In Situ Autologous Bladder tissue culture for Bladder Autoaugmentation in Animal Model: Bladder wall as A Bioreactor

PurposeTo introduce a new technique for bladder autoaugmentation using in situ autologous bladder tissue culture and expansion for augmentation cystoplasty in a rabbit model and report its preliminary surgical outcome.Material and MethodsTwenty-four rabbits were divided into 3 groups. Group I underwent classical autoaugmentation. Group II underwent insertion of tissue expander in a 2x1 cm² frame of bladder wall between the mucosa and seromuscular layer for autoaugmentation marked by non-absorbable sutures. In group III all animals were allocated the same technique although the inserted tissue expander was implanted with autologous tissue fragments. In this group a 10x5 mm² full thickness bladder biopsy was dissected and separated smooth muscle cell (SMC) and urothelial cell (UC) tissue layers were minced into 20 fragments. The SMC fragments were coated on the separated mucosal layer beneath the tissue expander and UC fragments were seeded on the expander under the seromuscular layer. After 6 weeks the 2 recombinant bladder tissue layers were grafted to the remaining host bladder.Immediately before grafting and at 30 d intervals after grafting, bladder biopsies were obtained for determination of CD31/34, SMC α-actin, and cytokeratin AE1/AE3 following cystometric evaluations.ResultsThe bladder wall frames containing fragment-seeded tissue expanders, demonstrated organized bladder wall generation in two different expanded layers with mature urothelium and muscular layers. While number of CD34+ endothelial progenitor cells and CD31+ microvessels were significantly higher(P <0.05). Group III showed a significant bladder capacity increment as compared with groups I-II (P <0.001).ConclusionsOur RESULTS demonstrate the bladder wall acted as an in situ bioreactor; preserved autologous bladder tissue culture with seeded fragments on a tissue expander provided a histologically organized bladder wall generated in vivo, adding 2 times more surfaces applicable in augmentation.     

Augmentation Cystoplasty: Long-Term follow up Of 112 Cases

PurposeThis paper reviews a single center experience of augmentation cystoplasty cases.Material and MethodsOf the 145 patients who have undergone augmentation (AG) cystoplasty between 1994 and 2006, 112 (54 M 58 F, mean age 10.5 years (3-25), were available for long term follow-up, with a mean follow-up period of 42 months (12-114). Indications for AG were: neurogenic bladder (n = 79), undiversion (12), bladder exstrophy (8), posterior urethral valve (8), and Hinman syndrome (5). Ileocystoplasty was done for 65 cases, autoaugmentation (AA) for 34 cases, gastrocystoplasty in five, and ureterocystoplasty in eight cases. Additional procedures included: Mitrofanoff (57), sling or bladder neck reconstruction (23), and anti-reflux (AF) procedures (25).ResultsContinence was achieved in 74% with augmentation, and 91% with additional procedures. The average bladder capacity was 41% of the capacity expected for age and mean compliance was 4 ml/cmH₂O which were increased to an average of 85% and 12.9 ml/cmH₂O respectively. The improvement in capacity and compliance with AA was the lowest. Of the 67 patients with VUR, 25 had an AF procedure with a success rate of 84% (21/25). In the remaining 42, reflux was not corrected surgically, and 20 had no reflux following augmentation procedure (47.6%), 13 persisted (31%), 6 had downgrading (14.3%), 3 had unilateral resolution (7.1%). Overall complications were seen in 30.4%. The most common complication was pyelonephritis in 7%, 8 patients required revision of Mitrofanoff stoma, bladder stones were in 3.6%. The remaining complications were all minor seen in 1-2% each.ConclusionsIleocystoplasty is still considered the first choice if the prerequisites of uroepithelial cystoplasty are absent. AA should be restricted to the detrusor hyperactivity group, AF procedure should only be done in high grade reflux and good care must be considered in the presence of previous pelvic surgery.     

Comparison of traditional enterocystoplasty and seromuscular colocystoplasty lined with urothelium

ObjectiveTo evaluate long-term outcomes between various methods of augmentation cystoplasty.MethodsA retrospective analysis was performed of patients undergoing seromuscular colocystoplasty lined with urothelium (SCLU, n = 26), and their outcomes compared to a similar population of patients in the same institution who had received traditional forms of bladder augmentation (colocystoplasty and ileocystoplasty, n = 32). Measurements included efficacy of the procedure in increasing bladder capacity and achieving urinary continence, and the need of subsequent surgery for complications.ResultsThere was no statistically significant difference in achieved bladder capacity, subjective urinary continence and the rates of subsequent surgery for stones, vesicoureteral reflux, augment failure, bladder neck continence and catheterizable channel. None of the patients in the SCLU group had spontaneous perforation or small bowel obstruction.ConclusionPatients with SCLU are at decreased risk for bowel obstruction and spontaneous perforation, but are not devoid of other long-term complications including bladder stones, vesicoureteral reflux and augment failure. Most of the risks and benefits of augmentation cystoplasty performed using ileum, colon, or SCLU appear similar.     

Bladder augmentation and artificial sphincter implantation: urodynamic behavior and effects on continence

ObjectiveTo quantify changes in bladder capacity, pressure and compliance after isolated bladder augmentation or augmentation associated with implantation of an artificial sphincter, and to compare the various types of augmentation.Patients and methodsPreoperative and postoperative urodynamic studies were performed in a group of 38 patients (18 males and 20 females; age range 2–19 years), who underwent a type of bladder augmentation.ResultsThe bladder improved in capacity in all patients (mean values: initial 137 ml, final 336 ml, individual increase 229 ml; 434%) except two, in which the augmentation was done with ureter. The mean pressure improved (initial 32 cm of H₂O, final 14, decrease per patient 18 cm of H₂O; 49%). The curve of compliance, progressively increasing typical of hyperreflexia and poor compliance, present in 70% of the cases preoperatively, improved in 78% cases postoperatively, although there were several different patterns. Urodynamic behavior was analyzed with regard to the tissue used for augmentation (ileum, ureter or sigmoid colon). In the sigmoid colon group, there were no significant differences in the urodynamic behavior of the bladder neo-reservoir in relation to the configuration used.ConclusionWith bladder augmentation comes an increase in bladder capacity, a reduction in pressure, and an improvement in compliance and continence. The level of change in capacity, pressure and compliance varies with the tissue used and the length and caliber of the insert. When the procedure is carried out using sigmoid colon tissue, there are no noteworthy differences among the various possible configurations.     

膀胱自体扩大术在神经性膀胱患儿中的应用评价

目的评价逼尿肌部分切除、膀胱自体扩大术的临床疗效。方法选择脊髓脊膜膨出患儿6例,其中男性3例,女性3例,年龄18个月至9岁。患儿均口服索利那新和行清洁间歇导尿3个月后无好转而行逼尿肌部分切除、膀胱自体扩大术,术后予清洁间歇导尿,手术前及术后1年行泌尿系超声、排泄性膀胱尿道造影,并行尿动力评价,评价指标为膀胱容量、膀胱顺应性和充盈末逼尿肌压。结果术前尿动力学检查显示6例患儿膀胱容量减小、膀胱顺应性下降及逼尿肌压升高,其中5例膀胱容量低于预期容量的50%。排泄性膀胱造影4例合并膀胱输尿管反流,其中左、右侧Ⅳ°反流各1例,双侧Ⅳ°反流2例。6例患儿手术后恢复顺利,无穿孔、感染发生。术后1年尿动力学检查显示6例患儿膀胱容量略有增加,但膀胱容量与预期膀胱容量(年龄×30+30)、膀胱顺应性及逼尿肌压力无明显变化,VCUG显示4例输尿管反流无减轻。结论对于膀胱容量明显变小的神经性膀胱患儿,逼尿肌部分切除、膀胱扩大术不能有效增加膀胱容量和顺应性,降低逼尿肌压,临床不能取得满意的效果。     

Effect of onabotulinumtoxinA treatment on symptoms and urodynamic findings in pediatric neurogenic bladder

ObjectiveTo evaluate clinical and urodynamic efficiency of onabotulinumtoxinA (Botox) treatment in pediatric patients with urinary incontinence due to neurogenic overactive bladder.Patients and methodsSeventeen patients aged from 6 to 17 years (median 11 years) were treated with Botox injections. Clinical response to incontinence, duration of the response, and urodynamic results before and 1–3 months after treatment were evaluated.ResultsMean incontinence frequency decreased significantly (p = 0.036); six of 17 patients had >90% reduction, and a further three patients had a 50–90% reduction in incontinence episodes. Median duration of the response was 15 months (range 3–42 months). Mean bladder volume changed from 380 ± 148 ml to 453 ± 147 (p = 0.078), maximal detrusor pressure decreased from 45 ± 31 cmH₂O to 32 ± 21 cmH₂O (p = 0.030), and the number of patients with detrusor contractions during filling decreased from 12 to three (p = 0.005) after the treatment. The patients with poor bladder compliance had either no response or a short duration of response. At follow-up eight patients had undergone bladder augmentation because of persistent incontinence.ConclusionsAbout one third of pediatric patients with neurogenic bladder had a good response to Botox treatment. In many patients, the clinical response was longer than expected. The patients who initially had poor bladder compliance had a poor response to the treatment.     

The use of an intra vesical silicon inflatable baloon device improves results of bladder autoaugmentation technique. Long term follow up

PurposeTo present the long-term RESULTS of bladder autoaugmentation in children with low compliant neurogenic bladders comparing the usual technique with a modified technique using an intra vesical silicon inflatable balloon device.Material and MethodsTwenty-two patients with low-compliant neurogenic bladders and incontinence confirmed urodynamically were divided in two groups. Group I (12 patients) underwent autoaugmentation using the classical detrusorectomy approach. Group II (10 patients) underwent autoaugmentation associated to an intra vesical silicon inflatable device filled with saline solution customized to allow urine elimination and sustain partial bladder distention.ResultsFollow up ranged from 2 to 11 years (mean 4 years). Patients in Group I showed unsatisfactory RESULTS, with only one patient achieving continence using clean intermittent catheterization (CIC). Four patients showed mild improve on urodynamic parameters. Patients in group II showed encouraging RESULTS. Six patients achieved continence with CIC. Two patients achieved continence using CIC and anticholinergic agents. Bladder capacity had a mean increase of approximately 71% and bladder compliance mean increased from 15.6 ± 16.8 ml/cmH2O to 34.3 ± 22.8 ml/cmH2O (p = 0.02). Two patients with previously dilated upper urinary tract showed a decrease in the grade of dilatation.ConclusionsBladder autoaugmentation using an intra vesical silicon inflatable balloon device showed better RESULTS compared to the usual autoaugmentation technique. The presented device didn't add morbidity to the surgical procedure. This technique can be used in selected patients in order to improve urodynamic parameters and continence without the potential disadvantages of using bowel segments for bladder augmentation.     

Management of vesicoureteral reflux secondary to neurogenic bladder

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH₂O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH₂O), reimplantation with bladder augmentation is recommended. Accepted: 6 January 1998     

Augmentation ureterocystoplasty in boys with valve bladder syndrome

ObjectiveChildren with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome.Patients and methodsEight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound.ResultsBladder capacity (as measured during cystometry at 30 cm H₂O) and compliance were significantly improved in all children following the procedure (P < 0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child.ConclusionUreterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.     

Upper tract changes in patients with neurogenic bladder and sustained pressures >40 cm following bladder neck surgery without augmentation

ObjectiveWe report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence.MaterialsConsecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥1 year were included as participants in the study.ResultsOf 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection.ConclusionsDespite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation.     

Long-term efficacy and safety of tolterodine in children with neurogenic detrusor overactivity

ObjectiveWe evaluated long-term (≥12 months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity.Subjects and methodsSubjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4 months–4 years, tolterodine oral solution 0.2–2 mg twice daily; 5–10 years, tolterodine oral solution 0.5–4 mg twice daily; 11–16 years, tolterodine extended-release capsules 2, 4, or 6 mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries.ResultsThirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40 cm H₂O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10 cm H₂O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24 h decreased in all subjects, as did the number of catheterizations per 24 h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported.ConclusionsBoth tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.     

Urological outcomes in the omphalocele exstrophy imperforate anus spinal defects (OEIS) complex: Experience with 80 patients

ObjectiveTo review the urological management and outcomes of patients with the OEIS (omphalocele, exstrophy of the bladder, imperforate anus, spinal abnormalities) complex.Patients and methods80 patients with the OEIS complex managed at a single institution between 1974 and 2009 were reviewed.Results37 had initial closure at our institution (2 failed – 5%); 22 with successful closure were referred for incontinence; 15 failed closure at an outside institution (2 of whom are awaiting closure); 6 are skin-covered variants. Osteotomy was performed in 39/43 (91%) with successful closure versus 8/17 (47%) who failed initial bladder closure. 40 were dry (56%), but most needed additional urinary reconstruction: 2 had small bowel neobladders; 32 (84%) had augmentation cystoplasty; 30 (79%) had a continent catheterizable channel; only 9 (24%) were continent with an intact urethra. Bladder neck reconstruction allowed dryness in 7 (18%). 45 patients had XY genotype – 19 had female gender assignment at birth. All patients with XX genotype had female gender assignment.ConclusionsOsteotomy improves success of initial bladder closure. A bladder neck procedure, catheterizable channel, and augmentation cystoplasty will be required in the majority of patients to attain urinary dryness.     

Bladder augmentation using acellular collagen biomatrix: a pilot experience in exstrophic patients

Purpose  

A preliminary experience on in vivo bladder wall regeneration in a subset of patients born with exstrophy–epispadias complex is reported. The objective was to improve bladder capacity and compliance without bowel augmentation.     

New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

ObjectiveWe report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence.Materials and methodsConsecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually.ResultsThere were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet).ConclusionsUpper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation.     

Outcome of complete primary bladder exstrophy repair: Single-center experience

ObjectiveReconstruction of bladder exstrophy remains a challenge. We evaluated our experience with complete primary repair in classic bladder exstrophy.MethodsA retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. Fifty-one patients (21 females and 30 males) with classic bladder exstrophy were included. Age of presentation ranged from 24 h to 14 months. Mean follow up was 3 years (1 month–7 years). Patients were evaluated for continence, upper tract dilatation and cosmetic result.ResultsEight patients (15.6%) had failed closures and six (11.7%) had fistulae. Evaluation of continence excluded 16 patients not followed up at our center. Thirty-seven percent were continent on clean intermittent catheterization after the age of 5 years. Patients became dry only after augmentation cystoplasty. Upper tract changes were mild during our study with all patients having normal serum creatinine.ConclusionPatients may require more than one procedure for reconstruction. In our series, augmentation was required to achieve acceptable dryness. Early promising results with dry intervals in young patients did not translate to continence in older patients.     

Sling suspension of the bladder neck for pediatric urinary incontinence

ObjectiveSurgery for urinary incontinence in childhood is in the process of an ongoing search for better results because a procedure that guarantees dryness still does not exist. This study has been conducted to assess the overall results of the fascia sling procedure for incontinence in children.Material and methodsEighty-nine patients with neurogenic lower urinary tract dysfunction and follow-up of more than 2 years have been included in the study (46 boys and 43 girls aged 2–17 years). All patients underwent U-type sling suspension of the bladder neck. In 59 patients detrusorectomy and in 11 patients bladder augmentation was performed. Sphincter incompetence was defined as low-pressure (<30 cm H₂O) leakage observed during urodynamic studies. The results of surgery were assessed clinically (dryness intervals).ResultsForty-two (47%) patients were completely dry, and 23 (26%) considerably improved. The success rate was higher in males (35) than in females (30) (76% vs 70%). Detrusorectomy did not improve the success rate of the sling procedure (68% vs 79% sling only), but bladder augmentation did (90%). Higher success rates have been observed in adolescents compared to prepubertal children (83% vs 56%). No serious complications were observed.ConclusionsRectus fascia sling suspension is a safe procedure and could be considered a good option for the treatment of neurogenic sphincter incompetence in children.     

Can regular Bladder washouts and Acetylcysteine instillation prevent stone formation and reduce the Incidence of Urine Infections in the Augmented Bladder?

PurposeTo monitor the effects of a regular bladder washout regime and the use of acetylcysteine in the prevention of stones and frequency of symptomatic urine infections in children post bladder augmentation.Material and Methods19 children, 8 boys and 11 girls (mean age 13.54 years) who underwent augmentation cystoplasty with a mean followup of 37 months (11–98)were included. All of them were contacted with questionnaires. Information requested included frequency of bladder washouts both in the first three months after surgery and presently to date, type of solution used and whether acetylcysteine solution was prescribed ay any time for the management of severe mucous production. The clinical nurse specialists in our department have an extended outdoor role with liaison in the community. The children and families are contacted regularly to ensure compliance and providing support to them as needed.ResultsFrequency of bladder washouts varied considerably from once daily up to four times a day in the first 3 months. Following that the ferquency reduced significantly to once daily to not at all. All chldren used saline for the washouts. Washout dwell time was less than 5 mins in 17 and 5-10 mins in 2. 7 children used acetylcysteine in the 1st six weeks postoperatively. 13 children were taking prophylactic antibiotics. The incidence of bladder stone formation to date is zero. The incidence of symptomtic urine infection was less than 1 episode in a 6 month period in these children.ConclusionsAdhering strictly to postoperative bladder washout regimes indicates that NO children in this study have any evidence of bladder stone formation and the incidence of symptomatic urine infections was significantly reduced. The services of a clinical nurse specialist with outdoor liaison duties is invaluable for the provision of such excellent standards of clinical care and outcomes and also in achieving good compliance from the children after major bladder reconstruction.     

Long-term fate of the bladder after isolated bladder neck procedure

ObjectiveRecent and historical studies suggest that bladder neck procedures (BNPs) without augmentation are safe and effective. In select patients we have performed BNPs without concomitant augmentation. We sought to determine long-term outcomes of this approach and attempt to identify risk factors for bladder deterioration.Patients and methodsA retrospective chart review was conducted to identify patients who underwent a BNP without bladder augmentation and followed for at least 4 years. BNPs were only performed in patients with favorable preoperative urodynamics (UDS). The charts were analyzed for long-term outcomes with the primary endpoint of bladder augmentation.ResultsTwenty-nine patients (21 females) with poor bladder outlet resistance underwent a BNP without augmentation (mean follow-up 8 years). Thirteen patients (45%) were augmented at an average of 2.6 years. No predictive UDS parameters were identified; however, exploratory analysis suggested detrusor pressure at 100 mL bladder volume prior to BNP (p = 0.009) was predictive of delayed augmentation.ConclusionWe report a 45% augmentation rate after isolated BNP in patients with favorable preoperative UDS parameters. We recommend close observation of this patient population with serial UDS, routine ultrasounds, and appropriate preoperative counseling prior to undertaking this approach, as this represents a life-long risk to the upper tracts.     

Urologic complications of major genitourinary reconstruction in the exstrophy–epispadias complex

ObjectiveTo present the authors' experiences with urologic complications associated with various techniques used to create a continent stoma (CS), augmentation cystoplasty (AC), and neobladder in the exstrophy–epispadias complex (EEC) population.MethodsRetrospective review of medical records of patients who underwent CS with or without bladder augmentation were identified from an institutional review board-approved database of 1208 EEC patients. Surgical indications, tissue type, length of hospital stay, age, preoperative bladder capacity, prior genitourinary surgeries, postoperative urological complications, and continence status were reviewed.ResultsAmong the EEC patients reviewed, 133 underwent CS (80 male, 53 female). Mean follow-up time after initial continent stoma was 5.31 years (range: 6 months to 20 years). Appendix and tapered ileum were the primary bowel segments used for the continent channel and stoma in the EEC population. The most common stomal complications in this population were stenosis, incontinence, and prolapse. Seventy-nine percent of EEC CS patients underwent AC primarily done with sigmoid colon or ileum. Eleven patients (8%) underwent neobladder creation with either colon or a combination of colon and ileum. Bladder calculi, vesicocutaneous fistula, and pyelonephritis were the most common non-stomal complications. Stomal ischemia was significantly increased in Monti ileovesicostomy compared to Mitrofanoff appendicovesicostomy in classic bladder exstrophy patients (p = 0.036). Furthermore, pyelonephritis was more than twice as likely in colonic neobladder than all other reservoir tissue types in the same cohort (OR = 2.53, 95% CI: 1.762–3.301, p < 0.001).ConclusionsTo the best of the authors' knowledge, this is the largest study examining catheterizable stomas in the exstrophy population. While Mitrofanoff appendicovesicostomy is preferred to Monti ileovesicostomy because it is technically less challenging, it may also confer a lower rate of stomal ischemia. Furthermore, even though ileum or colon can be used in AC with equally low complication rates, practitioners must be wary of potential urologic complications that should be primarily managed by an experienced reconstructive surgeon.     

Botulinum toxin-A (Botox®) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: A systematic literature review

ObjectivesDescribe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).MethodsA MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis.ResultsA total of six articles evaluating the efficacy and safety of Botox^® in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10–12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65–87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H₂O and compliance was increased >20 ml/cm H₂O) variables, without major adverse events.ConclusionsBotox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.