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The challenge of pediatric continent urinary diversion
Daniel Rapoport1, Sharon Secord, Andrew E MacNeily
1Division of Pediatric Urology, University of British Columbia, Vancouver BC, Canada V6H 3V4.
Insights
Continent urinary diversion (CUD) in children can achieve continence in most cases, but often requires further procedures and carries risks of complications. Patient and family commitment is crucial for successful outcomes.
Area of Science:
- Pediatric Urology
- Surgical Reconstruction
- Voiding Dysfunction Management
Background:
- Refractory incontinence in children with congenital malformations may necessitate continent urinary diversion (CUD).
- Understanding the success factors and challenges of CUD is vital for improving patient care.
Purpose of the Study:
- To review the experience with continent urinary diversion (CUD) in pediatric patients.
- To identify determinants of success and ongoing challenges associated with CUD.
Main Methods:
- Retrospective chart review of 43 consecutive pediatric patients undergoing CUD.
- Analysis of surgical techniques, complication rates, and continence outcomes.
Main Results:
- Continent urinary diversion achieved ultimate continence in 88% of patients.
- Early complications occurred in 21% of cases, with delayed complications requiring intervention in 30% (e.g., stomal stenosis, prolapse).
- Revision surgery was needed in 16% for persistent leakage, often managed with cystoscopic bulking agents.
Conclusions:
- Pediatric CUD is a complex procedure with a high success rate for continence but frequent complications.
- Many patients require additional minor procedures, and a significant minority need reoperation for delayed complications.
- Informed preoperative counseling regarding potential challenges and the necessity of strong family commitment is essential.
Objective:
Continent urinary diversion (CUD) may be required for refractory incontinence in children with various malformations. We review our experience with CUD to identify determinants of success and ongoing challenges.
Methods:
Retrospective chart review of 43 consecutive patients undergoing CUD since 1991 at British Columbia Children's Hospital.
Results:
Our preferred surgery was intestinal cystoplasty and either appendicovesicostomy (77%) or ileal-vesicostomy. Concomitant bladder neck surgery was performed in 67%. Mean follow-up was 2.5 years. There was a 16% revision rate for persistent leakage, the most common being cystoscopic injection of bulking agents. Continence was ultimately achieved in 88%. Early major and minor postoperative complications each occurred in 21% of cases. Delayed minor complications requiring surgical intervention occurred in 30% including stomal stenosis in 6 patients and stomal prolapse in 2. Urolithiasis required intervention in 5 patients.
Conclusions:
Pediatric CUD is a challenging endeavor. Most patients achieve continence although many require additional minor procedures to do so. Early major and minor complications are common. A significant minority of patients require reoperation for delayed minor complications. Patients and families should be informed of these frustrations as part of their preoperative counseling. A high degree of family motivation and commitment is essential.
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