Lower Urinary Tract Reconstruction Research Articles

27 years of experience with the comprehensive surgical treatment of prune belly syndrome

Prune belly syndrome (PBS) presents with three main features: abdominal wall flaccidity, urological abnormalities and cryptorchidism. As a result, urologists must consider the eventual repair of the abdominal wall flaccidity and urinary tract abnormalities, and the mandatory correction of cryptorchidism, as well as decide whether to perform the procedures in a single comprehensive approach or in multiple steps. To report experiences with comprehensive surgical management of prune belly syndrome. From 1987 to 2014, 46 children with PBS were submitted for comprehensive surgical treatment. According to individual needs, treatment aimed to correct the abdominal flaccidity, reconstruct the urinary tract, and perform bilateral orchiopexy and circumcision, which were performed in one procedure. Urinary tract reconstruction was indicated whenever pyelo-ureteral dilatation with evidence of significant stasis and/or vesicoureteral reflux was associated with recurrent urinary tract infections (UTI). Treatment for this cohort included: 44 abdominoplasties, 40 upper urinary tract reconstructions, 44 cystoplasties associated with three appendico-vesicostomies, 46 bilateral orchiopexies and 36 circumcisions. The median age at surgery was 16 months and children were followed for a median of 143 months. Abdominal appearance and tonus were improved in 90% of the children after the primary surgery and 100% after reoperation. Upper urinary tract reconstruction was performed in most children and long-term follow-up showed functional stabilization of the urinary tract in about 90% of the children, with progression to renal failure in 10%. Lower urinary tract reconstruction was performed in most children (95.6%); on late follow-up, continence was observed in 81% of them, while incontinence was present in 19% and usually associated with polyuria. Adequate bladder emptying was possible in most boys (82.6%), while the remaining required clean intermittent catheterization. Pre-operative UTI was present in 89.1% and urinary sepsis in 15.2%. Postoperatively, the incidence of laboratorial UTI was significantly reduced to 39.1%, while urinary sepsis was absent. Bilateral orchiopexy was performed in all children, with 85% of the testes becoming normal in size and well located in the scrotum. Comprehensive surgical treatment is feasible and has good long-term results. A considerable incidence of reoperations due to complications or progression of the disease was observed. The long-term results for reno-ureteral anatomy and function, bladder function, infection, testicular size and location, as well as abdominal aspect and tonus, show that comprehensive surgery is an adequate method for managing children with PBS.

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

Lower urinary tract reconstruction with augmentation cystoplasty (AC) is an effective strategy for achieving urinary continence in children with neurogenic or severely compromised bladder. We compared complications and need for secondary surgeries in children 3-5 years of age undergoing AC with continent reconstruction to those ≥ 6 years old. Medical charts of children undergoing AC with continent urinary diversion between 2003 and 2011 were reviewed. Complications and secondary surgeries were analyzed according to patient age. Patient demographics, etiology of bladder dysfunction, bowel segment used, and concomitant procedures were also assessed. One hundred and eight children underwent AC with continent urinary diversion. Mean age at augmentation was 8.5 years (range 3-20). Twenty-eight children (25.9%) were 3-5 years old and 80 (74.1%) were ≥ 6 years. Mean follow-up was 6.93 years (range 1.6-10 years). Bowel segment used included ileum in 59 (54.6%), sigmoid in 33 (30.6%), cecum in 4 (3.7%) and composite in 12 (11.1%). Major complications included bowel obstruction in 6 (5.6%), bladder perforation in 3 (2.8%) and fistula in 2 (1.9%). There was no difference in major complications based on bowel segment utilized (p = 0.804, OR 0.894) or age (p = 0.946, OR 0.969). Fifty children (46.3%) required no additional surgeries; the remaining 58 underwent 137 procedures post-augmentation. Surgeries included urolithiasis management (58/137, 42.3%), appendicovesicostomy revision including stoma revision or redo for persistent leakage between catheterizations in (34/137, 24.8%), bladder neck procedures (26/137, 19%) and revision of MACE (19/137, 13.9%) [Figure]. Incidence of stones in patients 3-5 years (32.1%) was not significantly different than children ≥ 6 years of age (25%, p = 0.463, OR 0.704). Mean number of secondary surgeries for those 3-5 years was 1.21 ± 1.34, which was not statistically different than those ≥ 6 (1.3 ± 1.82, p = 0.154). Children with myelomeningocele (MMC) were statistically more likely to require secondary surgeries than those with other bladder pathology (p = 0.01). Augmentation enterocystoplasty with cutaneous continent catheterizable channel is performed both to protect the upper urinary tract and afford the patient the option of social continence. Continent lower urinary tract reconstruction has been proven technically feasible and safe in preschool-aged children however, the ideal age for augmentation remains unknown. Urolithiasis accounted for over 40% of additional procedures in our series, with 26.9% of patients requiring one or more surgeries for stone disease. The incidence of stone disease in patients 3-5 years of age at the time of augmentation was comparable to that seen in older children. The overall need for additional post-augment procedures was not influenced by patient age or bowel segment utilized, however children with MMC were significantly more likely to require future surgeries than those with a different underlying etiology of bladder dysfunction. Our study has several limitations that warrant mention. Children with neurogenic bladder represent a heterogeneous population, and their surgical outcomes are inherently influenced by underlying disease processes and severity. Complications and secondary surgeries were assessed; however success rates were not evaluated in the current study. Patient and caregiver adherence with CIC and daily bladder irrigation was not assessed; whether noncompliance affected complication rates (i.e. stone formation) is unknown. Whether performed at a young or older age, families must be adequately counseled regarding the daily management responsibilities and potential risks associated with lower urinary tract reconstruction including bladder augmentation. Augmentation with continent urinary diversion in selected patients 3-5 years of age confers complication and secondary surgery risk equal to that observed in their older counterparts.

Renal transplantation in children weighing

We reviewed our experience with renal transplantation (RTx) in children weighing <15 kg to determine if the presence of lower urinary tract dysfunction (LUTD) influenced the outcome. Between 1987 and 2012, 68 RTx were performed in patients weighing less than 15 kg, including 17 with associated LUTD and 51 without. We detailed the lower urinary tract management in these patients, and compared graft survival rates and estimated clearance 12 and 60 months after RTx between groups. None of the patients without LUTD required any lower urinary tract surgery vs 8 out of 17 (47 %) with LUTD (p = 0.0001). The latter included a temporary incontinent urinary diversion in 5 cases (29 %), namely 2 vesicostomies and 3 cutaneous ureterostomies. After comparable follow-ups, there was no difference in patient survival, graft survival, and glomerular filtration rates between groups. Provided that there is appropriate bladder management, a concomitant LUTD does not adversely influence the outcome of RTx in patients weighing less than 15 kg. However, 50 % of our patients required lower urinary tract reconstruction and, in 30 %, a temporary incontinent urinary diversion was placed at RTx, since lower urinary tract function could not be assessed reliably, the patient was not collaborative enough to be involved in a voiding program, and/or the RTx was prioritized.

Total Bladder and Posterior Urethral Reconstruction: Salvage Technique for Defunctionalized Bladder with Recalcitrant Posterior Urethral Stenosis

Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis. We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined. No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion. Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

The evaluation and management of refractory neurogenic overactive bladder.

Patients with neurologic disease commonly develop overactive bladder (OAB) symptoms of urgency, frequency, and/or urge incontinence that remain bothersome despite oral pharmacologic therapy. Management of refractory OAB in the neurogenic population is a complex issue with no uniform treatment strategy. When treatment fails or patients generally are dissatisfied with the adverse effects of oral therapy, available options include sacral neuromodulation, percutaneous tibial nerve stimulation (PTNS), botulinum toxin injections, and lower urinary tract reconstruction such as augmentation cystoplasty. A thorough knowledge and understanding of available and emerging treatment options for neurogenic detrusor overactivity is paramount to assisting clinicians in choosing an appropriate treatment. This article reviews the non-pharmacologic treatment options for neurogenic OAB, mainly botulinum toxin, neuromodulation, and lower urinary tract reconstruction, and discusses important relevant studies.

A Novel Technique for Endoscopic Management of Stones in a Continent Urinary Reservoir

Urinary stones are a well-established complication of lower urinary tract reconstruction in children and can be managed through an open, percutaneous, or transurethral endoscopic approach for their surgical removal. For children with no urethral access, it is not generally advised to pursue an endoscopic approach through a catheterizable channel. In this study, we describe a safe and effective technique for the endoscopic management of stones through a catheterizable channel in a child with a continent urinary reservoir.

Simultaneous Augmentation Cystoplasty and Cuff Only Artificial Urinary Sphincter in Children and Young Adults with Neurogenic Urinary Incontinence

We review our experience with artificial urinary sphincter and augmentation cystoplasty in patients with neurogenic bladder. This is the largest known series to specifically evaluate cuff only artificial urinary sphincter at augmentation cystoplasty. A total of 18 males underwent simultaneous artificial urinary sphincter and augmentation cystoplasty at our institution between 1982 and 2012, of whom 13 (72%) underwent cuff only artificial urinary sphincter. Outcomes included urinary continence, emptying modality, artificial urinary sphincter status, complications and additional procedures. Of the patients undergoing augmentation cystoplasty and cuff only artificial urinary sphincter 10 (77%) were initially continent. Average time of continence was 52.9 months. Four patients (31%) required no additional procedures and remained continent. Urinary incontinence developed in 3 patients (23%) immediately postoperatively and in 6 (46%) subsequently. Ultimately 9 patients (69%) required conversion to complete artificial urinary sphincter at a mean of 36.9 months postoperatively. Overall 12 patients (92%) were continent at followup. There were no artificial sphincter specific complications in patients undergoing the cuff only procedure with conversion to complete artificial urinary sphincter. After conversion to complete artificial urinary sphincter 3 patients (23%) experienced artificial sphincter specific complications. Reoperation was performed in 10 patients (77%), for 13 total procedures (1.3 per patient). There were no complications with cuff only artificial urinary sphincter and 6 complications with complete artificial urinary sphincter (p = 0.025). Finally, patients undergoing cuff only artificial urinary sphincter requiring revision were younger than those not requiring revision (15.6 vs 30.8 years, p = 0.026). Simultaneous cuff only artificial urinary sphincter and augmentation cystoplasty appears safe and efficacious in patients with neurogenic bladder, with fewer complications than complete artificial urinary sphincter, and may provide definitive urinary continence in up to a third of patients. This procedure is technically easy, allows for outpatient revision, provides time for the child to mature and may be cost effective in avoiding placement of additional components in this select patient population.

Regenerative medicine as a new therapeutic strategy for lower urinary tract dysfunction

The use of regenerative medicine for the treatment of organic and functional disorders intractable to conventional treatment has increased worldwide. This innovative medical field might particularly hold promise for the treatment of life-threatening diseases or healing of irreplaceable organs, such as the heart, liver and brain. Dysfunction of the urogenital tract and associated organs other than the kidney might not have immediate life-threatening implications; furthermore, the effectiveness of alternative therapy, such as enterocystoplasty for bladder cancer, has been shown. Therefore, most physicians or scientists do not give much importance to these disorders. However, urological disease has increased in developed societies in recent years. Furthermore, medical costs have also escalated. Disorders of the lower urinary tract, such as urinary disturbance or incontinence, can lead to other complications, impairing quality of life and ultimately increasing short- and long-term medical expenses. Regenerative medicine might hold potential solutions to these problems. Recent advances in urogenital regenerative medicine are reviewed in the present article, with particular reference to lower urinary tract reconstruction. The potential of regenerative medicine for the treatment of intractable lower urinary tract dysfunction compared with conventional treatment is also discussed.

478 LOWER URINARY TRACT RECONSTRUCTION WITH CONCOMITANT CECOSTOMY BUTTON FOR ANTEGRADE ENEMA

You have accessJournal of UrologyPediatrics: Neuropathic Bladder/Reconstruction1 Apr 2013478 LOWER URINARY TRACT RECONSTRUCTION WITH CONCOMITANT CECOSTOMY BUTTON FOR ANTEGRADE ENEMA Chandra Singh, Daryl McLeod, Cheryl Baxter, Seth Alpert, and Venkata Jayanthi Chandra SinghChandra Singh Columbus, OH More articles by this author , Daryl McLeodDaryl McLeod Columbus, OH More articles by this author , Cheryl BaxterCheryl Baxter Columbus, OH More articles by this author , Seth AlpertSeth Alpert Columbus, OH More articles by this author , and Venkata JayanthiVenkata Jayanthi Columbus, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1870AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Procedures to enable antegrade enema improve the quality of life in children with intractable constipation related to neurogenic bowel and bladder dysfunction. Appendicocecostomy (AC) and Cecostomy button (CB) allow easy access for colonic wash-outs and help to achieve socially acceptable fecal continence. In children undergoing lower urinary tract reconstruction (LUTR), we have been offering concomitant CB to achieve total continence as an alternate to AC. This study aims to evaluate the outcome of LUTR with concomitant CB. METHODS We retrospectively reviewed the records of patients who underwent CB for intractable bowel dysfunction at the time of LUTR. Initial temporary cecostomy tubes were placed in the right iliac fossa during LUTR. After six weeks, this was exchanged for a Chait trapdoor CB. Subsequently, patients were scheduled for six month or annual exchange of the Chait tube by interventional radiology. Antegrade enema irrigation regimens varied and included water with or without additives. The outcome, follow up and complications were evaluated. RESULTS Between 2001 and 2011, a total of 110 patients underwent CB of whom 27 were performed at the time of LUTR, which included bladder outlet procedures, augmentations and abdominal catheterizable channels. There were 11 males and 16 females. The mean age at the time of surgery was 9.6 years (range 3.8–24.9). The mean follow was 29 months (range 1–115 months). Patients had an average of 4.2 (range 1–15) elective fluoroscopy guided tube changes during the study period. At studies end, 22 (81.5%) of patients continued to use their CB, reporting good functional results. Accidental removal of the CB occurred three times, and was managed by fluoroscopic replacement. Other self limiting complications included mucous discharge and pain around the tube. None of the patients required a visit to the operating room for complications related to CB. CONCLUSIONS Cecostomy button is a simple procedure for antegrade colonic enema administration. It can be combined with LUTR as an alternative to AC. By avoiding AC, the appendix can be spared for consideration during the LUTR, with minimal morbidity or complications noted in our study population. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e196 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chandra Singh Columbus, OH More articles by this author Daryl McLeod Columbus, OH More articles by this author Cheryl Baxter Columbus, OH More articles by this author Seth Alpert Columbus, OH More articles by this author Venkata Jayanthi Columbus, OH More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

1709 LONG-TERM FOLLOW-UP FOR ADULT MYELOMENINGOCELE PATIENTS AFTER LOWER URINARY TRACT RECONSTRUCTION

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Neurogenic Voiding Dysfunction1 Apr 20131709 LONG-TERM FOLLOW-UP FOR ADULT MYELOMENINGOCELE PATIENTS AFTER LOWER URINARY TRACT RECONSTRUCTION Michael Vainrib, Polina Reyblat, and David A Ginsberg Michael VainribMichael Vainrib Kfar Saba, Israel More articles by this author , Polina ReyblatPolina Reyblat Los Angeles, CA More articles by this author , and David A GinsbergDavid A Ginsberg Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2955AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The majority of literature evaluating neurogenic bladder (NGB) in myelomeningocele (MMC) patients (pts) focuses on pediatric pts. Due to significant improvements in care most reach adulthood. A small but significant number of patients ultimately require lower urinary tract reconstructive surgery (LUTRS) because of NGB. Our objective was to determine if long-term follow up (F/U) is required for those who have had prior LUTRS. METHODS A retrospective review of MMC pts with NGB after LUTRS was performed. RESULTS 118 adults with NGB secondary to MMC were identified, 55/118(65%) had LUTRS with a mean age of 23.4 years (range 5-42) at LUTRS and a mean age of 37.7 years (range 20-60) at last F/U with a mean follow-up of 11 years (range 1-29 years) post-LUTRS. A majority of patients (48/55 - 87%) manage their bladder with CIC, either through their native urethra (28/48 - 58%) or continent stoma (20/48 - 42%). Prior LUTRS includes: augmentation enterocystoplasty with or without continent stoma(40/55 - 73%), construction continent stoma alone (14%), Kock Pouch (13%). In addition 6/55 (11%) pts had a concomitant outlet surgery (sling, bladder neck closure or AUS) at time of LUTRS and 9/55 (16%) subsequently had outlet surgery after their initial reconstruction. Seven pts have undergone revision of their continent stoma and 3/7 had Kock Pouch revision. The majority of pts have normal renal function based on creatinine (0.77±0.59mg/ml) and renal ultrasound (US) (41/55 pts). Kidney stones were found in 4/55 studies and 16/55(29%) pts had a stone in their bladder or “pouch”. Bladder/pouch stones were treated endoscopically in 15/16 pts with 4 pts requiring a second procedure. CONCLUSIONS Pts with MMC and NGB who underwent LUTRS still require regular F/U. Issues include the need to screen for stone disease, upper tract changes and the possibility of a need for revision surgery for continence either at the level of the stoma or outlet. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e703 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Vainrib Kfar Saba, Israel More articles by this author Polina Reyblat Los Angeles, CA More articles by this author David A Ginsberg Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1541 INFECTIOUS OUTCOMES IN NEPHROSTOMY DRAINAGE PRIOR TO PERCUTANEOUS NEPHROLITHOTOMY COMPARED TO CONCURRENT ACCESS

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopy or Percutaneous Stone Removal (I)1 Apr 20131541 INFECTIOUS OUTCOMES IN NEPHROSTOMY DRAINAGE PRIOR TO PERCUTANEOUS NEPHROLITHOTOMY COMPARED TO CONCURRENT ACCESS Aaron Benson, Trisha Juliano, Ryan Pickens, and Nicole Miller Aaron BensonAaron Benson Nashville, TN More articles by this author , Trisha JulianoTrisha Juliano Nashville, TN More articles by this author , Ryan PickensRyan Pickens Nashville, TN More articles by this author , and Nicole MillerNicole Miller Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.3031AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Stone culture and renal pelvic urine cultures have been shown to be better predictors of urosepsis than pre-operative bladder culture. Short-term pre-operative antibiotics have also been shown to reduce the risk of urosepsis after percutaneous nephrolithotomy (PCNL). We hypothesized that establishing percutaneous nephrostomy drainage and treating with renal pelvic urine culture-specific antibiotics prior to PCNL would result in decreased risk of sepsis/systemic inflammatory response syndrome (SIRS) in patient undergoing PCNL, particularly in patients deemed to be at increased infection risk. To that end, we compared PCNL outcomes in patients with prior nephrostomy drainage to those that had percutaneous access performed concurrent with the PCNL. METHODS Data collected included patient age, gender, body mass index, pre-PCNL urine cultures, laterality/location, renal calculi burden size, pelvic urine/stone cultures, length of stay, and SIRS/complications. The data for patients with pre-placed nephrostomy drainage was compared to outcomes regarding PCNL with concurrent access using student's t-test and chi-squared test. RESULTS Between September 2007 and June 2012, 219 patients underwent PCNL. Sixty-seven (30.6%) patients had pre-placed nephrostomy drainage (Group 1) for acute obstruction/infection, lower urinary tract reconstruction, or both, while 152 (69.4%) patients had concurrent percutaneous renal access (Group 2) obtained by the urologist. Group 1 pre-PCNL pelvic and lower urinary tract (LUT) urine cultures were positive in 53.5% and 58.6%, respectively, which was higher than Group 2 (23.1%) (p = 0.0001). Group 1 was treated with pre-operative antibiotics for 13.7 days vs. 6.9 days in Group 2 (p = 0.0001). Stone size was larger in Group 2 than Group 1 (4.1 vs. 3.4 cm; p = 0.022). Stone culture was positive more often in Group 1 than Group 2 (64.2% vs. 25.7%; p = 0.0001). The concordance rate of Group 1 pre-PCNL pelvic urine culture results with stone culture results (30.6%) was higher than those for Group 1 or 2 LUT urine culture (21.4% or 7.3%). There were no SIRS episodes in Group 1 compared to a 6.6% SIRS rate in Group 2 (p = 0.034). CONCLUSIONS Pre-PCNL nephrostomy drainage with renal pelvic urine culture and culture-specific antibiotic treatment decreases sepsis rates in high risk patient populations. Stone culture is important to obtain as our data shows that a significant proportion of patients have positive stone cultures, which would increase the risk of infectious complication. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e632 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aaron Benson Nashville, TN More articles by this author Trisha Juliano Nashville, TN More articles by this author Ryan Pickens Nashville, TN More articles by this author Nicole Miller Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Lower Urinary Tract Reconstruction and the Long-Term Relationship Between Surgeon and Patient

Lower Urinary Tract Reconstruction and the Long-Term Relationship Between Surgeon and Patient

Differences in urodynamic study variables in adult patients with neurogenic bladder and myelomeningocele before and after augmentation enterocystoplasty

To evaluate urodynamic parameters in myelomeningocele patients with native bladders and after augmentation, continence rates and check the longevity of these parameters after lower urinary tract (LUT) reconstruction. A retrospective review of adult myelomeningocele patients with UDS. 118 adult patients with NGB secondary to myelomeningocele were identified. 58/118 (49.1%) had UDS performed in our clinic: 18/58 (31%) after prior reconstruction ("Augment" group) and 40/58 (69%) during annual urologic follow up ("NoSx" group). Urodyanmic findings after augmentation included: Pdet@MCC 31.1 (1-95) cmH(2)O, MCC 495.9 ml, NDO in 3/18 (16.7%), mean DLPP 54.0 (48-60) cmH(2)O and mean ALPP 39.6 (20-110) cmH(2)O in 5/18 with an incompetent sphincter. Patients in "NoSx" group had the following findings: Pdet@MCC of 39.6 (1-60) cmH(2)O, MCC 407.5 ml, 18/40 (45%) had NDO, mean DLPP of 48.1 (15-95) cmH(2)O and mean ALPP = 51 (17-78) cmH(2)O in 10/40 with incompetent sphincter. In the "NoSx" group, 19/40 (47.5%) had normal bladder compliance. Mean time from the surgery to UDS was 10.4 years. Continent patients in the "NoSx" group had a significantly higher MCC than incontinent patients in the same group (475 vs. 352 ml, P = 0.029). 8/17 (47.1%) continent patients in "NoSx" group had normal UDS. Most patients after augmentation maintain low bladder pressures for more than 10 years. Close long-term follow up should be maintained, especially in those patients that have not had prior augmentation. Urinary incontinence may be secondary to poor sphincteric function in patients with and without prior augmentation. Moreover, we should continue to follow patients after reconstruction as elevated detrusor pressures can still be seen. Strict follow up after LUT reconstruction still continues to be important.

Outpatient ‘mini’ percutaneous cystolithotomy following complex lower urinary tract reconstruction

PurposeTo present our initial experience with “mini” percutaneous cystolithotomy performed as an outpatient procedure in patients with neurogenic bladders. Materials & methodsOver the last 6 years, patients with neurogenic bladders and bladder calculi were managed with outpatient percutaneous cystolithotomy. All but 1 had previously undergone appendicovesicostomy (APV) creation. The procedure was performed by first passing a pediatric cystoscope per APV. Once the calculi were visualized, and following bladder distention, additional bladder access was obtained by passage of either a 16F Peel-Away introducer using the Seldinger technique or a 5 mm laparoscopic trocar under direct vision. An ultrasonic lithotripter was then advanced through the percutaneous access site and stone fragmentation completed. Following procedure completion, a catheter was placed for 24 h for bladder decompression. All procedures were performed on an outpatient basis. Results12 patients underwent 18 successful operations. In 1 patient, percutaneous access was unsuccessful. Mean age at surgery was 12.3 years. Mean operative time was 72 min 8 patients had undergone previous ileocystoplasty. The remainder was rendered stone free at the completion of surgery. One patient had persistent bleeding from the intravesical trocar site necessitating fulguration and an overnight stay for observation. The remainder were sent home the same day. There were no cases of urine extravasation. Conclusions“Mini” percutaneous cystolithotomy is a safe, effective technique for the outpatient management of bladder calculi.

606 GENDER AND CHRONIC KIDNEY DISEASE IN PATIENTS WITH SPINA BIFIDA

INTRODUCTION AND OBJECTIVES: Children born with spina bifida are at risk for chronic kidney disease (CKD). One of the goals of urologic intervention is to prevent the compromise of kidney function. Urologic intervention can include intermittent catheterization, medications, and/or lower urinary tract reconstruction. Much debate still exists regarding risk factors for developing CKD. We evaluated the role of gender on CKD in spina bifida patients. METHODS: We retrospectively evaluated spina bifida patients using the Vanderbilt Synthetic Derivative resource. The Synthetic Derivative is a collection of de-identified information extracted from the Vanderbilt University Medical Center clinical information systems. Content is changed by deletion or permutation of all identifiers contained within each record. Study inclusion criteria were: age 10 years and ICD-9 code 741 for spina bifida confirmed with specific mention of “spina bifida” or “myelomeningocele” in the patient record. Each record was then reviewed for age, sex, race, history of dialysis, history of renal transplant, serum creatinine, history of urodynamics, and history of urological operative procedures. Glomerular filtration rate (GFR) was calculated by the Modification of Diet in Renal Disease (MDRD) study equation at 18 years of age and the Bedside Schwartz equation at 18 years of age. CKD onset was defined as GFR 60, need for dialysis, or need for renal transplant. For our analysis, we assumed that patients without serum creatinine levels and without mention of CKD in the clinical record did not have CKD. Log-rank test for equality of survivor functions was used to compare the effect of gender on CKD onset. RESULTS: We identified 1196 spina bifida patients. To decrease confounding by race, we limited our analysis to the 901 patients identified as Caucasian. Of the 901 patients, 520 had documented serum creatinine values. CKD onset occurred in 54 patients (6.0%) at an average age of 34.7 years. Male spina bifida patients were more likely to develop CKD than female spina bifida patients (p 0.03). CONCLUSIONS: In our cohort of spina bifida patients, female gender was associated with less CKD onset. Whether this gender difference is due to lifestyle factors, sex hormone effects on the kidney and or lower urinary tract or a disparity in urologic and medical care remains to be elucidated.

607 IS A BLADDER NECK SLING SAFE AND SUFFICIENT FOR ALL MYELOMENINGOCELE PATIENTS: WHO, IF ANY, WILL REQUIRE A BLADDER AUGMENTATION?

You have accessJournal of UrologyPediatrics: Bladder Dysfunction - Myelodysplasia, Voiding Dysfnction, Enuresis1 Apr 2012607 IS A BLADDER NECK SLING SAFE AND SUFFICIENT FOR ALL MYELOMENINGOCELE PATIENTS: WHO, IF ANY, WILL REQUIRE A BLADDER AUGMENTATION? Blake Palmer, Yan Xiong, Jake Klein, Dominic Frimberger, and Bradley Kropp Blake PalmerBlake Palmer Oklahoma City, OK More articles by this author , Yan XiongYan Xiong Oklahoma City, OK More articles by this author , Jake KleinJake Klein Oklahoma City, OK More articles by this author , Dominic FrimbergerDominic Frimberger Oklahoma City, OK More articles by this author , and Bradley KroppBradley Kropp Oklahoma City, OK More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.684AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES More and more reports describe managing myelomeningocele neurogenic bladder (NGB) patients with an outlet procedure (bladder neck sling or bladder neck repair and sling) without bladder augmentation for patients with smaller than age expected bladder capacities. Historically, this was commonly unsuccessful and an unpredictable management strategy when artificial urinary sphincters were utilized as the outlet procedure. Our intent was to determine in our clinical practice if this was safe and in whom it could be predicted to be a sufficient management strategy. METHODS A retrospectively reviewed a database for all neurogenic bladder patients who underwent lower urinary tract reconstruction between 1997 and 2008 at the Children's Hospital of Oklahoma. We identified 2 cohorts of patients who underwent bladder neck sling alone and another who had a sling at the time of bladder augmentation. Preoperative urodynamic (UDS), postoperative UDS, bladder management, upper tract surveillance, surgical procedures, complications and long term continence outcomes were assessed for each group. RESULTS Group A has 6 patients who initially underwent bladder neck sling procedure only and Group B has 6 patients who had sling and concurrent bladder augmentation. In group A, 4 out of 6 patients bladder compliance deteriorated during postoperative follow-up and subsequently proceeded with bladder augmentation procedures because of decreased bladder capacity, increased detrusor leak point pressure (DLPP 40 cm H20), new and/or worsening hydronephrosis and persistent urinary incontinence. The dry rate (no leak for 4 hours with CIC) for Group A is 16.7% after initial sling procedures and 66.7% after 4 patients received bladder augmentation. CONCLUSIONS Although, the size of this study is small, numerical difference of preoperative UDS results and postoperative dry rate were clearly observed between groups. Patients with lower initial bladder capacity tended to have a higher chance to have bladder deterioration after sling procedure alone. However, after the subsequent augmentation these patients could still achieve similar dry rate as patient received concurrent augmentation. Bladder outlet management alone has the potential for deterioration of bladder dynamics and may require subsequent bladder augmentation. Close follow up is important if this management strategy is employed. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e247 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Blake Palmer Oklahoma City, OK More articles by this author Yan Xiong Oklahoma City, OK More articles by this author Jake Klein Oklahoma City, OK More articles by this author Dominic Frimberger Oklahoma City, OK More articles by this author Bradley Kropp Oklahoma City, OK More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Complications After Use of Gastric Segments for Lower Urinary Tract Reconstruction

We retrospectively reviewed our experience with the use of gastric segments for lower urinary tract reconstruction with an emphasis on long-term complications. A total of 29 patients underwent reconstruction of the lower urinary tract using gastric segments between 1993 and 2000. Diagnoses included neurogenic bladder (21), cloacal exstrophy (5), solitary kidney/ectopic ureter (1), posterior urethral valves (1) and rhabdomyosarcoma of prostate (1). Gastric segment was used as gastrocystoplasty (21), composite gastroenteric cystoplasty (6), demucosalized gastrocystoplasty (1) and continent gastric reservoir (1). Mean followup was 13.9 years (range 9 to 16.5). Complications were seen in 15 (51.7%) patients. Seven patients had the hematuria-dysuria syndrome, which was intractable in 1 and necessitated excision of the gastric patch. Due to severe complications necessitating major reoperations 3 patients underwent re-augmentation with enteric segments without excision of the gastric tissue (composite). One patient who underwent demucosalized gastrocystoplasty had excision of the gastric tissue and re-augmentation with enteric segment due to contraction of the gastric patch. A stone developed in 1 patient with a composite gastroenteric reservoir. Malignancy developed in the reservoir in 3 patients 11, 12 and 14 years after gastrocystoplasty, and all 3 died of metastasis. We do not recommend the use of gastric segments for reconstruction of the lower urinary tract due to the high incidence of reoperations and complications. In patients in whom gastric segments were used in the past for lower urinary tract reconstruction, regular surveillance and close followup are strongly advocated.

Complication of Minimally Invasive Radical Cystectomy

Introduction and Objectives: Open radical cystectomy (ORC) is the standard treatment for high-grade and muscle invasive bladder cancer, with the significant potential of early complications even in the most experienced hands and in high-volume center. Over the last decade, we have witnessed the emergence and progression of minimally invasive surgery in urology, including radical cystectomy. Any new technique applied to the treatment of invasive bladder cancer should be safe, should maintain similar oncological principles as ORC, and should provide similar options for lower urinary tract reconstruction. While many complications of radical cystectomy are shared between approaches, recognition and management in the robotic and laparoscopic surgery environment poses unique challenges. The goal of this video is to present graphic illustrations of complications during robotic or laparoscopic radical cystectomy (LRC). Methods: A multi-institutional collection of surgical videos was compiled. These videos illustrate vascular injury, rectal injury, benign ureteral strictures, and the presence of vesicovaginal fistula after surgery. Management techniques are illustrated where appropriate. Results: This video shows the possible complications and how often they are encountered, comparing the different approaches, open, laparoscopic, and robotic. In addition, short- and middle-term complications in patient after minimally invasive radical cystectomy are characterized. Conclusions: Robot-assisted radical cystectomy (RARC) and LRC must reproduce the robust oncological outcomes seen with ORC while attempting to minimize perioperative morbidity. RARC and LRC incur acceptably low postoperative morbidity, with the vast majority of complications being low grade. High-grade complications are infrequent and similar to those encountered after ORC. Complications are similar in all approaches, but may be surgeon or technique related. Early recognition and appropriate management is essential when these complications occur. No competing financial interests exist. Runtime of video: 7 mins 57 secs

Composite Urinary Reservoir in Dogs: Histological Findings

This animal study was designed to investigate whether the composite urinary reservoir might lessen the premalignant histological alterations observed after bladder augmentation performed with a gastric segment or large bowel. Composite urinary reservoirs were created using gastric and colonic segments simultaneously in 8, 3-month-old female beagle dogs by augmenting half the native bladder. Two dogs with gastrocystoplasty and 2 with colocystoplasty served as controls. Biopsies were taken from the native bladder, and the gastric and colonic segments at augmentation, and endoscopically 4 and 8 months postoperatively. The dogs were sacrificed and open biopsied 12 months postoperatively. Tissue specimens were examined with routine hematoxylin and eosin, reaction and immunohistological staining for PCNA. At the creation of composite reservoir and gastrocoloplasty or colocystoplasty all specimens showed normal histology. At 12 months postoperatively dysplasia was found in 1 gastric segment, 2 native bladders and 3 colonic segments in the composite reservoir group. There was a single carcinoma in situ in 1 gastric segment in the composite reservoir group. In the control groups 1 colonic segment and 1 native bladder dysplasia were detected at the end of 12-month followup. There was an in situ carcinoma in 1 gastric segment in the composite reservoir. A composite reservoir did not decrease premalignant changes in dogs during 12 months of followup. Laboratory investigations, molecular studies and longer followup are needed to approach the question of early malignant alterations after augmentation cystoplasty in animals and patients.

Complications After Use of Gastric Segments for Lower Urinary Tract Reconstruction

Complications After Use of Gastric Segments for Lower Urinary Tract Reconstruction