ESPU-SPU Meeting on Saturday 25, September 2021, 14:45 - 15:09
Konrad SZYMANSKI, Joshua ROTH, Arthur SZYMANSKI, Shelly KING, Benjamin WHITTAM, Martin KAEFER, Richard RINK, Mark CAIN and Rosalia MISSERI
Riley Hospital for Children at Indiana University Health, Pediatric Urology, Indianapolis, USA
To assess long-term MACE use and potential risk factors for abandoning use.
MATERIAL AND METHODS
Patients with SB who underwent MACE surgery (1994-2017) at our intuition were retrospectively reviewed. Main outcome: abandoning MACE use (no longer catheterizing for antegrade enemas) based on self-report (clinic questionnaire), or medical record (if seen before questionnaire introduced). Survival analysis was used.
Overall, 413 patients (54.5% female, 77.5% shunted, 65.4% augmented) underwent MACE surgery at median 7.9years old (median follow-up: 8.5years). After correcting for differential follow-up, 90.9% used their MACE at 10 years, 86.2% at 15 years and 80.1% at 20 years. Most common causes of abandoning use were channel stenosis (72.7%) and excision at colostomy or unrelated surgery (9.1%). Bowel management afterwards included oral agents+/-enemas (57.6%), Chait tube (27.1%), colostomy (12.1%) or Monti MACE (3.0%).
Gender, lesion type, shunt status, mobility status, having bladder augmentation or urinary catheterizable channel were not associated with stopping use (p>=0.32). Compared to younger children, surgery at 10years or older was associated with 2.27x the risk of MACE abandonment (p=0.02). At 15 years after MACE surgery, 89.4% of children who had a MACE made before age 10 were still using it, compared to 80.3% who had surgery at 10 years old or later.
On long-term follow-up, most patients with SB continue using their MACE and 1% abandon use annually, strongly suggesting its effectiveness. Patients undergoing surgery after age 10 are more likely to abandon use (20% vs. 10% at 15 years). Transitioning to self-care plays a role in maintaining long-term MACE use.
Roberto LOPES, Valeria ALENCAR, Cristiano GOMES, Eduardo MIRANDA, Maria Alice SANTOS, Patricia FERA, Jose BESSA JR, Francisco DÉNES, Miguel SROUGI and Homero BRUSCHINI
University of São Paulo Medical School, Urology, São Paulo, BRAZIL
Clean intermittent catheterization (CIC) is one of the main alternatives in the management of neurogenic bladder. This study is to evaluate the challenges of CIC and its implications on quality of life.
MATERIAL AND METHODS
A cross-sectional study was conducted in children with neurogenic bladder dysfunction on CIC and their caregivers. Medical records were reviewed and questionnaires applied to identify the burden of CIC on this population. Statistical analysis were applied to four instruments: a specifically structured questionnaire, the World Health Organization - Quality of Life questionnaire (WHOQOL-bref), the Caregiver Burden Scale (CBS) and the PedsQLTM4.0 inventory.
Seventy children (5-18 years) and their caregivers (25-76 years) were evaluated. Majority of caregivers (n=67) were mothers (58.6% ≤ 40 years), with basic education. Caregivers were the CIC performers in 45 cases (64.3%). Medical conditions of the children on CIC were neurospinal dysraphism (72.8%), complex congenital malformations (18.6%) and others (8.6%). In the PedsQL™ analysis, it was observed that children have better quality of life perception, in all domains, when compared to caregivers. Caregivers results yielded statistical difference on “school functioning” domain in patients performing CIC through a stoma when compared with patients performing urethral CIC. Also, according to WHOQOL-bref results, patients who could perform self-catheterization had lesser impact on caregiver’s quality of life. Concerning age, older caregivers (>40 years) suffered more impact from CIC on the Caregiver Burden Scale.
Severe illnesses could drastically alter life and cause family dysfunction. Self-catheterization could contribute to social acceptance of the child and decrease the burden of caregivers.
Patricio GARGOLLO 1, Mohamed AHMED 2, Mohit BUTANEY 2 and Candace GRANBERG 1
1) Mayo Clinic, Pediatric Urology, Rochester, USA - 2) Mayo Clinic, Urology, Rochester, USA
Inadequate urinary bladder function may lead to secondary renal injury either from increased pressures, urine reflux or recurrent urinary tract infections. This is particularly true in patients with neurogenic bladders or a history of posterior urethral valves. Previous attempts at generating bladder tissue substitutes have failed and the use of intestinal segments for urinary reconstruction is not physiologically ideal. The purpose of this study was to establish the feasibility of performing a urinary bladder vascularized composite allograft (VCA) transplant.
MATERIAL AND METHODS
Six adult fresh frozen cadavers were studied (3 M 3 F). Cadavers were excluded for any previous pelvic surgery, vascular surgery, history of pelvic malignancy, or history of pelvic radiation. Contrast enhanced CT imaging with 3-D reconstructions was used to delineate urinary bladder vascular anatomy variability. Bladders were explanted en bloc from two cadavers with bilateral vascular pedicles based on the external iliac vessels and “transplanted” to replicate a bladder transplant.
Contrast enhanced 3D-CT reconstructions and cadaver dissections revealed distal vascular variability with proximal blood supply based primarily on the internal iliac artery. Urinary bladder VCA was successfully performed during 2 mock transplants with the vascular anastomosis done at the recipient external iliac artery and vein.
Urinary bladder VCA is technically and anatomically feasible. This procedure may obviate the use of intestinal segments for bladder reconstruction in some patients especially if they undergo a concommitant renal transplant or have a history of renal transplantation. We have a prospective clinical trial currently open as a phase 1 study.
Matthieu PEYCELON 1, Konrad M. SZYMANSKI 2, M. Francesca MONN 2, Joshua D. ROTH 2, Cyrus M. ADAMS 2, Mark P. CAIN 2, Richard C. RINK 2, Benjamin WHITTAM 2 and Rosalia MISSERI 2
1) Indiana University School of Medicine, Department of Pediatric Urology of Riley Children Hospital; French Reference Centre for Rare Urinary Tract Malformations (MARVU), Indianapolis, USA - 2) Indiana University School of Medicine, Department of Pediatric Urology of Riley Children Hospital, Indianapolis, USA
Few studies have reported bladder calculi risk factors in spina bifida (SB) with bladder augmentation (BA). We sought to identify risk factors for bladder calculi in a large homogeneous cohort of SB with BA.
MATERIAL AND METHODS
Patients with SB using clean intermittent catheterization (CIC) after BA were retrospectively identified (1981-2019). We abstracted: gender, ethnicity, ambulatory status, type of BA, age at BA, catheterizable channel, bladder neck surgery, renal stone and bone fractures before and after BA. Statistics: univariate (Fisher's, Student's, Mann-Whitney), Kaplan-Meier survival, Cox proportional hazards analysis.
421 patients were included. Median (IQR) age at BA was 8.3 years (5.9-11.6) and follow-up of 11.3 years (5.7-15.8). Of 117 patients with a first episode of bladder calculi, 60 (51.3%) were female, and 70 (59.8%) were non-ambulatory. The first bladder calculi occurred at a median (IQR) of 5.4 years (2.2-9.7) after BA. On multivariate analysis, both presence of a catheterizable channel and renal stone after BA were independent risk factors for bladder calculi (86.3% vs. 70.1% (HR 2.5 (1.3-4.8)) and 27.4% vs. 6.3% (HR 2.2 (1.5-3.4)) respectively, p<0.001). Type of bowel segment, bladder neck surgery or any bone fracture after BA did not reach the significance (p>0.05). On survival analysis, 37.2% of patients had a first episode of bladder calculi by 10 years after BA. In SB patients with both a catheterizable channel and a renal stone after BA, 73.1% developed a bladder stone by 10 years.
In a cohort of patients with spina bifida and bladder augmentation, a first episode of bladder calculi occurred in 37.2% at 10 years after bladder augmentation. Catheterizable channel and renal stones after BA are risk factors for bladder calculi. In these high-risk groups, we particularly recommend annual imaging of the kidneys, ureters and bladder.