Augmentation cystoplasty in the patient with neurogenic bladder.

PURPOSE: To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries. METHODS: PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB. RESULTS: AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel. CONCLUSIONS: Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study.

AIMS: Evidence is sparse on the long-term outcomes of continent cutaneous ileocecocystoplasty (CCIC). We hypothesized that obesity, laparoscopic/robotic approach, and concomitant surgeries would affect morbidity after CCIC and aimed to evaluate the outcomes of CCIC in adults in a multicenter contemporary study. METHODS: We retrospectively reviewed the charts of adult patients from sites in the Neurogenic Bladder Research Group undergoing CCIC (2007-2017) who had at least 6 months of follow-up. We evaluated patient demographics, surgical details, 90-day complications, and follow-up surgeries. the Mann-Whitney U test was used to compare continuous variables and χ² and Fisher's Exact tests were used to compare categorical variables. RESULTS: We included 114 patients with a median age of 41 years. The median postoperative length of stay was 8 days. At 3 months postoperatively, major complications occurred in 18 (15.8%), and 24 patients (21.1%) were readmitted. During a median follow-up of 40 months, 48 patients (42.1%) underwent 80 additional related surgeries. Twenty-three patients (20.2%) underwent at least one channel revision, most often due to obstruction (15, 13.2%) or incontinence (4, 3.5%). Of the channel revisions, 10 (8.8%) were major and 14 (12.3%) were minor. Eleven patients (9.6%) abandoned the catheterizable channel during the follow-up period. Obesity and laparoscopic/robotic surgical approach did not affect outcomes, though concomitant surgery was associated with a higher rate of follow-up surgeries. CONCLUSIONS: In this contemporary multicenter series evaluating CCIC, we found that the short-term major complication rate was low, but many patients require follow-up surgeries, mostly related to the catheterizable channel.

Long-term functional outcomes of augmentation cystoplasty in adult spina bifida patients: A single-center experience in a multidisciplinary team.

AIM: To report the very long-term functional outcomes of augmentation cystoplasty (AC) in adult spina bifida patients. METHODS: All consecutive adult spina bifida patients who underwent AC between 1991 and 2008 were enrolled. Early postoperative complications (Clavien-Dindo classification) and long-term outcomes (voiding modalities, urodynamic parameters, renal function, continence, and quality of life) were assessed. RESULTS: Twenty-eight patients with a median age of 20 years (IQR 17-25) were included. They all underwent AC with a supratrigonal cystectomy (SC). The median follow-up was 13.6 years (IQR 6-16.5). Thirteen early postoperative complications (12 grade I-II, 1 grade III) were observed in 11 patients (39%). Eight patients (29%) had upper urinary tract infections managed with antibiotics, with 2 patients requiring ureteral stents. Bladder stones occurred in 2 patients (7%) and were managed with endoscopy and cystostomy. One bladder perforation was reported. One bladder cancer was observed 26 years after surgery. Creatinine clearance and all urodynamic parameters were significantly improved post-operatively. The overall complication and reoperation rates were 57% and 14%, respectively. At last follow up, the continence rate was 71% (n = 20), with 93% (n = 26) performing intermittent self-catheterization. Quality of life was improved for 71% of patients. CONCLUSION: In adult spina bifida population, AC is a high-risk procedure with an overall complication rate of 57% and a reoperation rate of 14%. However, AC is beneficial to the overall health of the patients since it provides a satisfying continence rate, an improvement of quality of life, and long-term protection of the upper urinary tract.

Bladder Augmentation (Enterocystoplasty): the Current State of a Historic Operation.

PURPOSE OF REVIEW: The goal of this paper was to evaluate the current use of enterocystoplasty, a historical operation for bladder dysfunction but with continued and increasing modern relevance. RECENT FINDINGS: Since the advent of third line neuromodulation techniques for neurogenic and idiopathic overactive bladder (OAB), the usage of enterocystoplasty has decreased. However, this procedure continues to be utilized in pediatric urology patients and the most refractory OAB patients. Adult urologist should be familiar with this operative technique in an effort to manage pediatric patients transitioning to adulthood. Minimally invasive techniques for this surgical procedure have been described with very limited outcome data. It is important for all urologists to be familiar with enterocystoplasty, both technically and with the unique needs of these patients postoperatively. Further studies evaluating the outcomes of this procedure in idiopathic overactive bladder patients and efforts to standardize recommendations for neurogenic bladder patients will help guide care in the future.

[The mechanism and role of autologous peritoneum transplantation to enterocystoplasty in porcine model].

Objective: To explore the pathological mechanism and role of autologous peritoneum transplantation onenterocystoplasty in porcine model. Methods: Randomly, four experimental female swine were chosen, and each of their body weight was 28-33 kg. By intravenous anesthesia, the transplantation of autologous peritoneum for bladder reconstruction operation was carried out (to transplant the peritoneum onto an ileum segment of which the mucosa and submucosa had been removed. These flaps were used to mend and augment the bladder by suturing the edge of detective bladders). After removal of ureteral catheters and balloon catheter at day 5 respectively, their voiding behaviors were monitored, and respectively 2 swine were euthanized at week 3/6 for routine pathology, immunohistochemistry, and electron microscopic examinations. Results: Four swine underwent reconstruction, but none died for complications such as peritonitis, ileus and urinary fistula. The length of ileum was 35 cm, and the area of peritoneum was 15 cm×10 cm. Voiding behaviorsof the swine were normal, with clear urine after removal of their catheters. At autopsy, reconstructed bladders were healthy. Pathological examination showed the neobladder had been covered by continuous urothelium while the peritoneum disappeared without ileal mucosa regrowth or residual. Scanning electron microscope showed that the transitional cells of neobladder of swine were complete and orderly, and urothelium around suture border was continuous withoutmalposition. Conclusions: In porcine model, autologous peritoneal transplantation witnessed no immune rejection response for itself, which was replaced by crawling transitional epithelium around anastomosis, rather than by metaplasia.

A real-world experience with augmentation enterocystoplasty-High patient satisfaction with high complication rates.

AIMS: To investigate the real treatment outcomes after augmentation enterocystoplasty (AE) of patients with refractory neurogenic lower urinary tract dysfunction. METHODS: Retrospective follow-up in a single center. The videourodynamic data, renal function, incontinence grade, voiding pattern and management, clinical outcome, and complications were evaluated. RESULTS: Seventy-nine patients (62 men and 17 women) were included. The mean age at operation was 39.4 ± 11.6 years and the mean follow-up period was 128.4 ± 85.2 months. At follow-up, 5 (6.7%) patients had spontaneous voiding, 60 (80%) had to perform clean intermittent catheterization, and 10 (13.3%) chose to keep the indwelling catheter. The catheter-dependent rate was 93.3% and complete catheter-dependent rate was 76%. Renal function of the patients did not appear to be significantly different after AE. Three patients developed end-stage renal disease. The incontinence grade showed significant improvement (P = 0.000). Among all the patients, 41.8% experienced recurrent urinary tract infections requiring medical treatment and 21.5% suffered from chronic diarrhea. Overall, 45.6% of the patients experienced complications requiring surgical interventions, most of which were stones. Life-threatening complications like bowel obstruction and bladder cancer were also noted. Three patients even expired within one year postoperatively. The majority (86.8%) of patients reported moderate to excellent satisfaction with the outcome of AE. CONCLUSIONS: AE is a procedure with long-term durability and high rates of patient satisfaction. However, several bothersome complications affecting life quality may occur. Both patients and doctors thus need to consider possible outcomes carefully before the operation.

Augmentation cystoplasty: Urodynamic and metabolic outcomes at 10-year follow-up.

OBJECTIVE: To review the urodynamic outcomes, renal function and metabolic complications after augmentation cystoplasty with at least 10 years of follow-up. METHODS: Augmentation cystoplasty performed in two tertiary referral centers from 1995 to 2004 were reviewed. Ten years or more postoperative course was studied by review of the clinical notes, urodynamic reports and laboratory results. RESULTS: A total of 40 patients were included in this study. The mean age at surgery was 43 years, and 47.5% of patients were female. Median follow up was 13 years. Bladder capacity significantly increased from 283 ± 151 to 492 ± 123 mL (P < 0.01), with a percentage change of +130%. The compliance of the bladder was increased by 87%, and detrusor overactivity decreased by 54.2%. There were no significant changes in preoperative and postoperative estimated glomerular filtration rate (68.3 mL/min vs. 76.6 mL/min, P = 0.798). Three patients (7.5%) had more than one episode of symptomatic urinary tract infection per year. CONCLUSION: The present study confirms the effectiveness of augmentation cystoplasty in increasing bladder capacity, improving bladder compliance and reducing detrusor overactivity. The preservation of renal function and low metabolic complication rate provide solid evidence for carrying out this time-honored procedure in patients with neurogenic or non-neurogenic bladder dysfunction.

Long-term results of clam enterocystoplasty in non-neurogenic refractory urge incontinence.

OBJECTIVES: This study aims to assess the efficacy of Clam enterocystoplasty (CECP) surgery for the treatment of non-neurogenic refractory urgency urinary incontinence (UUI). METHODS: We conducted a retrospective evaluation of 17 female patients who underwent CECP for non-neurogenic refractory UUI between May 2010 and November 2022. RESULTS: The median of ICIQ-SF was 19 (15-21) before treatment, which decreased to a median of 0 (0-5) after treatment (p = 0.01). The average preoperative pad use among the participants was 4 (3-6), while it became 0 postoperatively (p < 0.01). The median preoperative cystometric bladder capacity was 251 ml (100-350 ml), increasing to 456 ml (400-650 ml) postoperatively (p < 0.01). According to the Clavien-Dindo classification system, the majority of patients experienced either no complications (66%) or minor complications (CD I/CD II) (33%) within the initial 90 days following surgery. CONCLUSIONS: "Clam" iliocystoplasty emerges as a secure and successful treatment option in the patient group whose symptoms persist after first, second, and third-line treatments with the diagnosis of urge incontinence.

Comparison of quality of life after bladder augmentation in patients previously treated with intradetrusor botulinum toxin A for neurogenic detrusor overactivity.

PURPOSE: To compare the quality of life (QoL) in the same patients first treated with botulinum toxin A (BTA) injections for neurogenic detrusor overactivity (NDO) and then with bladder augmentation (BA). METHOD: Retrospective study of patients who had BA after BTA treatment between January 2012 and December 2022. Qualiveen Short Form questionnaires and a 7-level Likert/PGI-I scale to answer the question "How would you describe your quality of life after surgery compared to when you felt your best with BTA injections?" were collated and analyzed. RESULTS: Fifty-two BAs for neurogenic bladder (NDO or low compliance) were performed in patients with a median age of 43years [33; 52] previously treated with BTA. After a median follow-up of 33.5 [13.8; 54.3] months, the median Qualiveen-SF global score after BA was significantly higher than that obtained at best BTA efficacy (1.63 [1; 2.63] vs. 2.63 [1.88; 3], P=0.012), as were the scores for the fear, constraints/restrictions and limitations/inconvenience domains. The median PGI-I score was +3 [2; 3] (truly better QoL) and 85.4% of patients reported a QoL after BA superior to the best QoL under BTA. CONCLUSION: BA provides a greater range of QoL improvement than BTA injection for patients who have experienced both treatments. Long-lasting effects and absence of need to perform iterative retreatment were the main reasons.

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach.

BACKGROUND: Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed. OBJECTIVE: The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique. METHODS: A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed. RESULTS: A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P = 0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P = 0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P = 0.294, log-rank P = 0.832, and log-rank P = 0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P = 0.236). DISCUSSION: This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal. CONCLUSIONS: Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

False-positive urine pregnancy screening tests are uncommon in the hospital setting among patients with bowel-containing urinary tract reconstruction.

PURPOSE: False-positive urine pregnancy screening tests (UPST) have been reported among patients with bowel-containing urinary reconstruction (BCUR). However, the true frequency of such inaccurate results, which have been attributed to urinary mucous or other proteins interfering with or mimicking the binding of beta-HCG in the assay, is unknown in this population. We sought to determine the incidence of false-positive pregnancy screening tests among this patient population at our institution. MATERIALS AND METHODS: Using existing databases of patients with spina bifida, bladder exstrophy, and genitourinary rhabdomyosarcoma, we identified female patients with BCUR who had UPST over a 10-year period as screening prior to procedures or imaging. Patient and test result information was recorded. RESULTS: A total of 120 patients with a history of BCUR were identified: 33 with spina bifida, 73 within the exstrophy-epispadias complex (EEC), and 14 with genitourinary rhabdomyosarcoma. Of this group, 46 patients (38%) had at least one UPST during the study period; 15 had 1 UPST, 6 had 2 UPSTs, 4 had 3 UPSTs, and 21 had greater than 3 UPSTs, for a total of 244 UPST in this cohort. UPSTs used at our institution included Sure-Vue brand and Alere brand (HCG sensitivity 20 mIU/ml). Types of BCUR included ileal enterocystoplasty in 25 patients, colon enterocystoplasty in 6, stomach enterocystoplasty in 5, composite enterocystoplasty in 7, and continent catheterizable channel alone (e.g. Yang-Monti, appendicovesicostomy) in 3 patients. Of the 244 UPSTs in patients with BCUR, zero (0%) were positive. CONCLUSIONS: Despite reports in the literature that false-positive UPST are common among patients with bowel-containing urinary diversions, we found no positive UPST among patients with BCUR in the healthcare setting. False-positive UPST in the home setting may be due to variability in sensitivity thresholds, binding agents, technical errors in test technique, kit quality control, or other factors.

Additional surgery in patients with bladder augmentation.

INTRODUCTION: Bladder augmentation is an option to protect kidneys and treat incontinence in frequent neurogenic and congenital non-neurogenic disorders. However, patients may need also other procedures to treat incontinence or to aid catheterizations. In addition, the patients are prone to complications. OBJECTIVE: To evaluate complications or additional surgeries in augmentation cystoplasty according to the etiology of the bladder dysfunction. STUDY DESIGN: Data on additional surgical procedures related to bladder augmentation were collected from 128 patients who had undergone enterocystoplasty between 1990 and 2019, with a median age of 10.1 years (IQR 7.2-12.8) and a follow-up time of 11.8 years (IQR 5.7-18.6) after augmentation. RESULTS: Eighty-three patients had a neurogenic disease, and 45 patients had a non-neurogenic disease. Bladder neck operations were performed either at the time of or after augmentation for 62 patients (48.4%), more commonly in the non-neurogenic than neurogenic group <0.01. In addition, continent stoma operations in 56 (36.8%) patients were more common in the non-neurogenic group (p < 0.01). Ten patients received kidney transplantation (four in the neurogenic, six in the non-neurogenic group); seven of these patients originally had dysplastic kidneys, two developed nephrological kidney disease, and one had hydronephrosis and renal insufficiency at the time of diagnosis of neurogenic bladder. Surgical problems resulting from bladder augmentation were treated in 28 patients (21.8%). The risk for surgical treatment because of complications was 4%, 17%, 24%, 27% and 27% at 1, 5, 10, 15 and 20 years follow up respectively. Complications were more common in patients in non-neurogenic than in patients with neurogenic group (p < 0.01). However, the greater proportion of continent stomas in non-neurogenic group explained the difference (Fig.). The most frequent complication requiring surgery during follow-up was bladder stones, which occurred in 24 (18.8%) patients. The first stone was treated at a median of 3.3 years (range 0.3-14.2) after augmentation. Stones were more common in patients with a continent stoma than without (p < 0.01). Other indications for surgical treatment were as follows: obstructive ileus in five patients, reduced bladder capacity in three patients, bladder perforation in two patients and lobulated bladder with infections in one patient. CONCLUSIONS: The risk for surgical treatment was about 27% in 20-year follow-up after bladder augmentation, because of augmentation related complications. The most prevalent complication was bladder stone, that was mainly associated with continent stomas. Continent stomas were most prevalent in patients with non-neurogenic diagnosis.

A robotic approach to clamshell augmentation enterocystoplasty.

Augmentation cystoplasty (AC) is a well-established surgical option for the management of overactive bladder where conservative management has failed. We describe the case of a man in his 50s with chronic bladder dysfunction secondary to refractory detrusor overactivity and small capacity bladder. His lower urinary tract symptoms (LUTS) of urinary frequency and nocturia persisted despite pharmacological therapy and peripheral neural modulation; hence, he underwent surgical intervention for management of his bladder dysfunction. A robot-assisted clamshell enterocystoplasty was performed with a successful outcome. His LUTS have improved significantly post surgery. This case highlights modern advances in minimally invasive and robotic surgical techniques in the management of functional urological conditions. It also further demonstrates that the robotic approach is a viable option for AC, an operation traditionally performed as open surgery.

The concerns of mechanical upper urinary tract obstruction in neurogenic lower urinary tract dysfunction: Beyond augmentation cystoplasty.

Purpose: To evaluate the efficacy of augmentation uretero-enterocystoplasty (AUEC), a modified surgical procedure that focuses the mobilization of the ureter and the necessity of ureteroplasty in a series of neurogenic lower urinary tract dysfunction (NLUTD) patients with mechanical upper urinary tract obstruction (mUUTO). Methods: We retrospectively reviewed the medical records of NLUTD patients who underwent an AUEC from 2005 to 2022. mUUTO was diagnosed by preoperative bladder drainage, magnetic resonance urography (MRU), and isotope renography. Upper urinary tract dilatation (UUTD) was evaluated using MRU with the Liao MRU-UUTD system. Results: A total of 58 patients and 103 ureters were analyzed. Improvement in maximum bladder capacity (from 79.0 [41.3-163.8] to 500.0 [450.0-597.5] ml, P < 0.001), maximum detrusor pressure (from 32.0 [13.0-50.8] to 5.5 [4.0-10.0] cmH2O, P < 0.001) and bladder compliance (from 6.5 [3.0-11.9] to 50.1 [37.5-65.0] ml/cmH2O, P < 0.001), and stabilization of serum creatine (93.4 [73.0-142.7] to 94.9 [72.2-148.7] µmol/L, P = 0.886) were observed. The proportion of high-grade UUTD was significantly reduced after the surgery (92.3% vs. 13.5%, 92.1% to 9.8%, P < 0.001), and the typical imaging signs of preoperative obstruction disappeared. Conclusion: Beyond traditional augmentation cystoplasty, more attention should be paid to the relief of mUUTO and mobilization of the ureter in NLUTD patients.

Augmentation Uretero-enterocystoplasty Is an Effective Procedure in Protecting the Upper Urinary Tract Without Accelerating Deterioration of Renal Function.

Background: Augmentation uretero-enterocystoplasty (AUEC) provides a low-pressure urinary storage capsule that can preserve renal function in patients with lower urinary tract dysfunction for whom conservative treatments have failed. Objective: To summarize the effectiveness and safety of augmentation uretero-enterocystoplasty (AUEC) and evaluate whether it aggravates renal function deterioration in patients with renal insufficiency. Design setting and participants: This was a retrospective cohort study of patients who underwent AUEC from 2006 to 2021. Patients were grouped according to whether they had normal renal function (NRF) or renal dysfunction (serum creatinine >1.5 mg/dl). Outcome measurements and statistical analysis: Follow-up of upper and lower urinary tract function was assessed via review of clinical records, urodynamic data, and laboratory results. Results and limitations: We included 156 patients in the NRF group and 68 in the renal dysfunction group. We confirmed that urodynamic parameters and upper urinary tract dilation were significantly improved for patients after AUEC. Serum creatinine declined during the first 10 mo in both groups and remained stable thereafter. The reduction in serum creatine was significantly greater in the renal dysfunction group than in the NRF group in the first 10 mo (difference in reduction 4.19 units; p < 0.05). A multivariable regression model showed that baseline renal dysfunction was not a significant risk factor for deterioration of renal function in patients who had undergone AUEC (odds ratio 2.15; p = 0.11). The main limitations are selection bias because of the retrospective design, loss to follow-up, and missing data. Conclusions: AUEC is a safe and effective procedure to protect the upper urinary tract and will not hasten deterioration of renal function in patients with lower urinary tract dysfunction. In addition, AUEC improved and stabilized residual renal function in patients with renal insufficiency, which is important in preparation for renal transplantation. Patient summary: Bladder dysfunction is usually treated with medication or Botox injections. If these treatments fail, surgery to increase the bladder size using a portion of the patient's intestine is a possible option. Our study shows that this procedure was safe and feasible and improved bladder function. It did not lead to a further decrease in function in patients who already had impaired kidney function.

The Comparative Effectiveness of Botulinum Toxin-A Injection Therapy Versus Augmentation Uretero-Enterocystoplasty for the Treatment of Lower Urinary Tract Dysfunction.

PURPOSE: We investigated the effectiveness of intravesical botulinum toxin-A (BTX-A) injection therapy in patients with lower urinary tract dysfunction (LUTD) and upper urinary tract (UUT) deterioration and evaluated whether BTX-A injection therapy could substitute for augmentation uretero-enterocystoplasty (AUEC). METHODS: Data from a prospective, single-center cohort from 2017-2021 were analyzed. Patients were divided into 2 treatment groups: AUEC and BTX-A (i.e., patients who declined AUEC). Bladder and UUT functions were assessed by comparing clinical information, urodynamic data, laboratory results, and imaging records. RESULTS: In total, 121 patients were enrolled (BTX-A group: 41 patients; AUEC group: 80 patients). The BTX-A group showed a reduced maximum detrusor pressure and increases in the maximum bladder volume and bladder compliance (P<0.05). However, in follow-up evaluations, significantly smaller improvements (all P<0.05) in urodynamic parameters were found in the BTX-A group than in the AUEC group. Notably, there was no significant improvement in vesicoureteral reflux (VUR; P=0.66) or upper urinary tract dilatation (UUTD; P=0.75) in the BTX-A group, and no statistically significant difference in serum creatinine (Scr) levels or the estimated glomerular filtration rate (eGFR) was observed in the follow-up evaluations (all P>0.05). Both VUR and UUTD improved significantly in the AUEC group, and the Scr and eGFR levels significantly improved after AUEC relative to baseline levels (P<0.05). The reduction in the Scr level was significantly lower in the BTX-A group than in the AUEC group during 0-15 months of follow-up (Scr reduction differences, -1.36; P<0.01). CONCLUSION: Although BTX-A injection therapy was effective for improving bladder function, BTX-A injections did not alleviate UUT deterioration in this study, particularly in patients with advanced-stage LUTD. Conversely, AUEC for LUTD has a well-established role in improving UUT function. Hence, BTX-A injection therapy should not replace AUEC to ameliorate UUT impairment and protect UUT function.

What makes the bladder neck sling procedure a success in a selected population of children and adolescents? A STROBE-compliant investigation.

INTRODUCTION: Achievement of continence in children suffering from neurogenic bladder dysfunction or severe urogenital malformation is of fundamental importance to the wellbeing of affected children and their families. A valid approach to treating incontinence with hypoactive sphincter is the placement of a bladder neck sling thus increasing outlet resistance of the bladder. OBJECTIVES: In this retrospective study in children and adolescents, we aimed to assess the outcome of bladder neck sling procedures conducted at our institution. In addition, we aimed to identify predictors of the successful correction of incontinence. PATIENTS AND METHODS: We treated 36 patients (25 girls, 11 boys, aged 5.0-19.7 years). In total, 32 (88.9%) patients suffered from neurogenic incontinence. Overall, 16 patients had previously received unsuccessful injection of bulking agent into the bladder neck. For the bladder neck sling, we used a fascial strip of rectus abdominis muscle (n = 29), detrusor muscle (n = 6), or combined fascial and detrusor strip (n = 1). In 8 (22.2%) patients, the surgical procedure involved wrapping the strip around the bladder neck, while in 6 (16.7%) patients, the bladder neck was suspended with the sling. In 22 (61.1%) patients, the two techniques were combined. Overall, 22 (61.1%) and 9 (25.0%) patients additionally underwent enterocystoplasty or detrusorotomy, respectively. We assessed urinary continence of our patients after 3-6 months (first evaluation) and ≥12 months (final evaluation). We classified the state of continence as 'dry' (dry for >3 h between catheterizations and dry at night), 'significantly improved' (minimal incontinence, no more than one protective pad per day, interval of at least 3 h between catheterizations, dry at night, and no demand for additional treatment), or 'wet'. Bladder neck sling treatment was considered successful if the patient was rated as 'dry' or 'significantly improved'. RESULTS: At the first evaluation, the bladder neck sling procedure proved successful in 19 (52.8%) patients. Enterocystoplasty significantly increased the success rate compared to detrusorotomy or no bladder augmentation (68.1% vs. 28.6%; p = 0.04). The remaining 17 patients who were still classified as wet after bladder neck sling placement subsequently underwent one or more additional interventions, i.e. implant injection (n = 11), bladder augmentation (n = 10), and/or sling replacement (n = 5). At the final evaluation after a median follow-up of 64.5 months (range, 12-181 months), continence without sling replacement was achieved in 29 (80.6%) of the 36 patients. CONCLUSION: In our study population, bladder neck sling placement achieved good results in the treatment of severe organic urinary incontinence with hypoactive sphincter. To optimize treatment outcome, bladder neck sling placement should be combined with enterocystoplasty.

Video-Urodynamic Characteristics and Predictors of Switching from Botulinum Neurotoxin a Injection to Augmentation Enterocystoplasty in Spinal Cord Injury Patients.

Botulinum neurotoxin type A (BoNT-A) injection and augmentation enterocystoplasty (AE) are alternative and effective management strategies for neurogenic detrusor overactivity (NDO) refractory to pharmacotherapy. A great majority of patients with spinal cord injury (SCI) may, however, prefer BoNT-A injections to AE, due to the less invasive characteristics. In this study we evaluated the influence of various video-urodynamic study (VUDS) parameters in SCI patients who continuously received repeat BoNT-A detrusor injections or switched to AE to improve their bladder conditions. We compared the changes in the urodynamic parameters before and after each mode of treatment. In this retrospective study, all SCI patients with refractory NDO who had received at least one BoNT-A injection were enrolled. VUDS was performed before and after both BoNT-A injection and AE. All of the urodynamic parameters of the storage and micturition-including the bladder capacity of every sensation, maximal flow rate (Qmax), post-voiding residual volume, detrusor pressure at Qmax, and bladder contractility index-were recorded. A total of 126 patients, including 46 women and 80 men, with a mean age of 41.8 ± 13.1 years, were recruited for this study. All of the patients receiving either BoNT-A injection or AE had a statistically significant increase of bladder capacity at every time-point during filling and a decrease in detrusor pressure at Qmax during voiding. Patients who switched from BoNT-A to AE had greater improvements in their urodynamic parameters when compared with those who continued with BoNT-A injections. Accordingly, SCI patients receiving BoNT-A injections but experiencing few improvements in their urodynamic parameters should consider switching to AE to achieve a better storage function and bladder capacity.

Complication profile of augmentation cystoplasty in contemporary paediatric urology: a 20-year review.

BACKGROUND: The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics. METHODS: Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined. RESULTS: Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH2 O, P < 0.001). Bladder capacity improved significantly (67-89%, P = 0.041). The median follow-up was 4.5 years (interquartile range: 1.9-10 years). Bladder urolithiasis affected 13 (18%) patients, and symptomatic urinary tract infections 36 (51%) patients. Formation of a continent catheterisable channel contributed a number of complications relating predominantly to stenosis (50%). Repeat augmentation cystoplasty was necessary in three (4%) cases. CONCLUSION: Augmentation cystoplasty is a surgical intervention that improves bladder metrics. Given the potential complications, careful patient selection and appropriate pre-operative counselling are essential. Furthermore, pro-active post-operative management and transitional care are vital in the surgical care of children following augmentation cystoplasty.

Enterocystoplasty and appendicovesicostomy in adults: a description of demographics and 30-day outcomes of bladder augmentation.

Within the adult population, studies of the granular clinical outcomes of appendicovesicostomy (AV) and augmentation enterocystoplasty (AE) have been limited to case series. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data, this study sought to describe the population undergoing these procedures. An analysis of the ACS NSQIP database (2015 to 2018) was performed, capturing patients with procedure codes of enterocystoplasty with intestinal anastomosis or cutaneous appendicovesicostomy. Patients were stratified into three groups, if they underwent either procedure, or both procedures. Demographics, comorbidities, perioperative variables, surgeon specialty, and outcomes were described. 130 patients undergoing AV or AE were captured. Most of these patients were white (70.77%) and middle aged (46.78±17.33 years). Most patients were an American Society of Anesthesiologists class 3 or greater risk (71.54%). A higher percentage of AE patients were readmitted, returned to the operating room, and had postoperative UTI or sepsis compared to those undergoing AV or AV+AE. The most common complication overall was readmission related to the operation (14.62%). The most common postoperative diagnosis was neurogenic related in over half of cases. The study shows patients undergoing bladder augmentation and appendicovesicostomy are readmitted not infrequently. Risk of infection, sepsis, bleeding, and reoperation are also not insignificant. Further studies should be carried out to aid in decreasing complication rate and readmissions after these procedures.