Tubularized Bladder Flap as a Continent Catheterizable Channel in Adults.

OBJECTIVE: To describe a modified, less invasive, surgical technique to create a continent catheterizable channel (CCC) in adults: the tubularized bladder flap (TBF). MATERIALS AND METHODS: We retrospectively reviewed records of patients in whom a TBF CCC was constructed at adult age between 2019 and 2023. We reported on demographics, operative outcomes, and 30-day and post-30-day complications. RESULTS: A total of 11 patients (10 female) were described. The median operative time was 96 (range 90-115) minutes in patients with only TBF creation. Estimated blood loss was <100 cc in all patients. Within 30 days postoperatively, 6/11 (55%) patients developed a complication, all grade 1 Clavien Dindo. No bowel complications occurred (paralytic ileus, mechanical obstruction, or leakage/perforation). Median follow-up was 25 (range 6-56) months. In 2/11 (18%) patients surgical revision for stenosis was done; 3/11 (27%) patients underwent surgical revision for stomal leakage. CONCLUSION: TBF as a means to create a CCC avoids intraperitoneal surgery, and bowel closure (appendicovesicostomy) or anastomosis (retubularized ileum). Postoperative bowel complications were not seen in any of our patients. Surgical revision rates for a TBF CCC appear to be comparable to other CCCs. Therefore, TBF could be considered in patients with sufficient bladder capacity as TBF is less invasive than other CCC techniques and avoids potential bowel complications.

Continent catheterizable urinary channels: Lessons for lifelong urological care from a comparative analysis of very long-term complications and revision-free survival of three different types.

INTRODUCTION: Continent catheterizable channels (CCC) provide an alternative route to the bladder in both pediatric and adult patients. This study compared very long-term complications and revision-free survival of three different CCC techniques: appendicovesicostomy (AVS), ileum (Monti), and tubularized bladder flap (TBF). MATERIALS AND METHODS: A retrospective cohort study was performed. Data from adult patients with CCC under surveillance at our academic tertiary referral urological center in 2020 and 2021 were collected. Both patients who acquired the CCC as a child and as an adult were included. The primary outcome was revision-free survival of the three CCC types. The secondary outcome was the prevalence of complications requiring surgical revision. Revisions were categorized as major (open subfascial or complete revisions) and minor (open suprafascial or endoscopic). RESULTS: We included 173 CCCs (AVS 90, Monti 51, TBF 32). Median follow-up was 12.4 years (4.8-18). Mean revision-free survival was 162 ± 13 months, with no significant difference between the three types. Ninety-two individual CCCs (53%) required surgical revision and a total of 157 surgical revisions were performed. Seventy CCCs (40%) required major surgical revision: AVS (27/90%-30%), Monti (31/51%-61%), TBF (12/32%-38%). CONCLUSION: Complications of CCCs are common; in this study with very long-term follow-up, more than half of CCCs required surgical revision. Revisions were more common in Monti channels compared with AVS and TBF. The mean revision-free survival of >13 years illustrates the sustained long-term durability of CCCs which is important in the lifelong urological care of this population with high life expectancy.

Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists' experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice. METHODS: A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used. RESULTS: Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention. CONCLUSION: The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. MATERIALS AND METHODS: This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. RESULTS: A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. CONCLUSIONS: AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

A Retrospective Analysis of Female Müllerian Duct Anomalies in Association With Congenital Renal Abnormalities.

STUDY OBJECTIVE: Müllerian (paramesonephric) duct anomalies (MDAs) are associated with several coexisting congenital abnormalities, including renal abnormalities. Although congenital renal abnormalities may remain asymptomatic, the consequences should not be underestimated. In both the literature and clinical practice, it remains necessary to improve awareness of the co-occurrence of different congenital renal abnormalities in women with MDAs. To gain further insight into this co-occurrence and to estimate whether guidelines for women with MDAs should be optimized, this study was performed. DESIGN: A descriptive retrospective analysis. SETTING: University Medical Centre Utrecht in the Netherlands. PARTICIPANTS: Women with MDAs diagnosed or treated between 1980 and 2015. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The prevalence of the co-occurrence of congenital renal abnormalities in women with MDAs. RESULTS: Renal status was recorded in 186 of 255 women (72.9%), and the other women (27.1%) did not have a retrievable renal status. Congenital renal abnormalities were present in 90 of 186 women (48.4%) and were observed most frequently in women having a duplex uterus with obstructed hemivagina. The most common renal abnormality was unilateral renal agenesis, which was observed in 58 of 90 women (64.4%). CONCLUSIONS: MDAs are highly associated with different congenital renal abnormalities, and these results emphasize that women with MDAs should be routinely screened for their co-occurrence. However, these results also highlight that there remains a lack of awareness of this association. Whether all women with congenital renal abnormalities should be routinely screened for MDAs requires further investigation.

[A chancre instead of cancer]. / Geen kanker, maar een sjanker.

BACKGROUND: Syphilis (lues) is a sexually transmitted infection caused by the spirochete Treponema pallidum. In adolescents, the diagnosis of primary syphilis can be made promptly by taking a sexual medical history and inspecting the glans penis. CASE DESCRIPTION: A 17-year-old male was referred to the paediatric oncology centre for additional diagnostics due to inguinal lymphadenopathy, with a strong suspicion of a malignant lymphoma. None of the physicians took a sexual medical history or investigated the glans penis, as a result of which essential information was lacking. The combination of inguinal lymphadenopathy and the ultrasound findings for the inguinal region made the physicians only consider a malignancy. However, it actually concerned a reactive lymphadenopathy associated with primary syphilis. CONCLUSION: This case demonstrates that a full medical history and thorough physical examination can prevent the need for costly and invasive diagnostics.

Mono, bi- and tri-exponential diffusion MRI modelling for renal solid masses and comparison with histopathological findings.

PURPOSE: To compare diffusion tensor imaging (DTI), intravoxel incoherent motion (IVIM), and tri-exponential models of the diffusion magnetic resonance imaging (MRI) signal for the characterization of renal lesions in relationship to histopathological findings. METHODS: Sixteen patients planned to undergo nephrectomy for kidney tumour were scanned before surgery at 3 T magnetic resonance imaging (MRI), with T2-weighted imaging, DTI and diffusion weighted imaging (DWI) using ten b-values. DTI parameters (mean diffusivity [MD] and fractional anisotropy [FA]) were obtained by iterative weighted linear least squared fitting of the DTI data and bi-, and tri-exponential fit parameters (Dbi, fstar,and Dtri, ffast,finterm) using a nonlinear fit of the multiple b-value DWI data. Average parameters were calculated for regions of interest, selecting the lesions and healthy kidney tissue. Tumour type and specificities were determined after surgery by histological examination. Mean parameter values of healthy tissue and solid lesions were compared using a Wilcoxon-signed ranked test and MANOVA. RESULTS: Thirteen solid lesions (nine clear cell carcinomas, two papillary renal cell carcinoma, one haemangioma and one oncocytoma) and four cysts were included. The mean MD of solid lesions are significantly (p < 0.05) lower than healthy cortex and medulla, (1.94 ± 0.32*10- 3 mm2/s versus 2.16 ± 0.12*10- 3 mm2/s and 2.21 ± 0.14*10- 3 mm2/s, respectively) whereas ffast is significantly higher (7.30 ± 3.29% versus 4.14 ± 1.92% and 4.57 ± 1.74%) and finterm is significantly lower (18.7 ± 5.02% versus 28.8 ± 5.09% and 26.4 ± 6.65%). Diffusion coefficients were high (≥2.0*10- 3 mm2/s for MD, 1.90*10- 3 mm2/s for Dbi and 1.6*10- 3 mm2/s for Dtri) in cc-RCCs with cystic structures and/or haemorrhaging and low (≤1.80*10- 3 mm2/s for MD, 1.40*10- 3 mm2/s for Dbi and 1.05*10- 3 mm2/s for Dtri) in tumours with necrosis or sarcomatoid differentiation. CONCLUSION: Parameters derived from a two- or three-component fit of the diffusion signal are sensitive to histopathological features of kidney lesions.

Techniques Used to Create Continent Catheterizable Channels: A Comparison of Long-term Results in Children.

OBJECTIVE: To compare long-term results of 3 different techniques used to create continent catheterizable channels (CCCs) in children in a single institution. PATIENTS AND METHODS: Data were retrospectively collected from 112 children who had a CCC (appendicovesicostomy [APV], tubularized bladder flap [TBF] or Monti) created between December 1995 and December 2013. Primary outcome was revision-free survival. Secondary outcomes were channel stenosis, incontinence, and false channel requiring revision. Time-to-event survival was analyzed using a Kaplan-Meier survival curve. RESULTS: A total of 117 CCCs were identified with median follow-up of 85 months. Surgical revision was required in 52%, with no significant difference between the different techniques. Major revision was required in 27% of the cases and significantly more often in Monti channels. Complete revision was required in 7%. Stenosis requiring revision was seen in 33%. A false channel was formed in 9% of the cases. Incontinence with a low leak point pressure was seen in 12%. A time-to-event analysis with a Kaplan-Meier curve showed no significant differences between the 3 techniques. CONCLUSION: Although CCC is an effective solution for children who cannot perform urethral catheterization, 52% requires surgical revision. Because no differences were found in outcome between APV, TBF, and Monti, we conclude that a TBF CCC is a good alternative for the APV. If the appendix is not available and bladder volume is sufficient, a TBF channel is preferred to a Monti channel.

Intravoxel incoherent motion modeling in the kidneys: Comparison of mono-, bi-, and triexponential fit.

PURPOSE: To evaluate if a three-component model correctly describes the diffusion signal in the kidney and whether it can provide complementary anatomical or physiological information about the underlying tissue. MATERIALS AND METHODS: Ten healthy volunteers were examined at 3T, with T2 -weighted imaging, diffusion tensor imaging (DTI), and intravoxel incoherent motion (IVIM). Diffusion tensor parameters (mean diffusivity [MD] and fractional anisotropy [FA]) were obtained by iterative weighted linear least squares fitting of the DTI data and mono-, bi-, and triexponential fit parameters (D1 , D2 , D3 , ffast2 , ffast3 , and finterm ) using a nonlinear fit of the IVIM data. Average parameters were calculated for three regions of interest (ROIs) (cortex, medulla, and rest) and from fiber tractography. Goodness of fit was assessed with adjusted R2 ( Radj2) and the Shapiro-Wilk test was used to test residuals for normality. Maps of diffusion parameters were also visually compared. RESULTS: Fitting the diffusion signal was feasible for all models. The three-component model was best able to describe fast signal decay at low b values (b < 50), which was most apparent in Radj2 of the ROI containing high diffusion signals (ROIrest ), which was 0.42 ± 0.14, 0.61 ± 0.11, 0.77 ± 0.09, and 0.81 ± 0.08 for DTI, one-, two-, and three-component models, respectively, and in visual comparison of the fitted and measured S0 . None of the models showed significant differences (P > 0.05) between the diffusion constant of the medulla and cortex, whereas the ffast component of the two and three-component models were significantly different (P < 0.001). CONCLUSION: Triexponential fitting is feasible for the diffusion signal in the kidney, and provides additional information. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 1 J. MAGN. RESON. IMAGING 2017;46:228-239.

In Vitro Evaluation of Spider Silk Meshes as a Potential Biomaterial for Bladder Reconstruction.

Reconstruction of the bladder by means of both natural and synthetic materials remains a challenge due to severe adverse effects such as mechanical failure. Here we investigate the application of spider major ampullate gland-derived dragline silk from the Nephila edulis spider, a natural biomaterial with outstanding mechanical properties and a slow degradation rate, as a potential scaffold for bladder reconstruction by studying the cellular response of primary bladder cells to this biomaterial. We demonstrate that spider silk without any additional biological coating supports adhesion and growth of primary human urothelial cells (HUCs), which are multipotent bladder cells able to differentiate into the various epithelial layers of the bladder. HUCs cultured on spider silk did not show significant changes in the expression of various epithelial-to-mesenchymal transition and fibrosis associated genes, and demonstrated only slight reduction in the expression of adhesion and cellular differentiation genes. Furthermore, flow cytometric analysis showed that most of the silk-exposed HUCs maintain an undifferentiated immunophenotype. These results demonstrate that spider silk from the Nephila edulis spider supports adhesion, survival and growth of HUCs without significantly altering their cellular properties making this type of material a suitable candidate for being tested in pre-clinical models for bladder reconstruction.

Diffusion tensor imaging of the auditory nerve in patients with long-term single-sided deafness.

A cochlear implant (CI) can restore hearing in patients with profound sensorineural hearing loss by direct electrical stimulation of the auditory nerve. Therefore, the viability of the auditory nerve is vitally important in successful hearing recovery. However, the nerve typically degenerates following cochlear hair cell loss, and the amount of degeneration may considerably differ between the two ears, also in patients with bilateral deafness. A measure that reflects the nerve's condition would help to assess the best of both nerves and decide accordingly which ear should be implanted for optimal benefit from a CI. Diffusion tensor MRI (DTI) may provide such a measure, by allowing noninvasive investigations of the nerve's microstructure. In this pilot study, we show the first use of DTI to image the auditory nerve in five normal-hearing subjects and five patients with long-term profound single-sided sensorineural hearing loss. A specialized acquisition protocol was designed for a 3 T MRI scanner to image the small nerve bundle. The nerve was reconstructed using fiber tractography and DTI metrics - which reflect the nerve's microstructural properties - were computed per tract. Comparing DTI metrics from the deaf-sided with the healthy-sided nerves in patients showed no significant differences. There was a small but significant reduction in fractional anisotropy in both auditory nerves in patients compared with normal-hearing controls. These results are the first evidence of possible changes in the microstructure of the bilateral auditory nerves as a result of single-sided deafness. Our results also indicate that it is too early to assess the degenerative status of the auditory nerve of a subject-specific basis.

Diagnostic accuracy of Tc-99m DMSA scintigraphy and renal ultrasonography for detecting renal scarring and relative function in patients with spinal dysraphism.

AIMS: To study additional benefits of performing Tc-99m dimercaptosuccinic acid (Tc-99m-DMSA) scintigraphy as part of the follow-up of adults with spinal dysraphism (SD), compared with ultrasonography, with regard to finding renal scarring and difference in split renal function. METHODS: Between January 2011 and April 2013 every patient visiting our specialized outpatient clinic for adults with SD was invited to undergo both renal ultrasonography and Tc-99m-DMSA scintigraphy. Outcomes of both modalities were compared, with focus on renal scarring. The relation between renal scarring and hypertension was also assessed. RESULTS: In total, 122 patients (with 242 renal units) underwent both renal scintigraphy and ultrasonography. More scars were seen on DMSA scintigraphy than on ultrasonography: 45.9% vs. 10.3% of renal units; P < 0.001. Renal scarring seen on DMSA was associated with the presence of hypertension (P = 0.049) whereas scarring seen on ultrasonography was not (P = 0.10). If ultrasonography was difficult to interpret, many more scars were missed on ultrasonography (78.9%) compared with easily interpretable ultrasonographic images (30.6%; P < 0.001). CONCLUSIONS: In adults with SD, ultrasonography is of value to diagnose dilatation and stones of the upper urinary tract; however, compared with DMSA renography, renal scars are often missed, especially when the ultrasound is difficult to interpret.

Laparoscopic burch colposuspension in children: technical challenges and primary results.

OBJECTIVE: To present the primary results of laparoscopic, Burch-type colposuspension (LBC) in children. PATIENTS AND METHODS: LBC was performed in eight children (mean age, 14 years) with urinary incontinence after failed extensive urotherapy program. In all patients, bladder neck (BN) incompetence was proven by clinical observation, perineal ultrasound (US), and video-urodynamic study (V-UDS). The LBC was performed with patients in the lithotomy position by means of three 5-mm ports. The anterior wall of the vagina, lateral to the BN, was mobilized, and the vaginal wall was bilaterally lifted and sutured to Cooper's ligament, resulting in elevation and fixation of the BN. A catheter was left for 4 days. The mean operation time was 101 minutes (range, 56-150 minutes), and the follow-up time was >6 months. RESULTS: The postoperative period was uneventful for all patients. Shortly after the procedure, 5 patients (62.5%) were dry, and 1 patient improved (12.5%). After 6 months, 3 patients (37.5%) were dry, and 2 (25%) improved. In 3 wet patients, control US and V-UDS focused on the BN revealed hypermobility and persistent flat vesicourethral angle (VUA) in 1 patient, hypermobility with a good restoration of the VUA in 1 patient, and good fixation with good restoration of the VUA in 1 patient. CONCLUSIONS: LBC is a challenging procedure in children because of the small operation field. This procedure can be considered to cure refractory stress urinary incontinence in children with BN insufficiency when noninvasive methods have failed.

Diffusion tensor magnetic resonance imaging and fiber tractography of the sacral plexus in children with spina bifida.

PURPOSE: It is still largely unknown how neural tube defects in spina bifida affect the nerves at the level of the sacral plexus. Visualizing the sacral plexus in 3 dimensions could improve our anatomical understanding of neurological problems in patients with spina bifida. We investigated anatomical and microstructural properties of the sacral plexus of patients with spina bifida using diffusion tensor imaging and fiber tractography. MATERIALS AND METHODS: Ten patients 8 to 16 years old with spina bifida underwent diffusion tensor imaging on a 3 Tesla magnetic resonance imaging system. Anatomical 3-dimensional reconstructions were obtained of the sacral plexus of the 10 patients. Fiber tractography was performed with a diffusion magnetic resonance imaging toolbox to determine fractional anisotropy, and mean, axial and radial diffusivity in the sacral plexus of the patients. Results were compared to 10 healthy controls. RESULTS: Nerves of patients with spina bifida showed asymmetry and disorganization to a large extent compared to those of healthy controls. Especially at the myelomeningocele level it was difficult to find a connection with the cauda equina. Mean, axial and radial diffusivity values at S1-S3 were significantly lower in patients. CONCLUSIONS: To our knowledge this 3 Tesla magnetic resonance imaging study showed for the first time sacral plexus asymmetry and disorganization in 10 patients with spina bifida using diffusion tensor imaging and fiber tractography. The observed difference in diffusion values indicates that these methods may be used to identify nerve abnormalities. We expect that this technique could provide a valuable contribution to better analysis and understanding of the problems of patients with spina bifida in the future.

Cross-sectional study of determinants of upper and lower urinary tract outcomes in adults with spinal dysraphism--new recommendations for urodynamic followup guidelines?

PURPOSE: Although annual urodynamic study is currently recommended for all adults with spinal dysraphism, this followup might be overly intensive. Therefore, in this cross-sectional study we examine which determinants of upper and lower urinary tract outcomes are associated with relevant urodynamic findings. MATERIALS AND METHODS: All patients visiting our specialized outpatient clinic for adults with spinal dysraphism during a 26-month period underwent evaluation of the lower urinary tract by (video)urodynamic study. High end filling pressure (40 cm H2O or greater), poor compliance (less than 10 ml/cm H2O) and high detrusor leak point pressure (40 cm H2O or greater) were classified as relevant findings and together called unsafe bladder. Multivariable analysis was performed to reveal determinants of unsafe bladder (type of spinal dysraphism, being wheelchair bound, hydrocephalus, urological symptoms and renal dilatation) and diagnostic accuracy was calculated for the significant determinants. RESULTS: Of the 134 patients evaluated (median age 31.5 years) 120 underwent complete urodynamic study and were included in this study. In the multivariable model unsafe bladder was significantly associated with being wheelchair bound (OR 5.36, p=0.008). In patients without symptoms who were not wheelchair bound the negative predictive value of urodynamic study for finding an unsafe bladder was high (1.00). CONCLUSIONS: If an adult patient with spinal dysraphism is not wheelchair bound, unfavorable findings at urodynamic study are unlikely. If these patients are asymptomatic, these findings are even more unlikely. In these patients it is probably not necessary to perform urodynamic study as frequently as is currently recommended. Patients with an unsafe bladder need active surveillance and treatment when upper tract safety is threatened.

Spinal cord transection before scoliosis correction in myelomeningocele may improve bladder function.

AIMS: In patients with myelomeningocele (MMC) and coexistent scoliosis, a spinal cord transection (SC-transection) is sometimes performed before scoliosis correction to prevent traction on the myelum after stretching the spinal column. Performing a SC-transection may have positive effects on bladder function, especially in case of refractory detrusor-sphincter dyssynergia. This study investigates the effects of SC-transection on lower and upper urinary tract outcomes. METHODS: All children with MMC who underwent scoliosis correction (1989-2009) were retrospectively reviewed. Cases were defined as those who underwent a SC-transection before scoliosis correction, whereas the control group comprised children who had a scoliosis correction alone. Urodynamic and clinical outcomes were examined. RESULTS: A total of 7 cases and 13 controls were identified. Postoperatively, compared to the control group, cases had relatively more often improvement of compliance (improvement in 6/7 vs. 9/13) and bladder capacity (improvement in 6/7 vs. 8/13). No effect of SC-transection was found on incontinence severity, clean intermittent catheterization frequency, use of antimuscarinic drugs, or signs of renal damage on ultrasound. CONCLUSIONS: SC-transection before scoliosis correction in children with MMC without lower extremity function, may improve bladder function with respect to bladder compliance and bladder capacity. Changes in symptoms or renal ultrasound were not found. No harmful effects of SC-transection were found, indicating that this procedure can be performed safely with respect to bladder function in these patients. Whether or not SC-transection should be recommended during scoliosis correction in patients with MMC to improve bladder function requires further study.

Vesicoscopic bladder neck procedure in children: what we have learned from the first series.

OBJECTIVE: To assess the results of endoscopic bladder neck procedure on the anterior bladder wall in children. MATERIALS AND METHODS: Surgery is done in the lithotomy position using three 5-mm ports. The bladder is insufflated with CO2. A U-shaped incision is made around the bladder neck. A mucosal strip is tabularized around a 12 French catheter and covered with the second layer of mucosa. Twenty procedures were performed on 18 patients (mean age, 9.8 years), and the follow-up period was >1 year (mean, 34 months). Mean operation time was 149 minutes. Twelve patients had neurogenic lower urinary tract dysfunction. Fifteen patients failed earlier bladder neck surgery, predominantly fascia sling suspension. Preoperatively, all patients had low detrusor leak point pressure. Clean intermittent catheterization (CIC) was resumed through the urethra in 11 patients and through a stoma in 6 patients. RESULTS: Two patients needed conversion because of CO2 leakage. Six patients were dry, and 4 improved in the short term (3-6 months). After 1 year of follow-up, 2 patients were dry, and 6 improved. In the long term, 1 (9%) out of 11 patients who were catheterized through the urethra was dry, and 3 of the 11 patients (27%) improved. Of the 6 patients with a CIC stoma, 1 (17%) was dry, and 3 (50%) improved. CONCLUSIONS: Endoscopic bladder neck surgery is, for most patients, a minor operation, but the long-term results are disappointing. The construction of a continent channel for CIC can improve the outcome when anterior bladder neck plasty is performed.

Behavioral effects of long-term antimuscarinic use in patients with spinal dysraphism: a case control study.

PURPOSE: We explored possible associations between long-term antimuscarinic use and behavioral problems in children with spinal dysraphism and neurogenic bladder. MATERIALS AND METHODS: Children with open and closed spinal dysraphism were recruited from 2 pediatric hospitals, 1 in Amsterdam and 1 in Utrecht, The Netherlands. At the Amsterdam facility antimuscarinics were prescribed in selected patients with detrusor overactivity. At the Utrecht facility antimuscarinics were prescribed from birth onward in patients with spinal dysraphism beginning in the early 1990s. Parents of study participants were asked to fill out a Child Behavior Checklist. Demographics, data on level and type(s) of lesion, and presence of hydrocephalus with a drain (and, if applicable, number of drain revisions) were retrieved for each patient. Cases and controls (8 boys and 8 girls per group) were matched on a 1-to-1 basis. RESULTS: Data on 32 children were analyzed. Median age was 10.6 years in cases and 10.5 years in controls (p=0.877). In each group 9 of 16 patients had hydrocephalus with a drain. No significant difference in Child Behavior Checklist scores for total problems was found between cases and controls (median 52.0 vs 59.5, p=0.39). No differences were found between the groups on any subdomain of the Child Behavior Checklist. CONCLUSIONS: No significant differences in behavior were found between children with spinal dysraphism with and without long-term use of antimuscarinics.