The Need for Augmentation after Bladder Exstrophy Closure

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1 Annals of Pediatric Surgery Vol 5, No 2, April 2009, PP Original Article The Need for Augmentation after Bladder Exstrophy Closure Mohammed Abdel-Latif Ayad, Ehab El-Shafei, Hatem Abdel-Kader, Hesham Mohammed Abdel- Kader Pediatric Surgery Unit, Department of Surgery, Ain Shams University, Cairo, Egypt Purpose: Surgical procedures for continence in patients with exstrophy epispadias complex is challenging for the surgeon, patient, and family. Final outcome depends on the balance between the urine storage and the ability of complete bladder emptying with preservation of the upper urinary tract.the aim of this study was to assess the results of continence after Young-Dees-Leadbetter bladder neck reconstruction in patients with repaired bladder exstrophy and the need for augmentation based on pre-reconstruction bladder volume. Materials & Methods: Seventeen children with urinary incontinence secondary to bladder exstrophy wre treated in the Pediatric Surgery department (Ain Shams University Hospitals), during the period from June 2004 to June 2008,. Primary bladder closure was performed mainly in the neonatal period. All of them had their bladder capacity evaluated carefully under general anesthesia during the same session of bladder neck reconstruction, and augmentation cystoplasty was decided according to this assessment. Young-Dees-Leadbetter technique was used to reconstruct the bladder neck. Continence is assessed as good, acceptable, and poor according to the period of dry intervals and post voiding residual volume. Results: We have followed-up the 17 patients, 12 (70.5%) males and 5 (29.4%) females with their age ranging from 5 to 14 (mean 9) years, for a period ranging from 8 to 40 (mean 20.6) months. Patients were classified into 3 groups according to their pre-reconstruction bladder capacity (group A 50ml, group B >50ml but <100ml, and group C 100ml). There were four patients in group A, all of them underwent bladder augmentation in concomitant with bladder neck reconstruction. Two patients had good outcome. Five patients were in group B, two of them gained good outcome after subsequent bladder augmentation. Eight patients were in group C, reconstruction was done without augmentation to all of them. Four patients had good outcome. Conclusion: Urinary continence with preservation of the upper urinary tract is an achievable goal in patients with bladder exstrophy. Pre-reconstruction bladder capacity is important to achieve urinary continence. When bladder capacity is less than 100ml, bladder augmentation with clean intermittent catheterization () is the acceptable alternative. Index Word: bladder exstrophy, bladder neck reconstruction, continence. INTRODUCTION Urinary continence depends on an adequate capacity, low pressure reservoir, and appropriate bladder neck resistance. 1 Surgery for bladder exstrophy patients with severe urinary incontinence remains a formidable challenge. There are many surgical procedures to increase bladder outlet resistance, including injection of bulking agents, bladder neck reconstruction, and artificial urinary sphincters. 2 However, all of these procedures have variable degrees of success with none being successful in all patients. 3 Correspondence to: Abdel-Latif Ayad. MD., 2 Ibrahim Shawky, First district, Nasr City, Cairo, Egypt., Phone: , mlatif@tedata.net.eg.

2 Bladder neck reconstruction, originally designed for achievement of dynamic outlet control of the bladder, often leads to an unbalanced situation, where persistent incontinence, insufficient bladder emptying and high-pressure voiding coexist. 4 The difficulty encountered in this surgery is to find the adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure). Surgery cannot achieve continence (which implies active mechanisms), but only dryness (which implies passive mechanisms). 5 PATIENTS AND METHODS 17Seventeen children with urinary incontinence secondary to bladder exstrophy In wre treated in the Pediatric Surgery department (Ain Shams University Hospitals), during the period from June 2004 to June Primary bladder closure was performed mainly in the neonatal period, with no attempt to reconstruct the bladder neck. All of them had their bladder neck reconstructed, using Young-Dees-Leadbetter technique, during the period of the study, with or without augmentation cystoplasty. Degree of dryness was defined as: Good: dry intervals of at least 4 hours during the day, no more than one voiding event at night, and no post void residual after spontaneous voiding, and preservation of the upper urinary tract. Acceptable: dry intervals of at least 2 hours during the day, variable degrees of stress or nocturnal incontinence, little or no post void residual after spontaneous voiding, and preservation of the upper urinary tract. Poor: persistent UI and/or upper urinary tract affection. Post void residual volume was considered significant if more than 10% of the total bladder capacity. Bladder capacity assessment: cystogram was performed using radio-opaque contrast at a rate of 15ml/minute. After filling, the bladder was drained, and bladder volume was determined after subtracting the expected amount of reflux (grade II, 2cc; grade III, 3cc; grade IV, 4cc; grade V, 5cc per ureter) and adding the volume in the catheter balloon (usually 5 ml). If leakage occurred, the volume in the balloon was increased and capacity was remeasured. Study groups: Patients were assigned to one of three groups: Group A: bladder capacity 50ml, bladder augmentation was combined with bladder neck reconstruction Group B: bladder capacity more than 50ml and less than 100ml but (considered as the grey zone ), had given the chance of bladder neck reconstruction without augmentation but with great concern to detect any upper urinary tract affection early. Group C: bladder capacity 100ml, underwent bladder neck reconstruction without augmentation. Operative Technique: augmentation (Sigmoidocystoplasty) was performed in patients in group A, because their bladder capacities were too small to perform bladder neck reconstruction without augmentation. Patients in group B and group C underwent transtrigonal Cohen ureteral reimplantation, while patients in group A underwent ureteric reimplantation in the taenia coli of the part of the sigmoid colon used for augmentation. Young-Dees-Leadbetter technique for bladder neck reconstruction was used in all cases, with or without the modified sling (wrap) technique. Evaluation and follow-up of these patients included regular clinic visits at varying intervals, physical examination and urinalysis. Radiological evaluation depended mainly on renal and bladder ultrasonographic examination to state any upper urinary tract dilatation back pressure, renal dimensions, post reconstruction bladder capacity and post void residual. Voiding cystourethrograghy and renal scan DTPA or DMSA were requested only when needed. RESULTS We have followed-up 17 patients, 12 (70.5%) males and 5 (29.4%) females with their age ranging from 5 to 14 (mean 9) years, for a period ranging from 8 to 40 (mean 20.6) months. Group A, (Table 1) included 4 male patients (23.5%) ranging in age from 6 to 10 (mean 8) years, all had complicated trials of primary bladder closure in the neonatal period. All of them underwent Annals of Pediatric Surgery 110

3 sigmoidocystoplasty to reach a capacity near their 4 hours urine production according to the preoperative program. Their follow-up period ranged from 9 to 22 (mean 16.25) months. They could void from the urethra with an aid Credé maneuver. Follow up ultrasound revealed significant residual volume in all of them after voiding from the urethra. Initial outcome was acceptable, with 2 hours dry interval during day. Three of them started anticholinergic drugs 12 months postoperative with gradual improvement. Group B, (Table 2) included 5 (29.5%) patients: 3 males and 2 females aged from 5 to 11 (mean 8) years, three of them had successful primary closure (two in the neonatal period and one is delayed). Initial results were poor in 3 patients with no improvement after one year of follow-up, necessitating augmentation in two of them (one with bladder neck closure) and the third had additional medical treatment and refused augmentation (lost to follow up after). Concomitant modified Sling (Wrap) procedure was decided for the other 2 patients in this group. One developed upper urinary tract back pressure changes and suffered an attack of acute urinary retention with failure of urethral catheter insertion, sigmoidocystoplasty and Mitrofanoff procedure were performed with acceptable outcome. The last female patient within this group had acceptable outcome; she developed 4 hours dry interval after 9 months, but she is complaining of stress incontinence that is gradually improving. Group C, (Table 3) included 8 patients (47%): 5 males and 3 females aged from 7 to 14 (mean 10.25) years, all had successful primary closure except one. Their bladder capacity ranged from 100 to127cc (mean: 109.6cc). was good in 4 (50%); three of them are continent from the early postoperative period, while the fourth one required 10 months to achieve good outcome. was acceptable in 2, and poor in 3 with gradual improving by time. Anticholinergic drug therapy was initiated in one patient 12 months postoperative after clinical suspicion of unstable bladder contraction. Table 1. Group A patients No. Sex 1 Male 9 2 Male 10 3 Male 7 4 Male 6 Age (years) Primary Closure (fistula) (part disrup) (comp disrup) (part disrup) osteotomy Bladder Capacity (cc) 50 Associated Procedure Augmentation & Mitrofanoff Initial good Latter Management & Drug Therapy Follow-Up (months) Final 22 good 48 acceptable 19 good 42 acceptable 15 acceptable 39 acceptable 9 acceptable Table 2. Group B patients No. Sex 5 female 8 6 male 6 7 male 11 Age (years) Primary Closure complicated (part disrup) (comp disrupt) osteotomy Delayed osteotomy Bladder Capacity (cc) Associated Procedure Initial poor Latter Management Drug Therapy Aug & Mit Follow-Up (months) Final 35 good poor Drug Therapy 13 poor poor Drug Therapy Aug & Mit Bladder Neck closure 26 good 8 male 5 successful 63 Sling poor Aug & Mit 13 acceptable 9 female 10 successful 92 Sling acceptable acceptable 111 Vol 5, No 2, April 2009

4 Table 3. Group C patients No. Sex Age (years) Primary Closure Bladder Capacity (cc) Associated Procedure Initial Latter Management Follow-Up (months) Final 10 female 8 successful acceptabl e good 11 female 11 complicated (fistula) good good 12 male 13 successful poor acceptable 13 male 10 Delayed (osteotomy) acceptabl e acceptable 14 female 11 successful good good 15 male 14 successful good good 16 male 8 successful poor -- 8 poor 17 male 7 successful poor Drug Therapy 13 poor DISCUSSION Each child with the exstrophy-epispadias complex is unique with regard to bladder capacity, bladder compliance and degree of continence after initial closure or genital reconstruction. 6 The achievement of adequate bladder capacity after initial exstrophy closure is the single most important parameter, which will allow subsequent bladder neck reconstruction. Successful initial closure without wound infection, dehiscence or prolapse achieves an adequate bladder capacity for bladder neck reconstruction more rapidly. 7 This concept is clear in our study as 7 out of 10 patients with successful primary closure had sufficient bladder capacity for bladder neck reconstruction, while only one of 7 patients with complicated primary closure gained adequate bladder capacity for bladder neck reconstruction. Gearhart and coworkers found that only 60% of patients with a failed attempt of bladder closure achieved adequate capacity for bladder neck reconstruction. Of those patients who achieved the desired capacity, only 50% became continent. Results were worse in patients who suffered recurrent failed attempts. 8 The Young-Dees-Leadbetter technique for bladder neck reconstruction, in its current form, is one of the most reliable techniques for attaining continence in these patients. 9 In our study, after a mean follow up of 19.3 months, 8 (47%) patients are dry both day and night with good outcome, while 6 (35%) patients have acceptable outcome. Hollowell and Ransley reported 80% satisfactory urinary continence in 68 patients over 12 years. 10 Merguerian and colleagues found 61% dry in 37 bladder neck reconstructions (BNR) over 30 years. 11 Lottmann and colleagues reported 67% with good or acceptable results at a mean follow-up of 12 years. 12 Yerkes and coworkers reported 27 Young- Dees-Leadbetter reconstructions with a follow-up of >2 years (mean 5.9); dry intervals of 2 hours were achieved in 18 patients and all were considered by their parents to void well. 6 Surer and co-workers reported a satisfactory continence rate in 57 of 68 patients (83%), with urethral voiding, no augmentation and no 7. Mouriquand and coworkers reported 45% urinary continence for >3 hours and 20% dryness both day and night. 5 Merguerian and colleagues determined the factors that are imperative in attaining urinary continence in patients with bladder exstrophy after a staged reconstruction. 11 They are; (i) a bladder capacity of 100 ml; (ii) a functional urethral continence length of >2.0 cm; and (iii) an initial urethral closure pressure of >60 cm H2O. As these criteria do not take into account abnormal bladder dynamics in these patients both before and after bladder neck reconstruction, other important factors are also present. They are; (i) the ability of the bladder to accommodate an adequate volume at a sufficiently low pressure 13 and (ii) the appropriate cooperation by the child to permit both relaxed voiding and the use of the muscles of the pelvic diaphragm to stay continent. 14 Dave and coworkers stated the factors affecting bladder capacity after bladder neck reconstruction are: (i) the age and success of bladder closure, (ii) the urethral Annals of Pediatric Surgery 112

5 closure pressure after bladder neck reconstruction and (iii) the presence of unstable contractions. 15 Gearhart and co-workers reported that bladder capacity with the patient under anaesthesia before bladder neck plasty is the most important single predictor of eventual urinary continence. 16 In the current study, all exstrophied patients had their bladder capacities measured under anaesthesia just before bladder neck reconstruction. It was found that the mean bladder capacity in patients underwent associated or subsequent augmentation was 54.7ml, while in those without augmentation was 107.7ml. The least capacity found in our patients with good outcome and no augmentation was 92ml. This denotes that, while some bladder volume is lost after bladder neck reconstruction, bladders that have larger volumes immediately after bladder neck reconstruction will accommodate more quickly to increasing volumes of urine with time, and reach continent intervals sooner. The affirmative effect of adequate bladder capacity was reflected in a study published by Surer and colleagues. 7 They performed reconstruction without a bowel segment in 61 patients of whom 57 have social urinary continence associated with a mean capacity of 205ml, whereas volumes in patients continent less than one hour were less than 60ml. It is obvious that bladder augmentation is useful only when bladder capacity is significantly decreased. In such cases enterocystoplasty may be needed, which requires through a continent abdominal stoma. Other studies brought the same opinion; their recommendation was to perform urethral reconstruction and enterocystoplasty at the same time to allow catheterization via a continent mechanism. 17 In the current study, anticholinergic therapy was initiated on suspicion of unstable contractions. Their role was great in patients with small and grey zone capacities 5 out of 9 patients. In the optimal group one patient has started anticholinergic therapy and shows improvement, while another one is planned for this therapy. Unstable contractions could be a direct cause of incontinence and responsible for the poor increase in capacity. Unstable contractions may also be the cause of nocturnal wetting. Hollowell and colleagues found that involuntary detrusor contractions are the primary cause of leakage in 9 of 16 underwent BNR without augmentation 10. CONCLUSION Urinary continence can be achieved with socially acceptable dry intervals and preservation of the upper urinary tract in patients with bladder exstrophy. Prereconstruction adequate bladder capacity is an important factor to achieve urinary continence. Initial successful bladder closure is essential to achieve adequate bladder capacity. When bladder capacity is less than 100 ml, bladder augmentation with clean intermittent catheterization is an acceptable alternative. REFERENCES 1. Bugg CE, Joseph DB. Bladder neck cinch for pediatric neurogenic outlet deficiency. J Urol 170: 1501, Nguyen HT, Baskin LS. The outcome of bladder neck closure in children with severe urinary incontinence. J Urol 169: 1114, Kryger JV, González R, Barthold JS. Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence. J Urol 163: 256, Young HH. An operation for incontinence associated with epispadias. J Urol 7(1), Quoted from, Mouriquand PDE, Bubanj T, Feyaerts A, et al: Long term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias. BJU Int 92: 997, Mouriquand PDE, Bubanj T, Feyaerts A, et al. Long term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias. BJU Int 92: 997, Yerkes EB, Adams MC, Rink RC, et al. How Well do patients with exstrophy actually void? J Urol 164: 1044, Surer I, Baker LA, Jeffs RD, et al. Modified Young-Dees- Leadbetter Bladder Neck Reconstruction in Patients with Successful Primary Bladder Closure Elsewhere: A Single Institution Experience. J Urol 165: 2438, Gearhart JP, Ben-Chaim J, Sciortino C, et al. The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder? Urology 47: 240, Chan DY, Jeffs RD, Gearhart JP. Determinants of continence in the bladder exstrophy population: predictors of success? Urology 57: 774, Hollowell JG, Ransley PG. Surgical management of incontinence in bladder exstrophy. BJU 68: 543, Merguerian PA, McLorie GA, McMullin ND, et al. Continence in bladder exstrophy. Determinants of success. J Urol 145: 350, Vol 5, No 2, April 2009

6 12. Lottmann HB, Melin Y, Cendron M, et al. Bladder Exstrophy: Evaluation of factors leading to Continence with Spontaneous Voiding after Staged Reconstruction. J Urol; 158: 1041, Ahmed S, Fouda-Neel K, Borghol M. Continence after bladder neck reconstruction in patients with bladder exstrophy and pubic diastasis. BJU 77: 896, Mathews RI, Gearhart JP. The modern management of bladder exstrophy. Eur Board Urol Update Sep 7: 1, Dave S, Grover VP, Agarwala S, et al. Cystometric evaluation of reconstructed classical bladder exstrophy. BJU Int 88: 403, Gearhart JP, Yang A, Leonard MP, et al. Prostate size and configuration in adults with bladder exstrophy. J Urol 149: 308, Gearhart JP, Jeffs RD. Augmentation cystoplasty in the failed exstrophy reconstruction. J Uro 139: 790, 1988 Annals of Pediatric Surgery 114

Complications after primary bladder exstrophy closure role of pelvic osteotomy

104 original paper PEDIATRIC UROLOGY Complications after primary bladder exstrophy closure role of pelvic Małgorzata Baka Ostrowska 1, Kinga Kowalczyk 1, Karina Felberg 1, Zbigniew Wawer 2 1 Department