Achievement Of Urinary Continence Research Articles

Substantial incidence of bladder dysfunction in patients with VACTERL association: Implications for surveillance.

VACTERL association is defined as the nonrandom co-occurrence of a minimum of three of the following six key components: Vertebral anomalies, Anal atresia, Cardiac malformations, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities. Patients presenting with two components may also belong in the same spectrum. Additional components have been associated with VACTERL defects, including single umbilical artery, tethered spinal cord (TSC), and genital malformations. We observed a significant proportion of patients with bladder dysfunction (often called neurogenic bladder in the medical record) when reviewing a cohort of patients with VACTERL defects at our clinical center. Our finding calls attention to bladder dysfunction as an additional VACTERL phenotypic component. The prevalence of bladder dysfunction is greatest in those with genital anomalies, anorectal malformations, sacral dysplasia, renal anomalies, and TSC. We propose that patients with two or more VACTERL malformations be monitored for symptoms of bladder dysfunction if one or more of the identified risk factors are present until the achievement of urinary continence.

Intraoperative laser angiography in bladder exstrophy closure: A simple technique to monitor penile perfusion

The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach. We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition. This will reduce the risk of tissue compression and potential loss of penile tissue that has been reported to occur as a complication of the procedure. Consecutive patients presenting with bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (ICG) at a dose of 1mg per 10kg body weight. Measurements were taken at 80s post infusion and the medial thigh served as the reference control. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure. Eight consecutive patients were included in this study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion increased slightly following bladder dissection. Internal rotation of the hips with apposition of the symphysis pubis resulted in an average 50% reduction in penile blood flow. Patients undergoing CPRE experienced an additional mean 33% drop in blood flow. In all eight cases the penis was symmetric and healthy with no sign of tissue loss at three months follow up. This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion is markedly reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair. Future correlation with measures of penile viability and function are needed to define the clinical utility of this modality.

Clinical significance and risk factors of urethrovesical anastomotic urinary leakage following robot-assisted radical prostatectomy: a multi-institutional study

BackgroundThere has been a limited number of reports on the significance and risk factors of urethrovesical anastomotic urinary leakage (AUL) following robot-assisted radical prostatectomy (RARP). We aimed to analyze the clinical significance of AUL and evaluated its risk factors.MethodsWe conducted a multi-institutional study to review patients with prostate cancer undergoing RARP in three centers (The University of Tokyo Hospital, Mitsui Memorial Hospital, and Chiba Tokushukai Hospital). “Positive AUL” was defined as urinary extravasation at the anastomosis detected by post-operative cystogram and was further categorized into minor or major AUL. Univariate and multivariate analyses were performed to identify predictors of AUL. Postoperative continence rates and time to achieve continence were also analyzed.ResultsA total of 942 patients underwent RARP for prostate cancer in 3 centers. Of these patients, a cystogram after the RARP procedure was not performed in 26 patients leaving 916 patients for the final analysis. AUL was observed in 56 patients (6.1%); 34 patients (3.7%) with minor AUL and 22 patients (2.4%) with major AUL. Patients with major AUL exhibited a significantly longer time to achieve continence than those without major AUL. Multivariate analysis demonstrated that longer console time (≥ 184 min) was significantly associated with overall AUL, and higher body mass index (≥ 25 g/kg2) was a significant predictor of both major and overall AUL.ConclusionsThe presence of major AUL was associated with the achievement of urinary continence, suggesting clinical relevance of its diagnosis by postoperative cystogram. A selective cystogram has been proposed for high-risk cases. Furthermore, identification of the risk factors of AUL will lead to optimal application.

The preoperative pad test as a predictor of urinary incontinence and quality of life after robot-assisted radical prostatectomy: a prospective, observational, clinical study.

To assess whether the preoperative 1-h pad test could predict postoperative urinary incontinence and quality of life after robot-assisted radical prostatectomy. A total of 329 patients who underwent robot-assisted radical prostatectomy between 2013 and 2016 were prospectively enrolled in this study. These patients were divided into the preoperative urinary continence group and the preoperative urinary incontinence group according to the 1-h pad test. The time to achieve urinary continence, lower urinary tract function evaluated by uroflowmetry and post-voided residual urine volume, and quality of life evaluated by King's Health Questionnaire and International Consultation on Incontinence Questionnaire-Short Form were compared between these two groups. There were 190 patients (58%) in the preoperative urinary continence group (1-h pad test ≤ 2g) and 139 patients (42%) in the preoperative urinary incontinence group (1-h pad test > 2g). In the preoperative urinary continence/incontinence groups, 83%/76% of patients achieved continence within 12months, respectively, and urinary incontinence remained significantly longer in the preoperative incontinence group than in the preoperative continence group (P = 0.042). Although there were no significant differences in all quality of life items between the two groups before surgery, several items were significantly higher in the preoperative urinary continence group. Achievement of urinary continence and improvement of urinary quality of life are delayed in patients with preoperative urinary incontinence assessed by the 1-h pad test. The preoperative 1-h pad test could be a useful predictor of prolonged urinary incontinence and poor quality of life after robot-assisted radical prostatectomy.

Achieving urinary continence in children

Achievement of urinary continence is an important developmental step that most children attain with the assistance of their parents and caregivers. Debate continues as to the best time to toilet train; in some Asian and African cultures children are trained as infants, while training at age 2-3 years is more typical in Western cultures. Infant voiding is not merely a spinal reflex, as the sensation of bladder filling is relayed to the brain. However, the ability of the brain to inhibit bladder contractions, and to achieve coordinated bladder contraction with sphincter relaxation, matures over time. While there is a concern that later toilet training may be responsible for an increase in urinary incontinence in children, no controlled studies on early versus late toilet training exist to evaluate this hypothesis. A number of medical conditions such as spina bifida, posterior urethral valves, cerebral palsy and autism can cause incontinence and difficulties in toilet training. The decision to start toilet training a child should take into account both the parents' expectation of how independent the child will be in terms of toileting, and the child's developmental readiness, so that a realistic time course for toilet training can be implemented.

Operative Therapie der weiblichen Harninkontinenz unter Berücksichtigung sexualitätsrelevanter Strukturen

An evaluation of surgical treatment modalities for urinary incontinence shows that loop plasties are easy to use and with good short-term results with regard to achievement of urinary continence. However, in the light of reports of serious complications and the lack of long-term results, this indication must be reconsidered. In the framework of prolapse surgery Burch's colposuspension with sarcopexy and, possibly, rectopexy represents the standard therapy. Laparoscopic procedures are currently being evaluated. Experimental concepts such as, for example, tissue engineering for the reconstruction of a damaged sphincter apparatus or the use of hyaluronic acid as a bulking agent are potential procedures for the treatment of stress incontinence that need investigation, especially since these methods will probably not have visible negative impacts of the female patient's sexual function. What we need is an interdisciplinary project like that currently practiced in the German Centre for Pelvic Surgery. Objectives are the preservation and reattainment for female sexuality in the course of operations to achieve urinary continence and other pelvic interventions.

Strategies in urological reconstruction in myelomeningocele.

This paper reviews recent advances in the strategies for urinary tract reconstruction in children with spina bifida. The aims of reconstruction are the preservation of renal function and achievement of urinary continence. Considerable controversy exists on the subjects of bladder augmentation, procedures to increase outlet resistance, and continent stomas. The authors put the most recently published information in perspective in the light of their own personal experience. Thirty-seven papers covering the above-mentioned subjects published in the past 5 years (25 of them published since 2000) have been selected. Seven relevant older references are included. There is persistent interest in developing methods to enlarge the urinary bladder that avoid bringing the urine in contact with the intestinal mucosa. The artificial urinary sphincter and fascial slings are the most frequently reported methods to increase outlet resistance. The Mitrofanoff principle continues to be regarded as an effective method to construct a continent catheterizable channel, either with the appendix or reconfigured intestinal segments. The achievement of fecal continence has to be pursued in parallel with urinary continence. Incontinent diversions continue to be best for a small group of patients. The role of continent urinary diversion requires reassessment. Progress in this area continues to be made. Periodic, critical and objective reviews on the subject should help the practitioner to arrive at sound decisions.

The endoscopic treatment of incontinence in children.

The achievement of urinary continence in children may be very difficult with some congenital malformations of the lower urinary tract, such as bladder exstrophy, or in some neurogenic dysfunctions, such as neuropathic bladder. Endoscopic injection of bulging substances into the bladder neck or posterior urethra may be regarded as a minimally invasive procedure that may provide a better dry interval in these patients. Endoscopic treatment can be performed as either a primary or adjunctive procedure after open bladder neck surgery. It is also of use to increase the functional bladder capacity in some children. Although longer follow-up is wise, results so far are encouraging. The search for a safe and reliable substance to use is still ongoing, and the new available biodegradable implants seem adequate.

Modified Young-Dees-Leadbetter bladder neck reconstruction in patients with successful primary bladder closure elsewhere: a single institution experience.

Achievement of urinary continence in patients with the exstrophy-epispadias complex remains a challenge. We reviewed our experience with the modified Young-Dees-Leadbetter bladder neck repair in patients with bladder exstrophy who underwent primary bladder closure elsewhere. We retrospectively reviewed exstrophy charts and database of 57 male and 11 female with classic bladder exstrophy who underwent bladder neck repair at our institute and successful primary bladder closure elsewhere during the last 2 decades. Osteotomy was performed at primary closure in 14 (20%) cases and 9 (13%) patients at bladder neck repair in 9 (13%) to aid in stabilizing the urethra and pelvic ring, and to help reapproximate the pelvic floor musculature facilitating urinary continence. Primary closure was done within 72 hours of life elsewhere in 41 (60%) patients, and between ages 72 hours and 5 years (most during the first month of life) in 27. Paraexstrophy skin flaps were used in 33 (48%) cases, and the most common complication was bladder outlet obstruction of the posterior urethra secondary to the skin flaps. Of the 68 patients 57 (83%) are continent and voiding per urethra without need for augmentation or clean intermittent catheterization, 9 (13%) required clean intermittent catheterization including 7 who underwent continent urinary diversion after failed bladder neck repair, and 2 are still incontinent due to a severe posterior urethral stricture. Urinary retention was the most common symptom after bladder neck repair which resolved following catheter dilation or prolonged suprapubic catheter drainage. Successful early primary closure of a good bladder template is the most important determinant of eventual bladder capacity and compliance.

MODIFIED YOUNG-DEES-LEADBETTER BLADDER NECK RECONSTRUCTION IN PATIENTS WITH SUCCESSFUL PRIMARY BLADDER CLOSURE ELSEWHERE: A SINGLE INSTITUTION EXPERIENCE

Achievement of urinary continence in patients with the exstrophy-epispadias complex remains a challenge. We reviewed our experience with the modified Young-Dees-Leadbetter bladder neck repair in patients with bladder exstrophy who underwent primary bladder closure elsewhere. We retrospectively reviewed exstrophy charts and database of 57 male and 11 female with classic bladder exstrophy who underwent bladder neck repair at our institute and successful primary bladder closure elsewhere during the last 2 decades. Osteotomy was performed at primary closure in 14 (20%) cases and 9 (13%) patients at bladder neck repair in 9 (13%) to aid in stabilizing the urethra and pelvic ring, and to help reapproximate the pelvic floor musculature facilitating urinary continence. Primary closure was done within 72 hours of life elsewhere in 41 (60%) patients, and between ages 72 hours and 5 years (most during the first month of life) in 27. Paraexstrophy skin flaps were used in 33 (48%) cases, and the most common complication was bladder outlet obstruction of the posterior urethra secondary to the skin flaps. Of the 68 patients 57 (83%) are continent and voiding per urethra without need for augmentation or clean intermittent catheterization, 9 (13%) required clean intermittent catheterization including 7 who underwent continent urinary diversion after failed bladder neck repair, and 2 are still incontinent due to a severe posterior urethral stricture. Urinary retention was the most common symptom after bladder neck repair which resolved following catheter dilation or prolonged suprapubic catheter drainage. Successful early primary closure of a good bladder template is the most important determinant of eventual bladder capacity and compliance.

Complete Male Epispadias: Genital Reconstruction and Achieving Continence

We report on 15 patients who were primarily treated for complete male epispadias at our institution since 1975. Repair of epispadias was performed using a modified Young urethroplasty in 13 patients and a Cantwell-Ransley urethroplasty in 2. In addition, 2 patients underwent a Cantwell-Ransley urethroplasty with chordee repair after a previous Young urethroplasty failed. Bladder capacity increased from a mean of 50 cc before repair to 92 cc after urethroplasty. A urethrocutaneous fistula developed in 6 cases, including 5 Young repairs and 1 Cantwell-Ransley. Three fistulas resolved spontaneously and there were no urethral strictures. Bladder neck reconstruction was performed in 11 patients. Time to initial continence ranged from 21 days to 6 months (mean 3 months) postoperatively. All patients attained daytime continence in a mean of 9 months (range 21 days to 24 months) after bladder neck reconstruction, including 9 of 11 (82 percent) who achieved total day and night continence. Mean followup was 7 years (range 1 to 10). Modern treatment of complete male epispadias allows for an excellent genital appearance and achievement of urinary continence.

The Importance of Catheter Size in the Achievement of Urinary Continence in Patients Undergoing a Young-Dees-Leadbetter Procedure

During the last 8 years 49 patients have undergone urinary tract reconstruction at our institution to manage urinary incontinence. Of these patients 25 underwent a Young-Dees-Leadbetter procedure, of whom 13 boys and 6 girls were available for followup. Average patient age was 12.2 years and mean followup is 30.2 months. Augmentation cystoplasty was required in 14 cases. All 12 patients (100%) undergoing tubularization over an 8F catheter attained diurnal continence, and 92% are completely continent day and night. Furthermore, the 6 patients in whom augment capacities attained were less than the expected volume for age were also completely continent when tubularization was performed over an 8F catheter. We conclude that creation of a narrow (8F) Young-Dees-Leadbetter bladder neck tubularization leads to an increased likelihood of diurnal and nocturnal continence but precludes spontaneous unaided voiding to completion. Furthermore, achievement of urinary continence appears to be less dependent on bladder capacity when it is coupled with a narrow Young-Dees-Leadbetter tubularization.

The Importance of a Successful Initial Bladder Closure in the Surgical Management of Classical Bladder Exstrophy: Analysis of 144 Patients Treated at the Johns Hopkins Hospital Between 1975 and 1985

The staged functional closure of classical bladder exstrophy has produced improved results for many urologists involved in the surgical management of this congenital anomaly. To determine which factors are most important for achieving a successful outcome (urinary continence with preservation of normal renal function) the 144 patients treated at The Johns Hopkins Hospital between 1975 and 1985 were reviewed. Of these patients 51 were managed entirely at our institution, while 93 had had the initial surgical treatment elsewhere.All patients who had undergone primary bladder closure and bladder neck reconstruction were divided into 2 groups: group 1—patients who had a successful initial bladder closure (an exstrophied bladder that is converted into a complete epispadias without wound infection, dehiscence or any degree of bladder prolapse on the first attempt) and group 2—children whose initial bladder closure was not successful. Both groups were analyzed with respect to bladder capacity at the time of bladder neck reconstruction, time required for the bladder to become sufficiently large for bladder neck reconstruction, urinary continence rate, and interval between bladder neck reconstruction and achievement of urinary continence. Patients in group 1 had the largest bladders at the time of bladder neck reconstruction (mean capacity 79cc, p equals 0.03), shortest intervals between primary closure and bladder neck reconstruction (mean 3.5 years, p equals 0.006), highest urinary continence rate (92 per cent, p equals 0.002), and the shortest interval between bladder neck reconstruction and achievement of urinary continence (mean 1.5 years, p equals 0.18).These findings suggest that a successful initial bladder closure is an important factor for obtaining a larger bladder more quickly and for achieving a high urinary continence rate in patients with classical bladder exstrophy undergoing the staged functional bladder closure.