ESPU Meeting on Thursday 18, April 2024, 11:40 - 12:45
11:40 - 11:43
S09-1 (OP)
Ashley JOHNSTON, Konrad SZYMANSKI, Rosalia MISSERI and Joshua ROTH
Riley Children's Health at Indiana University, Indianapolis, USA
PURPOSE
Our objective was to assess decision regret (DR) in parents of adults with spina bifida (SB) who underwent surgery for neurogenic bladder/bowel in childhood.
MATERIAL AND METHODS
We surveyed consecutive adult patients with SB (≥18 years old [y]) and their parents (6/2018-1/2020). Patient had one of the following surgeries (<18y): bladder augmentation, creation of a catheterizable channel (CCC), bladder neck procedure (BNP) and/or Malone antegrade continence enema (MACE) creation. Patients and parents each completed the Decision Regret Scale (DRS) for bladder surgeries and MACE creation. We analyzed whether parental DR was impacted by patient DR, incontinence, history of augmentation, or difficulty catheterizing MACE. Non-parametric testing was used.
RESULTS
Regarding bladder surgeries, 50 paired patients (median 24y, 56% male) and parents (88% mothers) pairs were surveyed. Surgeries included augmentation (64%), CCC (92%), and/or BNP (62%). Median DRS for both groups was 0 (p=0.99). More parents (78%) reported no DR than patients (60%, p=0.02). Parental DR was strongly associated with patient DR (p=0.002). Neither urinary incontinence nor augmentation were associated with parental DR (p>0.60).
For MACE, 48 paired patients (median 23y, 54% male) and parents (90% mothers) were surveyed. Median DRS for both groups was 0 (p=0.93). More parents (73%) reported no DR than patients (60%, p=0.03). Parental DR was associated with patient DR (p<0.001). Neither fecal incontinence nor difficulty catheterizing were associated with parental DR (p>0.50).
In evaluating DR of those who underwent both bladder surgeries and MACE (n=43), DR about bladder surgeries was associated with DR about MACE in both groups(p<0.001).
CONCLUSIONS
The majority of parents of patients with SB do not regret childhood bladder surgeries or MACE creation. Parental DR is associated with patient DR. Parents with DR for bladder surgery were more likely to have DR for MACE surgery.
11:43 - 11:46
S09-2 (OP)
Yaser EL HOUT, Ananda NUNES, Jessica ARAG and Santiago VALLASCIANI
Sidra Medicine, Department of Surgery, Doha, QATAR
PURPOSE
Clean intermittent catheterization (CIC) is a vital procedure frequently necessary for children with
neurogenic bladder (NB) to ensure bladder emptying and safeguarding the upper tracts. It can
be challenging to convince children and parents to initiate CIC due to anticipated apprehension and perceived difficulty to perform CIC. Herein, we describe an innovative model we devised for teaching and practicing CIC for children with NB.
MATERIAL AND METHODS
An open-ended 16 Fr. catheter was utilized to mimic a urethra and was affixed to the prominent cylinder in a lid of a urine collection cup that was secured on a piece of cardboard. The other end of the catheter was connected to a valved water container positioned at a higher level. Drawing of a boy or girl was done on the cardboard to appeal to children. Catheterization of the 16 Fr. catheter is feasible using a 10 Fr. catheter, draining water upon reaching the container, signifying a successful catheterization.
RESULTS
The model was exhibited and tested by children who were present at the World Spina Bifida Day
event hosted at a pediatric tertiary care center. Twenty children, aged 6 to 12 years, performed catheterization with both visual and tactile assistance from their other hand while blindfolded.
All catheterizations were successfully conducted with little to no assistance. The task was described as "enjoyable," "simple," and "desirable."
CONCLUSIONS
We consider this to be a cheap, easy to assemble, readily available, low-fidelity model that will encourage, engage, "ice-break", teach and allow practice of CIC for children and caregivers, when it is clinically anticipated or required.
11:46 - 11:49
S09-3 (OP)
Sean HOU 1, Kristina GAM 2, Monica XING 1, Parviz HAJIYEV 2, Amrita MOHANTY 1, Alyssa LOMBARDO 1, David KIM 2 and Mohan GUNDETI 2
1) The University of Chicago Pritzker School of Medicine, Chicago, USA - 2) The University of Chicago, Comer Children's Hospital, Urology, Chicago, USA
PURPOSE
Stenosis of a catheterizable channel is one of the most common complications of these channels. We present the appendicocecovesicostomy (APCV) which incorporates a cecal flap for channel augmentation. We aim to examine if APCV confers lower stenosis rates compared to appendicovesicostomy without increased bowel complication rates.
MATERIAL AND METHODS
We performed a retrospective review of pediatric patients who underwent open or robotic APV or APCV between 2008 and 2021. We compared the outcomes of APV vs APCV in both robotic and open approaches.
RESULTS
In the robotic group, APCV had a lower rate of suprafascial stenosis but a higher rate of revision, although not statistically significant.
In the open group, APCV had a lower rate of suprafascial and subfascial stenosis, as well as lower rate of revision, although not statistically significant.
In both robotic and open groups, there was no difference in bowel complications. No patients had bowel leak or perforation.
| Robotic |
APV n (%) |
APCV n (%) |
p-value |
| n | 26 (67) | 13 (33) | |
| Suprafascial stenosis | 9 (35) | 2 (15) | 0.21 |
| Subfascial stenosis | 1 (4) | 2 (15) | 0.2 |
| Bowel obstruction | 1 (4) | 1 (8) | 0.65 |
| Ileus | 6 (23) | 4 (31) | 0.6 |
| CDG III complication | 15 (58) | 7 (54) | 0.82 |
| Channel revision | 10 (39) | 6 (46) | 0.65 |
| Open |
APV n (%) |
APCV n(%) |
p-value |
| n | 18 (75) | 6 (25) | |
| Suprafascial stenosis | 2 (11) | 1 (17) | 0.72 |
| Subfascial stenosis | 2 (11) | 0 | 0.39 |
|
Bowel obstruction |
1 (6) | 0 | 0.56 |
| Ileus | 5 (28) | 1 (17) | 0.59 |
| CDG III complication | 9 (50) | 3 (50) | 1 |
| Channel revision | 5 (28) | 1 (17) | 0.59 |
CONCLUSIONS
Appendicocecovesicostomy is a new concept with the goal of decreasing channel stenosis. With more patients and longer follow up, we hope to show its benefit to patients.
12:00 - 12:03
S09-4 (OP)
Alkan OKTAR 1, Abdurrahman JAFAROV 1, Mehmet Fatih ÖZKAYA 2, Emre ERDEM 1, Aykut AKINCI 3, Murat Can KARABURUN 4, Tarkan SOYGÜR 5 and Berk BURGU 5
1) Ankara Üniversitesi Tıp Fakültesi, Üroloji, Ankara, TURKEY - 2) Ankara University, Urology, Ankara, TURKEY - 3) Denizli State City Hospital, Pediatric Urology, Denizli, TURKEY - 4) Denizli Acipayam State Hospital, Urology, Denizli, TURKEY - 5) Ankara University, Pediatric Urology, Ankara, TURKEY
PURPOSE
Double Monti and Mitrofanoff procedures,are the current standart for continent catheterizable channels in our daily practice.We specifically examined the post operative onset time,underlying reason and management of stomal incontinence.
MATERIAL AND METHODS
Retrospectively patients that underwent aforementioned procedures and were compliant on follow-ups,between Jan-2000 and Dec-2022 (n = 143),were included in the study.All patients had been followed at 1st,3rd,6th months and then annually.Depending on the onset time of stomal incontinence,patients were categorized into 3 groups (immediate leakage:0-6 months,early-leakage:6-24 months,late-leakage:after24 months).Chi square test was used for statistical analysis.
RESULTS
Accompanied augmentation or type of channel did not reveal any difference in terms of leakage.13% of the patients (n=19)had immeadiate leakage after surgery.All of them are initially followed with anticholinergics.89% of them (n=17)were continent after 2 months without drugs.Remaining 2 patients were continent after bulking agent injection.6.2% of the patients had an early-leak (N = 9.)They were treated initially with anticholinergic medication.The medical treatment was successful only for 11% of patients(n = 1).
Late-leak was seen in 3% of patients (n=4).Among those,1 of them was non-compliant with the CIC schedule,3 patients were after anticholinergic medications.The success rates of treatment modalities were significantly different in 3 groups.(p<0.05)
CONCLUSIONS
Immediate leakage is mainly caused by bladder compliance and overactivity and likely to resolve spontaneously or medication.Whereas leakage after 6 months is very unlikely to respond medication and more likely to indicate an endoscopic intervention. Postponing the revision or injection at the early period is vital. Late-leakage is caused by non-compliance to CIC or bladder conditions and requires adequate tailored approach.
12:03 - 12:06
S09-5 (OP)
Gilmar DE OLIVEIRA GARRONE, Sérgio LEITE OTTONI, Marcela LEAL DA CRUZ, Taiane ROCHA CAMPELO, Renata ALVES CORREA, Emanuelle LIMA MACEDO, Raul GARCIA ARAGON, Rafael JORDAN BALLADARES, Ricardo MARCONDES DE MATTOS and Antonio MACEDO JR.
FEDERAL UNIVERSITY OF SÃO PAULO, NUPEP/CACAU PEDIATRIC UROLOGY, São Paulo, BRAZIL
PURPOSE
The Macedo ileal catheterizable channel (BJU, 2000) consists of an enterocystoplasty with a catheterizable channel precluding the need of the appendix for the outlet. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed by the author in a non-teaching hospital facility after the latest modifications of the procedure.
MATERIAL AND METHODS
Since 2008, we have performed a transverse incision with a semicircular flap to create stomata in the midline and the Yachia maneuver, which consists of crossing two 2-cm rectal muscle flaps in the midline to create a neosphincter over the catheterizable canal. We defined stoma continence if the interval between catheterizations was 4 hours. Early and late complications and reoperation rate were reported.
RESULTS
Of 52 patients. The indications were spinal dysraphism (77.1%), mainly myelomeningocele (67.9%) and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed high-risk bladder pressure in (66%), urinary incontinence (24.5%), bladder exstrophy (1.9%), detrusor hypocontractility (1.9%), incontinent urinary diversion conversion (3.8%). The mean age at the time of surgery was 7.3 years. Stoma continence was 90.6% after the first surgery (48 patients) and stoma revision was performed in 7 cases (4 skin flap revisions). canal and 3 leak revisions: 2 treated with an endoscopic procedure and 1 case with open revision).
CONCLUSIONS
With a follow-up of 7.3 years, we confirmed that the Macedo procedure associated with the Yachia maneuver is associated with 90.6% stoma continence, higher than most procedures.The cosmetic aspect with a small transverse incision (not superior to 5cm) and a midline stoma is another strength of the technique.
12:06 - 12:11
S09-6 (VP)
Bernhard HAID 1, Nina YOUNSI 2 and Raimund STEIN 2
1) Ordensklinikum Linz, Hospital of the Sisters of Charity, Pediatric Urology, Linz, AUSTRIA - 2) Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Center for Pediatric, Adolescent and Reconstructive Urology, Mannheim, GERMANY
PURPOSE
In patients with complex urogenital malformations and unusable or not existing [NY1] bladder outlet, continent catheterizable channels (CCC) are created during childhood. With a known, relatively high long-term complication and revision rate, these stomas are prone to pose problems later in life. However, treatment options are scarce. The intussuscepted ileal nipple was popularized during the late 1980s and 1990s, predominantly in combination with a continent MAINZ-I-reservoir. This video intends to present and review its use and the surgical technique as an isolated stoma replacement.
MATERIAL AND METHODS
The case of a 21-year-old female with multiple prior surgeries and an incontinent CCC in the right lower quadrant after cloacal exstrophy is presented. Surgical revision included the removal of a triple-revised Yang-Monti channel as well as the formation of an intussuscepted ileal nipple and its implantation into the augmented bladder.
RESULTS
The surgery resulted in a wide and continent catheterizable stoma, which could be brought to the umbilicus, respecting the patient’s wish. Three years later, the catheterizable channel is still continent.
CONCLUSIONS
In selected patients, creation of an intussuscepted ileal nipple can be a viable option in stoma revision surgery resulting in flexible and continent catheterizable access. The necessary staples are a manageable disadvantage of this technique.
12:11 - 12:15
S09-7 (LOP)
Nikolai JUUL 1, Oliver WILLACY 1, Mahboobeh AMOUSHAHI 1, Fatemeh AJALLOUEIAN 2, Clara I. CHAMORRO 3 and Magdalena FOSSUM 3
1) Rigshospitalet Copenhagen University Hospital, Laboratory of Tissue Engineering, Division of Pediatric Surgery, Department of Surgery and Transplantation, Copenhagen, DENMARK - 2) Department of Health Technology, Technical University of Denmark, The Danish National Research Foundation and Villum Foundation's Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Kgs. Lyngby, DENMARK - 3) Karolinska Institutet, Laboratory of Tissue Engineering, Department of Women's and Children's Health, Solna, SWEDEN
PURPOSE
Shortness of native tissue demands for alternative treatment strategies in reconstructive malformation surgery. Tissue-engineered scaffolds can be tailored to fit tissue-specific profiles, potentially improving clinical outcomes. In this study, we evaluated the performance of a composite collagen-based tubular scaffold, which was assembled and implanted as a singled-staged procedure in a minipig model. The primary aim was to assess the technical feasibility of the procedure, and the secondary aim was to assess the regenerative performance of micrografted versus acellular scaffolds.
MATERIAL AND METHODS
Ten full-grown female Göttingen minipigs were included. A mesh-reinforced collagen scaffold was tubularized around a biodegradable stent and anastomosed to the anterior bladder wall. In half of the animals (n=5), autologous bladder mucosa micrografts were embedded in the collagen perioperatively, whereas the other half were implanted with acellular but otherwise identical scaffolds. After 6 weeks, the animals were terminated and assessed by cystoscopy and CT-scans before final histology.
RESULTS
The procedure was successfully completed in all animals (mean time 3.2 ±0.6 hours) without postoperative complications, and all implants demonstrated good take at the time of autopsy. We found a tendency towards larger mean luminal areas in the micrografted group compared to acellular scaffolds (6.5 ±0.6 mm2 vs 5.5 ±0.8 mm2, p=0.251). The epithelium expressed urothelial differentiation markers with a tendency towards increased epithelialization in the micrografted group (59.8 ±26.6% vs. 40.5 ±31.1%, p=0.088).
CONCLUSIONS
A one-staged on-site construction and implantation of conduits proved feasible, with positive regenerative outcomes after six weeks. Scaffolds with autologous micrografts demonstrated beneficial effects on luminal size and appearance and could be performed in a standard surgical unit.
12:28 - 12:31
S09-8 (OP)
Raul SOSA 1, Martin KAEFER 2, Randall LOU 3, Richard RINK 2, Rosalia MISSERI 2, Mark CAIN 2, Benjamin WHITTAM 2, Konrad SZYMANSKI 2, Joshua ROTH 2, Pankaj DANGLE 2, Kirstan MELDRUM 2 and Javier BOLANOS 1
1) ROOSEVELT HOSPITAL, PEDIATRIC SURGERY, Guatemala City, GUATEMALA - 2) RILEY HOSPITAL FOR CHILDREN, PEDIATRIC UROLOGY, Indianapolis, USA - 3) ROOSEVELT HOSPITAL, PEDIATRIC NEPHROLOGY, Guatemala City, GUATEMALA
PURPOSE
Continent urinary diversion including bladder augmentation is a mainstay of surgical management for bladder dysfunction refractory to medical management. However, with inadequate social support the risks may outweigh the benefits. In these patients the Enteric Chimney (EC) may be considered to decompress the bladder and simplify care. We present the largest series of ECs to date. We hypothesize EC provides reliable bladder decompression, and that the larger caliber of the colon serves as a more reliable conduit than ileum.
MATERIAL AND METHODS
We reviewed the records of all patients undergoing EC (2003-2022). The proximal end was widely anastomosed to a flap of bladder and the distal end brought out as a budded stoma. Twice weekly irrigations were prescribed to minimize infection and stone formation. Patient demographic, intestinal segment utilized, length of follow up and complications were recorded. Statistical analysis: Fisher’s exact test.
RESULTS
62 children underwent EC (40 ileum / 22 sigmoid). Diagnosis included neurogenic bladder (43), exstrophy variants (8) and other (11). Average age at time of surgery was 9.0 vs 8.7 years. Average follow up was 5.5 vs 3.5 years. Renal function and hydronephrosis (if present) stabilized or improved in all patients. Complications occurred in 14 (20%) and included poor drainage (6), bladder stones (6) and other (2). Colon chimneys experienced fewer complications, but this did not reach statistical significance (Colon 2/22 = 9% vs Ileum 12/40 =30%, p = 0.1) All cases of poor drainage and lithiasis occurred in patients in whom ileum was utilized.
CONCLUSIONS
EC provides reliable, safe bladder drainage. Although there are limitations to this procedure, it has significant benefits as a safe alternative for individuals who are not candidates for bladder augmentation. Colonic segments may have the added advantage of a straighter course and wider stoma, potentially providing more reliable, long-term drainage.
12:31 - 12:34
S09-9 (OP)
Rosalia MISSERI 1, Martin KAEFER 2, Joshua ROTH 2, Konrad SZYMANSKI 3, Benjamin WHITTAM 3, Kirstan MELDRUM 3, Mark CAIN 3 and Richard RINK 3
1) Indiana University School of Medicine, Paediatric Urology, Indianapolis, USA - 2) Indiana University School of Medicine, Pediatric Urology, Indianapolis, USA - 3) Indiana University School of Medicine, Pediatric Urologyric, Indianapolis, USA
PURPOSE
When medical management fails, patients with spina bifida (SB) and hostile neurogenic bladder often undergo augmentation cystoplasty. Some of our augmented patients have subsequently undergone incontinent continent diversions. We sought to determine risk factors for incontinent diversion after bladder augmentation.
MATERIAL AND METHODS
Over 1100 patients with SB have been followed at our institution since 1979. 418 patients with myelomeningocele were augmented between 1979 and 2022. Thirty-three patients (8%) who had previously had bladder augmentations are known to have proceeded to incontinent diversions over the past 20 years.
RESULTS
The median age at augmentation was 9 years and 21.5 years for subsequent incontinent diversion. Fourteen patients had had at least 1 bladder perforation (4 once, 6 twice and 4 thrice). The most common reasons for diversion included: difficulties with adherence to catheterization (6), difficulties catheterizing (3), intractable incontinence (3), non-healing decubiti (2). Additional causes included bladder cancer, uterine prolapse, fistula after cystolithotomy, hematuria dysuria, recurrent UTI, recurrent bladder stones in one patient each. Four patients had simultaneous colostomies. Incontinent diversions included ileal conduit (18), ileal chimney (6), sigmoid conduit (4), sigmoid chimney (3), Indiana pouch (1) and augment converted to incontinent diversion (1). One patient who had perforated and proceeded to diversion requested subsequent undiversion.
CONCLUSIONS
The most common reasons for diversion after bladder augmentation are related to the ability to catheterize or incontinence long after bladder augmentation. This finding underscores the need for long-term care in patients with congenital diseases affecting the urinary tract.