Urinary Sphincter In Children Research Articles

External Sphincter Injection of Onabotulinum-A Toxin in Treatment of Children with Bladder- Sphincteric Dyssynergia

Abstract Background: The first application of Onabotulinum-A Toxin in urology was its injection into the urinary sphincter to treat neurogenic detrusor-sphincter dyssynergia in quadri-plegic men. Since that first report by Dyskatra et al., in 1988, the results of focal Onabotulinum-A Toxininjections into the sphincter, the bladder wall and lately into the prostate have raised the interest of the urology community in this promising new therapeutic modality. This is an evidence-based review of the current indications, techniques and outcomes of Ona-botulinum-A Toxin injections into the urethral sphincter. Aim of Study: We evaluated the effect of detrusor injection of onabotulinum-A toxin into the urethral urinary sphincter in children with bladder-external sphincter dyssynergia to decrease urethral resistance and improve voiding. Material and Methods: Prospective treatment was per-formed in 25 children 4 to 15 years old (mean age 7) with bladder-neck dyssynergia using onabotulinum-A toxin. Pre-operatively all children were evaluated by ultrasound, voiding cystourethrography, excretory urography, magnetic resonance imaging and urodynamic studies, including pressure flow, electromyography and uroflowmetry. Using a rigid pediatric endoscope and a 4Fr injection needle 50 to 100 IU onabotu-linum-A toxin was injected into the external sphincter at the 5 and 7 o'clock positions. Follow-up was 6 to 15 months. Repeat injections every 6 months were given according to the response with a maximum of 3 injections. Results: Immediately after onabotulinum-A toxin injection all except 1 patient were able to void without catheterization. No acute complications occurred. Postoperatively post-void residual urine decreased by 30%, detrusor leak point pressure decreased significantly by a mean ± SD of 66±18 vs 37±4cm H2O and uroflowmetry showed a marked increase in maximum urine flow of 7±2 vs 17.3±8ml per second. Conclusions: Urethral sphincter onabotulinum-A toxin injection could be considered a reliable treatment modality in children with nonneurogenic neurogenic bladder after the failure of conservative therapy.

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

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

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.

Complications of Complex Lower Urinary Tract Reconstruction in Patients With Neurogenic Versus Nonneurogenic Bladder—Is There a Difference?

The complications of lower urinary tract reconstruction have been well documented in children with neurogenic bladders. While most series include small numbers of nonneurogenic diagnoses, this group is typically underrepresented. Despite a number of fundamental anatomical and functional differences, a direct comparison of surgical complications of lower urinary tract reconstruction in patients with neurogenic vs nonneurogenic bladders has not been performed. We identified patients undergoing lower urinary tract reconstruction incorporating enterocystoplasty from 1996 to 2006. We performed a retrospective review of operative notes and medical records of patients who met inclusion criteria. Patients were divided into a neurogenic group and a nonneurogenic group based on the underlying diagnosis. The 2 groups were compared with respect to demographics, historical data, operative techniques, perioperative morbidity, long-term complications and need for surgical revision. Of the 127 patients who met inclusion criteria 72 were assigned to the nonneurogenic group and 55 to the neurogenic group. Overall the rates of significant perioperative morbidity (39%), long-term complications (54%) and need for surgical revision (39%) were substantial. The rates of catheter related complications, rehospitalization for dehydration and spontaneous bladder rupture were higher in the neurogenic group (p <0.05). Reconstruction of the lower urinary tract in children is associated with a considerable rate of complications and need for surgical revision regardless of whether the bladder is neurogenic or nonneurogenic. Children with neurogenic bladders are more prone to spontaneous rupture, catheter mishaps and early rehospitalization for dehydration.

Artificial Urinary Sphincter in Children—Voiding or Emptying? An Evaluation of Functional Results in 44 Patients

We evaluated functional results with an artificial urinary sphincter in children and adolescents in terms of complications, continence and voiding ability through followup. A total of 44 patients (39 males and 5 females, age 8.6 to 29.5 years, median 14) underwent implantation of a pericervical AMS 800trade mark artificial urinary sphincter, primarily for severe urinary incontinence of neuropathic origin, between 1986 and 2005. Of the patients 25 had undergone augmentation cystoplasty previously (8), simultaneously (7) or after implantation (10). Median followup was 5.5 years (range 1 to 18). Complications included dysuria and/or urinary retention (24 cases), worsening of bladder function (13), urethral erosion (2), scrotal erosion (5), mechanical dysfunction (7), infection of the artificial urinary sphincter (2) and accidental puncture of the tubes (2). These complications resulted in 9 removals, 5 deactivations, 6 revisions and 5 total replacements. Of 44 patients 9 (20%) were incontinent after removal of the artificial urinary sphincter. Among the remaining patients 32 (73%) were dry and 3 (7%) were incontinent with a deactivated device. Of the 35 patients with an artificial urinary sphincter in place 17 (48.6%) voided to completion with spontaneous voiding, 9 (25.7%) performed post-void clean intermittent catheterization and 9 (25.7%) emptied exclusively with clean intermittent catheterization. The ability to maintain voiding to completion after implantation was significantly decreased when the artificial urinary sphincter was implanted before puberty (p = 0.0025) or in conjunction with an augmented bladder (p = 0.01). The artificial urinary sphincter provides a good rate of continence. However, complications are frequent, leading to removal in 20% of the cases. In time only a limited number of patients can empty the bladder without clean intermittent catheterization.

Artificial urinary sphincter in children: voiding or emptying? an evaluation of functional results in 44 patients

Purpose To evaluate functional results with an artificial urinary sphincter (AUS) in children and adolescents in terms of complications, continence and voiding ability in long term follow-up. Material and methods From 1986 to 2005, at Hopital Necker-Enfants Malades, 44 patients (39 males, 5 females, aged 8,6-29,5 years, median age 14 years) had a pericervical AMS 800 AUS for severe urinary incontinence of neuropathic origin in 42. 25 patients had an augmentation cystoplasty before (8), simultaneously (7) or after (10) implantation. Median follow-up was 5,5 years (1-18 years). Complications included: dysuria and/or urinary retention (24 cases), bladder functional degradation (13), urethral (2) or scrotal erosions (5), mechanical malfunction (7) AUS infections (2) and accidental puncture of the tubes (2), which resulted in 9 removals, 5 deactivations, 6 revisions and 5 total replacements. Results 9/44 (20%) patients are incontinent after having their AUS removed; of the rest 32/44 (73%) are dry, while 3/44 (7%) are incontinent with a deactivated device. Of the 35 patients with an AUS in place, 17 (49%) void to completion with spontaneous micturition, 9 (25,5%) perform post voiding CIC and 9 (25,5%) empty exclusively with CIC. The possibility of voiding to completion after implantation was significantly lower (p 0.0025) when the AUS was implanted before puberty or with an augmented bladder (p 0.01). Conclusions An AUS provides good continence rates, however complications are frequent leading to removal in 20% of cases. With time, only a limited number of patients can empty their bladder without CIC. To evaluate functional results with an artificial urinary sphincter (AUS) in children and adolescents in terms of complications, continence and voiding ability in long term follow-up. From 1986 to 2005, at Hopital Necker-Enfants Malades, 44 patients (39 males, 5 females, aged 8,6-29,5 years, median age 14 years) had a pericervical AMS 800 AUS for severe urinary incontinence of neuropathic origin in 42. 25 patients had an augmentation cystoplasty before (8), simultaneously (7) or after (10) implantation. Median follow-up was 5,5 years (1-18 years). Complications included: dysuria and/or urinary retention (24 cases), bladder functional degradation (13), urethral (2) or scrotal erosions (5), mechanical malfunction (7) AUS infections (2) and accidental puncture of the tubes (2), which resulted in 9 removals, 5 deactivations, 6 revisions and 5 total replacements. 9/44 (20%) patients are incontinent after having their AUS removed; of the rest 32/44 (73%) are dry, while 3/44 (7%) are incontinent with a deactivated device. Of the 35 patients with an AUS in place, 17 (49%) void to completion with spontaneous micturition, 9 (25,5%) perform post voiding CIC and 9 (25,5%) empty exclusively with CIC. The possibility of voiding to completion after implantation was significantly lower (p 0.0025) when the AUS was implanted before puberty or with an augmented bladder (p 0.01). An AUS provides good continence rates, however complications are frequent leading to removal in 20% of cases. With time, only a limited number of patients can empty their bladder without CIC.

14 Years of Experience With the Artificial Urinary Sphincter in Children and Adolescents Without Spina Bifida

The efficacy of the artificial urinary sphincter to treat sphincteric incontinence in pediatric patients with spina bifida has been clearly reported. The possibility of maintaining spontaneous voiding has usually been the main reason for prosthetic device surgery. We reviewed our experience with the artificial urinary sphincter in patients without spina bifida who had had previous surgery of the bladder neck or proximal urethra. From 1990 to 2004, 112 children and adolescents underwent implantation of an AMS 800 artificial urinary sphincter. Of the patients 19 males and 4 females (20.5%) between ages 4 and 17 years (mean 8.1) had no spina bifida. Instead there were bladder exstrophy in 12 patients, anorectal malformation with a rectourethral or vesical fistula in 7 and epispadias in 4. A bladder neck cuff between 5.5 and 7.5 cm, and a 61-70 balloon were used in all patients. Only 1 patient was lost to followup. In 22 patients (95.6%) mean followup was 80 months (range 4 to 155). Three sphincters in patients with exstrophy were removed because of erosion and/or infection 5, 49 and 60 months after initial surgery, respectively. A total of 19 sphincters remained in place (86.3% survival rate) with 5 revisions (26.3%) because of the pump (2), the cuff (2) or balloon fluid leakage. In this group 13 patients (68.4%) voided spontaneously and 6 (31.6%) performed clean intermittent catheterization, although 3 also voided spontaneously. Overall continence was good in 87% of patients because 2 were still incontinent at night. The artificial urinary sphincter is a good long-term solution to urinary incontinence secondary to sphincter incompetence despite multiple previous surgeries of the bladder neck or proximal urethra. Patients with bladder exstrophy and many previous bladder procedures are more exposed to complications such as erosion compared with patients with epispadias or anorectal malformation. The high percent of patients maintaining spontaneous voiding and the good rate of continence are the most important benefits of this type of surgical option for sphincter incompetence.

Botulinum A Toxin Urethral Sphincter Injection in Children With Nonneurogenic Neurogenic Bladder

We evaluated botulinum-A toxin (Botox) injection into the urethral urinary sphincter in children with nonneurogenic neurogenic bladder to decrease urethral resistance and improve voiding. In these patients alpha-blocker medications had failed and injection was an alternative to unavailable biofeedback. Prospective treatment was performed in 10 children 6 to 17 years old (mean age 8) with nonneurogenic neurogenic bladder using botulinum-A toxin (Botox). Preoperatively all children were evaluated by ultrasound, voiding cystourethrography, excretory urography, magnetic resonance imaging and urodynamic studies, including pressure flow, electromyography and uroflowmetry. One patient had unilateral G3 reflux and 4 had bilateral G1 to G3 hydronephrosis. Using a rigid pediatric endoscope and a 4Fr injection needle 50 to 100 IU botulinum-A toxin were injected into the external sphincter at the 3, 6 and 9 o'clock positions. Followup was 6 to 15 months. Repeat injections every month were given according to the response with a maximum of 3 injections. Immediately after botulinum-A toxin injection all except 1 patient were able to void without catheterization. No acute complications occurred. Four patients with bilateral hydronephrosis and the patient with the refluxing unit showed regression. Postoperatively post-void residual urine decreased by 89%, detrusor leak point pressure decreased significantly by a mean +/- SD of 66 +/- 18 vs 37 +/- 4 cm H(2)O and uroflowmetry showed a marked increase in maximum urine flow of 2 +/- 2 vs 17.8 +/- 8 ml per second. Three injections were needed in 1 patient to attain the desired response. Urethral sphincter botulinum-A toxin injection could be considered a reliable treatment modality in children with nonneurogenic neurogenic bladder after the failure of conservative therapy.

NOCTURNAL BLADDER EMPTYING:: A SIMPLE TECHNIQUE FOR REVERSING URINARY TRACT DETERIORATION IN CHILDREN WITH NEUROGENIC BLADDER

In this preliminary study we sought to determine the effect of instituting nocturnal bladder emptying (NBE) in children with neurogenic (NGB) or nonneurogenic neurogenic bladder (NNGNGB) in whom urinary tract deterioration developed despite optimal daytime clean intermittent catheterization (CIC) and urotropic medications. We hypothesize that a syndrome of nocturnal overdistention of the bladder (SNOB) can cause urinary tract deterioration through increased nighttime storage pressures manifested by recurrent urinary tract infection (UTI), worsening incontinence, hydronephrosis and/or decreasing bladder compliance and capacity, and may be reversed by NBE. A total of 19 children with NGB (17) or NNGNGB (2) who displayed urinary tract deterioration while on CIC and urotropic medications were started on NBE. Of the patients 15 used a continuously draining nighttime catheter while 4 had scheduled awakenings during the night to perform CIC. The primary indications for NBE were recurrent symptomatic UTI in 5, new or progressive hydronephrosis in 7, and decreasing bladder capacity and compliance in 7. At a mean followup of 23 months 15 (79%) patients showed improvement or complete resolution of 1 or more signs or symptoms of hydronephrosis (7), increase in bladder capacity (5), recurrent UTI (6) and worsening incontinence (3). The remaining 4 patients had no response to NBE. No adverse effects were observed with 10 hours or less of nightly indwelling catheter time. Patients with NGB or NNGNGB on idealized daytime programs of CIC and urotropic drugs may have high intravesical pressures and experience urological deterioration because of an unrecognized SNOB. NBE is a simple technique for treating this condition and reversing the pathophysiological changes. The observation that NBE alone may increase bladder compliance and capacity sufficient to avoid bladder augmentation suggests that development of decreased bladder compliance and capacity in children with NGB may not simply represent normal progression of NGB disease. These changes may be avoidable consequences of untreated SNOB. Early institution of NBE may prevent urinary tract deterioration from developing in this population.

The Indiana Experience With Artificial Urinary Sphincters in Children and Young Adults

We reviewed a 22-year single institutional experience with the artificial urinary sphincter in children and adolescents. To our knowledge this report represents the largest series in the world in children.Between 1980 and 2002, 142 patients underwent implantation of an artificial urinary sphincter, of whom 93 males and 41 females with a median age of 10 years (range 3 to 39) were available for analysis. A total of 59 patients initially received an AMS 742/792 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter, of whom 33 were subsequently changed to an AMS 800, while 75 initially received an AMS 800 model. Sphincter followup was terminated at device removal or at the last documented contact. The etiology of incontinence was neuropathic bladder in 107 cases (80%), the exstrophy/epispadias complex in 21 (16%) and other in 6 (4%). Outcome measures included continence, mechanical complications (leakage, tube kink and pump malfunction), functioning sphincter revisions (change in cuff size, pump repositioning and bulbar cuff placement), surgical complications (erosion, infection and misplacement) and associated surgical procedures. Mean followup of the pre-800 and 800 models was 6.9 (range 0.2 to 21.5) and 7.5 years (range 0.1 to 17.1), respectively. Fisher's exact test, Kaplan-Meier life analysis and the chi-square test were used for statistical analysis.After artificial urinary sphincter placement in the 134 patients continence was achieved in 86%, improved in 4% and not achieved in 10%. Of those with a sphincter in place 92% were continent. In terms of bladder emptying after artificial urinary sphincter insertion 22% of patients voided, 11% voided combined with clean intermittent catheterization, 48% performed clean intermittent catheterization only via the urethra, 16% performed it via a catherizable channel and 3% used urinary diversion. A mechanical complication developed in 38 of the 59 patients (64%) with pre-800 model compared with 33 of the 109 (30%) with the 800 model (p <0.0001). A mechanical complication occurred every 7.6 versus 16 patient-years for the pre-800 versus 800 models (p = 0.0001). Revision was required in 15 of the 59 patients (25%) with a pre-800 model versus 17 of the 109 (16%) with the 800 model (p = 0.103). Revision was performed every 22.7 versus 44.3 patient-years for the pre-800 versus the 800 model (p = 0.023). The artificial urinary sphincter eroded in 11 of the 59 patients (19%) with the pre-800 versus 17 of the 109 (16%) with the 800 model (p = 0.52). Ten patients experienced a total of 12 perforations of the augmented bladder after artificial urinary sphincter implantation. A total of 164 secondary surgical procedures were performed, including 38 of 134 bladder augmentations (28%). A total of 30 sphincters were permanently removed.The artificial urinary sphincter is the only bladder neck procedure that allows spontaneous voiding in the neuropathic population, obviates the need for clean intermittent catheterization and yet is compatible with it when necessary. It is also equally versatile in the 2 genders. Mechanical complications occur but they were dramatically decreased by the modifications of the AMS 800 model. In addition, secondary bladder augmentation was required in 28% of our patients. Lifelong followup is mandatory in all patients with an artificial urinary sphincter.

Outcome Of The Artificial Urinary Sphincter In Female Patients

We reviewed the outcome in female patients at our unit in whom an artificial urinary sphincter was inserted. We reviewed notes on 68 patients and mailed a questionnaire to those without recent followup. Median time since insertion was 12 years. Overall 25 patients (37%) had the original artificial urinary sphincter in situ and were dry at a median followup of 7 years. The artificial urinary sphincter was replaced for loss of function in 12 patients, of whom 11 were dry with the replaced device. The device was removed for erosion or infection in 31 patients, of whom 19 underwent successful replacement or were continent after removal. Overall 55 of 68 patients (81%) were continent. Those with neuropathic bladder dysfunction achieved a continence rate of greater than 90%, although half required sphincter removal initially. When the indication for insertion was stress incontinence, 70% of the patients had the original or a replaced artificial urinary sphincter in situ and 82% were continent. All patients with previous pelvic irradiation had the sphincter removed and urinary diversion was done. The overall continence rate in female patients after insertion of an artificial urinary sphincter is satisfactory. A satisfactory outcome was achieved in terms of stress incontinence and we would recommend an artificial urinary sphincter after an adequate anti-stress incontinence operation fails. Continence in patients with neuropathic bladder dysfunction is excellent and the artificial urinary sphincter should be considered first line treatment in this group, although the risk of revision surgery is high. Pelvic irradiation is a contraindication to the artificial urinary sphincter in female patients.

Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty.

Previous studies have described placement of an artificial urinary sphincter and simultaneous augmentation cystoplasty with a segment of bowel. Conclusions from these studies indicated that infection rates were higher and a staged approach should be undertaken. Others have suggested that concurrent urinary reconstruction with stomach and sphincter placement can be performed safely. Results comparing infection rates of simultaneous sphincter placement and gastrocystoplasty versus staged sphincter placement and augmentation cystoplasty using a segment of ileum or stomach versus sphincter placement alone in a pediatric population have not been previously described to our knowledge. We reviewed these various groups of patients to determine if the difference in infectious complications were clinically and statistically significant. A retrospective review of medical records from 1986 to 1999 identified 28 pediatric patients (age 18 years or less) who had undergone placement of an AS800dagger artificial urinary sphincter. Data points were collected focusing on etiology of the neurogenic bladder, age at time of surgery, types of surgery performed, length of followup and complication rates. Complete data were available for 27 of the 28 patients. Neurogenic bladder was secondary to myelomeningocele in 25 cases, transverse myelitis in 1 and spinal cord injury in 2. Mean patient age at surgery was 12.7 years (range 6.1 to 18.2) and mean followup was 4.3 years (range 1 month to 13 years). Simultaneous gastrocystoplasty was performed in 7 cases (group 1), staged sphincter placement followed by augmentation cystoplasty with a segment of ileum or stomach was done in 8 (group 2) and 12 did not require bladder augmentation (group 3). Urethral device erosion requiring explantation was the most common complication, occurring in 3 patients in group 1 and 2 in group 3 (p = 0.101). Mean time to erosion was 22.1 months (range 2 to 46.4). Previous surgery (bladder neck or hernia repair) was a common factor in each group with complications. Urine cultures and culture of the explanted device were positive in 2 patients in group 1. Simultaneous placement of artificial urinary sphincter at the time of gastrocystoplasty can be performed in carefully selected patients, although those undergoing staged procedures did well without complications. Prior bladder neck surgery seems to be a significant risk for infection. A staged approach to lower urinary tract reconstruction would be more advantageous due to the absence of infection and erosion in those undergoing staged sphincter placement and augmentation cystoplasty.

THE LONG-TERM OUTCOME OF ARTIFICIAL URINARY SPHINCTERS

THE LONG-TERM OUTCOME OF ARTIFICIAL URINARY SPHINCTERS

ARTIFICIAL URINARY SPHINCTER IN THE TREATMENT OF URINARY INCONTINENCE: PREOPERATIVE URODYNAMICS DO NOT PREDICT THE NEED FOR FUTURE BLADDER AUGMENTATION

Purpose The artificial urinary sphincter has been used to treat urinary incontinence in pediatric patients with neurogenic bladders secondary to myelodysplasia. Frequently bladder augmentation is performed in conjunction with the artificial urinary sphincter implantation. Identifying patients with adequate urinary reservoirs who are candidates for implantation without bladder augmentation is a clinical challenge. We reviewed our experience with the artificial urinary sphincter in children with myelodysplasia to determine whether preoperative urodynamic findings predict the need for future augmentation cystoplasty. Materials and Methods We identified 38 patients younger than 18 years at artificial urinary sphincter implantation who did not undergo augmentation enterocystoplasty before or at implantation. We evaluated preoperative bladder capacity and compliance to determine whether these standard preoperative urodynamic measurements predict the eventual need for bladder augmentation in these patients. Results In the 15 patients who required eventual bladder augmentation after artificial urinary sphincter implantation mean bladder capacity plus or minus standard deviation was 62.9 +/− 29.9% of age expected capacity and mean bladder compliance was 8.0 +/− 4.8 ml./cm. water. In the 23 patients who did not require eventual bladder augmentation mean bladder capacity was 59.2 +/− 25.4% of age expected capacity and compliance was 7.0 +/− 3.3 ml./cm. water. There was no statistically significant difference between the 2 groups. Conclusions Standard preoperative urodynamics do not predict the patients who undergo isolated artificial urinary sphincter implantation and eventually require bladder augmentation.

Combined Reconstructive and Prosthetic Surgery In Complicated Lower Urinary Tract Dysfunction

The combined use of the appropriate reconstructive technique and available prosthetic material was evaluated to achieve an optimal functional result in complicated lower urinary tract dysfunction. The study included 16 male and 8 female patients. Urinary dysfunction was classified into 2 main categories: 1) neuropathic and 2) nonneuropathic. Of the patients 22 underwent some form of augmentation (21) or substitution (1) cystoplasty, 24 received an artificial urinary sphincter, 2 underwent abdominoperineal urethroplasty and 2 received a permanent urethral stent. One patient underwent renal transplantation and 1 received a penile prosthesis for concurrent impotence. A total of 20 patients (83.3%) became continent, 10 void spontaneously, while 14 must empty the bladder or pouch by clean intermittent self-catheterization. All patients have stable or improved renal function. Combined reconstructive and prosthetic surgery has an important role in the treatment of lower urinary tract dysfunction, with a high success rate and good quality of life.

Silicone Shedding from Artificial Urinary Sphincter in Children

Silicone is an inert material used in all genitourinary prosthetic devices. Silicone particle shedding has been documented in adults with penile prostheses and artificial urinary sphincters. We searched prospectively for silicone particles in the peri-prosthetic tissue and regional lymph nodes in 6 children who underwent removal or exchange of an artificial urinary sphincter. The peri-prosthetic fibrous capsule was biopsied and examined by light and polarizing microscopy. Regional lymph nodes were biopsied if clinically enlarged and evaluated in a similar manner. Lymph nodes from 2 children without an artificial urinary sphincter served as controls.An artificial urinary sphincter was in place from 3 to 10 years (mean 4.3 years) and none of the sphincters demonstrated infection or erosion. Silicone particles were found in the peri-sphincteric tissue of 3 patients, which induced foreign body giant cell reaction in 2 and eosinophilic infiltrate in 1. Focal histiocytic proliferation around the cuff was seen in another case without silicone migration. There was fibrosis around the sphincter in all cases. No silicone was found in the regional lymph nodes. Silicone shedding was documented in 50% of our patients. X-ray energy dispersive spectroscopy was not performed, raising the possibility that it was under-detected. Long-term effects of silicone in children with an artificial urinary sphincter are unknown and warrant further study.

The Artificial Urinary Sphincter in Children: Experience With the AS800 Series and Bowel Reconstruction

The Artificial Urinary Sphincter in Children: Experience With the AS800 Series and Bowel Reconstruction

The Artificial Urinary Sphincter in Children: Experience with the AS800 Series and Bowel Reconstruction

Recent reports have shown that the artificial urinary sphincter is a reliable means of achieving urinary continence in both adults and children who have urinary incontinence of various etiologies. Although complications may occur, currently the artificial urinary sphincter is the most efficient means of obtaining urinary continence. The author discusses the features of the device, how to trouble-shoot when problems occur, and the role of the device in patients who have undergone partial or total reconstruction of the bladder with bowel.

Experience With the Artificial Urinary Sphincter in Children and Young Adults

The artificial urinary sphincter (model AS 791-792), American Medical Systems, Minnetonka, Minn.) has been implanted in 41 patients (mean age 13.9 years) who were incontinent in spite of intensive efforts with other modes of management. Neurogenic bladder dysfunction is present in 34 patients. Seven patients have non-neuropathic dysfunction of the bladder neck and urethra (3 with exstrophy/epispadias, 3 incontinent after multiple bladder and urethral procedures, and 1 incontinent after a pelvic fracture). Twenty-two patients have had intestino-cystoplasty performed and 11 patients had previous urinary diversion. Mean follow-up for a given device in 23 months (range 6 to 47 months). Of these patients, 80.5% are totally or acceptably dry. Five patients (12.2%) were rated as fair, and three were failures (7.3%). Complications have been significant in that reoperation has been necessary in 16 patients. Indications for patient selection is emphasized.

The artificial urinary sphincter in children.

One hundred and thirty-two children underwent implantation of the AS792 artificial urinary sphincter over the past 5 years: 90% had an excellent result following the implantation. Thirty-one patients (24%) required further surgery to correct a malfunction of the device. The device was removed in 5.3% of the patients and the incidence of infection was 3.8%. The artificial urinary sphincter has been shown to be a reliable means of achieving urinary incontinence in children. With attention to patient selection and meticulous surgical technique, a high success rate can be expected.