Catheterizable Channel Research Articles

Long-term usage pattern and satisfaction survey of continent catheterizable channels

We investigated the long-term usage pattern and satisfaction of continent catheterizable channels (CCCs). From 2005 to 2018, CCCs, including Mitrofanoff and antegrade continent enema (ACE) channels, were made in 67 patients (Mitrofanoff in 21 patients, ACE channels in 43 patients, and both in three patients) in our institution. An online survey was conducted for these patients in order to assess usage pattern, continent status, difficulty in usage, and patient satisfaction. Sixteen (66.7%) out of 24 patients with the Mitrofanoff channel and 39 (84.7%) out of 46 patients with the ACE channel completed the online survey. In the Mitrofanoff channel group, 10 (62.5%) patients had spina bifida, two (12.5%) had Hinman syndrome, one (6.3%) had posterior urethral valves, and three (18.8%) had urethral trauma or atresia. Additionally, the mean age of the patients at the time of surgery was 10.0 years, and the median follow-up duration was 10.9 years. All patients were using the Mitrofanoff channel to perform clean intermittent catheterization (CIC). Eleven patients (68.8%) had difficulty with catheterization, mostly at the stomal site. Most patients conducted CIC more than four times a day (13, 81.3%). Regarding urination status, seven patients (43.8%) responded that they were satisfied and nine (56.2%) responded they were neutral. In the ACE channel group, 35 patients (89.7%) had spina bifida, seven (17.9%) had cloacal anomalies, and 26 (66.7%) had anorectal malformations. The mean age of the patients at the time of surgery was 8.4 years, and the median follow-up period was 7.4 years. Two (5.1%) patients were no longer using their ACE channels, but 15 (38.5%) patients were still using their channels almost daily. Twenty-eight (71.8%) patients complained that performing enema was time-consuming, and seven (17.9%) patients reported pain when performing ACE and fecal incontinence. Most patients were satisfied with their defecation status (23, 59%), 15 (38.5%) were neutral, and one (2.6%) was dissatisfied. While most patients who had either Mitrofanoff or ACE channels were still using their channels effectively, approximately half of the patients with CCCs demonstrated neutral satisfaction with their current status; this shows a poor result compared to previous reports. Considering the results of our patient-based study, thorough explanations should be provided to patients who are candidates for Mitrofanoff and ACE procedures; additionally, the discomfort related to the procedures should be comprehensively assessed during follow-up consults.

Diagnosis, management and recurrence rates of Mitrofanoff polyps

Intraluminal polyps are a known complication following creation of a urinary continent catheterizable channel (Mitrofanoff). These polyps can lead to difficult catheterizations in addition to symptomatic bleeding. However, there is limited data available regarding management and outcomes of these polyps. We aim to describe clinical presentation and management of a large series of polyps occurring in a Mitrofanoff channel. We performed a retrospective review of all patients that were treated for polyps in a Mitrofanoff at our institution. Information was collected regarding presenting symptoms, management and recurrence rates of the polyps. A total of 24 patients were identified that fulfilled inclusion criteria. The majority of these polyps developed in channels composed of appendix (87%), while only 3 patients (13%) had polyps develop in an ileal composed channel. Thirteen (54%) of these polyps were incidentally diagnosed while 11 patients presented with a variety of symptoms such as difficulty in catheterization, bleeding with catheterization or both difficulty catheterizing and bleeding. For management of the polyps, a cystoscopy was performed and snaring the polyp with stone basket was performed in 37%, energy was applied to base to remove polyps in 33%, 16% were fulgurated and only 13% were left in situ. All procedures were performed under general anesthesia and all of the pathology was benign showing chronic inflammatory tissue. Eight polyps (33%) recurred after initial treatment. We did not observe an asymptomatic channel polyp convert to a symptomatic during our follow up period. Our experience has led us to not intervene on all asymptomatic Mitrofanoff polyps encountered during cystoscopy under assumption they will inevitably become symptomatic. Although we admit our follow up period may not be long enough to make this a universal declaration of best practice when any Mitrofanoff polyp is diagnosed. Endoscopic treatment was effective minimally invasive method to address the symptomatic polyp rather than excision and construction of new channel. This is the largest series to date of polyps developing in urinary continent catheterizable channels. The majority of these polyps were encountered incidentally however symptomatic polyps presented with difficulty with catheterizations. Symptomatic polyps can be managed endoscopically but recurrence of the polyp can occur.

V01-09 ROBOTIC-ASSISTED CONTINENT CUTANEOUS DIVERSION: FEASIBILITY OF A ROBOTIC SPIRAL MONTI TECHNIQUE IN A PATIENT WITH INCOMPLETE EMPTYING

INTRODUCTION AND OBJECTIVE:The spiral Monti technique to continent cutaneous urinary diversion allows for maximal length of the catheterizable channel without multiple anastomoses that increase the...

MP51-17 DECISIONAL REGRET IN ADULTS WITH SPINA BIFIDA REGARDING SURGERIES THEY HAD AS CHILDREN FOR NEUROGENIC BLADDER

You have accessJournal of UrologyPediatric Urology IV (MP51)1 Sep 2021MP51-17 DECISIONAL REGRET IN ADULTS WITH SPINA BIFIDA REGARDING SURGERIES THEY HAD AS CHILDREN FOR NEUROGENIC BLADDER Joshua Roth, Konrad Szymanski, Benjamin Whittam, and Rosalia Misseri Joshua RothJoshua Roth More articles by this author , Konrad SzymanskiKonrad Szymanski More articles by this author , Benjamin WhittamBenjamin Whittam More articles by this author , and Rosalia MisseriRosalia Misseri More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002077.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess decisional regret (DR) amongst patients with spina bifida (SB) regarding the decisions caregivers made to manage their neurogenic bladder (NB) as children. METHODS: Consecutive adult patients with SB were surveyed at clinic appointments (6/18-1/20). Higher DR Scale scores indicated greater DR (range 0-100). We analyzed whether presence of a ventriculoperitoneal shunt (VPS), mobility, gender, age, history of a bladder augment, history of a catheterizable channel, history of a bladder neck procedure, history of a bladder stone, history of a catheterizable channel revision, urinary incontinence, bothersome urinary incontinence, or recurrent urinary tract infection (≥3/year) had any impact on DR. Non-parametric statistical tests were used. RESULTS: Ninety-six patients with a median age of 26.3 (79.2% shunted, 56.3% female) had childhood surgery for NB. Median DR score was 0 (mean 11.9). Overall, 60.4% reported no regret and of those who reported regret, 89.5% reported only mild-moderate regret. In total, 4.2% of patients reported strong or very strong regret. Having any regret was associated with having a bladder neck procedure (OR 3.45, p=0.007) or bothersome urinary incontinence (OR 5.59, p=0.001). Regret was not associated with other factors. CONCLUSIONS: Patients with SB and resultant NB reported low levels of DR after surgery to manage their NB in childhood. When present, DR is usually mild. DR is more likely in those with a bladder neck procedure or bothersome urinary incontinence. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e903-e903 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Roth More articles by this author Konrad Szymanski More articles by this author Benjamin Whittam More articles by this author Rosalia Misseri More articles by this author Expand All Advertisement Loading ...

Reoperation for Channel Complications in Children With Continent Cutaneous Catheterizable Channels: The Test of Time

ObjectivesTo examine the durability of continent cutaneous catheterizable urinary channels (CCCC) in children and assess whether channel complications continue to arise with extended follow-up. Previous studies demonstrated that complications of CCCC cluster in the early years following surgery. MethodsThe database of a tertiary center was queried for patients≤21 years who underwent CCCC. Patients with <6 years of follow-up were excluded. Patients were invited for follow-up to assess continence. Clinic visits and hospital admissions were reviewed for channel complications requiring reoperation. Complications were analyzed against patient and channel characteristics and time since initial surgery. ResultsBetween 1993 and 2012, a total of 120 patients underwent CCCC at a median age of 6.8(0.4-21) years and a median follow-up of 11.4(6.6-27) years. CCCC were created using the appendix, Monti channels and tapered ileal segments in 74(61.7%), 33(27.5%) and 13(10.8%), respectively. Continence relied on the extra-mural serous lined principle in 85.8% and the stoma was anastomosed to the umbilicus in 90%. Dryness with catheterization intervals of 3 hours or longer was eventually achieved in 90.8% with similar rates among different channel types (P=.149). 26(21.7%) required 42 interventions to treat channel complications with 32.5% occurring >5 years following initial surgery irrespective of the channel type (P=.978). On multivariate analysis, ileal channels had 3.372 higher odds of needing reoperation compared to appendicovesicostomy (95%CI=1.240-9.166; P = .037). ConclusionA high reoperation rate is anticipated throughout the lifetime of CCCC. Appendicovesicostomy has a low complication risk relative to ileal channels.

Long-term urological and gynecological outcomes following complete primary repair in females with bladder exstrophy

Long-term continence outcomes in patients undergoing complete primary repair of exstrophy (CPRE) have shown that a subset of patients do not achieve continence until after puberty. We aim to update the continence outcomes as well as describe gynecological outcomes for females having undergone CPRE. This was a retrospective review between 1989 and 2019at a single institution. Inclusion criteria were females with classic bladder exstrophy who underwent CPRE. Exclusion criteria were variant diagnoses and age <4 years. Continence was defined as dry for ≥3h (volitional voiding or clean intermittent catheterization (CIC)). Partial continence was defined as minor stress incontinence or enuresis. Vaginal stenosis was evaluated in post-pubertal patients. Eighteen patients met inclusion criteria. Median age at last follow-up was 15.9 years (IQR 13.1, 18.4). All patients underwent primary closure <30 days of life (n=18). Subsequent procedures included bladder augmentation (n=4), continent catheterizable channel (n=7), bladder neck injections (n=12) and bladder neck reconstruction (n=12). Continence and partial continence were achieved in 6/18 (33.3%) and 9/18 (50.0%), respectively, with mean 3.2±2.5 continence procedures at 9.6 years (IQR 7.3, 15.2). Volitional voiding was seen in 11/18 (61.1%) and 7/18 (38.9%) performed CIC, with no significant difference in continence. Mean bladder capacity was 199ml±96 versus 90ml±29 in the volitional voiding versus CIC group (P=0.0047). Eleven women with median age of 18.0 years (IQR 15.2, 21.4) had recorded menarche: 6/11 (54.5%) patients reported painful/irregular menses, controlled with hormonal therapy. Six of 11 (54.5%) women had vaginal stenosis managed with vaginal dilation (n=2) or vaginoplasty (n=4). Three (27.3%) reported tampon use and penetrative intercourse. Overall, the majority of women who have undergone CPRE achieved complete or partial continence, though most required additional procedures and time to attain it. Additionally, volitional voiding was achievable. Bladder capacity was significantly lower in patients dependent on CIC. Most required medical or surgical interventions for gynecologic concerns post menarche. This study underscores the unique needs of girls and young women with bladder exstrophy and further supports the importance of close long-term urologic and gynecologic management throughout development.

Split appendix catheterizable urinary channels are at no higher risk of undergoing revision compared to channels made with the intact appendix

To assess long-term APV and split-appendix MACE durability and to compare split and intact appendix APVs in a large patient cohort. This retrospective cohort study included consecutive patients ≤21 years old undergoing an APV at our institution (1990-2019). Main outcomes were stomal and subfascial revisions. Kaplan Meier survival and Cox proportional hazards analysis were used. A total of 339 patients underwent APV creation at a median 7.4 years old (41% female vs. 59% male; 37% umbilical stoma vs. 63% other). In total, 36 patients underwent a stomal revision and 19 a subfascial revision (median channel follow-up 6.3 years). On survival analysis, the risk of stomal revision of the APV was 9.1% at 5 years, 12.6% at 10 years and 16.5% at 15 years. Risk of subfascial revision of the APV was 5.1% at 5 years, 7.0% at 10 years and 8.2% at 15 years. A split-appendix APV was performed in 118 (34.8%) of 339 patients. They had a shorter follow-up compared to those with an intact APV (5.1 vs. 7.0 years, p=0.03). After correcting for differential follow-up time, there was no significant difference between groups for stomal revisions (HR 1.11, p=0.76) or subfascial revisions (HR 0.80, p=0.67, Figure). Risk of APV stomal revision was independent of stomal location and age at surgery (p≥0.37). Similarly, risk of subfascial APV revision was independent of stomal location and age at surgery (p≥0.18). Risk of stomal revision for split-appendix MACE channels was 16.2% at 5, 10 and 15 years (similar to split-appendix APV and all APVs, p≥0.26). Risk of MACE subfascial revision was 5.5% at 5 years, 5.5% at 10 years and 14.7% at 15 years (similar to split-appendix APV and all APVs, p≥0.36). We focused on surgical complications, as these entail the highest morbidity, however, we did not assess non-surgical, percutaneous or endoscopic management which also impact long-term outcome and patient quality of life. We did not compare the outcomes of the split-appendix MACE to an intact-appendix MACE cohort, as this patient population was not captured in this review. The split-appendix technique has durable long-term results for both the APV and MACE channels, which are comparable to the technique utilizing the intact appendix. Channel complications occur over the channel's lifetime, as 1 in 8 APVs in the entire cohort underwent a stomal revision and 1 in 14 APVs underwent a subfascial revision at 10 years after surgery.

Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels

Many patients with certain conditions require catheterizable channels for bladder and bowel management. There are a variety of accepted techniques for creating these channels; the split appendix technique enables the use of this organ for both procedures, obviating the need for more complex surgical procedures. Studies comparing outcomes across catheterizable channel types are limited. The aim of this study was to compare the urinary channel complication rates of the split appendix, intact appendix and transverse ileal tube (Monti) channels. We hypothesized that complication rates would be the same across all channel types. We retrospectively reviewed consecutive patients who underwent surgical creation of a urinary continent catheterizable channel. We recorded demographics, underlying diagnosis, body mass index, stoma location, surgical techniques, and surgical revisions. The primary outcome was complication (stenosis, leakage, or both) with or without surgical revision, and to compare the three different catheterizable channel types using time to event analysis. From January 2014-July 2018, 107 patients underwent creation of a continent catheterizable urinary channel; 86 (80.4%) patients also underwent simultaneous procedure for antegrade bowel management. The mean age was 7 years; 66 (60.8%) were females. Intact appendices were used in 46 (43.0%), Monti channel in 25 (23.4%), and split appendix technique in 36 (33.6%). The corresponding complication rates with or without surgical revision was 21.7%, 36.0%, and 47.2%, respectively. The only independent factor associated with increased risk of complication was the split appendix technique; these channels were more than twice as likely to require surgical revision with an adjusted hazard ratio of 2.32 (Table 4). The majority of revisions in all groups were skin level (58.3%). The most common indication for surgical revision was stenosis (55.6%). This analysis shows a statistically significant increase in risk of all complications, including an increase in need for surgical revision, in patients who underwent split appendix technique for simultaneous bladder and bowel catheterizable channels. This finding should be balanced with the fact that a bowel anastomosis is not required in cases where individuals need both a bowel and bladder catheterizable channel. This study is unique in its separation of split and intact appendix channels, and inclusion of patients experiencing complications that have not yet required surgical revision. Limitations of this study include its retrospective design, inclusion of a single institution, and the lack of consistency in documenting baseline appendiceal length. Split appendix catheterizable channels have a higher rate of channel complications than other techniques. The authors acknowledge that the split appendix technique has been proven feasible and effective, however recognize that it may not be appropriate for all patients and include counseling of the risks of its use.

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

The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics. Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined. Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH2 O, P< 0.001). Bladder capacity improved significantly (67-89%, P= 0.041). The median follow-up was 4.5 years (interquartile range: 1.9-10 years). Bladder urolithiasis affected 13 (18%) patients, and symptomatic urinary tract infections 36 (51%) patients. Formation of a continent catheterisable channel contributed a number of complications relating predominantly to stenosis (50%). Repeat augmentation cystoplasty was necessary in three (4%) cases. Augmentation cystoplasty is a surgical intervention that improves bladder metrics. Given the potential complications, careful patient selection and appropriate pre-operative counselling are essential. Furthermore, pro-active post-operative management and transitional care are vital in the surgical care of children following augmentation cystoplasty.

Conversion of vesicostomy into continent catheterizable reservoirs in myelomeningocele

ABSTRACTIntroduction:Vesicostomy should be considered in children with neuropathic bladder in case first-line therapies fail. This simple and reversible procedure can reduce febrile urinary tract infections and protect the upper urinary tract (1) until more definitive alternatives can be proposed.We describe in this video how we approach patients that underwent vesicostomy and want it to be converted into a continent catheterizable reservoir.Material and methods:We perform an infra-umbilical longitudinal incision with a semicircular flap where the stoma will be placed (outside vesicostomy). After releasing the bladder, we proceed with usual steps of the Macedo-Pouch technique (2). We perform the reservoir from 35cm of ileum that constructs a catheterizable channel from the same bowel segment from a 3cm width flap from anterior and posterior wall of ileum in the mid part of it. The continence mechanism of the efferent tube is based on angulation and a serous lined tunnel created with 3-4 3.0 prolene sutures. The stoma is placed in the midline (3).Results:Patient had an uneventful evolution and is continent performing CIC every 4 hours with 9 months of follow-up. We have in the last 3 years a consecutive series of 12 patients operated according to this principle.Discussion:Vesicostomy should be regarded as an alternative for patients with neurogenic bladder refractory to clinical treatment at a younger age in order to postpone definitive treatment such as any an enterocystoplasty.This option must be considered as transient, since definitive reconstructive surgery can provide preservation of renal function and continence achievement. In this context, our video demonstrates that performing a bladder augmentation on a patient with a vesicostomy is safe and feasible. We reinforce that our method precludes the need of appendix or creation of a Monti tube as the outlet channel and the whole procedure is performed from a single piece of bowel.

EDITORIAL COMMENT

The primary goal of urologic management of people with spina bifida (SB), according to the Spina Bifida Association 2018 Guidelines, is to “maintain normal renal function throughout the lifespan.” The past 50 years have delivered astounding advancements towards this goa—the introduction of clean intermittent catheterization, use of antimuscarinic medications and onabotulinumtoxin, and the evolution of surgery from incontinent urinary diversion to continent reconstructions incorporating enterocystoplasty, continent catheterizable channels, and/or bladder outlet procedures.

Percutaneous cystolithotripsy in the reconstructed bladder of cloacal exstrophy: A case report

Background: Bladder stones are common after bladder augmentation. The management of bladder stones is challenging, especially in patients who underwent complex urinary tract reconstruction. Case Presentation: We report our experience of percutaneous cystolithotripsy after bladder neck closure, creation of a catheterizable channel, and ileal bladder augmentation in a girl with cloacal exstrophy. Conclusion: Percutaneous cystolithotripsy is a safe, effective, and minimally invasive treatment option for bladder stones after bladder neck closure and the creation of a continent catheterizable channel.

This Month in Adult Urology

This Month in Adult Urology

Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction

With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions. Enhanced Recovery After Surgery (ERAS) is a comprehensive multidisciplinary perioperative protocol that includes minimization of opioid analgesia in favor of non-opioid alternatives and regional analgesia. While ERAS protocols have consistently been shown to decrease inpatient opioid utilization, the impact on opioid prescribing practices and use after discharge in pediatric surgical patients is unclear. This study aims to assess the impact of an ERAS protocol on outpatient opioid prescription patterns after pediatric lower urinary tract reconstructive surgery. We hypothesize that implementation of an ERAS protocol leads to fewer outpatient opioid prescriptions as measured by number and total quantity of oral morphine milligram equivalents by body weight per patient. All patients who underwent bladder augmentation, creation of a continent catheterizable channel, bladder neck reconstruction or closure, or revision of prior reconstructive procedures at our tertiary care facility between 2011 and 2017 were reviewed. Patients were divided into pre-ERAS and ERAS cohorts based on whether surgery occurred before or after ERAS implementation. The Colorado Prescription Drug Monitoring Program was used to track filling of postoperative opioid prescriptions for patients covered by the database. A total of 167 urologic reconstructive surgeries were analyzed, including 83 before ERAS and 84 after ERAS implementation. Patients in the ERAS cohort received and filled more outpatient opioid prescriptions at time of discharge (82.6% historical vs 93.9% ERAS, p=0.015; 76.1% vs 57.9%, p=0.012). There were no differences in prescription total morphine milligram equivalents normalized to body mass, total days supplied, or 90-day opioid prescription refill rates. We found an unexpected increase in postoperative outpatient opioid prescriptions following implementation of an ERAS protocol for lower urinary tract reconstructive surgery. Possible reasons include worry about pain crisis at home in the setting of decreased hospital length of stay in the ERAS cohort or generalized upward drift in opioid prescribing patterns over time. ERAS protocols in other subspecialties reveal mixed findings but consistently suggest standardization of outpatient opioid prescribing patterns leads to a decrease in opioid prescriptions. Patients received more, not fewer, outpatient opioid prescriptions following major urologic reconstructive surgery after implementation of an ERAS protocol. Purposeful efforts should be made to standardize opioid prescriptions at discharge based on meaningful clinical criteria.

Outcomes according to channel type for continent catheterizable channels in patients undergoing simultaneous urinary and fecal reconstruction

IntroductionWhen creating a continent catheterizable channel (CCC) the choice of bowel segment used as the conduit should be tempered with the morbidity associated with it. The split-appendix technique allows the creation of both a urinary and fecal CCC without the need for a bowel anastomosis. However, there is concern that by splitting the appendix there is compromise to its blood supply and may affect outcomes. We aim to compare what affect the bowel segment used for urinary and fecal CCCs has on perioperative and long-term outcomes in patients undergoing simultaneous urinary and fecal reconstruction. MethodsA retrospective review was performed analyzing all patients that underwent simultaneous continent catheterizable urinary and fecal CCC between the years 2010–2016. Patient demographics, channel characteristics, perioperative complications and clinical success rate were analyzed. ResultsA total of 106 patients were identified that had simultaneous fecal and urinary CCC created at time of reconstruction. For urinary CCC, there were 64 patients (60.4%) that underwent a split-appendix technique, 27 patients (25.4%) underwent a Monti, and 15 patients (14.2%) had the appendix used only for the urinary channel. Those patients undergoing a split-appendix technique had median operative time of 447 min compared to 619 min when a Monti channel was created. The median length of hospital stay was 9 days for the split-appendix technique compared to 12 and 13 day median hospital stay when the appendix was used only for the urinary channel or a Monti was created, respectively. There was no difference seen in revision free survival of the channel following surgery of any of the channels with median follow-up of 44.5 months. However, there were more subfascial revisions of urinary CCC in those that underwent a Monti (5 patients, 18.5%) compared to other bowel segments (0 patients). ConclusionsUtilizing a split-appendix approach for creation of urinary and fecal CCCs does not affect 30-day complications or long-term revision rates compared to other established techniques. This technique minimizes the potential surgical morbidity of a bowel anastomosis and provide shorter operative times, when feasible, at time of simultaneous creation of fecal and urinary CCC.

Continent Cutaneous Catheterizable Channels in Pediatric Patients: A Decade of Experience with Open and Robotic Approaches in a Single Center

BackgroundTo allow patients with bladder and bowel dysfunctions to achieve social continence, continent catheterizable channels (CCCs) are effective alternatives to intermittent self-catheterization and enema. ObjectiveWe aimed to describe our progressive advancement from open to robotic construction of CCCs, reporting outcomes and comparing the two approaches. Design, setting, and participantsWe retrospectively reviewed electronic medical records of pediatric patients who underwent construction of CCCs between 2008 and 2019. The inclusion criteria were age ≤18 yr, and CCCs with or without bladder augmentation or bladder neck surgery. We compared open versus robotic approaches for demographics, and intra- and postoperative outcomes; operative time was calculated as incision-to-closure time. Surgical procedureChannels performed were appendicovesicostomy (APV), Monti with tapered ileum, and antegrade colonic enema (ACE). A Monti channel with tapered ileum was preferred to a spiral Monti or double Monti, as it has more robust blood supply and it was performed only with an open approach. MeasurementsThe primary outcome was success rate, defined as postoperative stomal continence. Stomal incontinence was defined as the presence of urine leakage noted by caregivers or patients and confirmed by the surgeon. Secondary outcomes were stomal stenosis (supra- and subfascial), incontinence, need for surgical revision, and surgical site infection. Results and limitationsA total of 69 patients were included in the study, with 35 open and 34 robotic procedures. The robotic approach showed a significant decrease in length of hospital stay (LOS) compared with the open approach. Six primary subfascial revisions were performed in five patients––three Monti, two ACE, and one APV. Continence rates were 91.4% and 91.2% for open and robotic approaches, respectively. ConclusionsRobotic surgery for CCCs showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, LOS, and time to full diet, and better cosmesis. Patient summaryRobotic surgery for continent catheterizable channels showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach.

Robot-assisted continent urinary diversion according to the Mitrofanoff principle: results of a bicentric study.

To assess the outcomes of continent urinary diversion according to the Mitrofanoff principle by robot-assisted laparoscopic surgery in terms of continence, catheterization and repeat surgery. All adult patients who underwent procedures for continent urinary diversion via a robot-assisted laparoscopic route between October 2014 and November 2018 were enrolled retrospectively. Abdominal continence and clean intermittent catheterization ability were noted, as well as patient characteristics, details of the technique, intra- and perioperative parameters, and complications. Ten patients were included. Bladder-sphincter disorders were due to neurological causes in nine patients, and one patient had idiopathic bladder sphincter dyssynergia. A continent catheterizable channel was created using the appendix in six cases and the ileum in four cases. The median operative duration was 245min (IQR 228-370). Two patients had a Clavien 3 complication requiring laparoscopy to separately drain a haematoma and a pelvic abscess. The median follow-up was 21months (IQR 17-27). Abdominal continence without further intervention was obtained in 6/10 patients (60%). Two patients needed an open revision of the continent urinary diversion, one required injection of Deflux® and one an intradetrusorian injection of botulinum toxin type A (Botox®). Further surgery was needed for two patients to improve urethral continence. At the end of follow-up, all patients were continent and clean intermittent catheterization was possible. Continent urinary diversion performed according to the Mitrofanoff principle is possible via a robot-assisted laparoscopic route and yields good outcomes on abdominal continence in the short term in patients with clean intermittent catheterization ability.

Pregnancy and Delivery in Women with Lower Urinary Tract Reconstruction: A National Multicenter Retrospective Study from the French-Speaking Neuro-Urology Study Group (GENULF) and the Neuro-Urology Committee of the French Association of Urology.

Management of pregnancy and delivery in women with lower urinary tract reconstruction is challenging and the currently available literature is insufficient to guide clinical practice. We report pregnancy and delivery outcomes in this specific population. We conducted a national multicenter retrospective study (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation enterocystoplasty, catheterizable channel creation and/or artificial urinary sphincter implantation. Maternal and fetal complications during pregnancy and delivery were reported, as well as postpartum functional outcomes, according to the delivery mode. The chi-square test and Student's t-test were used to compare categorical and continuous variables, respectively. Overall 32% of reported pregnancies were complicated by febrile urinary tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% of deliveries. Delivery mode (p=0.293) and multiparity (p=0.572) had no impact on urinary continence. In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women.

437 - Efficacy and security of continent catheterizable channels at short and middle term for adult neurogenic bladder dysfunction

Summary Aims The objective of this study was to assess the effectiveness and the complications rate following continent cutaneous channels (CCC) procedures, at short and medium term follow-up (FU). Materials & Methods A continuous retrospective case series (2008–2018): all patients who have undergone a CCC for neurogenic bladder were included in our department. The primary outcome was the effectiveness of CCC defined by the status of catheterizability (by the patient or a care-giver), continence of the tube, and absence of reintervention at 3 and 12 months FU. The secondary outcome was the prevalence of postoperative complications at 3 and 12 months FU. Results Fifty-three patients were included during the study period in our department. Median follow up was 3,3 years (1.5–6.1). The overall effectiveness of CCC was 67.9% (n = 36/53) at 3 months FU and 45,3% (n = 24) at 12 months FU. The global rate of complications was 60.4% (n = 32/53) at 3 months, and 73.6% (n = 39/73) at 12 months FU. The statistical analysis showed no statistical differences on efficacy and complications in the different subgroups of CCC. Conclusions In the current series, the effectiveness and the complications rates following CCC were comparable across the procedure types. Level of evidence 4.

Complications in adulthood for patients with paediatric genitourinary reconstruction.

Caring for adults with prior paediatric genitourinary reconstruction remains a challenge for adult providers. Reconstructions typically have occurred decades before; surgical records are not always available and patients and families may be unable to convey procedures performed. Spina bifida (SB) patients are vulnerable to cognitive decline which may compound these challenges. Changes in patient body habitus and loss of function may contribute to problems with previous reconstructions. This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on the evaluation and management of complications arising from genitourinary reconstruction in congenital neurogenic bladder patients. Common complications experienced by congenital neurogenic bladder patients include recurrent urinary tract infection, incontinence of catheterizable channel and urinary reservoir as well as malignancy as this population ages. Preservation of renal function and prevention of urinary tract infection while optimizing continence are essential guiding principles in the care of these patients. Many of the recommendations, however, are gleaned from available data in the adult spinal cord patient (a more commonly studied population) or the paediatric urologic literature due to limited studies in adult management of such patients. Close follow-up and vigilance is warranted to monitor for infectious, mechanical and malignant complications while optimizing preservation of the upper urinary tracts and patient quality of life.