Is continent urinary diversion feasible in children under five years of age?

Multidisciplinary management of people with spina bifida across the lifespan

The average worldwide prevalence of neural tube defects (NTDs) is 1.0 per 1000 births. Its development is multifactorial due to genetic and non-genetic factors. Spina bifida (SB) is one of main representatives of NTD. The spinal cord lesion level is the main determinant of the level of paralysis, numbness, and difficulties with bladder/bowel functions. Myelomeningocele prenatal repair reduces hydrocephalus and hindbrain herniation and improves motor function. The severity of hydrocephalus is associated with poorer neurodevelopmental outcomes whether operated on prenatally or after birth. People with SB tend to have a lower IQ and cognitive difficulties. Early diagnosis, proactivity, and lifelong multidisciplinary follow-up are key protective issues. Invasive urological interventions should be considered in selected patients after failure of conservative treatment. Transition to adult care should be well planned as it is challenging. Health literacy is directly associated with success at transition. Sexuality and fertility should be addressed before/during puberty. Overall, the rates of fecal and urinary continence and skin breakdown increase with age, whereas the ability to ambulate declines with age. Bowel and urinary incontinence are independent predictors of lower health-related quality of life (HRQoL) in adults with SB. Bowel incontinence has negative impact on HRQoL regardless of frequency or amount. Long-term caregiver support should be offered at diagnosis. Survival at a mean of 50 years is poor, at 32%, due to central nervous system deaths, cancer, urological disease, and sepsis. Challenges to implementation of recommended practices exist, especially in low and middle-income countries.

Late secondary urological reconstruction of separated ischiopagus twins with exstrophic bladder and urinary incontinence

We report a case of secondary urinary reconstruction of previously separated conjoined twins with exstrophic bladder and urinary incontinence. Patients were male and aged 13-year-old. Twin one had a history of failed enterocystoplasty that extruded and was visible like an exstrophic neobladder. He underwent a procedure to close bladder neck and reconfigure abdominal wall. After the procedure the patient developed a fistula that was treated, but it persisted and, for this reason, a catheterizable pouch was constructed and native bladder was discarded. Twin two required the immediately construction of catheterizable pouch using the Macedo’s technique. Currently, both patients are continent at 4 hour intervals. The mean follow-up was 8 months. Modern continent urinary diversion techniques offer new perspectives and hope for such complex population.

Ureteric-urethral engraftment as a new surgical technique for management of incontinence in bladder exstrophy complex: A retrospective cohort

OBJECTIVES

To report the results of a novel surgical technique for achieving urinary continence in patients with bladder exstrophy complex (BEC) by ureteric-urethral engraftment (UUE) technique.

PATIENTS AND METHODS

Sixteen female patients with BEC and a mean ± SD age of 3.48 ± 1.75 years were referred for primary exstrophy repair from 2009 to 2012. From these, 9 patients were operated by single-stage bladder closure (group I); while 7 patients underwent the novel technique of UUE to compare the continence achievement (group II). In UUE technique, distal ureter was applied for total urethral replacement while the lower part of engraft was fixed in external genitalia. No osteotomy was performed in none of the groups. Continence and upper urinary tract evaluation were performed in the follow-ups with 3 months intervals for the first year and biannually thereafter. The patients were followed-up for a mean ± SD duration of 72 ± 6 months.

RESULTS

All patients in both groups experienced an uneventful postoperative period. In group II, 5 patients were continent day and night and voided per urethra without need for augmentation or intermittent catheterization technique (71.42%); while 55.55% of patients in group I achieved total continence (n = 5). Partial continence was achieved in 4 (44.44%) and 2 (28.57%) patients in group I and II, respectively. However, 3 patients in UUE group had postoperative vesicoureteral reflux that was successfully managed by Deflux injection.

CONCLUSION

The eventual clinical outcomes of BEC children undergoing the UUE technique were promising. This practicable, safe, and reproducible option will add one complementary stage to the previously used reconstruction techniques. These patients would necessitate further surveillance with upper urinary tract evaluations during the adult life.

Does augmentation cystoplasty with continent reconstruction at a young age increase the risk of complications or secondary surgeries?

INTRODUCTION AND OBJECTIVE

Lower urinary tract reconstruction with augmentation cystoplasty (AC) is an effective strategy for achieving urinary continence in children with neurogenic or severely compromised bladder. We compared complications and need for secondary surgeries in children 3-5 years of age undergoing AC with continent reconstruction to those ≥ 6 years old.

STUDY DESIGN

Medical charts of children undergoing AC with continent urinary diversion between 2003 and 2011 were reviewed. Complications and secondary surgeries were analyzed according to patient age. Patient demographics, etiology of bladder dysfunction, bowel segment used, and concomitant procedures were also assessed.

RESULTS

One hundred and eight children underwent AC with continent urinary diversion. Mean age at augmentation was 8.5 years (range 3-20). Twenty-eight children (25.9%) were 3-5 years old and 80 (74.1%) were ≥ 6 years. Mean follow-up was 6.93 years (range 1.6-10 years). Bowel segment used included ileum in 59 (54.6%), sigmoid in 33 (30.6%), cecum in 4 (3.7%) and composite in 12 (11.1%). Major complications included bowel obstruction in 6 (5.6%), bladder perforation in 3 (2.8%) and fistula in 2 (1.9%). There was no difference in major complications based on bowel segment utilized (p = 0.804, OR 0.894) or age (p = 0.946, OR 0.969). Fifty children (46.3%) required no additional surgeries; the remaining 58 underwent 137 procedures post-augmentation. Surgeries included urolithiasis management (58/137, 42.3%), appendicovesicostomy revision including stoma revision or redo for persistent leakage between catheterizations in (34/137, 24.8%), bladder neck procedures (26/137, 19%) and revision of MACE (19/137, 13.9%) [Figure]. Incidence of stones in patients 3-5 years (32.1%) was not significantly different than children ≥ 6 years of age (25%, p = 0.463, OR 0.704). Mean number of secondary surgeries for those 3-5 years was 1.21 ± 1.34, which was not statistically different than those ≥ 6 (1.3 ± 1.82, p = 0.154). Children with myelomeningocele (MMC) were statistically more likely to require secondary surgeries than those with other bladder pathology (p = 0.01).

DISCUSSION

Augmentation enterocystoplasty with cutaneous continent catheterizable channel is performed both to protect the upper urinary tract and afford the patient the option of social continence. Continent lower urinary tract reconstruction has been proven technically feasible and safe in preschool-aged children however, the ideal age for augmentation remains unknown. Urolithiasis accounted for over 40% of additional procedures in our series, with 26.9% of patients requiring one or more surgeries for stone disease. The incidence of stone disease in patients 3-5 years of age at the time of augmentation was comparable to that seen in older children. The overall need for additional post-augment procedures was not influenced by patient age or bowel segment utilized, however children with MMC were significantly more likely to require future surgeries than those with a different underlying etiology of bladder dysfunction. Our study has several limitations that warrant mention. Children with neurogenic bladder represent a heterogeneous population, and their surgical outcomes are inherently influenced by underlying disease processes and severity. Complications and secondary surgeries were assessed; however success rates were not evaluated in the current study. Patient and caregiver adherence with CIC and daily bladder irrigation was not assessed; whether noncompliance affected complication rates (i.e. stone formation) is unknown.

CONCLUSION

Whether performed at a young or older age, families must be adequately counseled regarding the daily management responsibilities and potential risks associated with lower urinary tract reconstruction including bladder augmentation. Augmentation with continent urinary diversion in selected patients 3-5 years of age confers complication and secondary surgery risk equal to that observed in their older counterparts.

A neosphincter for continent urinary catheterizable channels made from rectus abdominal muscle (Yachia principle): preliminary clinical experience in children

PURPOSE

We investigated continence outcomes for patients undergoing primary or redo reconstruction of a urinary catheterizable reservoir involving the Yachia technique of intersecting two rectus abdominis strips over the outlet channel.

MATERIALS AND METHODS

A retrospective evaluation of 22 consecutive patients operated from March 2009 to August 2010 was performed, consisting of 16 primary reconstructions (Macedo catheterizable ileal reservoirs) and 6 rescue cases for leaking stomas. Our data comprised 18 spina bifida patients, 1 sacral agenesis, 1 posterior urethral valves and 1 genitourinary tuberculosis. Mean age at surgery was 8.5 years (3-21 years). We evaluated continence at 3, 6, 12 months, and at the last follow-up based on data from urinary charts.

RESULTS

Mean follow-up was 21.1 months (12-29 months). Overall continence was 100% for the primary cases and 66% for the redos (2/6 failed). Three patients had initial difficulty in performing clean intermittent catheterization but this resolved with time and experience.

CONCLUSION

Using Yachia's technique has improved the continence rate of our catheterizable reservoirs and was partially successful for suprafascial revision of incontinent conduits.

Ten years' minimum follow-up with the ileal continent catheterizable reservoir: a test of time

OBJECTIVE

To evaluate long-term efficacy of an original technique of catheterizable ileal reservoir designed for bladder augmentation and/or substitution, precluding the need to use a Yang-Monti channel or appendix.

MATERIALS AND METHODS

Our series comprised 19 patients, operated in 1998-2000, with a mean age of 10.1 years (1.6-30). Two were excluded from analysis because lost to follow-up after 1.5 and 7 years of surveillance. The primary disease was posterior urethral valves (9), myelomeningocele (4), anorectal malformation (1), rhabdomyosarcoma (1), medullary astrocytoma (1) and urethral stricture (1). Surgery consisted of creating a continent catheterizable ileum-based reservoir from a 35-cm ileum segment.

RESULTS

Mean follow-up was 11.2 years (10-12.4). All 16 patients eligible for final evaluation of the procedure were continent, excluding two lost of follow-up and one that underwent undiversion. Complications noted were: stomal stenosis (3), leakage associated with false passage (1) and false passage (1). One patient underwent a Bricker undiversion procedure, an appendicovesicostomy was performed in 2, and 1 patient received a Monti channel to replace the outlet conduit. The overall complication rate was 29.4% (5/17).

CONCLUSION

We have confirmed the long-term efficacy of the technique. The results are comparable to other 'gold standard' treatments, with the advantage of being simpler, faster and sparing the appendix for other uses (Malone antegrade continent enema), as well as precluding the need to create a Monti channel.

Bladder exstrophy: reconstructed female patients achieving normal pregnancy and delivering normal babies

PURPOSE

Bladder exstrophy (BE) is an anterior midline defect that causes a series of genitourinary and muscular malformations, which demands surgical intervention for correction. Women with BE are fertile and able to have children without this disease. The purpose of this study is to assess the sexual function and quality of life of women treated for BE.

MATERIALS AND METHODS

All patients in our institution treated for BE from 1987 to 2007 were recruited to answer a questionnaire about their quality of life and pregnancies.

RESULTS

Fourteen women were submitted to surgical treatment for BE and had 22 pregnancies during the studied period. From those, 17 pregnancies (77.2%) resulted in healthy babies, while four patients (18.1%) had a spontaneous abortion due to genital prolapse, and there was one case (4.7%) of death due to a pneumopathy one week after delivery. There was also one case (5.8%) of premature birth without greater repercussions. During pregnancy, three patients (21.4%) had urinary tract infections and one patient (7.14%) presented urinary retention. After delivery, three patients (21.4%) presented temporary urinary incontinence; one patient (7.14%) had a vesicocutaneous fistula and seven patients (50%) had genital prolapsed. All patients confirmed to have achieved urinary continence, a regular sexual life and normal pregnancies. All patients got married and pregnant older than the general population.

CONCLUSIONS

BE is a severe condition that demands medical and family assistance. Nevertheless, it is possible for the bearers of this condition to have a satisfactory and productive lifestyle.

Urinary diversion in early childhood: indications and outcomes in the exstrophy patients

OBJECTIVE

To evaluate indications and applicability of continent and incontinent urinary diversion (CUD and IUD, respectively) in early childhood in patients with classic bladder exstrophy (CBE).

METHODS

Using an institutionally approved exstrophy database, patients with CBE born after 1980 who underwent CUD or IUD by 2 surgeons within the first 5 years of life were identified. All aspects of their care and clinical outcomes were studied.

RESULTS

In the CUD group (n = 14), only 21% had successful primary closure. Indications were desire to be dry (7), persistent hydronephrosis (4), urinary tract infections (UTIs) (1), repeat CUD (1), and inaccessible proper follow-up (1). Three patients had neobladder creation, 10 had bladder augmentation with continent stomas, and 2 underwent ureterosigmoidostomy. Currently, all patients are dry with clean intermittent catheterization (CIC). In the IUD group (n = 5), only 1 had successful primary closure. In addition to small, noncontractile bladders, the indications for IUD were severe hydronephrosis (2), recurrent UTIs (2), and noncompliance with catheterization (1). Four patients were re-diverted to CUD after a mean of 9.4 years and 1 has colon conduit. All are socially dry via catheterization. There was no case of renal function loss or malignant transformation.

CONCLUSION

The need for early diversion in CBE is primarily driven by upper tract changes after secondary closure and social factors. Urinary diversion can be safe in younger children with a favorable continence outcome.

Efficacy of transcutaneous functional electrical stimulation on urinary incontinence in myelomeningocele: results of a pilot study

PURPOSE

To investigate the efficacy of transcutaneous functional electrical stimulation (FES) on voiding symptoms in children with myelomeningocele (MMC) suffering from neuropathic urinary incontinence.

MATERIALS AND METHODS

Six girls and 6 boys with moderate to severe urinary incontinence secondary to MMC were included. Median age of children was 5.04 (range: 3-11) years. They underwent a urodynamic study (UDS) before and 3 months after FES with special attention to detrusor leak point pressure (DLPP) and maximal bladder capacity (MBC). Daily incontinence score, frequency of pad changing, and enuresis were also assessed before and three months after treatment. Fifteen courses of FES for 15 minutes 3 times per week were performed with low frequency (40 Hz) electrical current, duration of 250μs, with hold and rest time of 2 seconds.

RESULTS

Nine children had improvement on urinary incontinence score, while three children had no improvement. Median DLPP was significantly increased from 38.5 (range: 12-50) cm H2O to 59.5 (range: 18-83) cm H2O (P = 0.003). MBC was significantly increased from median value of 155 (range: 60-250) mL to 200 (range: 110-300) mL (P = 0.007).

CONCLUSIONS

This is a pilot study showing that FES therapy might have positive effects on improvement of voiding symptoms of MMC children with neurogenic urinary incontinence in terms of daily incontinence score and UDS parameters.