Understanding factors influencing primary treatment with intradetrusor onabotulinumtoxinA versus augmentation cystoplasty in patients with spina bifida.

PURPOSE: Surgical interventions in the urologic management of children with neurogenic bladder secondary to spina bifida aim to preserve upper tract function, prevent urinary tract infections, and optimize quality of life. However, since the introduction of intravesical onabotulinumtoxinA (Botox) in the management of these patients, the indications for choosing Botox over augmentation cystoplasty (AC) remain undefined. The objective of this study was to determine which factors lead patients to undergo Botox versus AC as a primary surgical treatment after failing medical management. METHODS: We retrospectively reviewed the records of pediatric patients with myelomeningocele undergoing either primary Botox or primary AC at our institution between 2013 and 2018. We recorded demographic and clinical information. We identified 10 important clinical decision-making factors: bladder trabeculation, vesicoureteral reflux, or hydronephrosis on imaging; end-filling pressure (EFP) ≥40 cm H2O, detrusor overactivity, detrusor-sphincter dyssynergia, or reduced capacity on urodynamic studies; physician-perceived bladder hostility; and patient/family desire for continence and independence. The presence of these factors was compared between patients undergoing either primary Botox or primary AC. RESULTS: We identified 14 and 50 myelomeningocele patients who underwent primary AC and primary Botox, respectively. We found no significant differences in age, sex, race, or history of reconstructive surgery (antegrade continence enema or catheterizable channel). For the 10 decision-making factors, desire for independence/continence (p = <0.001) and reduced capacity (p = 0.002) were significantly associated with AC, while trabeculation (p = 0.006), EFP ≥40 cm H2O (p = 0.029), rising slope (p = 0.019), and physician-perceived hostility (p = 0.012) were significantly more common with Botox. CONCLUSIONS: At our institution, quality of life measures prompted AC over objective urodynamic or imaging findings before attempting Botox. These findings support a shared decision-making approach when considering surgical intervention for neurogenic bladder secondary to myelomeningocele.

[Bladder augmentation in the era of botulinum toxin: Indications and results]. / L'entérocystoplastie d'agrandissement à l'ère de la toxine botulique : indications et résultats.

AIM: To determine the surgical indication and results of bladder augmentation (BA) during the last decade in a neurourology center in the era of intradetrusor botulinum toxin injection. MATERIAL: We conducted a retrospective study that included patients with BA between January 1, 2012 and December 31, 2022 in our centre. We collected pre-operative demographic, clinical, and urodynamic data, BA indication, and associated procedures. We analyzed early and late complications as well as continence and postoperative voiding mode in patients with first BA in a neurological pathology context. RESULTS: We performed 77 BA over the study period. The main indication was neurogenic overactive bladder, which was secondarily resistant to botulinum toxin. The main associated procedure was continent cutaneous diversion (n=31, 57.4%). Among patients who had a first BA for neurogenic bladder, 34 patients had early complications (50%) including 12 patients with≥Clavien 3 complications (17.6%). After a median follow-up of 33 [14; 55] months, 23 patients had late complications (33.8%) and 59 patients had complete continence (86.8%). CONCLUSION: In the era of botulinum toxin, the main indication of BA is the secondary failure of botulinum toxin for overactive neurogenic bladder. The BA provided continence in 86.8% of patients. It remains however an intervention with a significant rate of severe complications whose indication must be discussed by a multidisciplinary team. LEVEL OF EVIDENCE: Weak.

Supratrigonal cystectomy and augmentation cystoplasty with ileum or ileocecum in the treatment of ulcerative interstitial cystitis/bladder pain syndrome: a 14-year follow-up.

INTRODUCTION AND HYPOTHESIS: This study analyzes the long-term results of supratrigonal cystectomy and augmentation cystoplasty in patients with severe ulcerative interstitial cystitis/bladder pain syndrome (IC/BPS) and reduced bladder capacity. METHODS: Outcome data were retrospectively and prospectively collected and analyzed in women who underwent supratrigonal cystectomy and augmentation cystoplasty for ulcerative IC/BPS at Muenster University Hospital between 1991 and 2006. We used cross-tabulation and Pearson's Chi-squared test to examine how outcome is influenced by age, preoperative functional bladder volume, and choice of augmentation material. RESULTS: After a median 171-month follow-up, analysis could be done in 26 of 27 patients. Persistent pain necessitated early revision in 2 patients (7.7%). Mean postoperative O'Leary Sant IC Score was 12.7 in the prospectively questioned patients. Responses to Patient Global Impression of Improvement (PGI-I) were: "very much better" in 15 cases (65.2%) and "much better" in 7 (30.4%). Twelve patients (52.2%) emptied their augmented bladder voluntarily, whereas 7 (32%) needed intermittent self-catheterization (ISC). The rate of patients requiring ISC tended to be lower when detubularized ileocecal bowel was used. All 5 patients (19.2%) with late relapse of ulcerative IC/BPS needed ISC. CONCLUSIONS: Severe ulcerative IC/BPS can be curatively treated in some patients by supratrigonal cystectomy and augmentation, which is associated with a high satisfaction rate and few long-term complications even over a very long follow-up. In our analysis, the need for ISC is a risk factor for late relapse, although ileocecal augmentation could increase the proportion of patients with sufficient voluntary micturition.

Ureteral reimplantation during augmentation cystoplasty is not needed for vesicoureteral reflux in patients with neurogenic bladder: a long-term retrospective study.

BACKGROUND: To investigate the need for ureteral reimplantation for vesicoureteral reflux (VUR) during augmentation cystoplasty (AC) in the long term. METHODS: A total of 19 patients with a median age at surgery of 14 years (3-38 years) who underwent AC for neurogenic bladder with VUR between 1983 and 2016 were included in this study. The changes in VUR grade and urodynamic findings were retrospectively evaluated. We evaluated the renal function by periodic inspection of serum creatinine level and estimated glomerular filtration rate; eGFR. RESULTS: The median follow-up period from AC was 14.8 years (5.7-30 years). VUR was detected in 19 patients, involving 27 ureters. Reflux grade was V in 6, IV in 9, III in 5, II in 6, and I in 1. Ureteral reimplantation was not performed in 18 patients (26 ureters), whereas it was done for 1 patient (1 ureter) in the early era of our experience. Postoperative videourodynamics showed that the reflux was radiologically not verifiable in 23 ureters (85%), was downgraded in 3 ureters (11%), and was unchanged in 1 ureter (3%). There were no cases of deterioration of VUR. CONCLUSIONS: Ureteral reimplantation is not necessary for VUR during augmentation cystoplasty.

Efficacy of complete laparoscopic ileal augmentation cystoplasty for the treatment of low bladder capacity and compliance: a case series.

OBJECTIVES: To investigate the safety and efficacy of complete laparoscopic ileal augmentation cystoplasty for the treatment of low bladder capacity and compliance. METHODS: The clinical data of 13 patients with low bladder capacity and compliance were retrospectively analyzed. Therapeutic efficacy was evaluated at follow-up. The Clavien system was used to evaluate the severity of postoperative complications. RESULTS: All 13 operations were successfully completed laparoscopically. The operation duration was 140-248 min (average: 189.9 ± 29.6 min), the time to postoperative recovery of bowel function was 1-10 days (average: 2.9 ± 2.3 days). There were 4 cases of grade I complications and 1 case of grade II complications (i.e., paralytic ileus caused by urinary leakage from the anastomosis of the augmented bladder). Cystography showed that the morphology of the bladder was close to normal, and the maximum safe capacity and compliance of the bladder were significantly increased [103.8 ± 16.6 mL and 332.3 ± 20.5 mL, p < 0.01; 7.0 ± 1.3 mL/cm H2O and 32.4 ± 2.1 mL/cm H2O, p < 0.01]. All patients were able to urinate spontaneously after catheter removal. CONCLUSIONS: Complete laparoscopic ileal augmentation cystoplasty is a safe and feasible treatment for low bladder capacity and compliance, and has the advantages of less trauma, less bleeding, faster recovery of intestinal function, and fewer postoperative complications. This treatment effectively increases bladder capacity, protects upper urinary tract function, and improves patient quality of life, and thus warrants clinical application.

Long-term effectiveness and safety of bladder augmentation in spina bifida patients.

AIMS: To establish the long-term efficacy and safety of bladder augmentation in spina bifida patients. MATERIAL AND METHODS: Sixteen patients were operated on using the Bramble technique. Preoperative and postoperative evaluation included clinical history, blood tests, urine cultures, cystography, pyelography, ultrasound, and filling cystometry. In the final review a standardized quality of life questionnaire was applied. RESULTS: Median follow-up was 20 years (15-26). Kidney function was stabilized except for one case that required a kidney transplant. Hydronephrosis disappeared or improved (p = 0.03). Vesicoureteral reflux grades I-II was cured without reimplantation and grades III-IV responded better with reimplantation than without (p = 0.03). Quality of life improved in all patients, with all stating they would undergo the procedure again. After surgery, 94% of the patients exhibited diurnal continence but 25% exhibited nocturnal incontinence. Pressure at capacity decreased and bladder capacity increased (p < 0.001). One patient presented ureteral fistula with another presenting hemorrhage. Both required immediate surgical review. Late complications included urinary sphincter cuff erosion, renal lithiasis, four instances of bladder lithiasis and repeated pyelonephritis in one 24-year-old patient. All required surgery. The mean of urinary infections fell, from 2.5 per year (0.7) to 1 (0.5) (p = 0.03). CONCLUSION: Augmentation cystoplasty (AC) maintains its efficacy and improves quality of life in the long term. However, serious surgical complications can ensue, along with minor or major subsequent complications. This should be considered before surgery and makes lifelong monitoring of patients necessary.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature.

INTRODUCTION AND HYPOTHESIS: The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR). METHODS: We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies). RESULTS: Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section. CONCLUSIONS: Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Augmentation uretero-enterocystoplasty for refractory urinary tract dysfunction: a long-term retrospective study.

OBJECTIVES: To report the long-term efficacy and complications of the augmentation uretero-enterocystoplasty (AUEC), including augmentation cystoplasty with simultaneous ureteroplasty and ureteral anti-reflux implantation in a single center. METHODS: We retrospectively reviewed clinical records, video-urodynamic data, and magnetic resonance urography of 210 patients who underwent the procedure for refractory lower urinary tract dysfunction (LUTD) from 2003 to 2019. International vesicoureteral reflux (VUR) and upper urinary tract dilatation (UUTD) grading systems were applied to assess upper urinary tract function, and post-operative complications were assessed. RESULTS: Mean age was 28.1 years, with a mean follow-up time of 57.4 months. A total of 338 ureters were simultaneously re-implanted, and ureteroplasty was performed on all ureters. There was a significant postoperative improvement in the bladder capacity, intravesical pressure, and compliance (P < 0.05). VUR improvement rate was 97.7% and postoperative improvement of UUTD presented in 72.5% ureters. Mean serum creatinine (Scr) level was significantly improved compared to preoperative Scr values (226.0 ± 89.4 µmol/L vs. 217.5 ± 133.9 umol/L, P < 0.05). The 1.0% patients had unacceptably postoperative urinary incontinence and 85.4% preoperative megaureters were improved. Primary complications included metabolic acidosis (9.5%), vesicoureteral anastomosis stenosis (6.2%), persistent VUR (2.7%), urinary calculi (6.6%), and intestinal dysfunction requiring laparotomy (3.3%). CONCLUSION: In the study, a large series of patients treated with a complex surgical procedure was reported. It is novel, as this case series represents patients with aggressive surgical correction of VUR, ureteral tortuosity and upper tract dilation at the time of AC. AUEC was shown to have a positive role in treating patients with refractory LUTD associated with hydronephrosis and ureteral dilatation, stenosis or obstruction, with or without high- or low-pressure VUR. It was effective in improving renal function and protecting the UUT function from further deterioration in most patients with renal insufficiency.

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.

[Metastase from lobular breast carcinoma on the ileal patch of augmentation]. / Métastase de carcinome lobulaire mammaire sur un patch iléal d'entérocystoplastie.

Patients treated with bladder augmentation have a higher risk of developing bladder cancer than the general population. In these patients, tumours are most frequently primary bladder cancers. Metastasis in an augmentation cystoplasty is extremely rare and here we describe the first case of metastasis from lobular breast carcinoma in an ileal patch. A 52-year-old woman, with a medical history of invasive lobular breast cancer, presented with gross hematuria seven years after an ileal augmentation cystoplasty. A large bladder mass was found exclusively on the enteric patch, with lymphadenopathies from iliac vessels to right kidney hilum. Asurgical resection of the ileal segment with trigonal preservation was performed, associated with a complete cytoreduction. The bladder was reconstructed with a new ileal segment. Pathology confirmed the diagnosis of metastatic lobular breast carcinoma. Patients treated with augmentation cystoplasty need a close and long follow-up to detect the warning signs of tumor development. We herein report our experience of a metastatic lesion on the enteric part of a cystoplasty. Unusual characteristics of the bladder tumor and personal oncologic history of the patient may be suggestive of a secondary lesion.

Les patients traités par entérocystoplastie d'agrandissement présentent un risque plus important que la population générale de développer un cancer de vessie. Chez ceux-ci, les masses vésicales sont le plus souvent des cancers primitifs de la vessie. Les métastases au niveau d'iléocystoplasties sont très rares et nous décrivons le premier cas de métastase d'un carcinome lobulaire du sein sur patch iléal. Il s'agit d'une patiente de 52 ans, se présentant pour hématurie macroscopique survenue sept ans après une iléocystoplastie d'agrandissement. Elle a également été traitée antérieurement pour un carcinome lobulaire du sein. Une large masse vésicale est visualisée sur le patch intestinal uniquement, avec des adénopathies s'étendant des vaisseaux iliaques au hile rénal droit. Nous réalisons une exérèse du segment iléal avec préservation du trigone, associée à une cytoréduction tumorale complète. La vessie est reconstruite avec un nouveau segment d'iléon. L'analyse pathologique confirme le diagnostic de carcinome lobulaire métastatique. Les patients porteurs d'entérocystoplastie d'agrandissement nécessitent un suivi à long terme pour détecter les signes évocateurs d'une tumeur vésicale. Nous rapportons notre expérience d'une lésion métastatique exceptionnelle sur patch iléal d'agrandissement vésical. Des caractéristiques inhabituelles de la tumeur vésicale ainsi que l'historique oncologique du patient pouvaient suggérer une lésion métastatique.

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 changes after catheterizable channel creation in adults with cerebral palsy who are in chronic urinary retention.

AIMS: Cerebral palsy (CP) is characterized by motor impairments as a result of brain injury during development. Patients can have neurogenic bladder dysfunction and are often unable to catheterize through their native urethra. Catheterizable channel (CC) creation can facilitate clean intermittent catheterization (CIC). We have observed that patients with large capacity, low-pressure bladders can develop de novo neurogenic detrusor overactivity (NDO) postoperatively. We sought to better characterize this finding. METHODS: We reviewed the charts of patients 17 years or older with CP seen between 2006 and 2017. Patients undergoing creation of any type of CC without augmentation cystoplasty, due to adequate storage on pre-operative urodynamics (UDS), were included. Pre- and post-operative UDS were reviewed. Frequency of incontinence and use of anticholinergics or intravesical injections of onabotulinum toxin A (Btx) were reviewed. RESULTS: Eight patients with CP underwent CC creation without augmentation. Preoperatively, six of eight patients were in chronic retention with two others performing CIC. Following CC creation, patients in retention required additional NDO management with anticholinergics, mirabegron, or onabotulinumtoxin A. Among those with complete UDS data, 67% demonstrated lower maximum cystometric capacity postoperatively. Median follow-up was 25 months. CONCLUSIONS: CC creation facilitates CIC in adults with CP who are in chronic retention due to pseudodyssynergia. Despite preoperative UDS suggesting an adequate capacity, low-pressure bladder, such patients often manifest de novo NDO and worsening incontinence upon initiation of CIC after surgery. These findings should be considered when determining whether to perform augmentation at the time of CC in adults with CP.

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.

Can we create a valid treatment algorithm for patients with drug resistant overactive bladder (OAB) syndrome or detrusor overactivity (DO)? Results from a think tank (ICI-RS 2015).

AIMS: To review and assess the definitions of drug resistance and the evidence supporting treatment for drug resistant overactive bladder/detrusor overactivity (OAB/DO). METHODS: Evidence review of the extant literature and consensus of opinion was used to derive the summary recommendations. RESULTS: Drug resistance or drug refractory status has been inconsistently defined and reported in current evident sources. Recent publications use some correlation of lack of efficacy and or experienced side effects to define drug resistance. Algorithms based upon these definitions largely relate to the appropriate use of neuromodulation or botulinum neurotoxin, based upon patient selection and patient choice. Current treatment pathways are hampered by inability to consistently profile patients to optimize management, particularly after failure of initial pragmatic treatment. CONCLUSIONS: Further research is recommended to better identify patient phenotype for purposes of directing optimized therapy for OAB/DO. Current treatment algorithms are influenced by extensive data generated from recent neuromodulation and botulinum neurotoxin trials.

Pregnancy and delivery after myelomeningocele repair, ventriculoperitoneal shunt implantation, and augmentation cystoplasty.

INTRODUCTION: Management of pregnancy and delivery of a patient with a history of myelomeningocele requires a multidisciplinary team approach. CASE REPORT: We report a case of pregnancy and delivery by a patient who had a history of myelomeningocele surgical repair, ventriculoperitoneal (VP) shunt, and bladder augmentation enterocystoplasty. Regarding types of delivery style, anesthesiologists recommended a Cesarean section under general anesthesia. However, urologists recommended a vaginal delivery because they were concerned that she would require a nephrostomy because of severe adhesion between her uterus and the neobladder if she had a Cesarean section. DISCUSSION: In a pregnant myelomeningocele patient with a VP shunt, neurosurgeons are expected to manage the VP shunt during pregnancy and delivery. The possible types of delivery style and the best options based on the neurological deficit should be discussed together with a medical team.

Indications for Augmentation Cystoplasty in the Era of OnabotulinumtoxinA.

Overactive bladder (OAB) with or without a neurogenic etiology that is refractory to conventional first-, second-, and third-line therapies is a challenging condition that typically leaves the physician and the patient with few options. Historically, treatment for patients who did not respond to any of the few pharmacologic choices focused on more invasive surgical options--specifically, augmentation cystoplasty (AC). In 2011 and 2013, the Food and Drug Administration (FDA) approved intradetrusor injection of onabotulinumtoxinA for the treatment of neurogenic detrusor overactivity (NDO) and idiopathic detrusor overactivity (IDO), respectively. Since then, a dramatic decline in the use of AC has called into question its utility in the treatment algorithm of this difficult patient population. The purpose of this paper is to review the current body of literature in order to outline the circumstances in which AC is still a relevant therapeutic option.

Collagen-1 Membrane for Replacing the Bladder Wall.

We studied the possibility of using membrane fabricated from type 1 collagen isolated from cattle tissues (group 1) or porcine tissues (group 2) for replacement of the resected bladder wall defect in rabbits in order to retain functional volume of the organ. Satisfactory take of both types of collagen membranes with formation of competent anastomosis was observed. Histological studies revealed inflammatory process in the bladder wall at the site of contact with the implanted membrane (more pronounced in case of membranes from cattle tissues) that decreased by day 21 of the experiment. Bladder tissue ingrowth into the implant from was observed starting from day 14. The bladder capacity decreased in 7 days after surgery in both groups, presumably because of increasing tone of the organ wall resulting from surgical trauma and inflammation. In group 2, the bladder volume increased by day 14 after surgery and returned to normal by day 21, whereas in group 1 it remained below the control despite a trend to increase. These findings confirm good prospects of using collagen-1 membranes for plastic repair of the urinary bladder, the membranes from porcine collagen being more preferable.

Ureteritis cystica: A rare entity in children.

Ureteritis cystica (UC) is a benign condition. Although it can often be diagnosed with imaging techniques, we report a case of a child for whom we planned nephrectomy and ureteral augmentation cystoplasty, but abandoned the cystoplasty due to extensive UC in the ureter.

Long-term complications and outcomes of augmentation cystoplasty in children with neurogenic bladder.

Augmentation cystoplasty (AC) is an effective surgical procedure for patients with neurogenic bladder whenever conservative treatments have failed. The present study aimed to determine the risks of metabolic complications, malignancy, long-term outcomes and histopathologic changes of native bladder and the augmented intestine after AC in children with neurogenic bladder. Pediatric patients < 18 years who underwent AC between 2000 and 2020 were enrolled. Early postoperative complications, long-term outcomes and histopathologic changes in mucosal biopsies of native bladder and the augmented intestine after AC were reviewed. Twenty-two patients with a mean age of 7.6 ± 4.4 years were included. The ileum was used in 19 patients and the sigmoid colon in 3 patients. The length of hospital stay was 14.8 ± 6.8 days. Post-operatively, the urinary continence rate improved from 22.7 to 81.8% (p < 0.001). Hydronephrosis resolved in 17 of 19 patients. Vesicoureteral reflux resolved in 16 (64.0%) of the refluxing ureter units and was downgraded in 7 (28.0%). Grades of hydronephrosis and reflux significantly improved following AC (p < 0.001). The estimated glomerular filtration rate also significantly increased (p = 0.012). Formation of urinary tract stones was the most frequent late complication (in 8 patients, 36.4%). Life-threatening spontaneous bladder perforation occurred in 1 patient. After a mean follow-up of 13.4 ± 5.9 years, there were no cases of mortality, new-onset symptomatic metabolic acidosis, or changes in serum electrolytes. Of the 17 patients who were followed for > 10 years, no cases of malignancy or metaplastic changes were identified in the native bladder or augmented bowel epithelium. AC is a safe and effective procedure with low surgical and metabolic complication rates. In addition, AC provides a satisfactory continence rate and long-term protection of renal function, increases functional capacity, and regresses reflux and hydronephrosis. Individualized surveillance is recommended for the early identification of urolithiasis and metabolic disturbances.