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

Urinary considerations for adult patients with spinal dysraphism

The incidence of newborns with spinal dysraphism is diminishing worldwide, although survival of individuals with this condition into adulthood continues to improve. The number of adults with spinal dysraphism will, therefore, increase in the coming years, which will pose new challenges in patient management. Urological manifestations of spinal dysraphism can include increased risks of urinary incontinence, urinary tract infection, urinary calculi, sexual dysfunction, end-stage renal disease and iatrogenic metabolic disturbances; however, the severity and incidence of these symptoms varies substantially between patients. Owing to the presence of multiple comorbidities, treatment and follow-up protocols often have to be adapted to best suit the needs of specific patients. Authors describe bladder and kidney function and long-term complications of treatments initiated in childhood, as well as the potential for improvements in quality of life through better follow-up schedules and future development

Efficacy and safety of urethral de-obstruction in boys with overactive bladder complaints

To gain insight into the efficacy and safety of urethral de-obstruction in boys with overactive bladder (OAB) complaints refractory to conservative treatment. All boys, older than 5 years, referred in 2009 for OAB complaints were included, n = 180. Nine had abdominal or penile pain as predominant complaint. 82% were tertiary referrals after unsuccessful conservative treatment with antimuscarinic medication and/or urotherapy for OAB. In 121, urethral obstruction was urodynamically proven or seriously suspected, and they underwent urethrocystoscopy with relief of obstruction, when present. Average duration of unsuccessful conservative pre-treatment in this group of patients was 1.2 years. Postoperative results, in terms of relief of complaints, were analyzed. Safety was assessed by analyzing those patients who had a secondary transurethral procedure in the same year, or in the 3 years after primary treatment. Of 106 boys with OAB, urge incontinence or therapy-resistant bedwetting, after de-obstruction 33 became free of complaints and 39 showed significant improvement, totaling 72 (68%); dry after additional urotherapy 11 (10%); no change 21 (20%). Nine boys had de-obstruction because of penile or abdominal pain, with 5 completely cured after the procedure. Follow-up treatment was cognitive training in 39, temporary anticholinergic treatment in 26 and CIC in 2 cases. Recurrence of obstruction was seen in 10% during the 3-year follow-up period. After failure of conservative therapy, one should actively look for any urethral obstruction as underlying cause of OAB. For such patients, urethral de-obstruction is highly effective, with only a few minor late complications resulting in recurrence of obstructio

Evaluation of Burch colposuspension in girls with severe therapy resistant incontinence due to bladder neck insufficiency

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Open and Laparoscopic Colposuspension in Girls with Refractory Urinary Incontinence

Lower urinary tract symptoms (LUTS) are very common in children. Standard treatments consist of urotherapy, antibiotic prophylaxis, anti-muscarinics, physical therapy, and the treatment of coexisting constipation. A small group of girls also present with stress incontinence or with stress-induced urge incontinence. In cases of persistent LUTS due to congenital bladder neck insufficiency (BNI), surgical treatment might be considered. The aim of this paper is to assess the results of open and laparoscopic colposuspension in children with refractory urinary incontinence (UI). The results of 18 open and 18 laparoscopic consecutive colposuspensions were analyzed. All patients had UI and failed conservative treatment. BNI was proven by repeated perineal ultrasound and video-urodynamic study. The laparoscopic procedure was performed preperitoneally and the open procedure was via a transverse lower abdominal incision. The same postoperative protocol was used in both groups. The mean operation time was 65 min for the open and 90 min for the lap procedure (p  < 0.05). Full success was achieved in 7/18 in the open and in 8/18 in the lap group and partial response was seen in 3/18 and in 5/18, respectively (p = 0.64). No intraoperative complications occurred in this cohort. Open and laparoscopic colposuspension can be used to treat refractory UI in children with BNI when non-invasive methods fai