Adequate Bladder Capacity Research Articles

Achieving goal capacity for continence surgery: A cumulative event analysis of bladder exstrophy patients

Following successful closure of patients with classic bladder exstrophy (CBE), the next major milestone is the establishment of urinary continence. Prior to determining the most appropriate continence surgery, it is imperative to reach an adequate bladder capacity minimum of 100cc in order to make the decision between bladder neck reconstruction (BNR) or continent stoma, with or without augmentation cystoplasty (AC). To examine the timing of when patients achieve threshold bladder capacity for BNR eligibility. We hypothesize most patients will achieve an adequate bladder capacity (100cc) by 7 years old when continence surgeries will begin to be considered. An institutional database of 1388 exstrophy patients was retrospectively reviewed for CBE patients after successful primary bladder closure. Bladder capacities were measured via gravity cystography and data presented as descriptive statistics. The cohort was stratified by location, neonatal (≤28 days) or delayed closure period and osteotomy status. The bladder capacities were categorized to either reaching goal or not and a cumulative event analysis was performed. The event being reaching 100cc capacity or greater and time being the number of years between bladder closure and attainment of goal capacity. 253 patients met inclusion criteria between 1982 and 2019. The majority were of male gender (72.9%), had their closure performed at the authors' institution (52.5%), within the neonatal period (80.7%), and without an osteotomy (51.7%). 64.9% of patients reached goal bladder capacity. There were no significant differences in those who did or did not achieve goal except for clinical follow up. Cumulative event analysis demonstrated a median time of 5.73 years (95% CI 5.2-6.20) corresponded with a 50% event probability of reaching goal capacity. Cox-proportional hazards showed location of closure was significantly associated with hazards of reaching goal bladder capacity (HR=0.58, CI 0.40-0.85, p=0.005). Based on this model, the median time to event would be 5.20 years (95% CI 4.76-5.80) for cases done at the authors' hospital and 6.26 years for those performed at an outside hospital (95% CI 5.77-7.24). These findings help surgeons counsel families appropriately on the odds of attaining goal capacity at various ages. For those who do not reach 100cc by five years of age, it helps further characterize the odds of requiring a continent stoma with bladder augmentation and the best timing for reconstructive surgery in order to safely gain urinary continence. Families may also be assured that most patients would have the breadth of surgical options when it comes to continence as more than half of patients reached the bladder capacity threshold.

MP11-14 ACHIEVING GOAL CAPACITY FOR CONTINENCE SURGERY: A CUMULATIVE EVENT ANALYSIS OF BLADDER EXSTROPHY PATIENTS

You have accessJournal of UrologyCME1 May 2022MP11-14 ACHIEVING GOAL CAPACITY FOR CONTINENCE SURGERY: A CUMULATIVE EVENT ANALYSIS OF BLADDER EXSTROPHY PATIENTS Preeya Khandge, Kelly Harris, Wayland Wu, Mahir Maruf, Hiten Patel, Heather Di Carlo, and John Gearhart Preeya KhandgePreeya Khandge More articles by this author , Kelly HarrisKelly Harris More articles by this author , Wayland WuWayland Wu More articles by this author , Mahir MarufMahir Maruf More articles by this author , Hiten PatelHiten Patel More articles by this author , Heather Di CarloHeather Di Carlo More articles by this author , and John GearhartJohn Gearhart More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002533.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Following successful closure of patients with classic bladder exstrophy (CBE), the next major milestone is the establishment of urinary continence. However, prior to determining the appropriate continence surgery, it is imperative to reach an adequate bladder capacity of 100 cc minimum in order to make the decision between bladder neck reconstruction (BNR) and continent stoma with or without augmentation cystoplasty (AC). The authors sought to examine the timing of when patients achieve this threshold bladder capacity to be eligible for BNR. METHODS: An institutional database of 1388 exstrophy patients was retrospectively reviewed for CBE patients after successful primary bladder closure. Bladder capacities was measured via gravity cystography. The cohort was stratified by location, neonatal (≤28 days) or delayed closure period and osteotomy status. The bladder capacities were categorized to either reaching goal or not and a cumulative event analysis was performed. The event being reaching 100cc capacity or greater and time being the number of years between bladder closure and attainment of goal capacity. RESULTS: Two hundred fifty-three patients met inclusion criteria from 1982 to 2019. The majority were of male gender (72.9%), had their closure performed at the authors’ institution (52.5%), within the neonatal period (80.7%), and without an osteotomy (51.7%). 64.9% of patients reached goal bladder capacity. There were no significant differences in those who did or did not achieve goal except for clinical follow up. The cumulative event analysis demonstrated that a median time of 5.73 years (95% CI 5.2 – 6.20) corresponded with a 50% event probability of reaching goal capacity. Cox-proportional hazards showed location of closure was significant associated with hazards of reaching goal bladder capacity (HR = 0.58, CI 0.40 – 0.85, p = 0.005). Based on this model, the median time to event would be 5.20 years (95% CI 4.76 – 5.80) for cases done at the authors’ hospital and 6.26 years for those performed at an outside (95% CI 5.77 – 7.24). CONCLUSIONS: These findings help counsel families appropriately on the odds of attaining goal capacity at various ages. For those who do not reach 100cc by 5 years of age, it helps further characterize the odds of requiring bladder augmentation and the best timing for reconstructive surgery in order to safely gain urinary continence. Families may also be assured that most patients would have the breadth of options when it comes to continence surgery as more than half of patients reached the bladder capacity threshold. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e162 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Preeya Khandge More articles by this author Kelly Harris More articles by this author Wayland Wu More articles by this author Mahir Maruf More articles by this author Hiten Patel More articles by this author Heather Di Carlo More articles by this author John Gearhart More articles by this author Expand All Advertisement PDF DownloadLoading ...

Functional outcome of robotic-assisted intracorporeal versus extracorporeal neobladder following radical cystectomy: Initial experience.

Introduction:Worldwide, the seventh most commonly diagnosed cancer in the male population is Bladder cancer (BC), while it drops to eleventh when both genders are considered. Radical cystectomy is the surgical treatment of choice for patients with all muscle-invasive and some nonmuscle invasive BCs. An orthotopic continent diversion (neobladder) is preferred whenever possible to achieve a better postoperative quality of life. We attempt to study the functional outcomes of intracorporeal neobladder (ICNB) versus extracorporeal neobladder (ECNB) (ICNB vs. ECNB).Materials and Methods:Forty patients who underwent robot-assisted radical cystectomy with neobladder in our institute during the period of March 2016–March 2018 were included in the study. An orthotopic neobladder (Studer method) was created in all our patients. Our main outcomes of interest were peak flow rates, residual urine, attainment of continence, and Pdet at qmax of the neobladder.Results:The mean age of patients in our study group was 54 ± 6 years. The mean body mass index was 23 ± 2 kg/m2. The mean follow-up period was 24 ± 5 months. Twenty patients underwent ICNB and 20 patients underwent ECNB. The urodynamic assessment was done 1-year postprocedure. The same parameters applied to an intact bladder are used, and results analyzed by comparing it with other studies. Common in the initial postoperative period was incontinence which reduced substantially over time. After 1-year, 75% of patients did not require pads in the daytime, and a meager, <10% used more than one pad per day. There was no difference in outcome between both the groups, which was statistically significant.Conclusion:Both ICNB and ECNB groups achieved urodynamically proven values of adequate bladder capacity and compliance. Daytime continence was excellent, and night time continence was good in both groups. Furthermore, there was no significant difference between both the groups as regards to urodynamic parameters. However, continence is attained little earlier in the ICNB group. There is no perceived superiority of ICNB over ECNB.

Management of voiding dysfunction associated with pelvic malignancies.

Voiding dysfunction is common after surgical and radiation treatments in patients diagnosed with non-urological pelvic malignancies. Presentation might vary with lower urinary tract symptoms and/or overactive bladder, urinary retention, or incontinence. We reviewed the most recent literature with the aim of describing various types of urinary dysfunction that manifest after radical treatments for non-urological pelvic malignancies. Radical surgical or radiation treatment adversely affect other adjacent pelvic organ function, including viscera, pelvic musculature and the peripheral nervous system. This results in direct organ and indirect functional damage to the genitourinary tract. Multiple surgical and radiation modifications are available nowadays, allowing urologists to offer various treatments for better functional lower urinary tract outcomes. Diagnosing and understanding the type and severity of voiding dysfunction plays a key role in tailoring an appropriate treatment plan. The objective to better functional results relies on maintaining adequate bladder compliance and capacity while permitting volitional emptying, ideally through voiding. Management should routinely start with conservative measures, including pelvic floor muscle training with or without a combination of oral medication for urgency incontinence and clean intermittent catheterization for the management of urinary retention. Concomitant or isolated urinary incontinence can be further managed through multiple established surgical approaches. We attempted to address various treatment available for known lower urinary tract symptoms that might have been caused secondary to non-urological pelvic surgery or radiation. We discuss different diagnostic and treatment modalities individualized for patients with various entities, to help achieve optimal urinary function and improve quality of life.

Epidural Stimulation Targeting Lower Urinary Tract Function in Spinally Intact and Transected Urethane‐Anesthetized Rats

Bladder management for conditions such as spinal cord injury (SCI) includes a combination of catheterization (either self‐intermittent or suprapubic) and pharmacological approaches, which targets maintenance but does not promote recovery of function. We have exciting data from multiple individuals receiving spinal cord epidural stimulation (scES) that is optimized for stepping and standing, in combination with task‐specific training, that shows improvements in lower urinary tract function. The objective of our current functional mapping pre‐clinical animal studies is to identify scES configurations (electrode location, amplitude and frequency) that can promote optimal neural control of urine storage (adequate bladder capacity at safe pressures without incontinence) and sufficient controlled emptying (high voiding efficiency at safe leak point pressures). Initial mapping was done in acute anesthetized terminal preparations during cystometry (bladder filling) using a modified Medtronic Specify 5‐6‐5 epidural array that is being used by our group in parallel human scES studies. The current data compares the response to scES in spinally intact and transected male and female rats 6 weeks post‐injury at T13‐L1 (level of sympathetic supply), L3‐4 (region with circuits related to external urethral sphincter control) and L6‐S1 (level of parasympathetic supply) spinal segments. Results indicate that scES storage effects and voiding efficiency were dependent upon presence/absence of spinal transection, frequency and intensity stimulation patterns, electrode location, and sex of the animals. Taken together these results suggest that the circuitry is dissociable and amenable to stimulation that seeks to promote either storage or voiding. Furthermore, our innovative approach and novel application of this Medtronic Specify 5‐6‐5 epidural device will generate functional maps that will lay the groundwork for expedient translation of this promising technology to individuals with SCI as well as provide a powerful tool for elucidating underlying circuits present in the lumbosacral cord that are involved in urogenital function.Support or Funding InformationNIH SPARC OT2OD024898

V7-07 ROBOTIC BLADDER NECK RECONSTRUCTION WITH SLING AND SPLIT APPENDIX TECHNIQUE FOR APPENDICOVESICOSTOMY AND MACE

You have accessJournal of UrologyPediatrics1 Apr 2017V7-07 ROBOTIC BLADDER NECK RECONSTRUCTION WITH SLING AND SPLIT APPENDIX TECHNIQUE FOR APPENDICOVESICOSTOMY AND MACE Molly Fuchs, Christina Ching, Christopher Brown, Richard Wood, Mark Levitt, Rama Jayanthi, and Daniel DaJusta Molly FuchsMolly Fuchs More articles by this author , Christina ChingChristina Ching More articles by this author , Christopher BrownChristopher Brown More articles by this author , Richard WoodRichard Wood More articles by this author , Mark LevittMark Levitt More articles by this author , Rama JayanthiRama Jayanthi More articles by this author , and Daniel DaJustaDaniel DaJusta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1925AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic surgical techniques have been adopted for procedures in pediatric urology even in reconstruction for neurogenic bladder. Our aim was to expand on the previously described bladder neck reconstruction with sling and Appendicovesicostomy (APV), by showing that the well described open split appendix technique can also be perform robotically, allowing for the creation of both APV and MACE. This video is to our knowledge, the first to demonstrate the use of robotic split appendix technique. METHODS A 6 year-old male with myelomeningocele, neurogenic bladder and bowel was not able to achieve urinary continence on a standard regiment of IC and anticholinergic. Urodynamic showed adequate bladder capacity at 300 ml with low storage pressure and adequate compliance. Unfortunately he had a low leak point pressure indicating poor outlet resistance. Thus indication for a bladder neck reconstruction with APV was made. There was also a need for implementing a good bowel regiment and after evaluation at our Center for Colorectal and pelvic Reconstruction by the colorectal surgeon, indication for a MACE was also made. We selected to utilize the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of Botox into the detrusor muscle, we placed ureteral catheter for easy ureteral orifice identification during bladder neck reconstruction and an 8 French Foley catheter. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance. RESULTS The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning he was taken to the operating room for the procedure. Total operative time was 7 hours. Total console time was 6 hours. A 10 French Foley catheter was placed through the APV channel and an 8 French feeding tube was placed through the MACE. A 5 French feeding tube was left stenting the urethra and was removed prior to discharge. He was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4. CONCLUSIONS Robotic assisted bladder neck reconstruction with split appendix technique to create both APV and MACE is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery will continue to be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e825 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Molly Fuchs More articles by this author Christina Ching More articles by this author Christopher Brown More articles by this author Richard Wood More articles by this author Mark Levitt More articles by this author Rama Jayanthi More articles by this author Daniel DaJusta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study

To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes. A database of children (<18 years old) who underwent RTx between May 2008 and April 2012 was reviewed. Patients were divided into those with LUTD (group A, n = 29) and those with other causes of ESRD (group B, n = 74). RTx was performed after achieving low intravesical pressure (<30 cmH2 O) with adequate bladder capacity and drainage. The groups were compared using Student's t-test, Mann-Whitney, chi-squared or exact tests. Graft survival rates (GSRs) were evaluated using Kaplan-Meier curves and the log-rank test. The mean ± sd (range) age of the study cohort was 5.05 ± 12.4 (2.2-18) years. Causes of LUTD were posterior urethral valve (PUV; 41.4%), vesico-ureteric reflux (VUR; 37.9%), neurogenic bladder (10.3%), prune belly syndrome (3.4%), obstructive megaureter (3.4%) and urethral stricture disease (3.4%). There was no significant difference in age, dialysis duration or donor type. In group A, 25 of the 29 patients (86.2%) underwent ≥1 surgery to optimize the urinary tract for allograft. Pretransplant nephrectomy was performed in 15 of the 29 patients (51.7%), PUV ablation in nine patients (31%) and ileocystoplasty in four patients (13.7%). The mean ± sd follow-up was 4.52 ± 1.55 and 4.07 ± 1.27 years in groups A and B, respectively. There was no significant difference in creatinine and eGFR between the groups at different points of follow-up. The GSRs at the end of the study were 93.1 and 91.1% in groups A and B, respectively (P = 1.00). According to Kaplan-Meier survival curves, there was no significant difference in the GSR between the groups using the log-rank test (P = 0.503). No graft was lost as a result of urological complications. In group B, one child died from septicaemia. The rate of urinary tract infections was 24 and 12% in groups A and B, respectively, but was not significant. No significant difference was found between the groups with regard to the incidence of post-transplantation hydronephrosis. Of the 22 patients who had hydronephrosis after transplantation, three were complicated by UTI. Injection of bulking agents was required in two patients for treatment of grade 3 VUR. In the third patient, augmentation cystoplasty was needed. Acceptable graft function, survival and UTI rates can be achieved in children with ESRD attributable to LUTD. Thorough assessment and optimization of LUT, together with close follow-up, are key for successful RTx.

Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction.

To investigate the functional outcome after supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction (NLUTD). Retrospective follow-up investigation in a single spinal cord injury rehabilitation center. In 29 patients, urodynamic data before and after supratrigonal cystectomy and augmentation ileocystoplasty, clinical outcome and post-operative complications were evaluated. The median age of the 29 patients at the time of surgery was 31 years, a median 14 years after NLUTD had occurred. At the last follow-up visit (median 2.4, range 0.4-9.0 years post-operatively), 20/29 patients (69%) were continent compared to 2/29 pre-operatively (P = 0.001). Furthermore, 16 patients required no or less detrusor relaxation therapy after augmentation ileocystoplasty. Augmentation cystoplasty resulted in a significant (P = 0.001) increase in the median bladder capacity (from 240 ml to 500 ml) and compliance (from 13 ml/cm H2 O to 50 ml/cm H2 O). The median maximum detrusor pressure had decreased significantly (P = 0.001) from 38 cm H2 O to 15 cm H2 O. Significantly (P = 0.001) fewer patients presented with a risk for renal damage (1 vs. 15 with maximum detrusor pressure >40 cm H2 O and 1 vs. 12 with detrusor compliance <20 ml/cm H2 O) at the last follow-up. The following complications were observed in 11/29 (38%) patients: paralytic and obstructive ileus, impaired bowel function, bladder stones, dehiscence, metabolic acidosis and autonomic dysreflexia. Protection of renal function, adequate bladder capacity and low detrusor pressure can be achieved using supratrigonal cystectomy and augmentation ileocystoplasty in patients suffering from refractory NLUTD.

Endoscopic treatment with dextranomer/hyaluronic acid for persistent incontinence after continent urinary reconstruction.

To determine the applicability and long-term outcome of endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) to correct incontinence in patients who had previously undergone continent urinary reconstruction. A retrospective cohort study was performed of all patients who underwent Dx/HA injection at our institution from January 2001 to June 2011. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. "Success" was defined as either "continence" (daytime dry interval >3 hours) or "improvement" (daytime dry interval >2 hours). A total of 22 children (16 females and 6 males) had Dx/HA injections for persistent incontinence from either bladder neck (7), Mitrofanoff (10), or both (5). Median age at injection was 13 years (range 4-21). Children underwent an average of 1.6 injection sessions per patient with an average of 2.6 mL of Dx/HA per session. At a median follow-up of 72 months (range 4-104), 19 (86.4%) patients had successful results (16 continent, 3 improved). For those incontinent from bladder neck, 42% became continent after 1, 75% after 2, and 83% after 3 injections, with a success rate of 91% (10 continent, 1 improved). For those incontinent from Mitrofanoff, 20% became continent after 1, and 73% after 2 injections, with a success rate of 86% (11 continent, 2 improved). Endoscopic injection of Dx/HA to correct residual incontinence in selected children after urinary reconstruction appears to be safe and effective, achieving a dry interval in more than two-thirds of patients.

Bladder cancer: ESMO Practice Guidelines for diagnosis, treatment and follow-up

Bladder cancer: ESMO Practice Guidelines for diagnosis, treatment and follow-up

Bladder exstrophy associated with complete urethral duplication: Bladder can be augmented with dorsal urethral mucosa

Bladder exstrophy associated with complete urethral duplication is very rare with only 8 reported cases in the English literature. This is a report of a16 years old boy who had originally been diagnosed with only bladder exstrophy but was discovered to have a normal ventral urethra intra-operatively during penile disassembly. The mucosa of the dorsal urethral plate was transected at the corona and mobilised proximally to augment the bladder. The ventral urethra was preserved and the bladder closed. At 14 months follow up he is voiding normally, has adequate bladder capacity and a normal penis. Post operative voiding cystogram shows bilateral grade 2 vesicoureteric reflux.In conclusion, bladder exstrophy with urethra duplication is rare and the diagnosis usually missed. The mucosa of the dorsal urethral plate can be preserved and used to augment the bladder.

The modern staged repair of classic bladder exstrophy: A detailed postoperative management strategy for primary bladder closure

PurposeSuccessful primary bladder closure of classic bladder exstrophy sets the stage for development of adequate bladder capacity and eventual voided continence. The postoperative pathway following primary bladder closure at the authors’ institution is quantitatively and qualitatively detailed. Materials and methodsSixty-five consecutive newborns (47 male) undergoing primary closure of classic bladder exstrophy were identified and data were extracted relating to immediate postoperative care. Overall success rate was utilized to validate the pathway. ResultsMean age at time of primary closure was 4.6 days and mean hospital stay was 35.8 days. Osteotomy was performed in 19 patients (mean age 8.8 days), and was not required in 39 infants (mean age 2.9 days). All patients were immobilized for 4 weeks. Tunneled epidural analgesia was employed in 61/65 patients. All patients had ureteral catheters and a suprapubic tube, along with a comprehensive antibiotic regimen. Postoperative total parenteral nutrition was commonly administered, and enteral feedings started around day 4.6. Our success rate of primary closure was 95.4%. ConclusionsA detailed and regimented plan for bladder drainage, immobilization, pain control, nutrition, antimicrobial prophylaxis, and adequate healing time is a cornerstone for the postoperative management of the primary closure of bladder exstrophy.

Editorial Comment

The management of bladder exstrophy continues to be a surgical challenge, and consistent surgical results are difficult to obtain unless reconstruction is performed at defined Centers of Excellence. The development of voided continence in children with exstrophy requires a secure initial closure of the bladder, with the posterior urethra and bladder neck placed deep in the pelvis, and then development of an adequate bladder capacity for eventual bladder neck reconstruction. Multiple factors can affect the ability of the bladder to achieve this critical capacity, including failure of the initial closure, 1 Gearhart J.P. Ben-Chaim J. Sciortino C. et al. The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder?. Urology. 1996; 47: 240-243 Abstract Full Text PDF PubMed Scopus (82) Google Scholar obstruction of the outlet, 2 Baker L.A. Jeffs R.D. Gearhart J.P. Urethral obstruction after primary exstrophy closure: what is the fate of the genitourinary tract?. J Urol. 1999; 161: 618-621 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar recurrent urinary tract infections, and an inability of the bladder template to grow because of poor inherent characteristics. 3 Mathews R. Gosling J.A. Gearhart J.P. Ultrastructure of the bladder in classic exstrophy: correlation with development of continence. J Urol. 2004; 172: 1446-1449 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Evaluation of Need for Salvage Continence Procedures After Failed Modern Staged RepairUrologyVol. 76Issue 1PreviewTo assess our experience with salvage continence procedures in patients with bladder exstrophy. Full-Text PDF ReplyUrologyVol. 76Issue 1PreviewWe agree that because these children were referred from outside hospitals, it would be difficult to determine exactly what factors affected the bladder capacity and ultimate outcomes. New studies and evaluations were performed on their arrival at our center to direct our management. The aim of this study was to demonstrate that when patients were appropriately selected (ie, bladder capacity >85 mL), continence was ultimately achieved in most of the children with difficult and iatrogenically diverse features seeking treatment and improved quality of life. Full-Text PDF

Modified Young-Dees-Leadbetter Bladder Neck Reconstruction After Exstrophy Repair

We describe the application and results of modified Young-Dees-Leadbetter bladder neck reconstruction after successful complete primary repair in the newborn period. The records of 34 patients referred for a continence procedure after successful exstrophy closure were extracted from an institutionally approved database. Patient characteristics and surgical outcomes were assessed. A total of 31 male and 3 female patients were identified, of whom 27 and 1, respectively, underwent osteotomy at initial closure. No patients attained urinary continence and so they were referred for a continence procedure. Nine patients did not have adequate bladder capacity for bladder neck repair (mean bladder capacity 63 ml, range 20 to 80). In those with suitable capacity mean capacity was 119 ml (range 85 to 180) and they underwent bladder neck reconstruction at a mean age of 4.9 years. Of the 25 patients who underwent bladder neck repair 14 (56%) were dry during the day and night, 5 (20%) were dry during the day but wet at night and 6 (24%) were totally incontinent. Pelvic osteotomies were performed at initial closure in 14 totally continent patients (100%) and in 4 (80%) with daytime continence but in no totally incontinent patients. All continent patients underwent hypospadias repair before age 1 year and none required ureteral reimplantation before bladder neck repair. A number of patients require bladder neck reconstruction to achieve continence after successful initial closure with complete primary repair. The modified Young-Dees-Leadbetter technique provides reasonable results with daytime and nighttime dryness attained by more than half of the patients.

Radical Cystectomy for Transitional Cell Carcinoma with Orthotopic Neobladder in Renal Transplant Recipients: Surgical Procedure, Functional and Therapeutic Evaluation

Introduction Transitional Cell Carcinoma (TCC) shows a high prevalence in renal tranplant recipients, nevertheless urinary reconstruction by way of orthotopic neobladder is rarely reported. Patients and Methods Two kidney transplant patients (1 man and 1 woman) affected by TCC underwent radical cystectomy and urinary reconstruction by neobladder according to the “Vescica Ileale Padovana” technique. Results and Discussion No patients claimed incontinence or urine retention. The spherical rebuilding assured an adequate bladder capacity and a low endovesical pressure. After 48 months one patient died because of disease progression. The first relapse was detected in ureter two years after cystectomy. The other patient is still alive after 40 months and in good health conditions. Conclusions This anecdotal report suggests that the “Vescica Ileale Padovana” technique could be useful in renal transplant recipients with TCC. A possible role of Rapamycin on our results cannot yet be excluded.

Treatment of the neurogenic bladder in spina bifida

Renal damage and renal failure are among the most severe complications of spina bifida. Over the past decades, a comprehensive treatment strategy has been applied that results in minimal renal scaring. In addition, the majority of patients can be dry for urine by the time they go to primary school. To obtain such results, it is mandatory to treat detrusor overactivity from birth onward, as upper urinary tract changes predominantly start in the first months of life. This means that new patients with spina bifida should be treated from birth by clean intermittent catheterization and pharmacological suppression of detrusor overactivity. Urinary tract infections, when present, need aggressive treatment, and in many patients, permanent prophylaxis is indicated. Later in life, therapy can be tailored to urodynamic findings. Children with paralyzed pelvic floor and hence urinary incontinence are routinely offered surgery around the age of 5 years to become dry. Rectus abdominis sling suspension of the bladder neck is the first-choice procedure, with good to excellent results in both male and female patients. In children with detrusor hyperactivity, detrusorectomy can be performed as an alternative for ileocystoplasty provided there is adequate bladder capacity. Wheelchair-bound patients can manage their bladder more easily with a continent catheterizable stoma on top of the bladder. This stoma provides them extra privacy and diminishes parental burden. Bowel management is done by retrograde or antegrade enema therapy. Concerning sexuality, special attention is needed to address expectations of adolescent patients. Sensibility of the glans penis can be restored by surgery in the majority of patients.Electronic supplementary materialThe online version of this article (doi:10.1007/s00467-008-0780-7) contains supplementary material, which is available to authorized users.

Endoscopic Injection of Bulking Agents in Children With Incontinence: Dextranomer/Hyaluronic Acid Copolymer Versus Polytetrafluoroethylene

Treating pediatric incontinence can be challenging. Many surgical procedures are available with variable success and complications. Endoscopic injection of bulking agents into an incompetent bladder neck was first described using Teflon and most currently using Deflux. We compared the results of bladder neck injection using Deflux and Teflon to manage urinary incontinence in children. A retrospective study was performed in children who underwent primary endoscopic injection of Teflon or Deflux to the bladder neck. Patients with prior bladder neck surgery were excluded. Data were collected on underlying anatomical pathology, preoperative bladder capacity, endoscopic approach, quantity of bulking agent and outcome. Dry was defined as 3 hours or greater awake without wetting. Wet was defined as the need for a pad or diaper. A total of 34 patients underwent primary injection of bulking agents, including 32 via a retrograde approach and 2 via a combined antegrade-retrograde approach. A total of 20 children with a mean age of 2.7 years were injected with Teflon and 11 were injected with Deflux. One of the 20 Teflon injected patients was dry more than 6 months. One of the 14 Deflux injected patients was dry at 3 months in the daytime, another 2 improved at 3 months (antegrade/retrograde in 1) but worsened at 6 months and another was dry after a second injection. All 4 improved children had age appropriate bladder capacity. The volume of injected agent was 1 to 10 cc. No complications were seen. Five children per group underwent subsequent open continence surgery. Bladder neck injection of bulking agents is a generally ineffective therapy for incontinence. While neither the number of injections nor the bulking agent used affected the results, adequate bladder capacity and antegrade injection with Deflux heralded short-term improvement. Patients with exstrophy consistently did poorly.

Antegrade and Retrograde Endoscopic Dextranomer/Hyaluronic Acid Bladder Neck Bulking for Pediatric Incontinence

Endoscopic bladder neck bulking techniques offer the potential for a relatively noninvasive cure for a difficult clinical problem. We review our experience using antegrade and retrograde approaches. A total of 34 children (18 boys and 16 girls, mean age 11.7 years) have been treated since March 2003. Of the patients 28 (82%) had neurogenic bladder and 6 had nonneurogenic sphincteric incontinence. Urodynamics confirmed low detrusor leak point pressures and adequate bladder capacity. Patients were treated with either a retrograde or an antegrade approach. In 82% of patients an antegrade approach was used and a posttreatment suprapubic tube was placed. Mean followup was 11.7 months (range 3 to 31). Patients averaged 1.47 injections (range 1 to 5). Detailed followup of 19 patients revealed significant improvement in continence in 78% (mean 1.6 injections), with an average followup of approximately 1 year. Our 31 months of experience with antegrade/retrograde bladder neck bulking demonstrates that it is a viable therapy for this group of children. While some patients have experienced prolonged success, re-treatment can be beneficial. The antegrade approach offers several advantages, including intraoperative leak point pressures, improved visualization and placement of a suprapubic tube to limit post-procedural remodeling.

Incontinence Following Bladder Neck Reconstruction—Is There a Role for Endoscopic Management?

Little has been reported concerning the efficacy of endoscopic injection of dextranomer/hyaluronic acid for the treatment of residual incontinence following bladder neck reconstruction. We present the experience of 2 institutions using endoscopic submucosal injection of dextranomer/hyaluronic acid to correct incontinence in patients who had previously undergone bladder neck reconstruction with or without concomitant enterocystoplasty. A retrospective chart review was performed with patient demographics, indications for treatment and outcomes recorded. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. Continence was defined as at least a 3-hour daytime dry interval, while improvement was defined as an increase in the daytime dry interval to at least 2 hours. A total of 14 patients (10 females and 4 males) underwent 21 injections. At a median followup of 17 months 10 patients had successful results (6 continent, 4 improved). Endoscopic injection of dextranomer/hyaluronic acid to correct incontinence following bladder neck reconstruction appears safe and can increase the daytime dry interval in more than 70% of carefully selected patients. Continued followup is necessary to evaluate the long-term effectiveness of this treatment.

Augmentation ureterocystoplasty: is it the preferred choice?

Various methods of urinary bladder augmentation have been attempted in order to try and achieve adequate bladder capacity, urinary continence, control urinary tract infection and preserve the upper urinary tract; however, long-term complications have been unavoidable. To evaluate our experience with ureterocystoplasty as to whether it is the preferred method for bladder augmentation to achieve continence and preserve the upper urinary tract. Retrospective study. Paediatric urology unit, Dana Children's hospital, Tel Aviv Medical Center (affiliated to the Sackler School of Medicine), Tel Aviv University. Four children; three girls, one boy, mean age 7.3, range (3-14) years. Two had neurogenic bladder due to occult spinal dysrraphism, the other two had non-neurogenic neurogenic bladder. The indications for surgery were urinary incontinence with recurrent urinary tract infections in all patients, one also had upper tract dilatation. All underwent augmentation ureteroplasty, two required nephrectomy due to non-functioning kidney, two required clean intermittent catheterizatiom postoperatively. Urinary continence, bladder capacity, vesicoureteral reflux, renal function tests, urinary tract infection rate and surgical complications encountered. In a mean follow-up period of 24 (6-46) months, all of the patients achieved urinary continence, two of the patients who have a normal bladder outlet are continent and void spontaneously with no residual urine. The other two patients are continent on clean intermittent catheterization. Only one episode of urinary tract infection was seen, none of the patients are currently on prophylactic antibiotics. The urinary bladder in all patients is spherical with good capacity and no vesicoureteral reflux was demonstrated. The upper urinary tracts are stable and the renal function tests are normal. Ureterocystoplasty is our preferred choice of bladder augmentation in patients with small, inelastic, poor compliant bladder with at least a moderately dilated ureter. Complications normally seen with enterocystoplasties are minimal.