Pediatric Urinary Reconstruction Research Articles

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.

Adult Care of Children From Pediatric Urology

In this article we highlight the difference, from established adult urology, in required approach to the care of adolescents and young adults presenting with the long-term consequences of the major congenital anomalies of the genitourinary tract. We review some abnormalities of the kidneys, progressive renal failure and disorders of bladder function from which general conclusions can be drawn. The published literature was reviewed and augmented with material from our institutional databases. For renal function the CAKUT (congenital abnormalities of the kidney and urinary tract) database at University College London Hospitals was used, which includes 101 young adult patients with CAKUT in whom the urinary tract has not been diverted or augmented. For bladder function some data are from patient records at Boston Children's Hospital. Adolescents who grow up with the burden of a major congenital anomaly have an overwhelming desire to be normal. Many achieve high levels of education and occupy a wide range of employment scenarios. Babies born with damaged kidneys will usually experience improvement in renal function in the first 3 years of life. Approximately 50% of these cases will remain stable until puberty, after which half of them will experience deterioration. Any urologist who treats such patients needs to test for proteinuria as this is a significant indicator of such deterioration. In its absence, the urologist must have a reasonable strategy for seeking a urological cause. The most effective management for nephrological renal deterioration is with angiotensin converting enzyme inhibitors, which slow but do not prevent end stage renal failure. Renal deterioration is generally slower in these patients than in those with other forms of progressive renal disease. The bladder is damaged by obstruction or by functional abnormalities such as myelomeningocele. Every effort should be made to stabilize or reconstruct the bladder in childhood. A dysfunctional bladder is associated with or causes renal damage in utero, but continued dysfunction will cause further renal damage. Bladder function often changes in puberty, especially in boys with posterior urethral valves who may experience high pressure chronic retention. Dysfunction is managed with antimuscarinic drugs, clean intermittent self-catheterization and intestinal augmentation. Adult urologists must be able to manage the long-term problems associated with these treatments. Pediatric conditions requiring management in adolescence are rare but have major, lifelong implications. Their management requires a broad knowledge of pediatric and adult urology, and could well be a specialty in its own right. Therefore, adult urologists must remain aware of the conditions, the problems that they may encounter and the special management required for these patients to live normal lives.

Gastrocystoplasty: Long-Term Followup

The use of stomach has become controversial in pediatric lower urinary tract reconstruction. Recent series have reported a high incidence of hematuria-dysuria syndrome and metabolic abnormalities, which has prompted a significant decrease in its use at our institution during the last 5 years. We retrospectively reviewed the medical records of children who underwent urinary reconstruction with gastrocystoplasty. Patients were excluded from consideration if they had less than 5 years of followup. From 1989 to 1997, 18 males and 26 females were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 9.8 years. Urinary continence was present in 89% of cases, and upper tract dilatation was stable or improved in 91%. No patient had chronic metabolic alkalosis. Major surgery was required for complications of the gastrocystoplasty in 6 cases, including patch contraction and ureteral obstruction necessitating excision in 1. Two patients had severe hematuria while anuric from renal failure which was managed conservatively with bladder cycling and H2 blockers. Symptoms resolved completely after renal transplantation in both cases. Febrile urinary tract infection occurred in 20% of cases and asymptomatic bacteriuria was present in 36%. The use of stomach segments in pediatric urinary reconstruction can be beneficial in patients with chronic renal insufficiency, metabolic acidosis or short gut syndrome. Despite negative reports concerning serious complications of gastrocystoplasty, our long-term data confirm that it remains an important option in our reconstruction armamentarium.

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

OUTCOME OF GASTROCYSTOPLASTY IN TERTIARY PEDIATRIC UROLOGY PRACTICE

OUTCOME OF GASTROCYSTOPLASTY IN TERTIARY PEDIATRIC UROLOGY PRACTICE

URODYNAMIC EVALUATION AND LONG-TERM RESULTS OF THE ORTHOTOPIC GASTRIC NEOBLADDER IN MEN

Orthotopic neobladders are most commonly formed from colon and/or small bowel segments. However, after excellent results were reported in children, we constructed gastric neobladders in select men who had undergone cystectomy. Although gastric neobladders in adults have been reported to have decreased capacity, to our knowledge neither long-term followup nor urodynamic parameters have been reported in these patients. Gastric neobladder was performed in 8 patients following cystectomy for malignancy in 7 and undiversion in 1. Average followup was 43 months and all patients underwent urodynamic evaluations an average of 9.1 months after surgery. Patients also completed an incontinence questionnaire. The gastric neobladder group was compared to a similar group of patients who underwent neobladder construction from either small bowel (Kock/Hautmann/Studer) or ileocecal segments (Mainz). The gastric neobladder group had significantly reduced mean bladder capacity compared to the ileal or ileocecal neobladder group (309 versus 551 cc, respectively, t = 0.001), while compliance was similarly decreased (27 versus 59 cc/cm. H2O, respectively, t = 0.04). Incontinence rates were greater in the gastric neobladder group (63%) compared to the ileal or ileocecal neobladder group (8% to 23%, t = 0.02). Complication rates were comparable. Revision or removal was required in 3 (38%) patients for severe incontinence, intractable dysuria and ureterogastric anastomotic stricture, respectively. Adult gastric neobladders as currently constructed are associated with poor urodynamic parameters and high incontinence rates. Routine use of gastric neobladders in adults is not recommended. They may be appropriate, especially as composites, in select cases such as renal failure or inadequate bowel length. The reasons for success in some patients and not in others are unknown.

The use of stomach in pediatric urinary reconstruction : R. Gosalbez, Jr, J.R. Woodard, B.H. Broecker, et al. J Urol 150:438–440. (August), 1993

The use of stomach in pediatric urinary reconstruction : R. Gosalbez, Jr, J.R. Woodard, B.H. Broecker, et al. J Urol 150:438–440. (August), 1993

The Use of Stomach in Pediatric Urinary Reconstruction

We report on 30 consecutive patients (mean age 9 years) who underwent gastrocystoplasty (21) or received a continent urinary reservoir with stomach (9). A successful outcome, defined as complete urinary continence for intervals greater than 3hours, preservation or improvement of the upper tracts and renal function, and normal electrolyte and acid base balance, was achieved in 90% of the patients who received continent urinary reservoir and 72% of those who underwent gastrocystoplasty. Urodynamic data were obtained in 17 patients in the gastrocystoplasty group and 7 in the continent urinary reservoir group at a mean of 6 months postoperatively. Metabolic alkalosis associated with hypergastrinemia occurred in 2 children. Partial excision of the gastric segment was necessary in 1 patient refractory to medical treatment.

The Syndrome of Dysuria and Hematuria in Pediatric Urinary Reconstruction with Stomach

Between July 1989 and March 1992 at a single institution 27 male and 30 female patients underwent lower urinary reconstruction with stomach. Mean patient age was 9.9 years (range 1.5 to 28 years). The diagnoses were epispadias/exstrophy complex (19 patients), myelodysplasia (11), cloacal exstrophy (6), posterior urethral valves (6), Hinman syndrome (4), sacral agenesis (3) and other (8). Indications for surgery were urinary incontinence, upper tract deterioration or undiversion. A total of 54 patients underwent augmentation gastrocystoplasty and 3 had total bladder replacement. Mean followup time was 23.2 months (range 12 to 39 months).The syndrome of dysuria and hematuria is defined as 1 or a combination of the following symptoms: bladder spasm or suprapubic, penile or periurethral pain, coffee brown or bright red hematuria without infections, skin irritation or excoriation and dysuria without infections. Telephone and clinic interviews identified 21 patients (36%) with symptoms of the dysuria and hematuria syndrome. The most common symptoms were hematuria (71%) and bladder or suprapubic pain (76%). Of the patients 18 (86%) ranked the severity of symptoms as mild to moderate and 3 (14%) ranked them as severe. No medications were required to control the symptoms in 13 patients (62%) and 3 other patients only required medications on an as needed basis. Overall patients who required no medications had lower symptom scores than those who required medications. Patients with decreased renal function may be more at risk for the dysuria and hematuria syndrome than those with normal renal function. Patients who were wet were more prone to have the dysuria and hematuria syndrome than those who were totally dry. The pathophysiology of the dysuria and hematuria syndrome is currently unknown. Patients who require urinary reconstruction with stomach tissue need to be made aware of the potential of the dysuria and hematuria syndrome.

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction: H. N. Noe, O. S. Spivey, Jr., and G. R. Jerkins. Urology 23:144–147 (February), 1984

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction: H. N. Noe, O. S. Spivey, Jr., and G. R. Jerkins. Urology 23:144–147 (February), 1984

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction

If following posterior urethral valve fulguration a unilateral nonfunctioning or poorly functioning kidney remains, nephroureterectomy is the customary method of management. The distal ureter of such renal units can serve as a means of salvage for complications resulting from surgery on the ureter serving the remaining solitary functioning renal unit. We present 2 cases of posterior urethral valves where planned preservation of the distal ureter of a nonfunctioning kidney allowed salvage of such complications. We advocate preserving the ureter of a nonfunctioning renal unit if possible until the fate of the solitary functioning kidney and ureter is clear. This approach can be applied to other aspects of pediatric urologic reconstructive surgery.

The Use of Antirefluxing Intestinal Segments in Pediatric Urinary Reconstruction

Because of inadequate ureteral length or disease preventing direct ureterovesical anastomoses, antirefluxing intestinal segments were used in eight children during reconstruction of their urinary tracts. Previous urinary diversions by either ileal conduit or cutaneous ureterostomy had been done in six of the eight. In five of the children, bladder augmentation was also required because of nondistensible fibrotic bladders secondary to disuse or prior obstruction. The intestinal segments used were ileal (4), ileocecal (4), and sigmoid (1). The ileal segments were tapered along the antimesenteric border and reimplanted into the bladder with long submucosal tunnels to prevent reflux. Reflux was prevented in the ileocecal segments by plication of the normal ileocecal valve. Reflux has not developed postoperatively in any of these patients. In one patient in whom an ileal segment was used. In one patient in whom an ileal segment was used, partial obstruction occurred at the new bladder hiatus. The serum creatinine rose from 2.8 mg/dl to 3.5 mg/dl necessitating a secondary repair. Renal function and serum electrolytes have improved or remained stable in all other patients. For children who have undergone multiple previous procedures resulting in inadequate ureteral length and/or abnormal bladders, these techniques offer excellent alternatives to permanent urinary diversion.

The use of antirefluxing intestinal segments in pediatric urinary reconstruction

Because of inadequate ureteral length or disease preventing direct ureterovesical anastomoses, antirefluxing intestinal segments were used in eight children during reconstruction of their urinary tracts. Previous urinary diversions by either ileal conduit or cutaneous ureterostomy had been done in six of the eight. In five of the children, bladder augmentation was also required because of nondistensible fibrotic bladders secondary to disuse or prior obstruction. The intestinal segments used were ileal (4), ileocecal (4), and sigmoid (1). The ileal segments were tapered along the antimesenteric border and reimplanted into the bladder with long submucosal tunnels to prevent reflux. Reflux was prevented in the ileocecal segments by plication of the normal ileocecal valve. Reflux has not developed postoperatively in any of these patients. In one patient in whom an ileal segment was used. In one patient in whom an ileal segment was used, partial obstruction occurred at the new bladder hiatus. The serum creatinine rose from 2.8 mg/dl to 3.5 mg/dl necessitating a secondary repair. Renal function and serum electrolytes have improved or remained stable in all other patients. For children who have undergone multiple previous procedures resulting in inadequate ureteral length and/or abnormal bladders, these techniques offer excellent alternatives to permanent urinary diversion.