Bladder Reconstructive Surgery Research Articles

Caregiver decisional regret following reconstructive bladder surgery in children with neurogenic bladder

Surgical management for neurogenic bladder requires complex decision-making by physicians, patients, and caregivers. Assessing decisional regret (DR) as a patient-reported outcome among caregivers could inform future counseling and shared decision-making. To assess DR among caregivers of children with neurogenic bladder following reconstructive bladder surgery. A questionnaire including a validated DR survey was distributed to English-speaking caregivers of children with neurogenic bladder who had undergone reconstructive bladder surgery at Children's Hospital Colorado. DR scores range from zero to 100, with higher numbers indicating higher regret. Wilcoxon rank sum test and Spearman correlation were performed to assess differences in DR scores by patient demographic factors or disease factors. Forty-five of 210 English-speaking caregivers completed the DR survey. The median DR score was 5, with 40% of subjects reporting with a DR score of zero and 24% of subjects with a DR score of 30 or higher. Patient sex and Mitrofanoff leakage were found to be associated with DR, with caregivers of male patients reporting significantly higher DR. Surgical procedure did not have a statistically significant impact on DR scores. Sparse existing data exploring DR among patients with neurogenic bladder suggest DR following reconstructive bladder surgery is low, with few identifiable predictors of regret. While the majority of caregivers in our study report little or no DR, one quarter of caregivers report moderate to high DR. The limitations of this study include small cohort size, low response rate, exclusion of non-English speaking patients, and the potential for recall bias due to the survey design of the study. Caregiver DR following bladder reconstruction in children with neurogenic bladder is generally low, however a subset of caregivers reports significant DR. This study suggests that caregivers of male children may have higher DR, a finding that merits further investigation.

Mortality rates, cause and risk factors in people with spina bifida, register-based study over five decades.

Care for people with spina bifida can be improved. This may be done by evaluating mortality rates and causes of death. Between 1973 and 2021, 1735 people with spina bifida appeared in registers of the Swedish population. Survival rates and causes of death were calculated according to age and decade. Over almost 50 years, the prevalence of spina bifida decreased from 5.2 to 1.2 per 10 000 births. Mortality fell sharply during the first year of life, with survival rising from 75% to 94%. For children aged 2-18 years and adults, mortality rates were low and differences between decades were minimal. Causes of childhood deaths were congenital abnormalities, hydrocephalus and infections, the latter two also in adults. Adult causes also included self-inflicted injuries and substance abuse, with suicidal or unclear intent, both more common than in the general population. Bladder malignancies were also more frequent, although after reconstructive bladder surgery, mortality rates were similar. Survival in the first year of life increased in children with spina bifida, whereas there was no difference in survival rates between adults born between 1973 and 1999. For adults, proactive prevention methods regarding self-inflicted injury, substance abuse and bladder cancer are warranted.

Ureteroscopy in Patients with Urinary Diversion: Outcomes and Lessons Learned from Two European Centres

BackgroundUreteroscopy (URS) in patients with urinary diversion is technically challenging. Common difficulties include anastomotic strictures, tortuosity, and failure to cannulate the ureteric orifice. There are few studies reporting outcomes in this special population. ObjectiveOur aim was to report outcomes at two tertiary centres in Europe. Design, setting, and participantsA multicentre retrospective cohort study was conducted between 2010 and 2022. InterventionURS (antegrade and retrograde) procedures carried out in patients with urinary diversions. Outcome measurements and statistical analysisOutcomes of interest included success at cannulating the ureteric orifice, stone-free rate (SFR), and complications. A logistic regression analysis was performed to identify potential predictors for success at cannulating the ureteric orifice and success at completing the intended procedure in a single session. Results and limitationsFifty patients underwent 72 URS procedures, with most (86%) undergoing a retrograde approach. The majority (82%) of patients had undergone ileal conduit. Wallace was the commonest anastomosis type (64%). Ureteric anastomosis was cannulated successfully in 81% of cases. The most common reason for cannulation failure was the inability to identify the ureteric orifice (11%). A multivariable analysis revealed that an endourologist performing the case was associated with a significantly greater likelihood of cannulation success compared with consultants (odds ratio 25.9, p < 0.001). The mean operative time and hospital stay were 49 min (range: 11–126) and 1 d (range: 0–10), respectively. SFRs were 75% (zero fragments) and 81% (residual fragments ≤2 mm). No intraoperative complications were recorded. The overall postoperative complication rate was 6%. This study is limited by its retrospective status. ConclusionsEndourological experience increases the likelihood of successful ureteric cannulation and procedural success. A low complication rate can be achieved despite this being a population with often multiple comorbidities. Patient summaryPatients with previous bladder reconstructive surgery can undergo ureteroscopy with good outcomes. Surgeon experience increases the likelihood of treatment success.

An observational study on the sexual, genital and fertility outcomes in bladder exstrophy and epispadias patients

Bladder exstrophy and epispadias complex (BEEC) is a spectrum of congenital malformations ranging from an isolated epispadias to a full exstrophy. It is an uncommon disease and little is known on how patients cope with its implications later in life. The goal of this study is to assess the sexual, continence and fertility outcomes of BEEC patients, who had reconstructive bladder surgery during childhood. Considering the sensitive nature of these topics, they are not easily spoken about in the doctor's office. Our aim is to shed some light on possible points of improvement in follow-up. 63 patients between 18 and 45 years old were sent an electronic questionnaire based on previous existing standardized questionnaires. They were asked about sexual and psychosexual wellbeing, urinary incontinence and fertility. Data from their medical files (medical history on previous surgeries). and questionnaire answers are linked through an anonymous subject number and put into an Excel file for descriptive representation. 22 men and 8 women filled in the questionnaire. All but 2 are sexually active. Reasons to avoid sexual activity are equally divided as BEEC-related and non-BEEC-related. Sexual satisfaction is lower in the male group due to problems with erection, ejaculation, condom usage and embarrassment about physical appearance. In females problems concerning pain and reaching orgasm are mentioned. 30% report depressive feelings. There is a clear correlation between number of reconstructive surgeries and sexual satisfaction. 90% of patients urinate via catheterization, mostly through a Mitrofanoff connection. This leads to complications such as foul odors, infection, embarrassment and sexual dysfunction. 8 out of 13 men conceived a child (with the use of their own sperm), 2 out of 4 women did. A strength of this study is the use of standardized questionnaires which allow comparison to a control patient group. Our study is one of the first to show how patients cope with the challenges of BEEC by the use of open questions. We see an overall high quality of life yet an important impact on mental health. BEEC is associated with many challenges in the adult life of patients. A more holistic and interdisciplinary approach is needed to include sensitive topics in long term follow-up.

MO1004IMBALANCE IN URINARY PROTEOGLYCANS AND THE INSULIN GROWTH FACTOR (IGF) AXIS IN CHILDREN WITH NEPHROLITHIASIS*

Abstract Background and Aims In vitro experiments have shown that exposure of renal epithelial cells to calcium oxalate crystals leads to synthesis of proteins involved in extracellular matrix (ECM) production. Cell proliferation and accumulation of ECM proteins have been reported in animal models and kidney biopsies from patients with stones. Based on the role of ECM in the Randall plaque formation, we aimed to identify and quantify ECM proteins in the urine of children with nephrolithiasis (RS) using a proteomic approach. Method Prospective, controlled, pilot study of pooled urine from RS (N=30, 24 females, mean age 12.95±4.03 years) versus age- and gender-matched healthy controls (HC), using liquid chromatography-mass spectrometry (LC-MS/MS). Patient inclusion criteria consisted of age 5-18 years, history of clinically (typical renal colic) and radiographically (ultrasound or CT) proven renal stone, at least two 24-hour satisfactory urine collections (urinary creatinine more than 15 mg/kg/day), absence of hematuria or pyuria, and normal renal function. Children who were not toilet trained, or those with bladder stones, nephrocalcinosis, neuropathic bladder, major congenital bladder abnormality, active urinary tract infection, presence of blood in urine, chronic kidney disease, previous major reconstructive bladder surgery requiring catheterization, and significant cardiac, pulmonary, gastro-intestinal, and neurological problems were excluded. Relative protein abundance was estimated using spectral counting. The criteria for protein selection were: 1) patient/control abundance ratios of &amp;gt;5 or &amp;lt;0.2 as a threshold to be well above observed technical variations in MS experiments; and 2) ≤0.05 p-value for the Fisher’s Exact Test. Results were confirmed by ELISA testing. Statistical analyses were conducted with IBM SPSS® version 20. Results We found 36 (15.7%) ECM proteins out of 229 proteins that met the above criteria. Significant differences between RS and HC were found among two proteoglycans and four insulin growth factor (IGF) proteins (Table). Significant increase in the urinary excretion of IGFBP4 in RS (37.00 ± 37.68 ng/mg creatinine ) versus HC (19.04 ± 20.32 ng/mg creatinine) was confirmed by ELISA (p=0.049). Statistically significant correlation was found between urinary IGFBP4 concentration and 24-hour urinary calcium excretion (p&amp;lt;0.001). Conclusion Alteration in proteoglycans and the IGF axis appears to have a significant role in the mechanism of nephrolithiasis, likely by modulating ECM biosynthesis. Further understanding of their roles in nephrolithiasis may aid in generation of novel therapeutic approaches.

Duplex systems: Top-down or bottom-up approach?

Duplex systems can be complicated by reflux, ureterocele, obstruction (most commonly PUJ in a lower moiety) and wetting secondary to an ectopic ureteric insertion in girls. The decision making algorithm for selection of surgical approach is complex and there is no consensus. The authors described the outcomes following an upper urinary tract approach in 2011(1) and now compare these results in a similar group of patients managed using a lower approach. To assess whether a top-down or bottom-up approach results in different likelihoods for further surgery. A prospectively database was maintained for consecutive patients undergoing surgery for duplex systems by a single surgeon between 2003 and 2015. Patients were classified into 2 groups; Group 1 initial intention for upper urinary tract approach (heminephroureterectomy-HN) or Group 2 lower urinary tract approach (bladder reconstructive surgery-BRS). The requirement for further surgery was recorded-endoscopic incision (EI), bladder reconstructive surgery (BRS), endoscopic correction of reflux (ECR), heminephroureterectomy (HN). Indications for initial and subsequent surgery included urinary tract infection, VUJ obstruction and incontinence. Endoscopic incision was not performed for patients with an asymptomatic ureterocele. Statistical analysis consisted of Fisher's exact test with a 2 tail p value<0.05 being statistically significant. 79 patients underwent surgery for duplex systems. 39 patients had HN initially (Group 1) and 40 patients had BRS initially (Group 2). Further surgery was performed in 21% of patients from Group 1 (8 BRS) vs 5% of patients from Group 2 (1 redo BRS, 1 ECR). Significantly less additional surgical procedures were performed after BRS compared to HN (p=0.048). The presence of both reflux and ureterocele increases the chances of further surgery in those patients who had HN initially compared to BRS (p=0.01). No patients developed urinary retention or required intermittent catheterisation to improve bladder emptying. Bladder reconstructive surgery (BRS) reduces the requirement for further surgery compared to heminephroureterectomy (HN) in symptomatic patients with a duplex kidney and either dilating vesicoureteric reflux or ureterocele.

Robotic Approach to Creation of Continent Catheterisable Channels-Technical Steps, Current Status, and Review of Outcomes.

Purpose: To report the current status of Robotic approach to creation of Catheterisable channel (CC) with the author's personal experience compared to published literature on technical steps, follow up, and outcomes.Methods: CC data was extracted from the prospective database set up for all Robotic pediatric urology procedures performed by the author at his institution. A literature search was then performed to look at the evidence base.Results: Eighteen consecutive cases (8M:7F) of Robotic approach to creation of CC was identified and included. All attempted cases were successfully completed without any conversion to open approach. Median age at surgery was 10.75 years (IQR 6.9–16.5); Median OT 197 min (IQR 131–295) with concomitant procedures in 4 cases. Appendix was used in 14 cases as CC conduit and distal ureter in 4 cases. Median Length of stay (LOS) was 2.75 days (IQR 2–6) and Median FU 27.3 m. Whilst FU duration is comparable to published series, average OT and LOS was much lower in this series. The LOS in this robotic series is much lower than the author's experience with open approach (2.75 vs. 5.8 days). No major complications postoperatively except for one exit site wound infection managed conservatively. None of the CC have been revised in this series and all channels are patent with 12 F or 14 F admissible catheter size. There were no cases of incontinence related to technique of creation of CC and no incidence of exit site stomal stenosis with use of ACE stopper until channel matures and Clean intermittent catheterisation (CIC) is established.Conclusion: Robotic approach to CC is feasible, safe with excellent outcomes and minimum morbidity. Robotic complex bladder reconstructive surgery offers some advantages to children compared to open approach but is only currently performed in few tertiary centers with expertise.

Characterization of bladder calculi and urinalysis in rabbits (Oryctolagus cuniculus) treated with mesenchymal adipose-derived stem cells (ADSCs) after partial urinary bladder allotransplantation

Bladder calculi associated or not with early crystalluria or salt deposits can be a common finding after reconstructive bladder surgery. The objective of this study was to characterize calculi and urine of domestic rabbits treated with mesenchymal adipose-derived stem cells (ADSCs) after partial urinary bladder allotransplantation. Twenty-four New Zealand White rabbits were submitted to surgery and treated postoperatively with cyclosporine or ADSCs for immunosuppression. There were no signs of graft rejection in either treatment group 30 days after surgery. Fewer animals presented bladder calculi in the ADSC treated group (33.3%) compared to the cyclosporine treated group (58.3%). Calcium was the predominant component of calculi in both groups. Urinalysis revealed no haematuria or bacteriuria in the ADSC group, in contrast to the results obtained for the cyclosporine group. ADSCs may be an attractive alternative to cyclosporine for immunosuppression after bladder allotransplantation.

MP17-02 UROLOGIC MORBIDITY IN A CONTEMPORARY COHORT OF SCI PATIENTS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Neurogenic Voiding Dysfunction1 Apr 2016MP17-02 UROLOGIC MORBIDITY IN A CONTEMPORARY COHORT OF SCI PATIENTS Blayne Welk, Kuan Liu, Jennifer Winick-Ng, and Salimah Shariff Blayne WelkBlayne Welk More articles by this author , Kuan LiuKuan Liu More articles by this author , Jennifer Winick-NgJennifer Winick-Ng More articles by this author , and Salimah ShariffSalimah Shariff More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2670AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Traumatic spinal cord injured (TSCI) patients may suffer urologic complications. The objective of this study was to measure the incidence of urinary tract infections, urologic bladder reconstruction/diversion (including stress incontinence surgery), and renal dysfunction after TSCI. METHODS This was a retrospective cohort study using administrative data from Ontario, Canada. All incident adult TSCI patients identified from a validated algorithm (injured between 2002-2013) were included. The impact of lesion level was assessed, and the rate of the outcomes was compared to a matched sample (based on age, gender and region of residence) from the general population. RESULTS 2,023 incident TSCI had a median followup of 4.8 years. The majority of patients (73%) were male, and the median age was 50 years. Within the cohort, the lesion level was cervical (39%), thoracolumbar (44%), and unknown (17%). Urinary tract infections requiring emergency room visit or hospital admission were identified among 40%, and patients with a thoracolumbar lesion level experienced significantly more of these urinary infections (HR 1.4, 95% CI 1.1-1.7, p<0.01). Reconstructive bladder surgery/urinary diversion was carried out on 2.4% of patients, and was significantly more likely among patients with cervical injuries (HR 2.36, 95% CI 1.28-4.37, p<0.01. There were 107 patients with renal dysfunction, which was new since the TSCI for 79% (84/107). Lesion level was not significantly associated with renal dysfunction (HR 1.00, 95% CI 0.64-1.57, p=1.00). The rate ratio for urinary tract infections requiring a hospital visit (14.91, 95% CI 12.79-17.37), bladder reconstruction/diversion (6.48, 95% CI 3.07-13.68), and renal failure (1.79, 95% CI 1.31-2.45) was significantly increased among TSCI patients compared to matched controls. CONCLUSIONS Urologic disease is still an important source of morbidity for contemporary TSCI patients. Urinary tract infections are common. Reconstructive bladder surgery or diversion is rarely performed. Chronic renal failure is more common among TSCI patients, however the relative risk of this was modest. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e184-e185 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Blayne Welk More articles by this author Kuan Liu More articles by this author Jennifer Winick-Ng More articles by this author Salimah Shariff More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Whyever bladder tissue engineering clinical applications still remain unusual even though many intriguing technological advances have been reached?

To prevent problematic outcomes of bowel-based bladder reconstructive surgery, such as prosthetic tumors and systemic metabolic complications, research works, to either regenerate and strengthen failing organ or build organ replacement biosubstitute, have been turned, from 90s of the last century, to both regenerative medicine and tissue engineering.Various types of acellular matrices, naturally-derived materials, synthetic polymers have been used for either "unseeded" (cell free) or autologous "cell seeded" tissue engineering scaffolds. Different categories of cell sources - from autologous differentiated urothelial and smooth muscle cells to natural or laboratory procedure-derived stem cells - have been taken into consideration to reach the construction of suitable "cell seeded" templates. Current clinically validated bladder tissue engineering approaches essentially consist of augmentation cystoplasty in patients suffering from poorly compliant neuropathic bladder. No clinical applications of wholly tissue engineered neobladder have been carried out to radical-reconstructive surgical treatment of bladder malignancies or chronic inflammation-due vesical coarctation. Reliable reasons why bladder tissue engineering clinical applications so far remain unusual, particularly imply the risk of graft ischemia, hence its both fibrous contraction and even worse perforation. Therefore, the achievement of graft vascular network (vasculogenesis) could allow, together with the promotion of host surrounding vessel sprouting (angiogenesis), an effective graft blood supply, so avoiding the ischemia-related serious complications.

Ileal Augmentation Cystoplasty Combined with Ileal Ureter Replacement After Radical Treatment for Cervical Cancer.

This study reviewed the outcomes for patients who underwent simultaneous bladder and ureter reconstructive surgery using the ileum after radical treatment for cervical cancer. The medical records of seven patients who underwent augmentation ileocystoplasty with ileal ureter replacement between September 2006 and May 2013 were reviewed. Data on indications for surgery, underlying urologic comorbidities, type of ureteral replacement, postoperative complications, and changes in renal function were obtained. The median age of the patients was 56years. The primary tumor was cervical cancer in all the patients, and the majority of the patients (4/7, 57.1%) were previously treated with radical hysterectomy plus radiotherapy. Ileal ureter replacement was performed on 11 renal units, and bilateral ileal ureter substitution was performed for four patients, with the largest ureteral defect being 15cm. The median length of the ileum used for augmentation and ureter substitution was 30cm (range 15-40cm), and the median hospital stay was 23days (range 18-47days). The overall rate of major complications (grade ≥3) was 57.1% (4 of 7 patients). The median preoperative and immediate postoperative serum creatinine levels were respectively 1.2mg/dL and 0.9mg/dL. During a mean follow-up duration of 38months, none of the patients experienced deterioration of renal function after surgery. Ileal ureter substitution combined with augmentation ileocystoplasty is a useful surgical technique for bridging long ureteral defects caused by ureteric stenosis from surgery, radiotherapy, or both for pelvic tumors in contracted low-compliance bladders.

Evaluation and Management of Failed Bladder Reconstructions

Bladder reconstructions are commonly performed in patients with neurogenic bladders with a high rate of complications. We seek to help guide the evaluation and management of these complications by reviewing the available data. Augmentation cystoplasty and concomitant procedures such as continent catheterizable channels, bladder neck closure, and bladder neck sling can provide long-term solutions for patients with poorly compliant, high-pressure bladders or refractory detrusor overactivity. While these techniques improve symptoms and protect against upper tract deterioration, patients are exposed to new risks including bladder perforation, increased malignancy rates, urolithiasis, surgical failures, and persistent symptoms. The overall rate of reoperation is high. Evaluation with urodynamics and endoscopy, when indicated, remain critical tools to protect this patient population. Use of clean intermittent catheterization has helped popularize bladder reconstructive surgery, but a strict regimen is required to minimize postoperative risks in the long term. Additionally, various surgical techniques can be utilized to manage complications after bladder reconstruction, and concurrent use of anticholinergics and onabotulinum toxin injections can further mitigate these reconstructive failures. Bladder reconstruction can provide excellent long-term solutions, but patients are at a high risk of long-term complications. Appropriate patient counseling, close follow-up, and timely evaluation are crucial in managing the long-term complications of bladder reconstruction surgery.

Peristeen anal irrigation as a substitute for the MACE procedure in children who are in need of reconstructive bladder surgery

We evaluate the efficacy of the Peristeen (Coloplast A/S, Kokkedal, Denmark) transanal irrigation (TAI) system, as a stool cleansing mechanism, to gain stool continence in children who need reconstructive bladder surgery and have fecal incontinence. We prospectively evaluated children with neuropathic bladder and bowel dysfunction who were intended for reconstructive bladder surgery and the Malone antegrade continence enema (MACE) procedure. All patients were started on the Peristeen TAI system at least 3 months before surgery to assess their response. Each patient's bowel function, frequency of using the system, satisfaction (and that of their parents) and diaper independency were evaluated before and after reconstructive surgery. We included 18 patients (11 female, 7 male) who were evaluated from April 2006 to the present. The mean age of the group was 7.6 years (range: 4-15). Fifteen patients (83.3%) showed complete dryness from stools. Of the 15 patients, 8 (53.3%) were able to be diaper-free, while 6 continued wearing diapers due to fear of soiling and 1 due to urinary incontinence. The patients underwent reconstructive bladder surgery and continued to use the Peristeen TAI system with the same results postoperatively. The main limitation of this study is the small number of patients included, although this is a very specific patient group. Our initial results suggest that the Peristeen TAI system is a successful conservative substitute for the MACE procedure in children who require reconstructive bladder surgery.

The role of mucoregulatory agents after continence-preserving urinary diversion surgery

The postsurgical use of N-acetylcysteine, octreotide, and other agents to reduce mucus accumulation after urinary diversion procedures is described. Patients undergoing continence-sparing bladder resection are at risk for infection and stone formation due to mucus accumulation. In addition to N-acetylcysteine, agents studied for mucoregulatory control in such patients include aspirin, urea, ranitidine, and octreotide. N-acetylcysteine has high mucolytic activity in vitro, and positive outcomes with instillations of 20% N-acetylcysteine solution have been reported in some patients. Significant mucus reductions were reported in small numbers of patients treated with oral ranitidine 300 mg daily or instillations of 30 mL of urea 40% solution, while the benefits of aspirin are more questionable. To date, there has been only one randomized controlled trial comparing various agents for mucus reduction after reconstructive bladder surgery; the results indicated no significant benefits with the use of N-acetylcysteine, aspirin, or ranitidine. In one small study (n = 40), the use of subcutaneous octreotide immediately before and for 15 days after surgery was reported to yield significant reductions in mucus production, the need for bladder irrigation to clear blockages, and the mean duration of hospital stays. Various agents evaluated for mucus control after urinary diversion procedures (oral ranitidine or aspirin, N-acetylcysteine or urea instillations, and subcutaneous octreotide), while reportedly effective for some patients, remain of questionable benefit. More research is needed to define the optimal role of these agents for this indication.

Partial nephroureterectomy in a duplex system in children: the need for additional bladder procedures

Heminephroureterectomy (HN) is our treatment of choice in a duplex system with non-functioning moiety. We examined the need for endoscopic incision (EI)/bladder reconstructive surgery (BRS) and whether ureteroceles and/or vesicoureteric reflux (VUR) influenced management options. Retrospective study of patients undergoing HN by a single surgeon (2003-2008). Patients were classified according to the presence (Group 1) or absence (Group 2) of ureterocele. The groups were subdivided with coexisting dilating VUR (a) or not (b). Statistical analysis included Fisher's exact test. Thirty-one children were identified. Seventeen (54.8%) had ureterocele (Group 1) and 14 patients had no ureterocele (Group 2). Group 1 had eight with VUR (1a) and nine without (1b). Group 2 had seven with VUR (2a) and seven without (2b). Significantly more patients with ureterocele required EI/BRS (p = 0.006). Five (29%) in Group 1 required BRS versus none in Group 2 (p = 0.04). Six (75%) in Group 1a underwent EI/BRS versus three (33%) in Group 1b (p = 0.15). Significantly more in Group 1a required EI prior to HN versus Group 1b (p = 0.04). Similar numbers of patients required BRS in Groups 1a and 1b (p = 0.61). In the absence of ureterocele, there is minimal likelihood of requiring surgery apart from HN, independent of VUR. Presence of ureterocele is an indicator for additional procedure within the bladder. There is a higher incidence of EI when ureterocele co-exists with dilating VUR.

Outcome of Augmentation Cystoplasty and Bladder Substitution in a Pediatric Age Group

Aim of the study was to evaluate the outcome of augmentation cystoplasty and bladder substitution in a pediatric age group. Patient records of all children who underwent reconstructive bladder surgery between October 1999 and November 2007 were reviewed. Additionally, standardized interviews were performed to evaluate the postoperative outcome. Augmentation cystoplasty and bladder substitution were performed in 19 and 6 patients, respectively. 21 patients underwent continent catheterizable vesicostomy. Postoperative urodynamics revealed a significant increase in bladder volume (median 400 ml) as well as a significant improvement in bladder compliance (median 13.5 ml/cmH2O). 90% of the patients were reported to be socially continent. Renal function remained stable in 95% and decreased in 5% of the children. Major complications were lower urinary tract calculi (39%), stricture or insufficiency of the continent vesicostomy (28%), and intestinal obstruction (9%). No malignancies associated to bladder augmentation or substitution were detected yet. Augmentation cystoplasty and bladder substitution preserve renal function and provide urinary continence in most children with intractable lower urinary tract disease. However, the procedures remain associated with numerous complications.

Robot-Assisted Laparoscopic Intracorporeal Hand-Sewn Bowel Anastomosis During Pediatric Bladder Reconstructive Surgery

Bowel anastomosis performed during robot-assisted laparoscopic surgery in both adult and pediatric populations has typically been performed using endoscopic staplers or with exteriorization of the bowel. In the pediatric population, no articles have been published that explore the possibility of a completely intracorporeal hand-sewn anastomosis during robot-assisted laparoscopic surgery. We report our series of six children who were undergoing robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during bladder reconstructive surgery for neurogenic bladder. The postoperative course was uncomplicated with regard to the bowel anastomosis, demonstrating the feasibility of the technique in experienced hands.

Surgical antibiotic practices among pediatric urologists in the United States

Purpose We hypothesized that there are practice variations in the use of surgical antibiotics by pediatric urologists in the United States. Materials and methods A 31-question online survey was distributed to members of the Society of Pediatric Urology. The questionnaire examined physician preferences for surgical antibiotic use, including indications, antibiotic selection, timing of administration, and duration. Results 189 pediatric urologists responded to the survey. >85% of responders give antibiotics before open pyeloplasty, after hypospadias repair (when a urethral catheter is left in place), or perioperative or postoperative antibiotics for open neoureterocystostomy or bladder reconstructive surgery. >90% of responders do not give postoperative antibiotics to children who have undergone circumcisions, simple chordee repairs, herniorrhapies, or hydrocelectomies. For all other open, laparoscopic, and endoscopic operations, use of antibiotics varied significantly. Diverse opinions exist regarding antibiotic use, including the importance of costs, potential adverse reactions, reduction in infection risk, and antibiotic resistance. There are major differences in gentamicin dosing and timing of administration of perioperative antibiotics. Conclusions Perioperative and postoperative antibiotics are widely used by pediatric urologists. However, there is significant practice variation in surgical antibiotic administration with regards to most areas of pediatric urology, in particular laparoscopic, endoscopic and hypospadias surgery.

Reconstructive bladder surgery in genitourinary tuberculosis

Genitourinary tuberculosis (GUTB) occurs in 15-20% cases of pulmonary tuberculosis with a prevalence of 400 per 100,000 population. Reconstructive surgery for GUTB is required for cases with grossly distorted and dysfunctional anatomy that are unlikely to regress with chemotherapy alone. In the recent past, there has been a tremendous increase in the variety of reconstructive procedures for the urinary bladder, used in the management of GUTB. Augmentation cystoplasty includes the goals of increasing bladder capacity, while retaining as much of bladder as possible. Various bowel segments (from the stomach to the sigmoid colon) have been used for bladder reconstruction. The choice of material for reconstruction is purely the surgeon's prerogative--his skill, the ease, the mobility and length of mesentery (allowing bowel to reach the bladder neck without tension and maintaining an adequate blood supply). The presence or absence of concomitant reflux is of considerable importance. In the former, an ileocystoplasty with implantation of ureter to the proximal end of the isolated ileal loop and anastomosis of the distal end of the ileal loop to the bladder neck and trigone is advocated. In the latter case, the ureterovesical valve is preserved and colocystoplasty is preferred, wherein the sigmoid colon on being opened along its antimesentric border is joined to the trigone and bladder neck and then to itself to form a capacious pouch. Gastrocystoplasty reduces the risk of acidosis but is associated with complications like hypochloremic alkalosis and ‘hematuria-dysuria’ syndrome. Orthotopic neobladder reconstruction is a feasible option, suitable in cases of tubercular thimble bladder with a markedly reduced capacity (as little as 15 ml), where an augmentation alone may be associated with anastomatic narrowing or poor relief of symptoms. In this article, we review the various bladder reconstruction options used for the surgical management of GUTB, along with their indications and complications.

MP-02.10: Ectopic ureterocele: long-term results of open surgical therapy in 54 patients

Primary treatment for ectopic ureteroceles remains a topic for discussion: first endoscopic decompression, first upper pole resection only or immediate total reconstructive bladder surgery. In this study the long-term results of total reconstructive bladder surgery as initial treatment of ectopic ureteroceles was analyzed.