Treatment of the neurogenic bladder in spina bifida

Renal damage and renal failure are among the most severe complications of spina bifida. Over the past decades, a comprehensive treatment strategy has been applied that results in minimal renal scaring. In addition, the majority of patients can be dry for urine by the time they go to primary school. To obtain such results, it is mandatory to treat detrusor overactivity from birth onward, as upper urinary tract changes predominantly start in the first months of life. This means that new patients with spina bifida should be treated from birth by clean intermittent catheterization and pharmacological suppression of detrusor overactivity. Urinary tract infections, when present, need aggressive treatment, and in many patients, permanent prophylaxis is indicated. Later in life, therapy can be tailored to urodynamic findings. Children with paralyzed pelvic floor and hence urinary incontinence are routinely offered surgery around the age of 5 years to become dry. Rectus abdominis sling suspension of the bladder neck is the first-choice procedure, with good to excellent results in both male and female patients. In children with detrusor hyperactivity, detrusorectomy can be performed as an alternative for ileocystoplasty provided there is adequate bladder capacity. Wheelchair-bound patients can manage their bladder more easily with a continent catheterizable stoma on top of the bladder. This stoma provides them extra privacy and diminishes parental burden. Bowel management is done by retrograde or antegrade enema therapy. Concerning sexuality, special attention is needed to address expectations of adolescent patients. Sensibility of the glans penis can be restored by surgery in the majority of patient

U2B-dry: preliminary results of a new vesicoscopic technique for bladder neck repair in children

The aim of this work was to present a new vesicoscopic technique for treatment of sphincter insufficiency and to evaluate the short-term results. Eight children (mean age, 11.7 years), 4 with non-neurologic and 4 with neurologic sphincter incontinence, were operated on. All had previously failed open surgery. In all, leak-point pressure was below 30 cm H(2)O. Mean follow-up was 5.2 months. In the supine position, three ports were inserted into the bladder under direct visual control. A U-shaped incision was made in the mucosa around the bladder neck, leaving a strip of mucosa on the anterior bladder wall that was tubularized. One lateral mucosal flap was used to cover the tube. A transurethral catheter was left in for 3 weeks. One conversion to open procedure was necessary because of leakage. Mean operation time was 161 minutes (range, 150-194). Postoperative hospital stay was between 2 and 4 days (mean, 2.7). Transurethral clean intermittent catheterization has been resumed in 4 children without complications. Four patients are dry, 2 are sporadically wet but satisfied with the result, and 2 patients are wet. Vesicoscopic U-bladder neck plasty is a promising procedure. A major advantage of the technique is the fact that it is a relatively minor surgery with excellent cosmetic outcome and quick recover

Secondary endoscopic pyelotomy in children with failed pyeloplasty

To assess the results of secondary endopyelotomies (SEP) that were performed in our center in children who had earlier failed pyeloplasty. Eleven secondary endopyelotomies were done between 2005 and 2010 in 10 patients (5 boys and 5 girls, mean age 6.8 years), with a follow-up time of >6 months. The primary procedure was an open/laparoscopic pyeloplasty (n = 10) or a ureterocalicostomy (n = 1). In all cases, endopyelotomy was done by means of a monopolar electrocautery hook using the standard pediatric resectoscope. In 10 patients, SEP was done percutaneously, and in 1 patient it was done in a retrograde fashion. The mean operation time was 69 minutes. After a mean follow-up of 20 months, 70% of patients were free of complaints (n = 7), which was defined as a resolution of complaints, resolution of hydronephrosis, and improvement of renal wash-out curve and function. In 4 renal units, reintervention had to be considered; in one of these, a re-pyeloplasty has already been performed. The mean postoperative hospital stay was 2.8 days. No intraoperative complications occurred. In 1 patient, postoperative leakage around the nephrostomy drain occurred but resolved spontaneously. SEP is a fairly safe method to treat recurrent ureteropelvic junction-stenosis after failed pyeloplasty in children. However, because it seems to be less affective than the open redo pyeloplasty, it cannot be considered as a gold standard procedure and as such should be thoroughly discussed with the patient and parent

Nondismembered pyeloplasty in a pediatric population: results of 34 open and laparoscopic procedures

To assess the outcomes of nondismembered pyeloplasty for ureteropelvic junction obstruction in a pediatric population of children and adolescents. Between 2005 and 2009, a total of 129 pyeloplasties were performed at our institution. In all, 34 (24%) renal units underwent primary nondismembered Fenger-type plasty, 22 open (OPEN) and 12 laparoscopic (LAP). Gender distribution, left to right ratio, follow-up period, grade of kidney dilatation and split renal function were similar in both groups. The decision to perform a nondismembered procedure was made by the surgeon intraoperatively. The mean age at surgery was 4.5 years for the OPEN group and 14.2 years for the LAP group. Mean follow-up was 30 months (range 12-70 months). The overall success rate was 91% (95.5% the OPEN group and 83.5% in the LAP group). Secondary surgery was required for 3 renal units. Other complications included pyelonephritis in 3 patients (2 in OPEN and 1 in LAP), ileus in 1 patient (OPEN), and prolonged postoperative pain in 1 patient (LAP). The mean operation time was significantly shorter for open surgery (95 minutes for OPEN vs 179 minutes for LAP; P < .05). There was no significant difference in the length of the postoperative hospital stay (2.5 days for OPEN vs 3 days for LAP). Nondismembered pyeloplasty is an effective procedure for curing ureteropelvic junction obstruction in the pediatric population, and can be considered as an option in well selected case