Urinary Diversion In Children Research Articles

246Intestinal urinary diversion in children due for renal transplantation

246Intestinal urinary diversion in children due for renal transplantation

Urinary diversion in children with pelvic tumors

Purpose The aim of this study was to investigate children presenting with malignant pelvic tumors obstructing the upper urinary tract. Methods Seventeen children with upper urinary tract obstruction by a malignant tumor were reviewed. A nephrostomy tube or Double J (DJ) stent was inserted into each obstructed urinary system and removed after tumor shrinkage and/or hydronephrosis regression. Results There were 9 boys and 8 girls in the study; the mean age and median follow-up were 5.7 years and 2.5 years, respectively. The most common obstructing tumor was rhabdomyosarcoma. Twelve children underwent diversion by nephrostomy tubes and 3 by DJ stents; 2 patients underwent resection of the tumors with ureteroureterostomy. Complications after the insertion of the stents included febrile urinary tract infections (UTI) or pyelonephritis in 4 of the children with DJ stents. In the nephrostomy group, febrile UTI developed in 3 and the tube fell out in 1, and was blocked in another. Of the 17 children, 9 have no evidence of disease, 2 are currently under treatment, and 6 died of cancer. Conclusions The prognosis of children with malignant pelvic tumor obstructing the upper urinary system justifies urgent and optimal upper tract diversion, enabling chemotherapy to be started immediately.

Bladder Function Associated With Posterior Urethral Valves After Primary Valve Ablation or Proximal Urinary Diversion in Children and Adolescents

Bladder Function Associated With Posterior Urethral Valves After Primary Valve Ablation or Proximal Urinary Diversion in Children and Adolescents

Bladder Function Associated With Posterior Urethral Valves After Primary Valve Ablation or Proximal Urinary Diversion in Children and Adolescents

Bladder Function Associated With Posterior Urethral Valves After Primary Valve Ablation or Proximal Urinary Diversion in Children and Adolescents

Urinary diversion in children with mainly exstrophy and epispadias: alternative to primary bladder closure.

To review the long term outcome of children who underwent urinary diversion for various non-malignant conditions and to assess the suitability of urinary diversion as an alternative treatment to primary bladder closure in cases of bladder exstrophy epispadias complex. A retrospective study. Institute of Urology, Moshi, Tanzania. Fifteen children who underwent urinary diversion for various non-malignant conditions between 1985 and 1997. Fifteen children underwent urinary diversion for: exstrophy epispadias complex (n = 12) neurogenic bladder (n = 2) and trauma (n = 1). Seven children underwent Mainz pouch II diversion, six had classical ureterosigmoidostomy and two had appendicovesicostomy. One patient with a solitary kidney developed ureteral stenosis at the implantation site and was undiverted. Metabolic acidosis was well compensated with none of the patients requiring sodium bicarbonate supplements. All the patients except one were continent. We conclude that continent urinary diversion in children offers a viable alternative method for children with bladder exstrophy epispadias complex.

Kock Urinary Reservoir Maturation in Children and Adolescents: Consequences for Kidney and Upper Urinary Tract

Objective: To study Kock reservoir maturation in children and adolescents and its effects on the kidneys and upper urinary tract. Methods: Ten boys and 10 girls, aged 10.8–18 years, had Kock reservoir surgery for congenital urinary incontience. They were followed for 3–10 years, divided into 3 different periods, and assessed with urography and enterocystography, the findings of which were correlated to renal function as measured by ⁵¹Cr EDTA clearance, reservoir endoscopy and patient’s history. Results: The reservoir was located in the pelvis and remained in this position throughout the whole follow-up in 75% of patients and in the lower or midabdomen in 25%. Angled efferent nipple seen on enterocystoscopy or enterocystography coincided with nipple dysfunction, reservoir malposition or infrequent reservoir emptying. Upper urinary tract dilatation was detected in 84% of patients 3 months after surgery, 25% at 1 year and 30% at 2–10 years. The dilatation was improved in 56% of patients and unchanged in 25% after 1 year. The situation continued to improve at late follow-up. New focal renal scars were radiologically detected in 1 of 19 at early and in another 1 of 17 patients at late follow-up. Progression of old scars was detected in 1 of 19 at early and in 4 of 17 at late follow-up. Eight of 19 cases had deterioration of renal function with a change in the split renal function. Of these 8 patients, 7 reported infrequent reservoir evacuation. Conclusions: Kock reservoir is a useful form of urinary diversion in children and adolescents with congenital urinary incontinence. Radiological examinations are good methods of follow-up of the maturation of the pouch and its effects on the urinary tract and for detection of complications. Urinary tract dilatation is a frequent finding early after surgery but it subsides in most cases 3–12 months after surgery. Long-term efferent nipple dysfunction may be the result of angulation, reservoir stones, malposition and/or overdistension. Permanent renal damage may be due to pyelonephritis, stones, infrequent reservoir emptying or urinary obstruction. A strict regime of reservoir evacuation to avoid overdistension and nipple dysfunction and to decrease the possibility of renal function deterioration is strongly advisable in these patients. It is imperative that their own management of the reservoir is continuously supervised.

Evaluation of the functional significance of the colorectal valve used in rectal urinary diversion in children: a comparative study between cases with and without the valve

Objectives. To study the long-term impact of functional isolation of rectal reservoirs on the blood chemistries and acid-base balance of children who underwent this type of urinary diversion. Methods. A retrospective evaluation of 63 children with rectal reservoirs was performed. Of these, 40 had a colorectal valve and 23 had double-folded rectal reservoirs without a functional isolation valve. Evaluation included serum chemistry and arterial blood sample analysis to verify the impact of the created valve on homeostasis. Results. There was a statistically significant difference between the two groups relative to the value of pH, P co 2, bicarbonate, base excess, and chloride in favor of those having a colorectal valve. Reduction of the absorptive surface area of the colon is presumably the cause in view of the functional isolation created by the colorectal valve. Conclusions. In children, the long life expectancy and the benign condition for which they have diversion require the incorporation of the colorectal valve in any form of continent rectal diversion. Prophylactic alkalinization with strict follow-up is a must in those having no valve.

Early and late metabolic alterations in children and adolescents with a kock urinary reservoir.

To assess the early and late metabolic effects of urinary diversion in children and adolescents with a Kock urinary reservoir. Thirteen children (aged 10.8- 16 years) and seven adolescents (aged 16-18 years; 10 girls and 10 boys), underwent surgery for congenital urinary incontinence. They were followed for 3-10 years (mean 6.5), divided into an early (3 months to 2 years) and a late (2-10 years) period, and assessed for renal function and any metabolic effects. At the early and late follow-up, one of 19 and three of 16 patients, respectively, had metabolic acidosis. Hyperchloraemia was present in four of 20 patients at the early and in eight of 18 at the late follow-up. Serum creatinine was increased in four of 20 patients at the early and eight of 18 at the late follow-up. In patients with infrequent reservoir emptying (</=4 times/day), the serum creatinine level was increased in seven of 13 at the early and eight of 10 at the late follow-up (P<0.05). The glomerular filtration rate was below normal in four of 20 patients preoperatively, in six of 19 at the early and in eight of 18 at the late follow-up. The continent ileal reservoir in children and adolescents produces similar changes to those previously reported in adults. However, almost all patients with metabolic disorders were younger than 16 years at operation. The pre-existing impairment of renal function, together with associated congenital anomalies, mental and/or physical disorders, young age, recurrent urinary tract infections and infrequent reservoir emptying, leads to deterioration in renal function after the Kock operation. Even with this risk, the Kock pouch remains a viable alternative to other forms of continent urinary diversion, because it has a wide calibre stoma, allowing large-bore catheters, and is therefore especially suitable for individuals with weak hand function, e.g. quadriplegic or meningomyelocele patients. However, as shown by these results, the child with a Kock pouch requires continuous medical attention.

Urinary diversion in children and young adults using the Mainz Pouch I technique.

To determine the late complications and consequences for renal function, vitamin and acid-base metabolism after application of the Mainz Pouch I (MZP-I) technique in children and young adults. To November 1994, the MZP-I procedure was carried out in 463 patients at our institution, 91 of whom were children and adolescents (< or = 20 years old) using bladder augmentation in 21 and a continent cutaneous stoma in 70. A minimum follow-up of 1 year was possible in 87 patients or 163 renal units (RUs) with a mean of 5.5 years (range 1-10.5). At the last examination, 23 of 55 (42%) preoperatively dilated RUs had improved. 131 of the 163 RUs (80%) were stable and nine RUs (5.5%) showed a slight clinical asymptomatic increase in the upper tract dilatation. Through an extraperitoneal flank incision, 11% of the RUs which developed stenosis at the ureterocolic anastomosis were successfully reimplanted (16% in patients with neurogenic disorders, 17% with pre-operative irradiation and 5% in the remaining patients). Two of 32 patients with an intussuscepted and invaginated ileal nipple required re-operation due to incontinence, but none of the patients with an appendiceal stoma were incontinent. Open revision of a stomal stenosis was performed in three and endoscopic treatment in nine patients. In 54 patients, the levels of vitamins A, B1, B2, B6, E, folic and bile acid were within normal ranges. There was no significant decrease in vitamin B12 levels after operation. In none of the patients with normal pre-operative creatinine values had the levels increased and none developed severe acidosis or bowel neoplasm. The MZP-I is recommended as a technique for bladder augmentation or continent urinary diversion in children and young adults, with an acceptable complication rate which offers long-term protection of the upper urinary tract.

The modified rectal bladder in children: long-term follow-up.

The criteria for evaluation of urinary diversion procedures in children must be strict since their life expectancy is long. Our experience with the modified rectal bladder in children with considerable follow-up periods is reported herein. All patients were continent by day and night. Urography studies revealed a normal upper tract in all cases. Three early complications were encountered among patients who had a submucous tunnel reimplantation. Reflux to the proximal colon or the kidneys was not demonstrated. The metabolic status and growth-rate patterns of these patients were within normal limits without alkaline therapy. All urine samples aspirated from the renal pelves were sterile. We conclude that a modified rectal bladder with a second ileal intussusception valve is the operation of choice whenever urinary diversion in children is indicated.

Current indications for cutaneousureterostomy

Objective To assess the current indications for cutaneous ureterostomy in children. Method A total of 32 children underwent cutaneous ureterostomy at Texas Children'sHospital from 1975 to 1990. Medical records were reviewed to determine the urologic diagnosis, the indication for urinary diversion, the type of ureterostomy performed, and the outcome for each patient. Results Twenty patients underwent loop cutaneous ureterostomy (LCU) or pyelostomy and 12 patients underwent end cutaneous ureterostomy (ECU). The main indication for LCU was obstructive uropathy unresponsive to lower urinary tract drainage, and the most common cause was posterior urethral valves. Other indications for LCU included obstruction requiring delayed surgical correction, high-grade reflux into a solitary kidney, and obstruction with infection. The children who required ECU were an older, more diverse group than those who underwent LCU. The main indication for ECU was poor bladder function secondary to a variety of congenital anomalies, including prune-belly syndrome, posterior urethral valves, bladder exstrophy, and urogenital sinus defect. Conclusion LCU is easy to perform and is an excellent method for achieving temporaryupper urinary tract drainage. ECU is suited for long-term or permanent urinary diversion in children with at least one dilated ureter, and can provide a socially acceptable stoma when delayed reconstruction is necessary. Many children who were “permanently” diverted by ECU may be undiverted using newer reconstructive techniques.

Urinary diversion in children.

At the present time, urinary diversion in children remains an last resort type of treatment that must be carried out in selected cases when there is no alternative available. All forms of urinary diversion have the common goal of gaining control of a life-threatening situation; all, however, are fraught with serious disadvantages for the affected children. The newer forms (undiversion, pouch, ileocystoplasty, augmentation) undoubtedly improve the patient's quality of life, but the risks of long-term metabolic and renal complications and malignant degeneration persist. Harzmann, who for years has concerned himself with urinary diversion and, in particular, with malignant changes, has posed two difficult questions: 1. Is urinary diversion using bowel segments defensible for benign disorders, e.g., in children? 2. Which follow-up examinations should be performed after urinary diversion using bowel segments, and at what time intervals? Our goal should be to keep the number of urinary diversions as small as possible by means of appropriate treatment, prophylaxis, and in particular the means and type of primary reconstructive therapy. Children have a life-time ahead of them, and the complications of urinary diversion increase decade by decade. This fact has been demonstrated in children who have undergone ureterosigmoidostomy or ileal conduit. Grounds for the assumption that fewer serious long-term complications are to be expected after colon conduit, pouch, neobladder, or augmentation procedures have not been established.

Urinary Tract Reconstruction in Children

Urinary tract reconstruction and continent urinary diversion in children present a significant technical challenge. A major commitment is mandated from both surgeon and patient. We believe that although the principles and objectives of total bladder replacement rely on basic surgical and physiological tenets, the attainment of a successful outcome also requires patient involvement and cooperation.

Cutaneous vesicostomy for temporary urinary diversion in children: J.J. Weinberg, L. Gordon, P. Nanigian, et al. Pediatr Surg Int 4:47–51, (December), 1988

Cutaneous vesicostomy for temporary urinary diversion in children: J.J. Weinberg, L. Gordon, P. Nanigian, et al. Pediatr Surg Int 4:47–51, (December), 1988

Continent urinary diversion and bladder augmentation in children: the Mainz pouch procedure.

The formation of a bowel reservoir of large capacity at low pressure by using small and large bowel (ileocaecal segment) has proved reliable for achieving continent urinary diversion (n = 80), for bladder augmentation (n = 42) as well as for total bladder replacement (n = 24). Encouraged by the results we obtained in our adult patients, we have used this technique during the last 3.5 years in 29 children. Indications for urinary diversions in children have been: neurogenic bladder with diplegia (n = 8), bladder exstrophy (n = 2), traumatic loss of the bladder (n = 1), urogenital sinus (n = 1) and rhabdomyosarcoma of the prostate or bladder (n = 2). Bladder augmentation was indicated in 6 children with iatrogenic bladder loss, in 5 children with neurogenic bladder without diplegia and in 4 boys with incontinent epispadias or exstrophy. In children with bladder exstrophy or incontinent epispadias, continence was achieved using a modified Young-Dees technique with formation of a long intra-abdominal muscular tube made out of the bladder plate or the low-capacity bladder. The capacity of the urinary reservoir was guaranteed by bladder augmentation or bladder replacement with an ileocaecal pouch. During a mean follow-up period of 26 months (bladder augmentation) and 21 months (continent diversion) there was only one postoperative complication (intussusception ileus) which required operative revision. Two children had to undergo reoperation because of nipple problems. Follow-up, with monitoring of biochemical and metabolic parameters, is necessary to show whether this technique will provide a long-term successful solution for these problems.

Cutaneous vesicostomy for temporary urinary diversion in children

We report our experience with cutaneous vesicostomies performed in 55 children aged less than 3 months to 8 years as a means of temporary diversion. Renal function improved or remained normal in 53 patients and hydronephrosis improved in 53 of 54 in whom it was present pre-operatively. Mucosal prolapse requiring revision occurred in 3 children. Spontaneous vesicostomy closure and stomal stenosis occurred in 2 patients each. Significant cellulitis occurred in 1 patient. Five children have required higher diversion; 35 have undergone undiversion an average of 24 months after vesicostomy creation. A vesicostomy is simple to construct and easy to manage, with minimal complications. The operation does not compromise future continence and is easily reversible.

Cutaneous ureterostomy as a permanent external urinary diversion in children: B.A. Kogan and M.A. Gohary. J Urol 132:729–731, (October), 1984

Cutaneous ureterostomy as a permanent external urinary diversion in children: B.A. Kogan and M.A. Gohary. J Urol 132:729–731, (October), 1984

Cutaneous Ureterostomy as a Permanent External Urinary Diversion in Children

Permanent cutaneous ureterostomy was used in 20 children between 1967 and 1980. The result was excellent in 15 cases (75 per cent) and acceptable in 2 (10 per cent), with better results for those patients who underwent cutaneous ureterostomy with transureteroureterostomy. Upon reviewing our 3 failures and 8 from another group it became clear that the amount of ureteral dilatation present preoperatively was inadequate for this type of diversion in 5 of the 11 cases. Overall, poor results were common in patients less than 2 years old and in those with recurrent symptomatic infection or impaired renal function before diversion. There was no late deterioration, since the onset of problems always occurred within 3 years of diversion.

Comparison of the Ileal Conduit and Clean Intermittent Catheterization for Myelomeningocele

Clean intermittent catheterization has been shown to be a safe and effective means of regular vesical emptying in children with neurogenic bladders secondary to myelomeningocele. The major benefits appear to be the protection of the upper urinary tract, and in many children, improved urinary control. In contrast, the ileal conduit has been shown to produce significant long-term complications; the major one is deterioration of the upper urinary tract. Most children with myelomeningocele begin life with normal kidneys. Our goal of therapy, therefore, is a continent independent child with normal renal function. With proper patient selection, clean intermittent catheterization offers an excellent means of achieving this result in many children; the ileal conduit for permanent urinary diversion in children is outmoded.

Comparison of the Ileal Conduit and Clean Intermittent Catheterization for Myelomeningocele

Clean intermittent catheterization has been shown to be a safe and effective means of regular vesical emptying in children with neurogenic bladders secondary to myelomeningocele. The major benefits appear to be the protection of the upper urinary tract, and in many children, improved urinary control. In contrast, the ileal conduit has been shown to produce significant long-term complications; the major one is deterioration of the upper urinary tract. Most children with myelomeningocele begin life with normal kidneys. Our goal of therapy, therefore, is a continent independent child with normal renal function. With proper patient selection, clean intermittent catheterization offers an excellent means of achieving this result in many children; the ileal conduit for permanent urinary diversion in children is outmoded.