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Strategies in urological reconstruction in myelomeningocele
Ricardo González1, Christa M Schimke
1Division of Pediatric Urology, University of Miami, Florida 33101, USA. rgonzal4@med.miami.edu
Insights
This review examines updated strategies for urinary tract reconstruction in children with spina bifida, focusing on preserving kidney function and achieving urinary continence. Advances include bladder augmentation and continent stomas, aiding clinical decision-making.
Area of Science:
- Pediatric Urology
- Spina Bifida Management
- Reconstructive Surgery
Background:
- Spina bifida presents complex challenges in urinary tract reconstruction.
- Key goals include preserving renal function and achieving urinary continence.
- Controversies persist regarding bladder augmentation, outlet resistance procedures, and continent stomas.
Purpose of the Study:
- To review recent advances in urinary tract reconstruction strategies for pediatric spina bifida patients.
- To provide perspective on current literature and personal experience.
- To aid practitioners in making informed clinical decisions.
Main Methods:
- Systematic review of 37 papers published in the last 5 years, with 7 older relevant references.
- Analysis of strategies for bladder augmentation, outlet resistance, and continent stomas.
- Evaluation of techniques avoiding intestinal mucosa contact with urine.
Main Results:
- Persistent interest in bladder enlargement methods avoiding intestinal mucosa.
- Artificial urinary sphincters and fascial slings are common for outlet resistance.
- The Mitrofanoff principle remains effective for continent catheterizable channels.
- Fecal continence must be addressed concurrently with urinary continence.
- Incontinent diversions suit a small patient subset; continent diversion role needs reassessment.
Conclusions:
- Continuous progress is being made in urinary tract reconstruction for spina bifida.
- Objective reviews are crucial for guiding clinical practice.
- Further evaluation of continent urinary diversion is warranted.
Purpose Of Review:
This paper reviews recent advances in the strategies for urinary tract reconstruction in children with spina bifida. The aims of reconstruction are the preservation of renal function and achievement of urinary continence. Considerable controversy exists on the subjects of bladder augmentation, procedures to increase outlet resistance, and continent stomas. The authors put the most recently published information in perspective in the light of their own personal experience.
Recent Findings:
Thirty-seven papers covering the above-mentioned subjects published in the past 5 years (25 of them published since 2000) have been selected. Seven relevant older references are included. There is persistent interest in developing methods to enlarge the urinary bladder that avoid bringing the urine in contact with the intestinal mucosa. The artificial urinary sphincter and fascial slings are the most frequently reported methods to increase outlet resistance. The Mitrofanoff principle continues to be regarded as an effective method to construct a continent catheterizable channel, either with the appendix or reconfigured intestinal segments. The achievement of fecal continence has to be pursued in parallel with urinary continence. Incontinent diversions continue to be best for a small group of patients. The role of continent urinary diversion requires reassessment.
Summary:
Progress in this area continues to be made. Periodic, critical and objective reviews on the subject should help the practitioner to arrive at sound decisions.