Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1281_Библиотеки_им_академика_М_И_Перельмана
.pdf
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
51
Procedure Indications Contraindications Advantages Disadvantages
Ileocystoplasty Severe bladder
Sigmoid
cystoplasty
Ureteral
cystoplasty
Table 1.
Indications and contraindications of augmentation cystoplasty, advantages and disadvantages.
dysfunction,
refractory cases.
Increased bladder
capacity, severe
vesicoureteral
reflux.
Cases with
severe ureteral
involvement
or specific
anatomical
considerations.
Severe renal
dysfunction,
intestinal issues.
Excessive mucus
production, higher
risk of stone
formation.
Not typically
first-line due to the
complex surgical
nature.
Greater
compliance
and distension
capacity.
Proximity
to bladder,
lower risk of
metabolic
issues.
Utilizes
existing tissue
with minimal
additional
risk.
Risk of metabolic
acidosis, loss of
vitamin B and
bile acids leading to
diarrhea.
Mucus production,
elevated risk of
stone formation,
potential digestive
issues.
Complex surgical
procedure,
potential for
significant
complications.
colon, while the colon’s proximity to the bladder is advantageous. However, the use
of the ileum is associated with potential drawbacks, such as vitamin B and bile acid
loss leading to diarrhea, whereas the colon tends to produce more mucus, thereby
increasing the risk of stone formation (Table ) [–].
Recurrent cases may involve continued or new episodes of incontinence, bladder
infections, or complications arising from the augmentation material. Re-evaluation
of bladder function and potential imaging studies are necessary in these cases.
Treatment options might include additional surgery, medication for infections, and
adjustments to dietary habits. Concretely for urinary tract infections is useful vaccine
prescription [–].
Failure can include persistent bladder dysfunction, severe metabolic issues, or
complications at the surgical site. Revision surgery might be required. It is often
necessary to consult with a multidisciplinary team for comprehensive care, including
urologists, nephrologists, and dietitians, to manage these complications effectively
[–].
. Procedures to decrease bladder outlet resistance
. Transurethral incision of bladder neck
Reducing urethral resistance may be necessary in cases of urethral stricture or
other conditions that impede proper bladder emptying. In children with neurogenic
bladder, reducing urethral resistance may involve various surgical techniques or
minimally invasive procedures, depending on the severity and underlying cause of
the issue. Procedures such as bladder neck resection or incision can establish effective
vesical emptying or reduce detrusor reflex activity [, , , ].
There are no recent publications on the use of these techniques in pediatric
patients with neurogenic bladder.
Pediatric Surgical Procedures – An Updated Guide – Volume I
52
. External sphincterotomy
The indications for external sphincterotomy in these patients include large residual
urine volume, external urinary sphincter pressure higher than the maximum detrusor pressure, a well-developed phallus, and a history of successful external urinary
drainage [, ].
The sphincterotomy can be performed using a pediatric electric resectoscope and
a modified Collin’s knife. The incision is typically made at the and o’clock positions
around the external sphincter, avoiding the and o’clock positions due to the risk
of troublesome bleeding, which is often observed in adult patients [, ].
However, it is important to note that there are no recent publications recommending its use in pediatric patients with neurogenic bladder [, ].
. Urethral stent
There are no recent publications on its use in pediatric patients with neurogenic
bladder.
. Procedures to increase bladder outlet resistance
Sphincteric insufficiency is one of the most common abnormalities in pediatric
neurogenic bladder patients. The effective management of vesical neck incompetence,
and consequently the onset of urinary incontinence, poses a significant challenge for
pediatric urologists. Enhancing bladder outlet resistance, therefore, presents a major
obstacle in the treatment of these patients [, ].
A bladder outlet that lacks strength or is insufficiently functional poses minimal
risk to the upper urinary tract but can lead to significant social issues due to persistent
incontinence. To date, no pharmacological intervention has been proven effective in
augmenting bladder outlet resistance [, ].
The advantages and disadvantages of different treatments for pediatric patients, as
documented in the literature, can be categorized into four groups: injection of bulking
agents, mesh placement, surgical reconfiguration of the vesical neck, and placement
of artificial sphincters [, ].
. Injection of bulking agents
The injection of inert bulking agents for the control of urinary incontinence
was first described by Vorstman et al. using polytetrafluoroethylene. Over the
years, following the implementation of dextranomer/hyaluronic acid (Dx/HA)
for the treatment of vesicoureteral reflux (VUR), its use expanded to treat urinary
incontinence, as it is a non-migratory, non-allergenic, and non-immunogenic
agent [–].
Currently, the best results from injections achieve continence in up to of
cases. In a study conducted on children who had previously undergone bladder
reconstruction, of patients achieved continence with one injection, increasing to
after three injections, with results maintained for months [].
The amount of injected agent typically ranges from .ml to .ml, with injections administered at the , , , and o’clock positions [, ]. The surgical
approach can be performed antegrade (using the Mitrofanoff channel or through
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
53
suprapubic puncture) or retrograde. The antegrade route appears to offer greater
comfort and better direct vision and is preferred by some authors [–]. Monitoring
of intra-abdominal pressure increase during the procedure does not predict the
outcome or its subsequent duration [].
The use of injectables as a first-line treatment is questionable, as most studies are
conducted on children who have previously undergone surgery, and those conducted
on children without surgical history often have a small sample size. However, the
injection of bulking agents does not contraindicate subsequent or synchronous treatments [, ].
Regarding the number of injections, some authors advocate for multiple injections to achieve total continence, while others find no improvement after subsequent
injections [–].
In conclusion, bulking agent injections are not recommended as a primary treatment, as they generally require more than one injection to be effective. However, their
use is not contraindicated following reconstructive surgery or mesh placement, and
they can serve as a complementary option to these treatments [–].
. Sling surgery
The mechanism of urethrosuspension involves compressing the urethra and
elevating it to an intra-abdominal position, thereby increasing passive resistance
to urine outflow and the leak point. The initial procedures in children were
described by McGuire et al. in , using a rectal fascia mesh, and reported
improvements in quality of life and continence by extending the interval between
catheterizations [].
The most commonly used sling is an autologous fascial sling (Figure ). Factors
such as age, sex, and the possibility of future pregnancy are important considerations;
therefore, this procedure is more frequently performed in young women [–].
Figure 4.
Rectus fascia flap principle. Rectus fascia flap (a) placed down urethra to create a sling suspension (b). Bladder
(c). Pubis (d).
Pediatric Surgical Procedures – An Updated Guide – Volume I
54
The placement of fascial slings, either using an autologous fascial strip or synthetic
material, has demonstrated continence rates ranging from to . However, in
males, sling procedures tend to be less successful compared to females. This procedure is typically performed concurrently with bladder augmentation. Catheterization
through a reconstructed bladder neck or a urethra compressed by a sling can be
challenging, leading many surgeons to combine this approach with a continent
catheterizable channel. Unlike autologous slings, artificial slings are associated with a
high complication rate in girls who perform transurethral clean intermittent catheterization [–].
The most recent and extensive review, conducted in by Taskinen et al.,
reported a continence rate of in patients, which is higher than that achieved
with injectable agents but lower than bladder neck closure []. Similar results were
obtained by Chrzan () and Brönnimann (.) [, ].
However, determining the effectiveness of slings alone is complicated, as they are
often accompanied by bladder capacity augmentation surgery or subsequent intermittent catheterization. Jones et al. achieved continence in of patients by combining
bladder augmentation in the same procedure, with a -year follow-up. They concluded that the intervention may be the treatment of choice, but only if simultaneous
bladder augmentation is performed []. Only one study observed similar outcomes
in slings with and without associated enterocystoplasty [].
The recommended surgical technique involves the placement of a –cm
rectus fascia flap with omentum interposition. The detrusor muscle can also be used
[, ]. Garcia Fernández et al. reported an improvement in continence in of
patients following the implantation of a polypropylene mini-sling in young adults
[]. A transvaginal surgical approach is recommended for women, while a perineal
approach is preferred for men to avoid complications [, ].
An important consideration is the likelihood of combining two surgical procedures. For example, in the study by Noordhoff et al., of patients undergoing
intervention required bladder augmentation surgery, with only remaining
continent after years of follow-up [].
Recurrent issues may include ongoing leakage or discomfort post-surgery. Surgical
evaluation may be necessary to determine if the sling needs adjustment or replacement. Additional procedures might be required to address any persistent problems
[, , ].
Failure may involve significant postoperative complications or a complete lack of
improvement, necessitating further surgical interventions. In some cases, alternative treatments such as bladder augmentation or botulinum toxin injections may be
considered [, , ].
In conclusion, sling treatment is effective as a primary option, but to ensure
proper bladder emptying, bladder augmentation surgery or postoperative intermittent catheterization may be needed. Families should be fully informed, and decisions
should be made jointly [–].
. Artificial urinary sphincter
The first artificial urinary sphincter (AUS) surgery was performed by Scott et al. in
. Reported continence rates in the literature have been achieved in approximately
of patients but can reach as high as in carefully selected cases. Ideally,
candidates for AUS are postpubertal individuals capable of spontaneous voiding and
possess the manual dexterity to operate the sphincter-pump mechanism [–].
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
55
In highly selected cases, intermittent catheterization (CIC) through the sphincter in a
bladder that has undergone augmentation may also be feasible [–].
However, a series of steps are required to deactivate the artificial sphincter and primarily empty the bladder via CIC. Erosion rates can reach up to in cases, and revision
rates can potentially reach , depending on the duration of follow-up [–].
The most frequent complications include infection, erosion of adjacent structures,
and device failure. Despite these issues, the durability of the AUS has improved since
its inception []. A bladder with sufficient capacity and distensibility is essential for
the success of AUS, but even in these cases, deterioration can occur after increasing
bladder resistance []. If bladder capacity is insufficient, bladder augmentation
surgery should be considered [].
. Bladder neck reconstruction
Patients who undergo a bladder neck procedure face a risk exceeding of
developing a low-compliance bladder, which may necessitate augmentation. Even
in patients with satisfactory bladder capacity and compliance preoperatively, there
remains a possibility of postoperative changes in bladder function. Approximately
half of these individuals may experience upper urinary tract alterations due to
elevated bladder pressure. Therefore, meticulous postoperative monitoring of
Figure 5.
The Young-Dees-Leadbetter bladder neck reconstruction [34]. (1) Exposed bladder and urethra to allow
for visualization and access, (a) Bilateral ureteroneocystostomy (Cephalotrigonal or cross-trigonal ureteral
reimplantation). Flap of bladder tissue created. (2) Performing a plication of mucosal neourethra layer
surrounding catheter (b). (3) Second layer of bladder tissue closing the cervicoplasty.
Pediatric Surgical Procedures – An Updated Guide – Volume I
56
patients with neurogenic bladder who undergo bladder neck surgery is imperative to
prevent upper urinary tract damage and the onset of chronic renal failure [, ].
The Young-Dees-Leadbetter repair is a surgical procedure designed to correct
urinary incontinence caused by a malfunctioning or incompetent bladder neck by
reconstructing it (Figure ). The procedure involves exposing the bladder and urethra
to allow for visualization and access. Cephalotrigonal or cross-trigonal ureteral reimplantation should be performed to mobilize the ureters in relation to the proposed
bladder neck and correct reflux. The surgeon reconstructs the bladder neck using
various techniques, such as creating a flap of bladder tissue or tightening the muscles
around the bladder neck. While the Young-Dees-Leadbetter procedure can lead to
continence in most cases, it typically requires augmentation cystoplasty for long-term
success [, , , ]. This technique may be the optimal choice for bladder neck
reconstruction because it is technically less challenging than other methods, does not
significantly reduce existing bladder capacity (and even if an augmentation cystoplasty is required, it does not complicate the procedure), and consistently yields good
results [, , , ].
. Bladder neck closure
Bladder neck closure combined with the creation of a continent catheterizable stoma
is often considered the final option to achieve urinary continence in individuals with
persistent urinary incontinence. This procedure is frequently associated with augmentation cystoplasty, due to the potential changes in bladder dynamics following bladder
neck closure and the subsequent increase in retrograde pressure [, , , ].
. Urinary diversion (UD)
. Incontinent UD
Incontinent urinary diversion should be considered in patients with neurogenic
bladder dysfunction and high bladder pressures who are unable or unwilling to perform intermittent bladder catheterization. Options for incontinent urinary diversion
include vesicostomy, and ileal or colonic conduits [, , , , ].
The primary indications for vesicostomy, preferably using a Blocksom stoma,
include elevated bladder pressure in pediatric patients or neonates, challenges in performing bladder catheterization due to caregiver non-compliance, or when urethral
access is exceedingly difficult or impossible due to anatomical or social factors [, ,
, , ].
In children and adolescents, the colonic conduit has been shown to have fewer
complications compared to the ileal conduit [, , , , ].
. Continent UD
Continent urinary diversion should be considered in patients with neurogenic
bladder and total bladder replacement [, ]. The indication for this procedure in
children and adolescents with myelodysplasia and neurogenic bladder dysfunction is
extremely rare but may be necessary in some adults due to secondary malignancies or
complications from previous urinary diversions [, , –].
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
57
Absolute contraindications for continent urinary diversion (UD) include compromised
renal function resulting from long-standing obstruction or chronic renal failure with a
serum creatinine level above –mol/L (.–.mg/dl), severe hepatic dysfunction, compromised intestinal function (e.g., inflammatory bowel disease), and conditions requiring urethrectomy due to disease in the urethra [, , –].
Relative contraindications include mental impairment, external sphincter dysfunction, recurrent urethral strictures, and a history of abdominal or pelvic radiation [,
, –].
Continent reservoirs can be constructed using either small bowel, large bowel,
or a combination of both. The key principles for effective diversion involve opening
and detubularizing the bowel segment. Detubularized bowel segments offer greater
capacity at lower pressure and require a shorter length of intestine compared to intact
segments, thereby mitigating the high-pressure contractions typical of the intestine.
Additionally, urinary reservoirs should be designed with a generous radius to ensure
ample capacity. Collectively, these methodologies result in the formation of a continent urinary reservoir characterized by low pressure and high compliance [–].
Continent urinary diversion procedures can increase the functional capacity of the
bladder, allowing most patients to achieve continence while preserving renal function.
Bladder neck closure is typically unnecessary to achieve urinary continence and may
even eliminate a useful pop-off mechanism. Neocystoureterostomy is not required for
every refluxing ureter unless it can be performed on the original bladder [–].
Continent urinary diversions encompass three primary categories. The first includes
ureterosigmoidostomy, which facilitates urine excretion through evacuation. The second involves orthotopic voiding pouches, suitable for patients with an intact sphincter
mechanism. The third category comprises continent diversions that require catheterization for urine emptying from the created reservoir (Mitrofanoff principle) [].
The complications associated with “neobladder” formation can be categorized into
early and late complications based on the initial surgical procedure, as some complications may not be directly related to the neobladder itself. Bladder stones and stomal
stenosis are the most significant long-term complications in these patients [–].
Nocturnal urinary incontinence is a common issue associated with neobladders,
affecting approximately – of patients. Daytime incontinence occurs less frequently, ranging from less than –. It is worth noting that continence rates tend
to improve over time in “neobladder” patients, likely due to the enhanced capacity of
the neobladder [–].
.. Ureterosigmoidostomy
Ureterosigmoidostomy is a surgical method of urinary diversion that redirects
urine from the lower urinary tract into the sigmoid colon. This continent rectal reservoir technique allows for the storage and excretion of urine through the rectum, using
the anus for continence. Due to its potential for significant metabolic complications,
its use is not typically indicated in pediatric patients [, , –].
.. Orthotopic voiding pouches
All orthotopic “neobladder” operations share common principles. Continence
depends on the preservation of the external sphincteric apparatus, and there is a
risk of urethral cancer recurrence in procedures performed to treat bladder cancer.
Pediatric Surgical Procedures – An Updated Guide – Volume I
58
Thesefactors must be carefully considered when the patient is not a young adult suffering from neurogenic bladder [–].
Continent urinary diversion, particularly the ileocecal pouch formation
(Mainz pouch I), is preferred in patients with suitable physical and psychological
conditions. This approach addresses concerns about long-term safety and patient
satisfaction [–].
In a retrospective study spanning several decades, various forms of urinary
diversion were evaluated in pediatric patients with neurogenic bladder. The results
indicated favorable outcomes with continent diversion techniques, including low
complication rates and high continence rates during both day and night. Surgical
techniques such as submucosal ureteral implantation and ileocecal pouch formation were associated with improved upper urinary tract stability and a reduced
risk of complications compared to traditional bladder augmentation procedures.
Additionally, the reconstruction of the ileocecal valve helped address issues like
increased stool frequency postoperatively [–].
Various segments of the intestine can be utilized to create a neobladder or reservoir. To achieve this, bowel segments are opened and reshaped (detubularized).
This method mitigates the typical high-pressure contractions of the intestine.
Additionally, a larger radius is crafted to ensure greater capacity and lower pressures [].
For example, the ileal neobladder is a distal ileal reservoir that is fully detubularized. A cm segment of the ileum, with preservation of the terminal ileum, is
selected. After rejoining the bowel, the ileal segment is spatulated at its antimesenteric border, forming a U-shaped flap at the anterior mesenteric border to serve as
the new bladder neck. The bowel is then arranged in either an M or W shape, and the
limbs are sutured together. A cm tissue button is excised at the new bladder neck
to create the ileourethral anastomosis. A Foley catheter is then inserted through the
urethra into the ileum, and sutures are used to join the ileal segment to the urethral
stump. LeDuc ureteral implants are placed into the posterior ileal segment, which is
then closed to form the pouch [–].
The Hautmann neobladder, known for its W shape, utilizes non-detubularized
segments that can be left intact at either end of the W, with the ureters individually
implanted into each segment. These reservoirs, characterized by a larger diameter and
lower pressure compared to non-detubularized bowel, have led to enhanced continence rates [–].
Studer et al. introduced a technique for a low-pressure bladder substitute
involving a cm ileal segment. The segment is rotated degrees on its mesentery, allowing the proximal end to reach the right retroperitoneum. Both ends of
the ileum are oversewn, and the distal cm is opened along the antimesenteric
border and folded into a U shape. The posterior section is joined to the limbs of the
U, and standard ureteroileal anastomoses are performed at the apex. The ileal segment is then closed in a cup cystoplasty configuration before being anastomosed to
the urethra [–].
.. Continent catheterizing pouches
Continent urinary diversion (UD) involves creating a catheterizable reservoir
within the abdomen using segments of the ileum, the entire right colon, or a combination of small and large bowel. Patients with adequate hand-eye coordination and
Surgical Approaches in Pediatric Neurogenic Low Urinary Tract Dysfunction
DOI: http://dx.doi.org/10.5772/intechopen.115463
59
cognitive function are suitable candidates for this procedure, as regular catheterization is necessary to prevent complications such as acute renal failure, perforation, and
infection. The catheterization portal is typically located either in the lower abdomen
for cosmetic reasons or at the umbilicus, with the latter preferred for wheelchairbound patients [, , –].
Constructing the continence mechanism for catheterizing pouches is intricate and
involves four primary techniques: appendiceal techniques or ileocecal valve plications
for right colon pouches, tapered or imbricated terminal ileum and ileocecal valve for
right colonic pouches, intussuscepted nipple valves, and hydraulic valves such as the
Benchekroun nipple [–].
.. Mitrofanoff appendicovesicostomy
In , Paul Mitrofanoff’s description of the “trans-appendicular continent
cystostomy,” combined with the clean intermittent catheterization (CIC) technique
introduced by Lapides eight years earlier, revolutionized the treatment of neurogenic
bladder. The Mitrofanoff principle introduced the novel concept of emptying the
bladder via a route other than the urethra [].
Initially, the appendix was the sole bowel segment used for this procedure, typically
accompanied by concurrent closure of the bladder neck. However, due to the occasional
unavailability of the appendix, alternative methodologies based on the Mitrofanoff principle have since evolved, incorporating different intestinal segments. These include the
transverse ileal tube method (Yang-Monti technique), the double tube approach (Monti
technique), and the Casale technique (Monti spiral technique) [, , ].
The Mitrofanoff channel is now employed for a wide range of clinical indications.
These include complex urethral strictures in challenging anatomical locations, cases
where urethral reconstructive surgery is non-viable, traumatic loss with unsuccessful reconstruction attempts, congenital absence of the urethra, conditions such as
posterior urethral valves and Prune Belly syndrome, as well as complex anomalies like
bladder or cloacal exstrophy-epispadias complex. Additionally, it is utilized in managing cases of idiopathic dysfunctional bladder [, , ].
Appendicovesicostomy can be used as an anastomosis in the bladder of a patient
who cannot perform intermittent catheterization via the urethra, as an aid for catheterization of a continent reservoir, bladder augmentation, or as a means of catheterization in the case of cervical closure [, , ].
. Quality of life following the different approaches
Quality of life following different approaches to the treatment of bladder dysfunction in children with neurogenic urinary tract dysfunction can vary significantly
depending on the procedure performed. Below is an overview of how quality of life
may be affected by different approaches, based on the available literature.
. Botulinum toxin injections
• Positive Aspects: Immediate improvement in bladder function and reduction in
episodes of incontinence. The procedure is minimally invasive with a relatively
low risk of complications [, –, ].
Pediatric Surgical Procedures – An Updated Guide – Volume I
60
• Negative Aspects: The effects are temporary, requiring repeated treatments.
Some children may experience discomfort during injections, and occasional side
effects such as urinary tract infections may occur. In this situation an autoimmune vaccine treatment could be useful.
. Sacral neuromodulation and stimulation (SNM)
• Positive Aspects:
Improved Bladder Function: SNM can significantly improve bladder con-
trol by normalizing bladder contractions, reducing urinary frequency and
urgency, and decreasing episodes of incontinence. This can greatly enhance
daily living activities and reduce the psychological stress associated with
incontinence [, , ].
Non-invasive Adjustment: Once the device is implanted, the stimulation
parameters can be adjusted non-invasively, which is convenient for ongoing
management and optimization of therapeutic effects.
• Negative Aspects:
Surgical Risks: As with any surgical procedure, there are risks associated
with the implantation of the neurostimulator, including infection, pain at the
implantation site, and device malfunction.
Follow-up Care: Regular follow-up appointments are necessary to monitor the
device and adjust settings, which can be burdensome for some families.
. Transcutaneous electrical nerve stimulation (TENS)
• Positive Aspects:
Non-invasive Treatment: TENS is non-invasive and relatively simple, allowing
treatment at home and reducing the need for hospital visits [, , ].
Symptom Relief: Significant reductions in symptoms such as urinary fre-
quency, urgency, and incontinence can lead to improved participation in daily
and social activities.
• Negative Aspects:
Temporary Effects: The relief provided by TENS can be temporary, requiring
regular sessions to maintain benefits.
Variable Efficacy: The effectiveness of TENS can vary, with some children
responding better than others.
. Bulking agents
• Positive Aspects:
Соседние файлы в папке Библиотека им академика М.И. Перельмана