David R. Vandersteen

Sacral Neuromodulation for the Dysfunctional Elimination Syndrome: A Single Center Experience With 20 Children

PURPOSE Recent advances in neuromodulation have demonstrated promise in treating children with the dysfunctional elimination syndrome refractory to medical management. Sacral nerve stimulation with the InterStim implantable device has been used in adults for management of chronic urinary complaints. However, there are few data regarding the usefulness of sacral nerve stimulation in children. We report our experience with sacral nerve stimulation for severe dysfunctional elimination syndrome. MATERIALS AND METHODS A total of 20 patients 8 to 17 years old with the dysfunctional elimination syndrome refractory to maximum medical treatment underwent sacral nerve stimulation at our institution. Patients were followed prospectively for a median of 27 months after the procedure. RESULTS Urinary incontinence, urgency and frequency, nocturnal enuresis and constipation were improved or resolved in 88% (14 of 16), 69% (9 of 13), 89% (8 of 9), 69% (11 of 16) and 71% (12 of 17) of the patients, respectively. Urinary retention requiring intermittent catheterization persisted in 75% of the patients (3 of 4) despite sacral nerve stimulation. Complications requiring operative treatment occurred in 20% of the patients (4 of 20). Following marked symptomatic improvement 2 devices were explanted at 20 and 19 months following placement, and both patients have remained symptom-free. CONCLUSIONS Sacral nerve stimulation is effective in the majority of our patients, and should be considered in children with severe dysfunctional elimination syndrome refractory to maximum medical treatment.

Single Center Experience With Endoscopic Management of Vesicoureteral Reflux in Children

PURPOSE Dx/HA copolymer was approved by the Food and Drug Administration in 2001 for the treatment of VUR in children. Published results have varied widely, prompting us to report our single center experience with 300 consecutive patients. MATERIALS AND METHODS All patients undergoing Dx/HA injection (300 children, median age 5.4 years) at our institution were eligible for this study. We examined several parameters to determine which variables influence the success of Dx/HA injection, including preoperative reflux grade, bladder diverticula, neurogenic bladder, ureteral duplication, perioperative urinary tract infection, dysfunctional voiding, laterality of reflux and amount of Dx/HA injected. RESULTS A total of 225 patients (75%) underwent postoperative studies, and, thus, were eligible for study inclusion. Reflux was cured in 144 patients (64%) and improved in 44 (20%). A total of 20 patients had ureteral duplication anomalies. Cure rates in this subgroup were significantly decreased compared to nonduplicated cases (40% vs 66%). Injection in low grade (I to II) reflux was significantly more successful than in high grade (III to IV) reflux (72% vs 54%). A total of 10 patients (8.3%) with unilateral reflux had development of de novo contralateral reflux. Of the patients who failed initial injection 10 (4%) underwent repeat injection, of whom 5 (50%) were cured after the second injection. Two patients (0.9%) had development of temporary ureteral obstruction. CONCLUSIONS We report a large short-term single center experience with endoscopically injected Dx/HA. Although our cure rate of 64% was less than published rates for open surgery, the minimal morbidity and low complication rate of endoscopic treatment make it an attractive first line therapy for patients with VUR. Longer followup is required to better evaluate this technique.

Sacral Neuromodulation for the Dysfunctional Elimination Syndrome: A 10-Year Single-center Experience With 105 Consecutive Children

OBJECTIVE To evaluate our initial experience using sacral neuromodulation via implanted pulse generator as a treatment for children with dysfunctional elimination syndrome and symptoms refractory to maximum medical therapy. MATERIALS AND METHODS There were 105 consecutive patients who underwent a 2-stage procedure with a trial period (n = 89) or a single procedure (n = 16) for device implantation. They were followed up prospectively for a median of 2.72 years (average, 3.18 years; range, 0.01-9.63 years) for symptom improvement and resolution. RESULTS Nearly all children (99 of 105 [94%]) experienced improvement of at least 1 symptom; 12 of 105 patients (11%) had at least 1 symptom worsen. Urinary incontinence, constipation, frequency and/or urgency, and nocturnal enuresis improved in 89 of 101 (88%), 73 of 92 (79%), 54 of 81 (67%), and 59 of 89 (66%) children, respectively, and resolved in 41 of 101 (41%), 37 of 92 (40%), 23 of 81 (28%), and 25 of 89 (28%) children, respectively. Outcomes among patients who did and did not undergo the trial were not significantly different (P = .19-1.00), and only 2 of 88 patients did not undergo permanent implantation. Reoperations (n = 85) occurred in 59 of 105 children (56%), mainly for device malfunction (n = 42), whereas explantation was performed in 36 of 104 children (35%) at an average of 2.68 years since implantation (median, 2.36 years; range, 0.03-9.04 years), mainly for complete symptom resolution (n = 12). Explantation for any reason was less common after single-stage procedures (1 of 16 [6%] vs 35 of 88 [40%] patients; P = .01). CONCLUSION Sacral neuromodulation should be considered for children with dysfunctional elimination syndrome whose symptoms are refractory to maximum medical therapy understanding that the risk of reoperation is >50%. Elimination of the trial period reduces the number of general anesthetics without sacrificing outcomes.

Sacral Neuromodulation in Children With Dysfunctional Elimination Syndrome: Description of Incisionless First Stage and Second Stage Without Fluoroscopy

OBJECTIVES To detail a percutaneous technique of sacral nerve neuromodulation (SN) that eliminates the first-stage incisions and the need for second-stage fluoroscopy. Our group has previously described the results of SN in children with medically refractory dysfunctional elimination syndrome. The drawbacks to SN include the use of fluoroscopy and the need to reopen recent skin incisions during the second stage. This results in increased radiation exposure, poor cosmesis, and possible wound infection. METHODS The incisionless first stage consisted of percutaneously tunneling the temporary external appliance to the contralateral axillary line at the buttock after localization of the S3 nerve root and placement of a quadripolar tined lead under fluoroscopic guidance. A subcutaneous bolus of methylene blue marked the lead connector site, obviating the need for later fluoroscopic localization to place the implantable pulse generator at the second stage. RESULTS A total of 27 children with refractory dysfunctional elimination syndrome underwent SN using the InterStim device. Of the 27 patients, 19 underwent our modified technique. The operative time for our modified tunneling and placement technique was < or = 2 minutes. The mean hospital stay was 0.6 day, with no patient requiring postoperative intravenous narcotics. At a mean follow-up of 35.9 months, no wound infections had occurred in the incisionless cohort compared with 1 postoperative wound infection requiring device explantation in the conventional lead placement group. CONCLUSIONS The incisionless technique of SN device implantation is technically simple, quick to perform, and results in decreased radiation exposure, excellent pain control, and improved cosmesis without compromising the outcomes.

URINARY CONTINENCE AFTER STAGED BLADDER RECONSTRUCTION FOR CLOACAL EXSTROPHY: THE EFFECT OF COEXISTING NEUROLOGICAL ABNORMALITIES ON URINARY CONTINENCE

PURPOSE We determined whether there is a difference in the incidence of urinary continence in cloacal and classic bladder exstrophy after staged bladder neck reconstruction using the Young-Dees-Leadbetter technique. MATERIALS AND METHODS We reviewed the records of patients with cloacal and classic bladder exstrophy who underwent staged bladder neck reconstruction from 1971 to 1997. RESULTS The Young-Dees-Leadbetter bladder neck reconstruction was completed in 23 patients with cloacal exstrophy, of whom 5 (22%) became continent and 18 (78%) have persistent incontinence. A clinically apparent neurological abnormality significantly hindered the achievement of continence. Specifically 1 of the 13 children (7%) with versus 4 of the 10 (40%) without a neurological abnormality became continent (p <0.05). In contrast, staged reconstruction of classic bladder exstrophy resulted in urinary continence in 67 of the 82 patients (82%). Of the 67 continent patients 23 (34%) cannot void and require intermittent catheterization. None of the patients with classic exstrophy had a neurological deficit. CONCLUSIONS The ability of the Young-Dees-Leadbetter bladder neck reconstruction to result in urinary continence significantly differs in the cloacal and classic bladder exstrophy populations (22 versus 82%, p <0.001). Our findings also suggest that a coexisting neurological abnormality significantly hinders the ability to reconstruct a functional bladder in patients with cloacal exstrophy.

Predicting Renal Outcomes in Children With Anterior Urethral Valves: A Systematic Review

PURPOSE Prognostic information is limited on children with congenital anterior urethral valves or a diverticulum. We reviewed the literature and examined our clinical database to identify clinical features predicting a poor renal outcome, defined as azotemia, renal failure or death. MATERIALS AND METHODS We reviewed 97 English language studies of patients 18 years old or younger. Seven patients from our institutions were also included in analysis. After data abstraction we used multivariate models to define factors associated with outcomes of interest. RESULTS We identified 239 male patients with anterior urethral valves, of whom 139 had adequate data available for study inclusion. Of these patients 108 (78%) had normal renal function after treatment. On bivariate analysis vesicoureteral reflux (OR 22.4, p <0.0001), pretreatment azotemia (OR 17.1, p <0.0001), urinary tract infection (OR 3.3, p = 0.006), hydronephrosis (OR 10.0, p = 0.0004) and bladder trabeculation (OR 7.3, p = 0.01) were associated with renal failure or death while treatment method (p = 0.9), obstruction type (valve vs diverticulum, p = 0.4) and valve location (p = 0.6) were not. After adjusting for other factors only pretreatment azotemia (p = 0.0005) and vesicoureteral reflux (p = 0.01) remained associated with renal failure and/or death with a trend toward significance for urinary tract infection (p = 0.06). When all 3 factors were present, the odds of a poor renal outcome increased 25-fold (p = 0.005). CONCLUSIONS Congenital anterior urethral obstruction in children has a generally good prognosis but may occasionally result in a poor renal outcome. The combination of pretreatment azotemia, vesicoureteral reflux and urinary tract infection is highly predictive of a poor renal outcome.

Mini-Ureteroneocystostomy: A Safe and Effective Outpatient Treatment for Unilateral Vesicoureteral Reflux

PURPOSE Medically refractory vesicoureteral reflux is a common condition that can be cured by open surgery. Extravesical ureteroneocystostomy is a safe and effective surgical procedure. We determined whether this could be accomplished with limited dissection via an approximately 2 cm inguinal incision (mini-ureteroneocystostomy). MATERIALS AND METHODS All patients with unilateral vesicoureteral reflux who underwent mini-ureteroneocystostomy from 2003 to 2007 were evaluated. We present preoperative characteristics, surgical technique and outcomes in this analysis. RESULTS From 2003 to 2007, 57 children underwent mini-ureteroneocystostomy for unilateral vesicoureteral reflux. The group was predominantly female (48 of 57 patients or 84%) with median age of 4.8 years. Median vesicoureteral reflux grade was 3 (range 2 to 5). Duplication anomalies were present in 8 patients, while 5 had a Hutch diverticulum and 5 had a solitary kidney. A total of 47 patients (82%) underwent postoperative voiding cystourethrogram and surgical cure was achieved in all. De novo vesicoureteral reflux was identified in the contralateral ureter in 3 of 47 patients (6%). The procedure was performed on an outpatient basis in 47 of 57 patients (82%). Postoperative complications requiring surgical intervention developed in 2 children. CONCLUSIONS Mini-ureteroneocystostomy is an effective modified extravesical technique for vesicoureteral reflux. This procedure is safe and it can be performed on an outpatient basis with excellent results. It has become our standard of care in patients with unilateral vesicoureteral reflux.

Utility of dextranomer/hyaluronic acid injection in setting of bladder and ureteral anomalies.

OBJECTIVES Previous studies have shown that the cure rates after dextranomer/hyaluronic acid (Dx/HA) injection can be decreased in patients with neurogenic bladder, previous ureteroneocystostomy, duplicated ureters, or periureteral diverticula. We attempted to determine whether these factors reduce the efficacy of Dx/HA injection compared with that in otherwise normal patients. METHODS All children with vesicoureteral reflux (VUR) undergoing Dx/HA injection from April 2002 to March 2006 at two institutions were eligible for this study. Multivariate logistic regression models were built to assess the effect of bladder/ureteral anomalies on the success of Dx/HA injection. We adjusted for previously described predictors of injection success, including VUR grade, sex, age, surgeon experience, and injection technique. RESULTS A total of 543 refluxing ureters (373 patients) were included, of which 145 (27%) had persistent VUR on postoperative voiding cystourethrography; 86 ureters (16%) had anatomic anomalies. On univariate analysis, the most important predictors of injection failure were increasing VUR grade, male sex, younger age, subureteral injection, ureteral duplication anomaly, increasing Dx/HA volume, and surgeon experience. On multivariate analysis, however, the only significant predictors of injection failure were increasing VUR grade, subureteral injection technique, and surgeon experience. No anatomic or functional abnormalities, considered individually or grouped, significantly affected the probability of injection failure. CONCLUSIONS In our experience, children with functional and anatomic bladder/ureteral anomalies were no more likely to have Dx/HA injection fail than were children with uncomplicated VUR. The most important predictors of Dx/HA success remained VUR grade, injection technique, and surgeon experience. Dx/HA injection in patients with complex bladders could be a reasonable therapeutic option.

Outcome analysis of mini-ureteroneocystostomy versus dextranomer/hyaluronic acid copolymer injection for unilateral vesicoureteral reflux.

PURPOSE Injecting dextranomer/hyaluronic acid copolymer has gained popularity as first line treatment for vesicoureteral reflux. However, ureteroneocystostomy has typically been more successful than endoscopic treatments. We evaluated the outcome of dextranomer/hyaluronic acid copolymer injection vs that of extravesical ureteroneocystostomy via a 2 cm inguinal incision (mini-ureteroneocystostomy) for unilateral vesicoureteral reflux. MATERIALS AND METHODS The records were analyzed of all patients from 2003 to 2007 with unilateral vesicoureteral reflux who underwent mini-ureteroneocystostomy or dextranomer/hyaluronic acid copolymer injection. Mini-ureteroneocystostomy was performed via a 2 cm inguinal incision. Of the injections 66% were delivered via an intraureteral tunnel technique. Statistical analysis was done to compare differences in clinical features and success rates. All p values were 2-sided with significance at p <0.05. RESULTS From 2003 to 2007, 99 children underwent operative repair of unilateral vesicoureteral reflux, including 42 via dextranomer/hyaluronic acid copolymer injection and 57 via mini-ureteroneocystostomy. There were no significant differences between the groups in terms of preoperative clinical or anatomical variables except for higher preoperative reflux grade in the mini-ureteroneocystostomy cohort (p <0.001). Patients undergoing mini-ureteroneocystostomy were more likely to be cured (100% vs 78%, p = 0.001). De novo contralateral vesicoureteral reflux occurred in the 2 cohorts to a similar degree (p = 0.15). The injection cohort was more likely to be discharged home on an outpatient basis (100% vs 82%, p = 0.002). No complications occurred in the dextranomer/hyaluronic acid copolymer cohort, while 2 children required intervention for complications after mini-ureteroneocystostomy. CONCLUSIONS This study details that the 2 procedures may be successfully performed in the outpatient setting, and yet even for more advanced vesicoureteral reflux mini-ureteroneocystostomy achieves greater overall success. This procedure has become our standard of care for unilateral vesicoureteral reflux.

Anatomy of Cloacal Exstrophy

Cloacal exstrophy with an estimated incidence of 1 in 200–400,000, is the rarest and most severe form of the exstrophy epispadias complex.1,2 Prior to 1960 the multiple systemic defects found in association with this anomaly inevitably lead to death of the infant.3,4 Refinements in surgical technology, neonatal care, hyperalimentation and antibiotic therapy currently allow us to obtain survival rates in the range of 85–90%.1,5 To appropriately plan for the surgical reconstruction of these patients, the pediatric urologist, surgeon and radiologist managing these individuals must beware of the multiple anomalies that coexist with this entity. The purpose of this paper is to outline the associated congenital defects and review their impact on the surgical treatment and management of this patient population.