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Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty
N M Holmes1, B A Kogan, L S Baskin
1Division of Urology, Albany Medical College, Albany, New York, USA.
Insights
A staged approach to lower urinary tract reconstruction involving artificial urinary sphincter placement and augmentation cystoplasty showed fewer complications than simultaneous procedures. This staged method is more advantageous for pediatric patients, reducing risks of infection and erosion.
Area of Science:
- Pediatric Urology
- Reconstructive Surgery
- Neurogenic Bladder Management
Background:
- Augmentation cystoplasty and artificial urinary sphincter (AUS) placement are used for neurogenic bladder. Previous studies suggest higher infection rates with simultaneous procedures.
- Concurrent urinary reconstruction with stomach and AUS placement has been reported as safe.
- Comparative data on infection rates between simultaneous and staged AUS placement with augmentation cystoplasty in pediatric patients are limited.
Purpose of the Study:
- To compare infection complication rates between simultaneous AUS placement and gastrocystoplasty versus staged AUS placement and augmentation cystoplasty.
- To evaluate the safety and efficacy of different surgical approaches for lower urinary tract reconstruction in pediatric patients with neurogenic bladder.
- To determine if differences in infectious complications are clinically and statistically significant.
Main Methods:
- Retrospective review of medical records for 28 pediatric patients (≤18 years) who underwent AUS (AS800dagger) placement between 1986 and 1999.
- Data collected included etiology of neurogenic bladder, age at surgery, surgical procedures performed, follow-up duration, and complication rates.
- Patients were categorized into three groups: simultaneous gastrocystoplasty with AUS, staged AUS placement followed by augmentation cystoplasty, and AUS placement without bladder augmentation.
Main Results:
- Data from 27 patients were analyzed; myelomeningocele was the most common etiology (25 cases).
- Urethral device erosion was the most frequent complication (3 in simultaneous group, 2 in no augmentation group).
- Infection and device explantation occurred in 2 patients undergoing simultaneous gastrocystoplasty; staged procedures showed no infections or erosions.
Conclusions:
- Simultaneous AUS placement and gastrocystoplasty can be performed in select pediatric patients.
- Prior bladder neck surgery appears to be a significant risk factor for infection.
- A staged approach to lower urinary tract reconstruction is more advantageous, demonstrating absence of infection and erosion in the studied cohort.
Purpose:
Previous studies have described placement of an artificial urinary sphincter and simultaneous augmentation cystoplasty with a segment of bowel. Conclusions from these studies indicated that infection rates were higher and a staged approach should be undertaken. Others have suggested that concurrent urinary reconstruction with stomach and sphincter placement can be performed safely. Results comparing infection rates of simultaneous sphincter placement and gastrocystoplasty versus staged sphincter placement and augmentation cystoplasty using a segment of ileum or stomach versus sphincter placement alone in a pediatric population have not been previously described to our knowledge. We reviewed these various groups of patients to determine if the difference in infectious complications were clinically and statistically significant.
Materials And Methods:
A retrospective review of medical records from 1986 to 1999 identified 28 pediatric patients (age 18 years or less) who had undergone placement of an AS800dagger artificial urinary sphincter. Data points were collected focusing on etiology of the neurogenic bladder, age at time of surgery, types of surgery performed, length of followup and complication rates.
Results:
Complete data were available for 27 of the 28 patients. Neurogenic bladder was secondary to myelomeningocele in 25 cases, transverse myelitis in 1 and spinal cord injury in 2. Mean patient age at surgery was 12.7 years (range 6.1 to 18.2) and mean followup was 4.3 years (range 1 month to 13 years). Simultaneous gastrocystoplasty was performed in 7 cases (group 1), staged sphincter placement followed by augmentation cystoplasty with a segment of ileum or stomach was done in 8 (group 2) and 12 did not require bladder augmentation (group 3). Urethral device erosion requiring explantation was the most common complication, occurring in 3 patients in group 1 and 2 in group 3 (p = 0.101). Mean time to erosion was 22.1 months (range 2 to 46.4). Previous surgery (bladder neck or hernia repair) was a common factor in each group with complications. Urine cultures and culture of the explanted device were positive in 2 patients in group 1.
Conclusions:
Simultaneous placement of artificial urinary sphincter at the time of gastrocystoplasty can be performed in carefully selected patients, although those undergoing staged procedures did well without complications. Prior bladder neck surgery seems to be a significant risk for infection. A staged approach to lower urinary tract reconstruction would be more advantageous due to the absence of infection and erosion in those undergoing staged sphincter placement and augmentation cystoplasty.