Julia Spencer Barthold

Surgical complications of bladder augmentation: comparison between various enterocystoplasties in 133 patients.

OBJECTIVES Ileal and sigmoid augmentation are equally effective at increasing bladder capacity and compliance. Therefore, knowledge of the incidence of major complications, including perforation, small bowel obstruction (SBO), anastomotic complications, calculus formation, and indications for revision may be useful in choosing the ideal segment. We compared the complications of ileocystoplasty and two types of sigmoidocystoplasty that required reoperative surgery. METHODS Between 1981 and 1997, 158 patients with a mean age of 11 years (range 2 to 25) underwent augmentation cystoplasty. Ileum or sigmoid colon was used in 133 patients, who were the subjects of this study. The mean follow-up was 64 months (range 6 to 185). Indications included neurogenic bladder (n = 100), bladder exstrophy (n = 12), cloacal exstrophy (n = 6), posterior urethral valves (n = 3), and miscellaneous (n = 12). Ileum was used in 65 patients and sigmoid colon in 68. Of these, 48 underwent conventional colocystoplasty and 20 seromuscular colocystoplasty lined with urothelium (SCLU). Seventy-nine percent required additional procedures to achieve continence or facilitate catheterization, which included bladder neck procedures in 56% or continent stomas alone in 23%. RESULTS There were no deaths or complications of bowel anastomosis. Overall, continence was achieved in 95%. Spontaneous bladder perforation was highest in patients with neurogenic bladder. Calculi developed more frequently in patients with continent stomas (P = 0.04) and in patients with bladder/cloacal exstrophy (32%) than in patients with neurogenic bladder (P = 0.01). Additional procedures and route of catheterization did not increase the risk of perforation. One patient with SCLU with known hypercalciuria developed bladder calculi. CONCLUSIONS Sigmoid colon showed a trend of a lower rate of SBO with no difference in perforation or stone formation compared with ileum. Primary diagnoses of bladder or cloacal exstrophy and continent stomas are risk factors for the development of calculi. SCLU has a low rate of surgical complications and no incidence of perforation or SBO thus far; therefore, we advocate the use of SCLU when feasible, and sigmoid as the preferred bowel segment for augmentation cystoplasty.

ALTERNATIVE TECHNIQUES FOR AUGMENTATION CYSTOPLASTY

PURPOSE We discuss conventional intestinal cystoplasty and show how concern about potential complications has led to an interest in alternative methods for cystoplasty. Techniques such as gastrocystoplasty, ureterocystoplasty, vesicomyomectomy (autoaugmentation), seromuscular augmentation, alloplastic replacement and bioprosthetic materials are reviewed. Laboratory and clinical results of these techniques are examined critically to compare advantages, disadvantages and potential applications. MATERIALS AND METHODS Computer searches of available medical data bases were used to generate a list of relevant publications, including original contributions and review articles, which were then reviewed, compared and summarized. RESULTS Augmentation cystoplasty is used routinely for treatment of reduced bladder compliance and capacity secondary to infectious, inflammatory, neurogenic and congenital disorders. Sigmoidocystoplasty and ileocystoplasty have become standard techniques but there is renewed interest in alternative techniques due to the relatively high morbidity of intestinal cystoplasty. Alternative techniques have been described to avoid inclusion of intestinal mucosa in the urinary tract while creating a compliant bladder of adequate capacity. These techniques include gastrocystoplasty, vesicomyotomy, seromuscular augmentation, various alloplastic or biodegradable scaffolds and in vitro culture with subsequent grafting of autologous urothelium. Although encouraging animal and human results have been reported, each technique is associated with its own limitations and disadvantages. CONCLUSIONS While intestinal cystoplasty remains the standard, several alternative techniques show promise. At present only gastrocystoplasty, ureterocystoplasty and seromuscular augmentation should be considered clinically useful.

Re: Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence.

PURPOSE There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique. MATERIALS AND METHODS A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate. RESULTS Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional voiding and avoidance of bladder augmentation. Revision rates of various procedures were similar but the incidence of complications was highest with the Kropp procedure. Long-term published data were limited in regard to bladder neck sling, reconstruction, injection, suspension and urethral lengthening techniques. CONCLUSIONS Long-term published data support artificial urinary sphincter creation as first line surgical management of neurogenic sphincteric incontinence. Girls who already depend on intermittent catheterization may benefit equally from a sling procedure if successful long-term continence is demonstrated in future studies.

REVIEW ARTICLE: SURGICAL MANAGEMENT OF URINARY INCONTINENCE IN CHILDREN WITH NEUROGENIC SPHINCTERIC INCOMPETENCE

Purpose:: There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique.Materials and Methods:: A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate.Results:: Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional void...

Long-term outcome based on the initial surgical approach to ureterocele.

PURPOSE The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele. MATERIALS AND METHODS We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery. RESULTS Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months). CONCLUSIONS Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.

TESTICULAR POSITION IN THE ANDROGEN INSENSITIVITY SYNDROME: IMPLICATIONS FOR THE ROLE OF ANDROGENS IN TESTICULAR DESCENT

PURPOSE We compared testicular position with genital phenotype in a clinical series and a literature review of androgen receptor mutations to assess the role of androgens in testicular descent. MATERIALS AND METHODS Our clinical reports, the androgen receptor mutations database and selected literature were reviewed. Subjects with a proved androgen receptor mutation were included in our study when a female or ambiguous phenotype was present (Quigley grade 3 to 7) and testicular position was documented. Comparison among groups was done by Fishers exact or chi-square test. RESULTS Of the 7 patients with detailed clinical records 5 had abdominal (bilateral in 4) and 2 had bilateral inguinal testes. Four patients with abdominal testes also had aberrant pelvic ligaments extending medially from the gonads. Including an additional 102 cases identified in the literature, abdominal testes were present in 52% and 3% of those with complete and partial androgen insensitivity, respectively. The incidence of abdominal testes was highest (86%) in patients with a complete female phenotype and no pubic hair (grade 7). It decreased significantly with increasing masculinization and was higher in phenotypic females diagnosed at or after (67%) than in those identified before (22%) puberty. Hernia was associated with inguinal and abdominal testes. CONCLUSIONS Testicular position correlates with genital phenotype in patients with androgen receptor mutations, supporting a major role for androgens in testicular descent. Inguinal hernia and abnormal pelvic ligaments in these individuals may partially determine testicular position but to our knowledge the role of androgen receptors, if any, in their development is unknown.

EARLY PROGNOSTIC VALUE OF SERUM CREATININE LEVELS IN CHILDREN WITH POSTERIOR URETHRAL VALVES

PURPOSE We evaluated the prognostic value of serum creatinine level at initial treatment for future renal function in children with posterior urethral valves. MATERIALS AND METHODS We reviewed the records of 35 patients with posterior urethral valves presenting in the first year of life and treated initially at our institution between 1973 and 1990 with valve ablation or vesicostomy. Initial assessment included serum creatinine determination, urine culture, renal ultrasonography and voiding cystourethrography. After 4 or 5 days of catheter bladder drainage renal ultrasound and serum creatinine measurement were repeated. At the end of followup patients were divided into 2 groups according to glomerular filtration rate calculated by the Schwartz formula: group 1--69 ml. or less per minute per 1.73 m.2 (median 15) and group 2--greater than 70 ml. per minute per 1.73 m.2 (median 110). Median followup was 102 months (8.5 years, range 50 to 219 months). RESULTS Mean serum creatinine at diagnosis plus or minus standard deviation was 3.60 +/- 2.01 and 1.3 +/- 0.7 mg./dl. in groups 1 and 2, respectively (normal 0.1 to 0.6, p < 0.01). Mean serum creatinine after catheterization was 2.4 +/- 1.1 and 0.6 +/- 0.2 mg./dl. in groups 1 and 2, respectively (p < 0.01). Mean nadir creatinine during the first year of life was 1.7 +/- 0.6 and 0.4 +/- 0.2 mg./dl. in groups 1 and 2, respectively (p < 0.01). All differences were statistically significant. Linear regression analysis of creatinine after catheterization and glomerular filtration rate at last followup demonstrated a correlation coefficient of -0.7 (p < 0.01). CONCLUSIONS Although it is well known that nadir creatinine in the first year of life correlates with prognosis, the correlation of long-term renal function with creatinine at valve ablation or vesicostomy is more useful to the clinician. These data indicate that serum creatinine level 4 to 5 days after the initial diagnosis correlates strongly with long-term renal function in children with posterior urethral valves.

ASSOCIATION OF EPIDIDYMAL ANOMALIES WITH PATENT PROCESSUS VAGINALIS IN HERNIA, HYDROCELE AND CRYPTORCHIDISM

PURPOSE We performed a prospective study to assess the relationship between epididymal anomalies and patency of the processus vaginalis in boys presenting with hernia, hydrocele or cryptorchidism. MATERIALS AND METHODS The degree of patency of the processus vaginalis (closed, partially closed or open) and morphology of the ipsilateral epididymis were recorded in 159 consecutive inguinal explorations. RESULTS A closed, partially closed and open processus vaginalis was associated with an abnormal epididymis in 14, 36 and 69% of cases, respectively. Epididymal anomalies were more frequent in association with undescended (72%) than descended (34%) testes. CONCLUSIONS These data confirm the observation of a higher incidence of epididymal anomalies associated with patency of the processus vaginalis irrespective of testicular position, and they support the theory that androgenic stimulation may be required for closure of the processus vaginalis as well as epididymal development.

Bladder calculi in children who perform clean intermittent catheterization.

Objective To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients.

MANAGEMENT OF URETHRAL STRICTURES AFTER HYPOSPADIAS REPAIR

PURPOSE We conducted a retrospective study of patients with strictures after hypospadias repair to identify factors contributing to the development of strictures and to attempt to define an optimal strategy for management. MATERIALS AND METHODS Patients with the diagnosis of hypospadias who had undergone direct vision internal urethrotomy, urethral dilation or urethroplasty were identified. The original location of the meatus, type of initial repair, subsequent procedures and outcome of the interventions were recorded. RESULTS A total of 38 patients were identified. Of the 29 patients who were initially treated with direct vision internal urethrotomy or urethral dilation 23 (79%) ultimately required open urethroplasty and did well. Of the 8 patients treated with initial urethroplasty 7 had successful outcomes. Overall success, defined as asymptomatic voiding without fistula or residual stricture, was 78% at a mean followup of 6.3 years. CONCLUSIONS Stricture disease continues to be a significant complication of hypospadias reconstruction. Initial therapy should be urethral dilation but it should be recognized that the majority of these patients will ultimately require open urethroplasty.