease, nephrotic syndrome and atypical haemolytic uraemic syndrome. The long-term consequences of childhood CKD, such as the cardiovascular consequences, cognition and education as well as bone health, nutrition and growth are also discussed.

Biodegradable polyurethane scaffolds in regenerative medicine: Clinical translation review

Early explorations of tissue engineering and regenerative medicine concepts commonly utilized simple polyesters such as polyglycolide, polylactide, and their copolymers as scaffolds. These biomaterials were deemed clinically acceptable, readily accessible, and provided processability and a generally known biological response. With experience and refinement of approaches, greater control of material properties and integrated bioactivity has received emphasis and a broadened palette of synthetic biomaterials has been employed. Biodegradable polyurethanes (PUs) have emerged as an attractive option for synthetic scaffolds in a variety of tissue applications because of their flexibility in molecular design and ability to fulfill mechanical property objectives, particularly in soft tissue applications. Biodegradable PUs are highly customizable based on their composition and processability to impart tailored mechanical and degradation behavior. Additionally, bioactive agents can be readily incorporated into these scaffolds to drive a desired biological response. Enthusiasm for biodegradable PU scaffolds has soared in recent years, leading to rapid growth in the literature documenting novel PU chemistries, scaffold designs, mechanical properties, and aspects of biocompatibility. Despite the enthusiasm in the field, there are still few examples of biodegradable PU scaffolds that have achieved regulatory approval and routine clinical use. However, there is a growing literature where biodegradable PU scaffolds are being specifically developed for a wide range of pathologies and where relevant pre-clinical models are being employed. The purpose of this review is first to highlight examples of clinically used biodegradable PU scaffolds, and then to summarize the growing body of reports on pre-clinical applications of biodegradable PU scaffolds.

Ureteral reimplantation during augmentation cystoplasty is not needed for vesicoureteral reflux in patients with neurogenic bladder: a long-term retrospective study

BACKGROUND

To investigate the need for ureteral reimplantation for vesicoureteral reflux (VUR) during augmentation cystoplasty (AC) in the long term.

METHODS

A total of 19 patients with a median age at surgery of 14 years (3-38 years) who underwent AC for neurogenic bladder with VUR between 1983 and 2016 were included in this study. The changes in VUR grade and urodynamic findings were retrospectively evaluated. We evaluated the renal function by periodic inspection of serum creatinine level and estimated glomerular filtration rate; eGFR.

RESULTS

The median follow-up period from AC was 14.8 years (5.7-30 years). VUR was detected in 19 patients, involving 27 ureters. Reflux grade was V in 6, IV in 9, III in 5, II in 6, and I in 1. Ureteral reimplantation was not performed in 18 patients (26 ureters), whereas it was done for 1 patient (1 ureter) in the early era of our experience. Postoperative videourodynamics showed that the reflux was radiologically not verifiable in 23 ureters (85%), was downgraded in 3 ureters (11%), and was unchanged in 1 ureter (3%). There were no cases of deterioration of VUR.

CONCLUSIONS

Ureteral reimplantation is not necessary for VUR during augmentation cystoplasty.

Application of biomaterials and tissue engineering in bladder regeneration

The primary functions of the bladder are storing urine under low and stable pressure and micturition. Various forms of trauma, tumors, and iatrogenic injuries can cause the loss of or reduce bladder function or capacity. If such damage is not treated in time, it will eventually lead to kidney damage and can even be life-threatening in severe cases. The emergence of tissue engineering technology has led to the development of more possibilities for bladder repair and reconstruction, in which the selection of scaffolds is crucial. In recent years, a growing number of tissue-engineered bladder scaffolds have been constructed. Therefore, this paper will discuss the development of tissue-engineered bladder scaffolds and will further analyze the limitations of and challenges encountered in bladder reconstruction.

Augmentation uretero-enterocystoplasty for refractory urinary tract dysfunction: a long-term retrospective study

Objectives

To report the long-term efficacy and complications of the augmentation uretero-enterocystoplasty (AUEC), including augmentation cystoplasty with simultaneous ureteroplasty and ureteral anti-reflux implantation in a single center.

Methods

We retrospectively reviewed clinical records, video-urodynamic data, and magnetic resonance urography of 210 patients who underwent the procedure for refractory lower urinary tract dysfunction (LUTD) from 2003 to 2019. International vesicoureteral reflux (VUR) and upper urinary tract dilatation (UUTD) grading systems were applied to assess upper urinary tract function, and post-operative complications were assessed.

Results

Mean age was 28.1 years, with a mean follow-up time of 57.4 months. A total of 338 ureters were simultaneously re-implanted, and ureteroplasty was performed on all ureters. There was a significant postoperative improvement in the bladder capacity, intravesical pressure, and compliance (P < 0.05). VUR improvement rate was 97.7% and postoperative improvement of UUTD presented in 72.5% ureters. Mean serum creatinine (Scr) level was significantly improved compared to preoperative Scr values (226.0 ± 89.4 μmol/L vs. 217.5 ± 133.9 umol/L, P < 0.05). The 1.0% patients had unacceptably postoperative urinary incontinence and 85.4% preoperative megaureters were improved. Primary complications included metabolic acidosis (9.5%), vesicoureteral anastomosis stenosis (6.2%), persistent VUR (2.7%), urinary calculi (6.6%), and intestinal dysfunction requiring laparotomy (3.3%).

Conclusion

In the study, a large series of patients treated with a complex surgical procedure was reported. It is novel, as this case series represents patients with aggressive surgical correction of VUR, ureteral tortuosity and upper tract dilation at the time of AC. AUEC was shown to have a positive role in treating patients with refractory LUTD associated with hydronephrosis and ureteral dilatation, stenosis or obstruction, with or without high- or low-pressure VUR. It was effective in improving renal function and protecting the UUT function from further deterioration in most patients with renal insufficiency.

The Significance of Biomechanics and Scaffold Structure for Bladder Tissue Engineering

Current approaches for bladder reconstruction surgery are associated with many morbidities. Tissue engineering is considered an ideal approach to create constructs capable of restoring the function of the bladder wall. However, many constructs to date have failed to create a sufficient improvement in bladder capacity due to insufficient neobladder compliance. This review evaluates the biomechanical properties of the bladder wall and how the current reconstructive materials aim to meet this need. To date, limited data from mechanical testing and tissue anisotropy make it challenging to reach a consensus on the native properties of the bladder wall. Many of the materials whose mechanical properties have been quantified do not fall within the range of mechanical properties measured for native bladder wall tissue. Many promising new materials have yet to be mechanically quantified, which makes it difficult to ascertain their likely effectiveness. The impact of scaffold structures and the long-term effect of implanting these materials on their inherent mechanical properties are areas yet to be widely investigated that could provide important insight into the likely longevity of the neobladder construct. In conclusion, there are many opportunities for further investigation into novel materials for bladder reconstruction. Currently, the field would benefit from a consensus on the target values of key mechanical parameters for bladder wall scaffolds.

Outcomes of kidney‐transplanted patients with history of intestinal reconstruction of the urinary tract

Background

Methods

Results

Conclusions

Current Applications and Future Directions of Bioengineering Approaches for Bladder Augmentation and Reconstruction

End-stage neurogenic bladder usually results in the insufficiency of upper urinary tract, requiring bladder augmentation with intestinal tissue. To avoid complications of augmentation cystoplasty, tissue-engineering technique could offer a new approach to bladder reconstruction. This work reviews the current state of bioengineering progress and barriers in bladder augmentation or reconstruction and proposes an innovative method to address the obstacles of bladder augmentation. The ideal tissue-engineered bladder has the characteristics of high biocompatibility, compliance, and specialized urothelium to protect the upper urinary tract and prevent extravasation of urine. Despite that many reports have demonstrated that bioengineered bladder possessed a similar structure to native bladder, few large animal experiments, and clinical applications have been performed successfully. The lack of satisfactory outcomes over the past decades may have become an important factor hindering the development in this field. More studies should be warranted to promote the use of tissue-engineered bladders in clinical practice.

Procyanidins-crosslinked small intestine submucosa: A bladder patch promotes smooth muscle regeneration and bladder function restoration in a rabbit model

Currently the standard surgical treatment for bladder defects is augmentation cystoplasty with autologous tissues, which has many side effects. Biomaterials such as small intestine submucosa (SIS) can provide an alternative scaffold for the repair as bladder patches. Previous studies have shown that SIS could enhance the capacity and compliance of the bladder, but its application is hindered by issues like limited smooth muscle regeneration and stone formation since the fast degradation and poor mechanical properties of the SIS. Procyanidins (PC), a natural bio-crosslinking agent, has shown anti-calcification, anti-inflammatory and anti-oxidation properties. More importantly, PC and SIS can crosslink through hydrogen bonds, which may endow the material with enhanced mechanical property and stabilized functionalities. In this study, various concentrations of PC-crosslinked SIS (PC-SIS) were prepared to repair the full-thickness bladder defects, with an aim to reduce complications and enhance bladder functions. In vitro assays showed that the crosslinking has conferred the biomaterial with superior mechanical property and anti-calcification property, ability to promote smooth muscle cell adhesion and upregulate functional genes expression. Using a rabbit model with bladder defects, we demonstrated that the PC-SIS scaffold can rapidly promote in situ tissue regrowth and regeneration, in particular smooth muscle remodeling and improvement of urinary functions. The PC-SIS scaffold has therefore provided a promising material for the reconstruction of a functional bladder.

Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization

BACKGROUND

Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population.

METHODS

Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results.

RESULTS

A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5-5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0-5.3), no patients underwent urinary diversion.

CONCLUSIONS

Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

Complication profile of augmentation cystoplasty in contemporary paediatric urology: a 20-year review

BACKGROUND

The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics.

METHODS

Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined.

RESULTS

Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH₂ O, P < 0.001). Bladder capacity improved significantly (67-89%, P = 0.041). The median follow-up was 4.5 years (interquartile range: 1.9-10 years). Bladder urolithiasis affected 13 (18%) patients, and symptomatic urinary tract infections 36 (51%) patients. Formation of a continent catheterisable channel contributed a number of complications relating predominantly to stenosis (50%). Repeat augmentation cystoplasty was necessary in three (4%) cases.

CONCLUSION

Augmentation cystoplasty is a surgical intervention that improves bladder metrics. Given the potential complications, careful patient selection and appropriate pre-operative counselling are essential. Furthermore, pro-active post-operative management and transitional care are vital in the surgical care of children following augmentation cystoplasty.

Long-term results of augmentation ileocystoplasty in spinal cord injury patients

INTRODUCTION

The aim of this article was to report the long-term results of increased ileocystoplasty in 58 patients with spinal cord injury (SCI) with an impact on overall renal function and quality of life. In a representative number of patients, where we followed individual subjects for more than 20 years, we wanted to determine their quality of life and preservation of renal function after surgery.

MATERIAL AND METHODS

After unsuccessful conservative therapy of urinary incontinence, increased ileocystoplasty was performed. In addition to biochemical analysis, intravenous urography (IVU) was performed preoperatively (urography and/or ultrasound assessment of the upper urinary tract) and urodynamic tests were performed in all patients preoperatively.

RESULTS

After a follow-up of patients within the group (>20 years), 2 patients reported being incontinent. The median elapsed time of action was 20 (13-24) years. Vesical capacity increased in all cases postoperatively when the median vesical capacity was 420.0 (387.5-460.0) ml (p <0.001). Long-term complications included use of bladder chambers, kidney stones and urosepsis. Creatinine clearance confirmed satisfactory renal function after the elapsed time period from surgery.

CONCLUSIONS

The results confirmed that augmentation ileocystoplasty had excellent long-term outcomes in the definitive therapy of refractory neurogenic detrusor overactivity in patients with SCI.

Case report: The theory of post-ileocystoplasty spherical configuration in patients with low-capacity bladder

•

Detubularization form offers greater volume and lower pressure in the reservoir to augment the bladder.

•

Patients with low-capacity bladder who have poor compliance with ureteral involvement have poor renal function.

•

Low compliance bladder will cause numerous symptom such which will lead to insufficient bladder emptying.

•

Bladder augmentation is a management option for neurogenic and non-neurogenic bladder dysfunction when conservative management, medical pharmacological therapy and minimally invasive management have not yielded satisfactory results.

•

The aim of doing bladder augmentation is to create a reservoir with adequate functional capacity and low bladder filling pressure so that low intravesical pressure will not interfere with the flow of urine from the bladder to the urethra.

Introduction

Bladder augmentation can be performed by detubularization of the small or large intestine. A large capacity bladder is necessary to avoid frequent urination; thus, the ileal sac must be able to store the maximum volume of urine with relatively low pressure and the shortest length of the intestine. The acceptable pressure capacity should always be under ureteric pressure to avoid back pressure and kidney damage. Large capacity at low pressure is referred to as good compliance. Desirable preparations for augmentation, which is the use of the shortest length of the intestine, reduce the chance of diarrhea and vitamin deficiency and retain the intestines which may be required for augmentation.

Aim

Clinical and urodynamic evaluation of the recent postoperative condition of the patient who underwent ileocystoplasty, confirmed by the theory of detubularization (spherical) configuration.

Case presentation

Patient with complaints of frequent urination and small amount of urine. Ultrasound examination showed low volume bladder capacity and bilateral hydronephrosis and hydroureter. From cystography and VCUG examination, low capacity bladder, grade 1 VUR on the right side, grade 4 VUR on the left side accompanied by bilateral hydronephrosis and hydroureter. The patient has a history of right nephrectomy in 2014 for pyonephrosis due to kidney stones. The patient was then subjected to bladder augmentation using a segment of the ileum (ileocystoplasty) in 2015. In the postoperative evaluation, clinical symptoms, radiological and uroflowmetric examinations were evaluated.

Conclusion

The detubularization form offers greater volume and lower pressure in the reservoir to augment the bladder.

Sexual function in adult patients who have undergone augmentation surgery in childhood: what is really important?

Problems relating to the development of a healthy approach to sex and intimacy during puberty, after augmentation cystoplasty, are scarcely discussed in literature. Therefore, this may suggest that such issues are insufficiently addressed by pediatric urologists. We gathered four experts in the field as well as an experienced leader of a patient group and mother of a girl with spina bifida and asked questions relevant to the following areas of care: (a) diversion, urinary incontinence, and sexual life; (b) impact of a stoma on body image perception and self-esteem; (c) specific female concerns with regard to fertility and recurrent urinary infections; (d) specific male concerns on anejaculation and erectile dysfunction. Their answers are discussed in view of the available literature. All experts and the patient group representative agreed that most of these patients will experience: lack of self-confidence as the most frequent obstacle to starting a relationship and incontinence as a barrier to sexual activity. The cosmesis of the stoma and abdominal scars might influence self-esteem and therefore the sexual activity, however it appears to be a less common concern in males than females. Our results outline the importance and influence that the body image, self-esteem, and confidence present for the individual expectations of the patients related to sex life and sexual activity. Physicians should be encouraged to ask all postpubertal patients about their sexual concerns at every visit. Further studies and exchange of information between clinicians are needed to provide meaningful and analyzable patient-related outcome measures (PROMs).

Electrospinning: Application and Prospects for Urologic Tissue Engineering

Functional disorders and injuries of urinary bladder, urethra, and ureter may necessitate the application of urologic reconstructive surgeries to recover normal urine passage, prevent progressive damages of these organs and upstream structures, and improve the quality of life of patients. Reconstructive surgeries are generally very invasive procedures that utilize autologous tissues. In addition to imperfect functional outcomes, these procedures are associated with significant complications owing to long-term contact of urine with unspecific tissues, donor site morbidity, and lack of sufficient tissue for vast reconstructions. Thanks to the extensive advancements in tissue engineering strategies, reconstruction of the diseased urologic organs through tissue engineering have provided promising vistas during the last two decades. Several biomaterials and fabrication methods have been utilized for reconstruction of the urinary tract in animal models and human subjects; however, limited success has been reported, which inspires the application of new methods and biomaterials. Electrospinning is the primary method for the production of nanofibers from a broad array of natural and synthetic biomaterials. The biomimetic structure of electrospun scaffolds provides an ECM-like matrix that can modulate cells' function. In addition, electrospinning is a versatile technique for the incorporation of drugs, biomolecules, and living cells into the constructed scaffolds. This method can also be integrated with other fabrication procedures to achieve hybrid smart constructs with improved performance. Herein, we reviewed the application and outcomes of electrospun scaffolds in tissue engineering of bladder, urethra, and ureter. First, we presented the current status of tissue engineering in each organ, then reviewed electrospun scaffolds from the simplest to the most intricate designs, and summarized the outcomes of preclinical (animal) studies in this area.

Robot-assisted Supratrigonal Cystectomy and Augmentation Cystoplasty with Totally Intracorporeal Reconstruction in Neurourological Patients: Technique Description and Preliminary Results

BACKGROUND

Augmentation cystoplasty as a third-line therapy for neurogenic detrusor overactivity performed by an open approach has long been studied. Few laparoscopic and robot-assisted series have been reported.

OBJECTIVE

To evaluate the feasibility, safety, and functional outcomes of completely intracorporeal robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RASCAC) in patients with refractory neurogenic detrusor overactivity.

DESIGN, SETTING, AND PARTICIPANTS

We identified all patients undergoing RASCAC, as treatment for refractory neurogenic detrusor overactivity, from August 2016 to April 2018.

SURGICAL PROCEDURE

RASCAC was performed in all cases using a standardized technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration.

MEASUREMENTS

Perioperative data, and functional and urodynamic results at 1-yr follow-up were assessed. Statistical analysis was performed using Stata version 15.1.

RESULTS AND LIMITATIONS

Ten patients were identified. No conversion to open surgery was needed. The median operative time was 250 (interquartile range 210-268) min, the median estimated blood loss was 75 (50-255) ml, and the median hospitalization time was 12 (10.5-13) d. The 30-d major complication rate was 10%. Two patients presented a late urinary fistula; in one of the cases, surgical revision was needed. In both cases, low compliance to intermittent self-catheterization was identified. At 1-yr follow-up, functional and urodynamic outcomes were excellent.

CONCLUSIONS

Robot-assisted augmentation cystoplasty has been shown to be safe and feasible, with a reasonable operative time and low complication rate in experienced hands. A higher number of patients and longer follow-up are, however, warranted to draw definitive conclusions.

PATIENT SUMMARY

In this report, we look at the outcomes of robot-assisted supratrigonal cystectomy and augmentation cystoplasty in neurourological patients. Perioperative, functional, and urodynamic results are promising. Further studies with a longer follow-up are needed to confirm these findings.

The Current Positioning of Augmentation Enterocystoplasty in the Treatment for Neurogenic Bladder

Augmentation enterocystoplasty (AEC) is a surgical procedure in which the bladder is enlarged using an intestinal segment in patients with lower urinary tract dysfunction who fail to achieve satisfactory results with all conservative treatments. Currently, surgical materials and procedures, concomitant correction of upper urinary tract abnormalities, or bladder neck reconstruction may vary depending on the experience and preferences of the surgeons. AEC has been proven to be successful with respect to surgical goals, such as achieving urinary continence, improving quality of life, and preserving the upper urinary tract over the long term. The advantage of AEC over intravesical injection of botulinum toxin—a more recent and less invasive procedure—is that the prevention of upper urinary tract damage and the improvement of urinary incontinence are more reliably guaranteed, especially considering that these surgical effects are permanent. Compared to less invasive treatments, the quality of life of patients after surgery is also much higher, and AEC may be more cost-effective in the long run. Thus, in patients with neurogenic bladder, AEC is still the gold standard surgical procedure with strong evidence in support of its efficacy. In this article, the indications, surgical methods, possible complications, long-term follow-up, and current positioning of AEC in lower urinary tract dysfunction is discussed.

Treatment for refractory overactive bladder: a systematic review and meta-analysis of sacral neuromodulation and onabotulinumtoxinA

INTRODUCTION AND HYPOTHESIS

This systematic review and meta-analysis aim to evaluate the outcomes between SNM and BTX in the treatment of refractory OAB.

METHODS

PubMed, Embase, and CENTRAL were comprehensively searched from their inception to December 2019. Randomized and nonrandomized controlled trials evaluating OAB patients who underwent SNM and BTX were included. Data extraction and quality assessment were conducted by two independent reviewers. The outcomes, side effects, and cost-effectiveness values of both procedures were compared in meta-analysis.

RESULTS

This review involved six articles (2629 patients). Specifically, three articles were based on the same trial, and the other studies were retrospective cohort studies. No significant difference was found in successful treatment between BTX and SNM at 6 months after procedures [risk ratio (RR) = 0.93, 95% confidence interval (CI) 0.63-1.39]. BTX exhibited a significantly higher total adverse event rate than SNM through 6 months (RR = 1.55, 95% CI 1.28-1.88). Patients suffered more urinary tract infection (UTI) risk under BTX injection at the early stage (RR = 1.58, 95% CI 1.10-2.25); however, the difference in UTI events was not significant between the two groups (RR = 1.13, 95% CI 1.10-2.25) during the period of 7-12 months postoperatively. Obviously, the short-term cost (1-2 years) of BTX was significantly lower than that of the SNM procedure.

CONCLUSIONS

Both treatments were effective; however, because of the high complication rate of BTX, it may not be a better way to treat refractory OAB than SNM, although BTX is more cost-effective for short-term treatment at present.

The efficacy of onabotulinumtoxinA in patients with previous failed augmentation cystoplasty: Cohort series and literature review

AIMS

To investigate the role of onabotulinumtoxinA (BTX-A) injections in patients with failed augmentation cystoplasty for neuropathic or idiopathic detrusor overactivity (NDO or IDO).

METHODS

A retrospective review of all cystoplasty patients who underwent onabotulinumtoxinA injection at a tertiary center between 2008 and 2019 was performed. Details including indications and time from cystoplasty, video-urodynamic parameters, onabotulinumtoxinA dose, and clinical outcomes were analyzed. Telephone interview was performed for patients that requested repeat onabotulinumtoxinA injections. The interview included a modified PGIC7 and UDI6 questionnaires. A positive clinical response was considered improvement of overactive symptoms sufficient to merit repeat onabotulinumtoxinA injection and a modified PGIC7 of four or above.

RESULTS

Thirty patients were identified (11 men and 19 women). The indications for augmentation were IDO (n = 18) or NDO (n = 12). Mean age at the time of cystoplasty was 42 years (range, 10-61). Interval between cystoplasty and initial onabotulinumtoxinA was 98 months (range, 3-271). Video-urodynamics before onabotulinumtoxinA revealed low compliance in 13 patients, DO in 22 patients, and combined low compliance/DO in 10. The median maximum cystometric bladder capacity was 338 mL (range, 77-570 mL). Thirteen patients responded to onabotulinumtoxinA injections. Higher peak DO pressure was associated with a significantly higher chance that the patient would experience benefit from the injections P = .026). The patients that responded to onabotulinumtoxin A underwent a total of 115 procedures (mean, 8.8 injections) over a mean 88 months (range, 20-157 months).

CONCLUSIONS

Forty-three percent of patients responded well to intra-detrusor onabotulinumtoxinA injections. This avoided the need for more invasive surgery and had a positive impact on their quality of life.

Utilization of Augmentation Cystoplasty for Myelomeningocele Patients Remained Stable Over the Past Decade

OBJECTIVE

To understand the utilization of augmentation cystoplasty (AC) for the management of neurogenic bladder in children with myelomeningocele (MMC). AC carries considerable risk. To mitigate this, recent studies have emphasized alternatives to AC, but it is unknown if these interventions have resulted in fewer ACs being performed. Our goal was to evaluate the use of AC in MMC patients over the past decade. We hypothesized that the use of AC had decreased and that the age at AC increased.

METHODS

Using the Pediatric Health Information System, we studied patients with MMC who had an AC between January 2009 and December 2018. International Classification of Disease procedure codes were used to identify AC procedures. We quantified trends in AC utilization by estimating the annual proportion of MMC admissions with an AC. We also assessed trends in patient age at the time of AC.

RESULTS

Proportion of AC per MMC admissions across the study period was 4.8%. There was no significant annual trend in the overall number of ACs performed each quarter over the past decade nor was there any change in the estimated annual incidence rate ratio of AC (1.01, 95% confidence interval 0.96, 1.05; P =.75). The estimated annual change in patient age at procedure remained relatively constant over the study period (-0.03 years, 95% confidence interval -0.13, 0.07; P = .51).

CONCLUSION

Practice patterns for the utilization of AC in MMC did not change significantly over the past decade despite prominent voices in the literature emphasizing alternative interventions in this patient population.

Clinical guidelines for the diagnosis and treatment of lower urinary tract dysfunction in patients with spinal cord injury

The present article is an abridged English translation of the Japanese clinical guidelines for the diagnosis and treatment of lower urinary tract dysfunction in patients with spinal cord injury updated as of July 2019. The patients are adult spinal cord injured patients with lower urinary tract dysfunction; special consideration of pediatric and elderly populations is presented separately. The target audience is healthcare providers who are engaged in the medical care of patients with spinal cord injury. The mandatory assessment includes medical history, physical examination, frequency-volume chart, urinalysis, blood chemistry, transabdominal ultrasonography, measurement of post-void residual urine, uroflowmetry and video-urodynamic study. Optional assessments include questionnaires on the quality of life, renal scintigraphy and cystourethroscopy. The presence or absence of risk factors for renal damage and symptomatic urinary tract infection affects urinary management, as well as pharmacological treatments. Further treatment is recommended if the maximum conservative treatment fails to improve or prevent renal damage and symptomatic urinary tract infection. In addition, management of urinary incontinence should be considered individually in patients with risk factors for urinary incontinence and decreased quality of life.

Adherence with bladder irrigation following augmentation

BACKGROUND

Patients with bladder augmentation (BA) are routinely counseled to irrigate their bladders daily. However, reports of adherence with this regimen are lacking.

OBJECTIVE

To evaluate adherence to a bladder irrigation protocol and identify risk factors associated with adherence among adults with spina bifida (SB) and BA.

STUDY DESIGN

Adults with SB after BA followed in a multidisciplinary clinic were identified (2017-2019). All patients or caregivers were taught the importance of and the technique for the bladder irrigation protocol prior to and after BA. Patient demographics (age, gender, ambulatory status, and presence of a caregiver in clinics) and surgical details (type of BA, age at surgery, length of follow-up, presence of a catheterizable channel, position of stoma, bladder neck surgery, presence of Malone antegrade colonic enema or ventriculo-peritoneal shunt, and number of stone surgeries) were obtained from the medical record. Patients reported other variables in a standardized clinic questionnaire. Answers were confirmed by health care providers. The variables included who performs clean intermittent catheterization (CIC), size of catheter, frequency of CIC, use of overnight catheterization, difficulties with CIC, number of UTIs, and continence per urethra and per catheterizable channel. Adherence to bladder irrigation was also assessed in the questionnaire. ‛Strict adherence' was defined as bladder irrigation performed ≥6 times/week with ≥120 mL of saline. For statistical analysis, a more lenient definition of ‛higher adherence' was used: bladder irrigation ≥2 times/week with at least 60 mL. ‛Lower adherence' was defined as ≤1 time/week or with less than 60 mL. Factors associated with ‛higher adherence' were assessed with non-parametric tests (Bonferroni-corrected p-value: 0.002).

RESULTS

Adherence was assessed in 87 eligible patients (60.9% females; mean age of 28.8 ± 8.2 years). No patient (0.0%) reported ‛strict adherence', and 62 and 25 patients (71.3% and 28.7%) reported ‛higher' and ‛lower' adherence' to bladder irrigation, respectively. Nine patients (10.3%) in the ‛lower adherence' group did not irrigate at all. No variables were statistically significant on univariate analysis, including previous bladder stone surgery or having a channel (p ≥ 0.01). On exploratory analysis, higher adherence was only associated with self-catheterizations versus those performed by caregivers (76.7% vs 33.3%, p = 0.01).

CONCLUSIONS

Adherence to a bladder irrigation protocol in adults with SB and BA is poor. A history of bladder stones requiring surgery and the presence of a catheterizable channel do not appear to affect adherence. It remains unclear why some patients are more likely than others to irrigate their bladders. Future work will focus on methods to improve adherence.