Referral and Prescription Patterns for Female Patients With Urinary Incontinence

IMPORTANCE

Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them.

OBJECTIVES

To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system.

STUDY DESIGN

Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates.

RESULTS

In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48).

CONCLUSION

Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.

Does choice of anesthesia during stage 1 sacral neuromodulation testing influence outcomes?

INTRODUCTION

Staged sacral neuromodulation (SNM) testing has been shown to have a high rate of progression to permanent implantation for the management of voiding dysfunction. Stage 1 lead placement (SNM-I) can be performed under monitored anesthesia care (MAC) or general anesthesia (GA). MAC allows for interpretation of sensory and motor responses to optimize lead placement while GA only permits for motor assessment. However, patient discomfort and movement can make lead placement challenging during MAC. Herein we evaluate whether the anesthesia type impacts the progression rate to permanent implantation (SNM-II).

MATERIALS AND METHODS

A retrospective chart review was performed for patients who underwent SNM-I in the operating room for wet overactive bladder between 2005 and 2023. Patients were divided into two groups based on the type of anesthesia used, MAC or GA. Clinical variables and progression to SNM-II were compared between cohorts. Progression to SNM-II was based on ≥50% symptomatic improvement during a 1-2 week trial period following SNM-I.

RESULTS

Of 121 patients included in the study, 95 (79%) underwent MAC and 26 (21%) GA for SNM-I. No difference in the progression rate to SNM-II was noted between groups (MAC, 68/95 patients, 72%; GA, 19/26, 73%; p = 0.39). We also found no difference when comparing the GA group to the 26 most recent MAC patients (MAC, 20/26 patients, 77%; GA, 19/26, 73%; p = 0.48).

CONCLUSION

Types of anesthesia for SNM-I did not affect rate of progression to SNM-II. The result lends support to the reliance on motor responses alone for lead placement during SNM-I.

Factors associated with recurrent urinary tract infections in spinal cord injured patients who use intermittent catheterization

INTRODUCTION

Urinary Tract Infection (UTI) has been cited as the primary cause of morbidity in patients with history of spinal cord injury (SCI). Despite the significance of recurrent UTI (rUTI) in this population, the causative physiologic and patient characteristics are not well described. We sought to assess associations between demographic, clinical and urodynamic variables and rUTI.

MATERIALS AND METHODS

The records of 136 individuals with SCI who perform clean intermittent catheterization (CIC) were retrospectively reviewed. All had a video urodynamics study (VUDS) available for analysis. Individuals were divided into non-recurrent (< 3/year) or rUTI (≥ 3/year) groups. Differences between the cohorts were analyzed. Multivariable logistic regression was performed to determine associations between various demographic, clinical, and VUDS variables and rUTI.

RESULTS

Self-reported rUTI were noted in 58 of 136 individuals. Of 124 individuals with urinary culture results, African American race (43.3% vs. 22.3%) and 'Other' race (13.3% vs. 8.5%) made up larger proportions in the rUTI group. Female gender (OR 4.96, 95% CI [1.44-17.13]) and African American race (OR 5.16, 95% CI [1.80-14.79]) were increasingly associated with rUTI on multivariable logistic regression. Shorter interval since injury was also significantly associated with recurrent infections with each year since injury indicating diminished likelihood (OR 0.91, 95% CI [0.82-0.99]). There were no significant differences in VUDS variables between groups and none were significant on regression as potential determinants of rUTI.

CONCLUSIONS

Patient race, gender, and time since SCI appear to have significant associations with rUTI in individuals with SCI using CIC. However, VUDS variables were not found to be significantly associated with rUTI.

Is a 50% improvement threshold adequate to justify progression from sacral neuromodulation testing to implant?

PURPOSE

A ≥50% subjective improvement in urinary symptoms during sacral neuromodulation testing (SNM-I) is currently used as the indication for progression to second-stage implantation (SNM-II). While most patients will have successful SNM-I and proceed to SNM-II, deterioration in efficacy over time has been reported. It remains unclear if the durability of efficacy is related to the initial symptom reduction. We sought to determine if the degree of improvement after SNM-I is sufficient to predict long-term success.

METHODS

The records of all patients who underwent sacral neuromodulation (SNM) for overactive bladder were reviewed. Subjects were divided into those who reported 50%-75% improvement (Group 1) and more than 75% improvement (Group 2) after SNM-I. Differences in clinical variables and long-term device efficacy were compared between groups.

RESULTS

Of 213 patients who underwent SNM-I, 137 underwent permanent device implantation. A total of 76 (55%) and 61 (45%) patients reported 50%-75% (Group 1) and more than 75% (Group 2) symptomatic improvement, respectively. With a mean follow-up of 46 months, 44% of Group 1 patients and 68% of Group 2 patients still had a functioning device providing the symptomatic benefit (p = 0.007). Univariate analyses identified the presence of stress urinary incontinence at baseline and having a more than 75% improvement after SNM-I as predictors of long-term functional success.

CONCLUSIONS

Compared to patients reporting 50%-75% symptomatic reduction after SNM-I, individuals with a more than 75% improvement during SNM-I were more likely to maintain device efficacy over time. Additional study is warranted to determine if the improvement threshold for progression to SNM-II should be increased.

Intradetrusor botulinum toxin injections (300 units) for the treatment of poorly compliant bladders in patients with adult neurogenic lower urinary tract dysfunction

AIMS

To evaluate the therapeutic effects of intradetrusor onabotulinum toxin A (BTX) injections in patients with adult neurogenic lower urinary tract dysfunction (ANLUTD) and medically refractory poorly compliant bladders.

METHODS

We retrospectively evaluated patients with urodynamic studies (UDS)-proven, medically refractory impaired bladder compliance (≤20 mL/cm H₂ O) secondary to spinal myelopathy treated with 300 units of BTX cystoscopically injected into the detrusor muscle. Objective improvement in compliance was defined as an increase ≥5 mL/cm H₂ O on repeat urodynamics. Characteristics were compared between patients who demonstrated symptomatic and objective improvement following treatment versus those without.

RESULTS

Seventy-one individuals were included in the final analysis. Mean patient age was 37.2 years (range: 18-78) and ANLUTD duration was 14.5 years (range: 1-34). Average pre-injection bladder compliance was 9.2 mL/cm H₂ O (range: 3.0-16.7). After treatment with BTX, 37 of 71 (52%) patients reported subjective reductions in lower urinary tract symptoms. Repeat UDS demonstrated objective bladder compliance improvements in 22 of 71 (31%). Individuals with shorter time intervals since neurologic injury responded better to BTX than those with longer durations (P = .032).

CONCLUSION

BTX injections significantly improved symptoms and bladder compliance in 31% of ANLUTD patients with medical refractory poorly compliant bladders.

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study

Introduction

Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.

Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk.

Methods

This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother’s linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour.

Results

ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. ‘Clinical Classifications Software’ ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported.

Conclusion

There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners.

Key words

Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol

Correction to: The help for people with money, employment or housing problems (HOPE) intervention: pilot randomised trial with mixed methods feasibility research

[This corrects the article DOI: 10.1186/s40814-018-0365-6.].

The Impact of Age and Deprivation on NHS Payment Claims for Domiciliary Dental Care in England

Domiciliary dental care provides care to patients who are unable to attend dental clinics for a variety of reasons.

OBJECTIVE

This research analyses NHS payment claim data for domiciliary dental care in England to identify any variations by area and determine whether age or deprivation are associated with levels of domiciliary care provided.

METHODS

Publicly available data from the NHS Business Services Authority and demographic data from additional public datasets were linked to assess the variation in claims made for NHS domiciliary activity across England. Associations with factors such as the proportion of older people and deprivation were investigated using correlation, univariable and multivariable regression models.

RESULTS

There was substantial variation by area in the number of NHS payment claims made for domiciliary activity and a statistically significant but very weak positive correlation between the population of each area and the number of domiciliary payment claims made. Correlation, univariable and multivariable analyses demonstrated positive but weak associations between area deprivation measures and the number of claims per population. There was little evidence of an association between proportions of older adults and numbers of domiciliary claims per population.

CONCLUSION

As older and more deprived populations are those most likely to require domiciliary dental care, these results suggest that access to services is variable and not always based upon need. This highlights a potential need to reconsider the criteria upon which this type of dental care is offered and the commissioning of these services in different localities.

The help for people with money, employment or housing problems (HOPE) intervention: pilot randomised trial with mixed methods feasibility research

Background

Job loss, austerity measures, financial difficulties and house repossession contribute to the risk of self-harm and suicide during recessions. Navigating the benefits system and accessing sources of welfare and debt advice is a difficult experience for vulnerable people, further contributing to their distress. Whilst there is some evidence that advice-type interventions can lead to financial gain, there is mixed evidence for their effectiveness in improving mental health in those experiencing financial difficulties. There have been no interventions targeting those who have self-harmed due to economic hardship.

Methods

Our aim was to determine the feasibility and acceptability of a brief psychosocial intervention (the ‘HOPE’ service) for people presenting to hospital emergency departments (ED) following self-harm or in acute distress because of financial, employment or welfare (benefit) difficulties. Nineteen people consented to random allocation to the intervention or control arm on a 2:1 basis. Participants randomised to the intervention arm (n = 13) received up to six sessions of 1:1 support provided by community support staff trained in Motivational Interviewing (MI). Control participants (n = 6) received a one-off session signposting them to relevant support organisations. Fourteen participants were followed up after 3 months. Participants and mental health workers took part in qualitative interviews. The acceptability of outcome measures including the PHQ-9, GAD-7, repeat self-harm, EQ5D-5 L and questions about debt, employment and welfare benefits were explored.

Results

Interviews indicated the main benefits of the service as the resolution of specific financial problems and receiving support when participants were feeling most vulnerable. Randomisation was acceptable to most participants although not always fully understood and control participants could be disappointed. Recruitment was slow (1–2 per month). The outcome measures were acceptable and appeared sensitive to change.

Discussion

The HOPE intervention is feasible and acceptable. There was evidence of need and it is a relatively inexpensive intervention. Refining aspects of the intervention would be straightforward. A full-scale RCT would be feasible, if broadened eligibility criteria led to increased recruitment and improvements were made to staff training and support.

Trial registration

ISRCTN58531248.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0365-6) contains supplementary material, which is available to authorized users.

Is mesenteric defect closure needed in urologic surgery using ileum?

INTRODUCTION

Classic surgical teaching advocates for closure of the mesenteric defect (MD) after bowel anastomosis but the necessity is controversial. We sought to evaluate the necessity of MD closure at the time of harvest of ileum for genitourinary reconstructive surgery (GURS) by analyzing the incidence of early and late gastrointestinal adverse events (GIAE) in patients with and without MD closure.

MATERIALS AND METHODS

A retrospective review was conducted on patients undergoing urologic reconstruction with ileum to identify incidence of ileus, small bowel obstruction (SBO), gastrointestinal (GI) fistula and stoma complications. Patient and procedure variables were analyzed to identify risk factors for GIAE.

RESULTS

A total of 288 patients met inclusion criteria and 93% of GURS was for urinary diversion following cystectomy. MD was closed in 194 cases (67%). Median follow up was 19 months. Early (< 30 day) GIAE rates were 16.5% (n = 32) and 21.3% (n = 20) in the closure and non-closure groups, respectively (p = 0.22). The rate of early ileus/SBO requiring nasogastric tube decompression or laparotomy were similar after closure (15.0%) and non-closure (21.3%) (p = .18). The late GIAE rates were 5.7% (n = 11) and 6.4% (n = 6) in the closure and non-closure cohorts, respectively (p = 0.56). The rate of late SBO were similar and no cases of early or late SBO in either cohort were due to internal herniation. On multivariate analysis, increasing BMI was associated with both early and late GIAE.

CONCLUSIONS

After harvesting ileum for urologic reconstruction, the MD can safely be left open as we found no association between non-closure and early or late GIAE..

HOPE: Help fOr People with money, employment, benefit or housing problems: study protocol for a randomised controlled trial

BACKGROUND

Self-harm and suicide increase in times of economic recession. Factors including job loss, austerity measures, financial difficulties and house repossession contribute to the risk. Vulnerable individuals commonly experience difficulties in navigating the benefits system and in accessing the available sources of welfare and debt advice, and this contributes to their distress. Our aim is to determine the feasibility and acceptability of a brief psychosocial intervention (the "HOPE" service) for people presenting to hospital emergency departments (ED) following self-harm or in acute distress because of financial, employment, or welfare (benefit) difficulties.

METHOD

A pilot study including randomisation will be employed to determine whether it is possible to undertake a full-scale trial. Twenty people presenting to the ED who have self-harmed, have suicidal thoughts and depression and/or are in crisis and where financial, employment or benefit problems are cited as contributory factors will be asked to consent to random allocation to the intervention or control arm on a 2:1 basis. People who require secondary mental health follow-up will be excluded. Those randomised to the intervention arm will receive up to six sessions with a mental health worker who will provide practical help with financial and other problems. The mental health worker will use the motivational interviewing method in their interactions with participants. Control participants will receive one session signposting them to existing relevant support organisations. Participants will be followed up after 3 months. Participants and the mental health workers will take part in qualitative interviews to enable refinement of the intervention. The acceptability of outcome measures including the PHQ-9, GAD-7, repeat self-harm, EQ5D-5L and questions about debt, employment and welfare benefits will be explored.

DISCUSSION

This study will assess whether a full-scale randomised trial of this novel intervention to prevent self-harm among those distressed because of financial difficulties is feasible, including the acceptability of randomisation, potential rate of recruitment and the acceptability of outcome measures.

TRIAL REGISTRATION

ISRCTN58531248.

Less is more-A pilot study evaluating one to three intradetrusor sites for injection of OnabotulinumtoxinA for neurogenic and idiopathic detrusor overactivity

AIMS

To determine if minimizing the number of onabotulinumtoxinA (BTX) injection sites to one to three locations provides similar clinical efficacy and duration of effect compared to the established technique in treating patients with neurogenic (NDO) or idiopathic detrusor overactivity (IDO).

METHODS

Prospective data were collected on BTX naïve patients with NDO or IDO who were intolerant or refractory to oral medications. Patients were treated with 100-300 U of BTX via one to three injection sites. Patients completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) prior to and after treatment. The primary endpoint was defined as ICIQ-SF score improvement of >5 points. Secondary endpoints included subjective success, complete continence, quality of life score, post void residual (PVR), duration of effect and adverse events.

RESULTS

Fourty-five patients (22 IDO, 23 NDO) were included. ICIQ-SF score improvement of >5 points was achieved in 73% (IDO 55%, NDO 91%) and the subjective success rate was 69% (50% IDO, 87% NDO). 52% of NDO patients attained complete continence. PVR increased by a mean of 32 and 156 ml in the IDO and NDO groups. Hematuria occurred in 6.7% and symptomatic urinary tract infection occurred in 11.1%. No systemic BTX adverse events occurred. Mean duration of effect was 31 weeks.

CONCLUSIONS

Our technique for administering BTX via one to three intradetrusor injection sites has similar clinical efficacy and rates of adverse events compared to the established technique for treating patients with IDO and NDO. Neurourol. Urodynam. 36:1104-1107, 2017. © 2016 Wiley Periodicals, Inc.

Cystectomy and Urinary Diversion for the Management of a Devastated Lower Urinary Tract Following Prostatic Cryotherapy and/or Radiotherapy

INTRODUCTION

We investigated the outcomes and quality of life measures in men who underwent cystectomy and urinary diversion for devastating lower urinary tract toxicity after prostatic radiotherapy and/or cryotherapy for the treatment of prostate cancer.

METHODS

Records of patients who underwent cystectomy and urinary diversion for the management of a devastated lower urinary tract following prostatic radiotherapy or cryotherapy were reviewed retrospectively. A postoperative, retrospective quality of life (QOL) survey was designed specific to this patient subset and obtained by telephone interview.

RESULTS

Extirpative surgery with urinary diversion for management of a devastated lower urinary tract was performed on 15 patients with a mean age of 72 years (range 63-82). Toxicities leading to bladder removal included bladder neck contractures, prostatic necrosis, incontinence, osteomyelitis, bladder calculi, fistulae, urethral strictures, abscesses, necrotizing fasciitis, and radiation/hemorrhagic cystitis. The mean number of failed conservative, minimally invasive interventions per patients prior to cystectomy was 3.7 (range 1-12). The average time period from major complication following radiotherapy/cryotherapy to cystectomy was 29.1 months (range 5-65). The QOL survey showed all of the patients who completed the survey (n = 13) would undergo the procedure again and 11 (85%) would have undergone the procedure an average of 13.2 months sooner (range 5-36).

CONCLUSION

Toxicities secondary to prostatic radiotherapy or cryotherapy may be debilitating. Our results demonstrate that cystectomy with urinary diversion can improve QOL in patients with a devastated lower urinary tract.

Sacral neuromodulation outcomes for the treatment of refractory idiopathic detrusor overactivity stratified by indication: Lack of anticholinergic efficacy versus intolerability

INTRODUCTION

Patients may fail oral overactive bladder therapies due to either poor drug efficacy or intolerability. We determined if the success of sacral neuromodulation varies if performed secondary to lack of anticholinergic efficacy versus drug intolerability.

METHODS

A retrospective review was performed on 152 patients undergoing staged sacral neuromodulation from 2004 to 2010 for refractory idiopathic detrusor overactivity with or without urge incontinence. Outcomes following sacral neuromodulation trials were compared based on the primary indication for anticholinergic failure: lack of drug efficacy versus intolerable side effects.

RESULTS

Overall, successful sacral neuromodulation trials were reported in 70% (106/152) of patients. Successful outcomes were noted in 70% (89/128) and 71% (17/24) of patients with poor anti-cholinergic efficacy and drug intolerability, respectively (p = NS).

CONCLUSIONS

We found no significant difference in outcome success in patients undergoing sacral neuromodulation trials for refractory detrusor overactivity due to lack of anticholinergic efficacy versus intolerability.

Lower urinary tract dysfunction in patients with dysautonomia

OBJECTIVE

With the goal of better defining the types of bladder dysfunction observed in this population, we present the chief urologic complaints, results of urodynamic studies, and treatments of patients with dysautonomia-related urinary symptoms.

METHODS

All patients with dysautonomia referred to our neurourology clinic between 2005 and 2015 for management of lower urinary tract dysfunction were retrospectively reviewed. Each patient's chief urologic complaint was recorded and used to initially characterize the bladder storage or voiding symptoms. Patient evaluation included history and physical examination, urinalysis, post void bladder ultrasound, and urodynamic studies. Successful treatment modalities that subjectively or objectively improved symptoms were recorded.

RESULTS

Of 815 patients with the diagnosis of dysautonomia, 82 (10 %) were referred for evaluation of lower urinary tract dysfunction. Mean age was 47 years (range 12-83) and 84 % were female. The chief complaint was urinary urgency ± incontinence in 61 % and hesitancy in 23 % of patients. Urodynamic findings demonstrated detrusor overactivity ± incontinence in 50 % of patients, although chief complaint did not reliably predict objective findings. Successful objective and subjective treatments were multimodal and typically non-operative.

INTERPRETATION

Lower urinary tract dysfunction may develop in at least 10 % of patients with dysautonomia, predominantly females. Bladder storage or voiding complaints do not reliably predict urodynamic findings. Urodynamically, most patients exhibited detrusor overactivity. The majority of patients were successfully managed with medical or physical therapy.

Initial experience with ketamine-based analgesia in patients undergoing robotic radical cystectomy and diversion

INTRODUCTION

We instituted a ketamine-predominant analgesic regimen in the peri- and postoperative periods to limit the effects of narcotic analgesia on bowel function in patients undergoing radical cystectomy. The primary end points of interest were time to return of bowel function, time to discharge, and efficacy of the analgesic regimen.

METHODS

We performed a retrospective chart review of patients undergoing robotic-assisted laparoscopic cystectomy (RARC) with urinary diversion by a single surgeon at our institution from January 1, 2011 to June 30, 2012. Patients receiving the opioid-minimizing ketamine protocol were compared to a cohort of patients undergoing RARC with an opioid-predominant analgesic regimen.

RESULTS

In total, 15 patients (Group A) were included in the ketamine-predominant regimen and 25 patients (Group B) in the opioid-predominant control group. Three patients (19%) in Group A discontinued the protocol due to ketamine side effects. The mean time to bowel movement and length of stay in Group A versus Group B was 3 versus 6 days (p < 0.001), and 4 versus 8 days, respectively (p < 0.001). Group A patients received an average of 13.0 mg of morphine versus 97.5 mg in Group B (p < 0.001).

CONCLUSIONS

Patients who received our ketamine pain control regimen had a shorter time to return of bowel function and length of hospitalization after RARC. Our study has its limitations as a retrospective, single surgeon, single institution study and the non-randomization of patients. Notwithstanding these limitations, this study was not designed to show inferiority of one approach, but instead to show that our protocol is safe and efficacious, warranting further study in a prospective fashion.

Comparison of clinical outcomes between "ideal" and "nonideal" transobturator male sling patients for treatment of postprostatectomy incontinence

OBJECTIVE

To review the clinical outcomes of "ideal" vs "nonideal" postprostatectomy stress urinary incontinence (PPI) patients who underwent male sling placement.

METHODS

The medical records of 95 consecutive patients with PPI who underwent male sling insertion (AdVance male sling, American Medical Systems, Minnetonka, MN) were reviewed. Patients were divided into "ideal" vs "nonideal" cohorts. The ideal group consisted of patients with mild to moderate incontinence (<4 pads/day or <300 g daily pad weight), ability to volitionally contract the external urinary sphincter, no history of pelvic radiation or cryotherapy, no history of previous anti-incontinence surgical procedures, the ability to generate a volitional detrusor contraction when voiding, and a postvoid residual urine volume <100 mL. Patients in the nonideal group did not satisfy all these criteria.

RESULTS

Significant reductions in daily pad usage and weight were noted in both cohorts. In the ideal patient group, 66 of 72 patients (92%) would undergo the procedure again. Conversely, only 7 of 23 nonideal men (30%) would undergo the procedure again.

CONCLUSION

Preoperative patient selection can influence favorable outcomes after the treatment of PPI with AdVance male slings. Attention to ideal vs nonideal patient characteristics should be used when counseling men considering male sling surgery.

Immediate total parenteral nutrition after radical cystectomy and urinary diversion

INTRODUCTION

The purpose of this study is to determine if administration of total parenteral nutrition (TPN) immediately following radical cystectomy and urinary diversion provides significant recovery benefit when compared to patients who did not receive TPN.

METHODS

Retrospective chart review was performed on patients who underwent open radical cystectomy and urinary diversion from February 2002 to June 2010. Patients were divided into 2 cohorts-those who received immediate postoperative TPN and those who did not. Preoperative demographics, length of hospital stay, time until tolerating a regular diet and early postoperative complications of the 2 groups were extracted and compared.

RESULTS

One hundred seventy-four patients (104 receiving TPN, 70 without TPN) were available for analysis. No significant difference in preoperative characteristics, length of hospital stay, estimated blood loss, or time until tolerating a general diet between the 2 groups was noted. With regard to complications, the incidence of bacteremia was significantly higher in the TPN vs non-TPN cohort (9% vs 1%, P < 0.05).

CONCLUSION

Immediate administration of TPN following radical cystectomy and urinary diversion does not provide a significant postoperative benefit and may lead to an increased risk of bacteremia.

V-Loc urethro-intestinal anastomosis during robotic cystectomy with orthotopic urinary diversion

INTRODUCTION

Robotic-assisted radical cystectomy (RARC) is an emerging minimally invasive alternative for the treatment of invasive bladder cancer. The V-loc (Covidien, Mansfield, MA) suture is a unidirectional barbed suture that provides even distribution of tension. We determined the rate of urinary leak at the urethro-intestinal anastomosis following orthotopic neobladder construction performed with V-loc suture.

METHODS

We retrospectively reviewed charts on all patients that underwent RARC with orthotopic neobladder urinary diversion performed with a V-loc suture from February 2010 to February 2012. The urethro-intestinal anastomosis was evaluated for urinary leak by cystogram at 3 to 4 weeks, postoperatively.

RESULTS

In total, 11 patients were available for analysis. The mean patient age was 57.2 years (range: 47-71). The average clinical follow-up was 8 months (range: 4-15). On surgical pathology, 8 (73%) patients had pT2 or less disease, 3 (27%) had pT3/T4 disease, and 1 (9%) had N+ disease. The mean intraoperative blood loss was 315 mL (range: 150-600) and the average operative time was 496 minutes (range: 485-519). No patient (0%) demonstrated a urinary leak at the urethro-intestinal anastomosis on postoperative cystogram. Eight patients (73%) were continent by 4 months, postoperatively.

CONCLUSIONS

Orthotopic neobladder urethro-intestinal anastomosis can be performed effectively and safely with V-loc suture with an acceptably low urinary leak rate.

The utility of abdominal ultrasound during percutaneous suprapubic catheter placement

INTRODUCTION

To evaluate the use of ultrasound (US) at the time of percutaneous suprapubic catheter (SPC) placement. US has been recommended as a way to minimize complications, such as bowel injury, during percutaneous SPC placement, yet there is limited data supporting this recommendation.

MATERIALS AND METHODS

A retrospective chart review was performed on patients undergoing percutaneous SPC placement from 2002 to 2011. The method of percutaneous SPC placement (cystoscopic and/or ultrasound guidance, blind) was recorded and patients were subdivided into groups based on the use of US. The need to modify the approach based on US findings and complications such as bleeding or bowel injury were noted and compared between groups.

RESULTS

A total of 307 percutaneous SPCs were placed: cystoscopy alone was used in 190 (62%) patients, cystoscopy + US in 86 (28%) patients, US alone in 6 (2%) patients, and 25 (8%) patients had the SPC placed blindly. Previous lower abdominal surgery was noted in 41/92 (45%) of patients with and 32/215 (15%) of patients without US usage. US identified intervening loops of bowel in 5/92 cases (5%), all of whom had a history of lower abdominal surgery. The approach was modified in 2/5 and abandoned in 3/5 based on US findings. Postoperative bleeding occurred in 1/215 (0.5%) of patients with and 1/92 (1%) of patients without US usage. No bowel injuries occurred.

CONCLUSIONS

While US may not be needed in most patients, particularly when cystoscopy is used, it may help to avoid bowel injury in patients with a history of lower abdominal surgery.

Transitioning adolescents and young adults with a chronic health condition to adult healthcare - an exemplar program

Pediatric specialists have successfully improved the longevity and quality of life of many children with chronic health conditions. As these children reach adolescence and young adulthood, the scope of their concomitant medical problems often include those typically seen in older patients. As a result, these individuals need continuing quality health care in focused adult healthcare facilities. This article describes the effective partnership between pediatric and adult healthcare providers to create and implement an exemplar Spina Bifida Transition Program. The processes, strategies and tools discussed are likely to be useful to other healthcare professionals interested in developing pediatric to adult transition programs for adolescents and young adults with chronic health conditions.

Duloxetine for the treatment of post-prostatectomy stress urinary incontinence

OBJECTIVES

Stress urinary incontinence (SUI) is a known complication following prostatectomy. Duloxetine, a combined serotonin/norepinephrine reuptake inhibitor, can decrease SUI by increasing urethral sphincter contractility. We examined the outcomes of patients with mild to moderate post-prostatectomy SUI treated with duloxetine.

METHODS

We conducted a retrospective review of men treated with duloxetine to manage mild to moderate post-prostatectomy SUI from 2006 to 2012. All patients received oral duloxetine 30 mg once a week, then 60 mg thereafter. Patients were seen one month later to determine drug efficacy and side effects.

RESULTS

In total, 94 men were included in the study. Daily pad usage decreased from 2.9 (range: 1-5) to 1.6 (range: 0-4) (p < 0.05). Incontinence Impact Questionnaire (IIQ-7) scores decreased from 13.0 (range: 6-18) to 7.9 (range: 2-16) (p < 0.05). Linear satisfaction scores improved from 0.8 (range: 0-2) to 2.0 (range: 1-3) (p < 0.05). Following a 1-month duloxetine trial, 33/94 (35%) men reported satisfactory SUI improvement and requested to continue the medication. The drug was discontinued in 61/94 (65%) patients due to poor efficacy in 32/94 (34%), intolerable side effects in 14/94 (15%) or both in 15/94 (16%). Reported side effects included fatigue, light-headedness, insomnia, nausea and dry mouth.

CONCLUSIONS

Duloxetine improved post-prostatectomy SUI in 47/94 (50%) men following a 1-month trial. However, only 33/94 (35%) patients were able to tolerate the drug. Duloxetine may be considered a treatment option for men with mild to moderate post-prostatectomy SUI.

Intimate partner abuse and suicidality: a systematic review

Research has demonstrated an association between intimate partner abuse and suicidality, presenting a serious mental health issue. However, studies have differed widely in the samples and methods employed, and in the depth of the investigation. Given the level of heterogeneity in the literature, this systematic review examines, for the first time, the nature of the relationship between intimate partner abuse and suicidality. The three main psychological and medical databases (PsychInfo 1887-March 2011; Medline, 1966-March 2011; Web of Knowledge 1981-March 2011) were searched. Thirty-seven papers on the topic of intimate partner abuse and suicidality were found. With only one exception, all of the studies found a strong and consistent association between intimate partner abuse and suicidality. Significantly, this relationship held irrespective of study design, sample and measurement of abuse and suicidality, thus demonstrating a consistently strong relationship between intimate partner abuse and suicidality. This review highlights that intimate partner abuse is a significant risk factor for suicidal thoughts and behaviours, which has important clinical implications.

Antimuscarinic drugs: review of the cognitive impact when used to treat overactive bladder in elderly patients

The blockade of muscarinic receptors in the management of overactive bladder (OAB) symptoms provides beneficial as well as adverse effects. The cognitive changes observed are caused by the drugs' ability to cross the blood-brain barrier and bind to muscarinic receptors within the central nervous system (CNS). To date, while not specifically testing for CNS side effects, most of the controlled efficacy trials of multiple OAB medications have not shown significant adverse effects on cognitive function. However, elderly individuals, in whom OAB is more prevalent, often are excluded from these studies. The few trials that have performed cognitive testing in healthy elderly people taking antimuscarinics have clearly shown that oxybutynin can adversely affect cognition. Darifenacin, trospium, solifenacin, and tolterodine appear to have little to no risk of causing CNS side effects in this population. However, caution needs to be used in elderly patients with preexisting dementia.

Outcomes of grafted bulbar urethroplasty in men with class II or III obesity

OBJECTIVE

To evaluate the outcomes of grafted bulbar urethroplasty in class II or III obese patients.

MATERIAL AND METHODS

Retrospective chart review was performed for men with World Health Organization class II/III obesity undergoing grafted urethroplasty for management of bulbar strictures from 2003-2010. Extracted data included age, body mass index (BMI), stricture etiology, stricture length/location, number/type of previous therapies, definitive therapy, follow-up, outcome, and complications. Outcomes were compared with a cohort of 20 age-matched nonobese men with bulbar strictures managed with grafted urethroplasty.

RESULTS

Fifteen class II/III obese men were included in the study. Obese patient age (43.8 years, range 27-60) and BMI (44.0 kg/m(2), range 35-57) were averaged. Each patient reported a mean of 3.8 previous dilations or urethrotomies (range 0-9). All men were treated with grafted bulbar urethroplasty (11 ventral, 4 dorsal) with oral mucosa (13 buccal, 2 lingual). After a mean follow-up of 29.4 months (range 7-62), the urethral patency rate was 66.7% (10/15). Complications included prolonged urethral leak in 5/15 (33%) and wound infection in 5/15 (33%) patients. Urethral patency rates and complications were significantly higher in class II/III obese patients when compared with the nonobese cohort.

CONCLUSION

Obese men demonstrated poorer outcomes after grafted bulbar urethroplasty when compared with published success rates in the general population as well as an aged-matched, nonobese cohort from our institution. Prior failed endoscopic procedures and other medical comorbidities may have also contributed to the observed results in this patient population.

Endoscopic ablation of Hunner's lesions in interstitial cystitis patients

INTRODUCTION

We report our experience with endoscopic ablation of Hunner's lesions in women with interstitial cystitis (IC).

METHODS

A chart review was performed on 14 patients with IC symptoms who were identified to have bladder lesions and underwent endoscopic ablation. A Hunner's lesion was identified as an area of erythema that reproduced the patients' pain when touched by the cystoscope. Pathology reports were reviewed and improvement in pain was used as the main outcome measure.

RESULTS

Of the 14 patients, 12 had more than 50% symptomatic improvement and 8 patients reported 100% improvement. Mean improvement was 76%. In all patients who improved, the biopsy specimen showed inflammatory cystitis, often with epithelial denudation. Four patients had symptomatic recurrence, but all had improvement after repeat ablation.

CONCLUSION

Endoscopic ablation of Hunner's lesions improves symptoms in IC patients. Recurrence of symptoms should prompt repeat cystoscopy to identify recurrent lesions, as repeat ablation offers symptomatic improvement.

Successful use of sacral neuromodulation after failed bladder augmentation

Sacral neuromodulation has become a standard minimally invasive therapy for refractory urinary urge/frequency and urge incontinence. Prior to the widespread use of sacral neuromodulation, augmentation cystoplasty was a standard treatment for refractory overactive bladder (OAB). The use of sacral neuromodulation following bladder augmentation has not been previously reported in the literature. We report 2 cases of successful sacral neuromodulation in patients with OAB refractory to bladder augmentation.

Assessment and management of irritative voiding symptoms

Irritative voiding symptoms are to the urinary tract much as a cough is to the pulmonary system, that is, a nonspecific manifestation of multiple potential underlying causes. Key to the evaluation and management of patients with these symptoms is a clear understanding of the differential diagnosis, the diagnostic tests required for evaluation, and the role of specialists in diagnosis and treatment. This article outlines a general diagnostic approach for patients with irritative voiding symptoms. Treatment approaches for the diseases, as well as the initial management that may be performed in the primary care setting, are also discussed.

Unilateral versus bilateral stage I neuromodulator lead placement for the treatment of refractory voiding dysfunction

AIMS

To determine if bilateral S3 lead placement during the stage I trial period improves the "success" rate for advancing to stage II (permanent) sacral neuromodulator placement.

METHODS

A retrospective chart review of 124 (20 male and 104 female) patients undergoing stage I sacral neuromodulation (InterStim, Medtronic, Minneapolis, Minnesota) implantation for the treatment of refractory voiding dysfunction was performed. Patients were divided into two cohorts based on unilateral versus bilateral stage I lead placement in the S3 foramina. Both groups were then evaluated and compared with regards to overall "success", defined as progression from stage I to stage II placement.

RESULTS

Fifty-five (44%) patients underwent unilateral stage I lead placement and 69 (56%) received bilateral S3 leads. Successful stage I trials were reported in 32/55 (58%) and 53/69 (76%) of unilateral and bilateral cohorts, respectively (P = 0.03). Five wound infections were reported-2 (3.6%) following unilateral and 3 (4.3%) after bilateral stage I lead placement. No other complications were encountered.

CONCLUSIONS

Bilateral stage I neuromodulation trial provides a significantly higher rate of improvement in refractory voiding symptoms to allow for the progress to stage II implantation.

Recutting prostate needle core biopsies with high grade prostatic intraepithelial neoplasia increases detection of adenocarcinoma

OBJECTIVES

We sought to evaluate the ability of biopsy core recutting to increase cancer detection in patients with high grade prostatic intraepithelial neoplasia (HGPIN).

METHODS

This prospective study encompasses all patients undergoing 12 core TRUS guided prostate biopsy between February 2004 and January 2007. In patients with HGPIN on initial biopsy, the paraffin blocks were resampled for cancer by additional deeper levels per core. Additional analysis was performed in the patients with HGPIN in order to detect whether significant differences in prebiopsy variables were associated with patients subsequently found to have benign versus carcinoma on recutting. Last, the costs associated with this procedure were studied.

RESULTS

Forty of 584 (6.8%) patients undergoing prostate biopsy were found to have HGPIN in the absence of prostatic adenocarcinoma on initial histopathology. Following recutting, 12.5% (5/40) of these patients were found to have prostatic adenocarcinoma not previously detected. Of the remaining 35 patients, 18 underwent repeat biopsy. Of these, five patients were found to have adenocarcinoma and three were found to have persistent HGPIN. The PSA, PSA density (PSAD), and PSA velocity (PSAV) prior to initial biopsy were not statistically different when comparing patients found to have benign tissue versus carcinoma on recutting. In patients with HGPIN, at our institution, recutting the biopsy would yield a cost savings of $436/patient as opposed to universal rebiopsy.

CONCLUSIONS

Our data suggest that prostate biopsy recutting may increase cancer detection in patients initially found to have HGPIN. Additionally, a significant cost savings is associated with the recutting protocol.

Characteristics of infections in patients undergoing staged implantation for sacral nerve stimulation

OBJECTIVES

To review clinical and surgical factors in patients who have undergone staged sacral nerve stimulator implantation and to determine whether there are any identifiable risk factors for infection.

METHODS

A retrospective chart review was performed on 76 consecutive patients undergoing staged implantation for sacral nerve stimulation for voiding dysfunction. Patients with postprocedural wound infections (after Stage 1 or Stage 2) were compared with those without infections with regard to demographic factors and surgical characteristics, such as operative time and duration of exposed lead wire. Organisms cultured were also documented.

RESULTS

Lead infection occurred in 9 of 76 patients (12%). All cultures grew Staphylococcus aureus. Of 9 patients with lead infection, 6 had organisms sensitive to their perioperative antibiotic. Forty-five patients had an implantable pulse generator implanted, and 5 infections occurred (11%). Four cultures grew S. aureus (all sensitive to the perioperative antibiotic given), whereas one grew Pseudomonas. The only significant difference in clinical/surgical characteristics between infected and noninfected patients was a longer operative time for Stage 2 in infected patients. In addition, 3 patients with infection had one or more known risk factors for wound infection (steroid use, severe psoriasis, recurrent skin abscess).

CONCLUSIONS

Apart from known risk factors for surgical wound infections, the only variable we could identify that might increase the risk for infection is a longer operative time for Stage 2. S. aureus was the organism most commonly cultured. Often it was sensitive to the perioperative antibiotic prophylaxis.

Review of female stress urinary incontinence

Stress urinary incontinence (SUI) is a common problem affecting up to 35% of the female population. SUI results from a laxity of the pelvic floor anatomy, neuromuscular injury of the external urinary sphincter mechanism or both. Evaluation of the condition includes careful history, physical examination and urine analysis. Additional tests such as urodynamic studies and cystoscopic inspection are determined on a case by case basis. Treatment options range from behavior modification to medications to surgery. We present a review of the incidence, pathophysiology, evaluation and medical/surgical treatment options for SUI.

Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?

OBJECTIVE

We sought to determine if there are differences in clinical and urodynamic parameters between women with urge predominant and those with stress predominant mixed urinary incontinence (MUI).

METHODS

Charts of 99 female patients with complaints of MUI were reviewed. Patients were divided into two groups based on the subjective predominance of either stress incontinence (MSUI) or urge incontinence (MUUI). All patients completed a subjective evaluation including an AUA Symptom Index, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Objective non-invasive measures included physical exam, 48-hr voiding diary, and a 24-hr pad test. Videourodynamics studies (VUDS), performed in all patients, were reviewed and the presence and characteristics of detrusor overactivity (DO) and stress incontinence were noted.

RESULTS

There were no significant differences between groups with respect to symptom scores. MUUI patients had significantly higher pad usage, and lower maximum and average voided volumes than MSUI patients. They were also more likely to have lower urodynamic bladder capacities and demonstrable DO (70% vs. 26%) on VUDS with contractions occurring at lower bladder volumes and with higher amplitude. MSUI patients were more likely to have demonstrable SUI on physical examination (63% vs. 16%) and on VUDS (100% vs. 61%).

CONCLUSIONS

There do appear to be differences in clinical and urodynamic parameters between patients with stress predominant and urge predominant MUI. These may help to determine which component of the mixed incontinence is more problematic.

Artificial urinary sphincter placement in elderly men

OBJECTIVES

To evaluate the outcomes of primary artificial urinary sphincter (AUS) placement for the treatment of postprostatectomy stress urinary incontinence in patients aged 75 years or older at surgery.

METHODS

From September 1987 through June 2005, 33 men aged 75 years or older underwent AUS insertion for postprostatectomy stress urinary incontinence. Through retrospective chart review and personal/family interview, the patients' outcomes with regard to continence, complications, and the need to deactivate the AUS for medical or social reasons were determined.

RESULTS

Four patients were lost to follow-up and were excluded from the analysis. The mean patient age was 77.6 years (range 75 to 83). The average follow-up was 5.0 years (range 1 to 11). After AUS insertion, the mean pad use improved from 6.7 (range 3 to 10) to 0.8 (range 0 to 2) per day. Overall, 16 (55%) of 29 men reported no complications. AUS revision was necessary in 4 men (14%), and sphincter removal in 4 (14%). Six men (21%) required deactivation of the implant because of poor overall health an average of 47 months after placement. The "success" rate improved to 72% (21 of 29 men) when cuff deactivation without revision or removal was not considered a complication.

CONCLUSIONS

In our study, elderly men did well after AUS placement for postprostatectomy stress urinary incontinence. The procedure should not be withheld solely on the basis of the age of the patient.

Early outcomes of mid-urethral slings for female stress urinary incontinence stratified by valsalva leak point pressure

AIMS

To assess the early results of mid-urethral slings placed via the transobturator approach (TVT-O) for stress urinary incontinence (SUI) in women with high (>60 cm H(2)O) and low (<or=60 cm H(2)O) valsalva leak point pressure (VLPP).

MATERIALS AND METHODS

Forty-three women with urodynamically proven SUI underwent TVT-O. Patients were divided into either high (>60 cm H(2)O) or low (<or=60 cm H(2)O) VLPP categories based on preoperative urodynamic studies. Patient outcomes were assessed based on degree of postoperative SUI as either dry (no pads, no SUI), or wet (any leakage). Follow-up visits were at 1, 6, 12, and 24 weeks.

RESULTS

Overall, 65% (28/43) women were cured following TVT-O for SUI. When stratified based on preoperative VLPP, 77% (24/31) of patients with VLPP greater than 60 were cured while only 25% (3/12) of patients with VLPP less than or equal to 60 were cured. No intraoperative complications were noted. The odds of continued SUI following TVT-O were 12 times greater for women with VLPP <or=60 compared to those with VLPP >60.

CONCLUSIONS

With limited follow up, TVT-O appears to be a safe and effective surgical treatment for female SUI producing excellent results in patients with VLPP >60 cm/H(2)0. Patients with low VLPP may consider conventional, retropubic mid-urethral slings or other procedures as treatment for SUI.

Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet

OBJECTIVES

To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets.

METHODS

A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications.

RESULTS

With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively.

CONCLUSIONS

High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

Complications after cystectomy and urinary diversion in patients previously treated for localized prostate cancer

OBJECTIVES

To assess the morbidity associated with radical cystectomy in patients who had previously undergone definitive treatment of prostate cancer.

METHODS

A retrospective review was undertaken, identifying 35 patients undergoing radical cystectomy with a previous history of radical prostatectomy and/or radiotherapy for prostate cancer. The clinical and surgical information was analyzed to assess patient outcomes. Specific attention was given to the rate, severity, and time course of the postoperative complications. In addition, outcomes after orthotopic and continent cutaneous diversion in this patient cohort were examined.

RESULTS

An overall complication rate of 76% was seen in this patient cohort, with 47% of patients experiencing a complication that presented later than postoperative day 30. Radiotherapy was associated with a slightly greater complication rate compared with radical prostatectomy monotherapy (77% versus 71%). Continent urinary diversion (n = 14) was associated with increased morbidity compared with ileal conduit diversion (n = 21). However, a greater percentage of the complications occurring in patients undergoing ileal conduit diversion were major (80% versus 67%).

CONCLUSIONS

Our experience has suggested that radical cystectomy in patients previously treated for prostate cancer with radiotherapy and/or radical prostatectomy may be associated with a greater level of morbidity than previously reported. This finding may be, in part, because a significant portion of complications present in a delayed fashion and, as such, have not been seen in previous reports with limited follow-up. For this reason, careful consideration of these risks is necessary when counseling this patient cohort regarding the decision to undergo radical cystectomy.

Vesicostomy revisited: the best treatment for the hostile bladder in myelodysplastic children?

OBJECTIVE

To evaluate the effects of vesicostomy on the urinary tract of myelodysplastic children in whom conservative bladder management with clean intermittent catheterization (CIC) has failed to preserve upper and lower urinary tract function.

PATIENTS AND METHODS

Sixteen children with myelodysplasia underwent vesicostomy. Indications included worsening hydronephrosis, vesico-ureteric reflux (VUR), recurrent urinary tract infections (UTIs), and increasing renal insufficiency despite CIC and/or difficulty with CIC. The mean (range) age at vesicostomy was 36.5 (9-82) months and the follow-up 7.4 (2-16) years.

RESULTS

Hydronephrosis resolved or improved in 12 of 14 children, the incidence of UTI decreased to one or fewer per year in 10, VUR resolved or improved in nine, and renal function improved or stabilized in six of seven patients. One patient initially presented with renal insufficiency and subsequently required dialysis despite vesicostomy. Complications occurred in three of 15 children, and included stomal stenosis and bladder calculi. The vesicostomy was closed in six patients after a mean of 4.4 (1.5-9) years. Four of these patients required concomitant bladder augmentation.

CONCLUSIONS

Vesicostomy in myelodysplastic children is effective in preventing and/or resolving the deleterious consequences of a 'hostile' bladder. The procedure is uncomplicated, well tolerated, reversible and should be considered in managing children in whom conservative management by CIC has failed.