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Relationship between the size of the bladder template and the subsequent bladder capacity in bladder exstrophy
Journal of Pediatric Surgery (2012) 47, 380–382
www.elsevier.com/locate/jpedsurg
Relationship between the size of the bladder template and the subsequent bladder capacity in bladder exstrophy Salvatore Arena, Alan P. Dickson, Raimondo M. Cervellione ⁎ Department of Paediatric Urology, Royal Manchester Children's Hospital, Manchester, United Kingdom Received 5 November 2011; accepted 10 November 2011
Key words: Bladder exstrophy; Bladder template; Bladder capacity
Abstract Aim: The aim of this study is to evaluate the relationship between the size of the bladder template in infants born with bladder exstrophy and the subsequent bladder capacity at the age of 1 and 5 years. Materials and Methods: Infants with bladder exstrophy were photographed at birth, and 2 parallel lines were drawn transversally on the photograph across the anterior-superior iliac spines and on the bladder template. The ratio between the 2 lines was calculated, and the bladder templates categorized as (a) small (≥4), (b) medium (3-4), and (c) large (b3). Bladder capacity was subsequently measured at 1 and 5 years and considered satisfactory when 60 mL or greater at the age of 1 year and 100 mL or greater at the age of 5 years. Results: Sixteen patients were identified. At the age of 1 and 5 years, 81% and 94% had achieved a satisfactory bladder capacity, irrespective of their original template group. Nonetheless, those in group C still showed significantly larger capacities at the age of 5 years than those in groups A and B (P b .05). Conclusion: Bladder exstrophy patients, who undergo a successful primary closure, can achieve satisfactory capacities despite smaller bladder templates at birth. © 2012 Elsevier Inc. All rights reserved.
Adequate bladder capacity is considered one of the main goals in the treatment of bladder exstrophy (BE) [1] because it is integral to the achievement of a successful bladder outlet procedure, thereby allowing urethral micturition and continence. A successful initial closure without wound dehiscence, bladder prolapse, or bladder outlet obstruction is the first fundamental step. Previous studies have suggested that after 1 or 2 failed bladder closures, only approximately 60% and 4%, respectively, reach adequate capacity for bladder neck reconstruction [1,2]. Presented at the 58th Annual Meeting of the British Association of Paediatric Surgeons, Belfast, Northern Ireland, July 20-22, 2011. ⁎ Corresponding author. Tel.: +44 161 701 1635; fax: +44 161 701 2928. E-mail address: [email protected] (R.M. Cervellione). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.11.036
“Bladder template” refers to the exposed bladder mucosa in the lower part of the abdomen in patients with BE. It has been suggested that excellent functional results can be expected when the template is “good” [3]. However, no quantitative studies measuring this template have been published. The aim of this study was to obtain an accurate measurement of the bladder template in newborns with BE and to evaluate its relationship with subsequent bladder capacity at the age of 1 and 5 years.
1. Materials and methods Children with classic BE treated at the authors' institution who had preoperative photos taken by the medical illustration service in the newborn period were included in
Size of the bladder template and the subsequent bladder capacity in BE
381
capacity as satisfactory when there was 60 mL or more at the age of 1 year [6] and 100 mL or more at the age of 5 years [3] Nonparametric statistical tests (Kruskal-Wallis, MannWhitney R tests) were used to compare bladder capacities. GraphPad Prism 5 software (GraphPad Software Inc., La Jolla, CA) was used for statistical analysis, and data are quoted as median (range) unless where indicated when a mean (SD) is used. P ≤.05 was considered significant.
2. Results
Fig. 1
Bladder exstrophy ratio.
the study. The infant was kept in supine position, and a standard frontal photo was taken showing abdomen and legs. The picture was printed, and 2 parallel lines were drawn transversally in the image across the anterior-superior iliac spines and on the bladder template (Fig. 1). The ratio between the 2 lines was calculated, and a proportion was given [4]. Infants who experienced a breakdown of the closure were excluded from the study. According to the ratio, infants were divided into 3 groups: group A, small bladder templates with a ratio 4 or more; group B, medium size templates with a ratio 3 or greater, but less than 4; and group C, large templates with a ratio less than 3. Bladder growth was assessed reviewing the cystograms performed at the age of 1 and 5 years. This assessment was done under anesthesia obstructing the bladder neck with a Foley catheter, and the bladder was filled at 20 cm H2O under gravity. When vesicoureteric reflux was present, the volume of the contrast migrated into the ureter was calculated, considering the ureter as a cylinder: (1/2 diameter of the refluxing ureter)2 × π × ureteral length. Ureteral length was calculated using the following formula: 10 + age in years [5]. The diameter of ureter was measured behind the bladder with abdominal ultrasound. The amount of contrast in the ureter in low-grade reflux (grades 1 and 2) was considered irrelevant and was not calculated. The authors considered a bladder Table 1
During the period 2000 to 2005, 24 patients with classic BE were treated, from which 8 were excluded (6 did not have a preoperative photo taken and 2 had failed primary closure). Sixteen (8 males) children from the study group had undergone a modern staged repair with primary neonatal bladder closure with epispadias (in boys) corrected between the age of 24 and 31 months. Vesicoureteric reflux occurred in 8 (50%) at 1 and 5 years. The median (range) ratio between the distance of the anterior-superior iliac spines and the major diameter of the bladder template was 3.16 (1.74-4.85). Their initial bladder template was defined as group A (n = 5), group B (n = 4), and group C (n = 7). At 1 year, 4 (80%) in group A, 3 (75%) in group B, and 6 (86%) in group C had a satisfactory bladder capacity. There was no significant difference between the groups (60 [50-100] vs 70 [35-90] vs and 95 [30-110] mL, respectively; P = .28). At 5 years, 15 (94%) of 16 had a satisfactory bladder capacity. The only patient with an unsatisfactory bladder capacity was originally in group B. There was a significant difference in attained bladder capacity overall with groups A and B being lower than group C (120 [100-150] vs 105 [45165] vs 170 [120-210] mL, respectively [overall P = .04; A vs C, P = .04; B vs C, P = .05]) (Table 1).
3. Discussion The construction of a compliant urinary reservoir of adequate volume preserving the upper urinary tract is the
Demographic details and outcome for infants with classic BE according to initial “bladder template”
Group
Sex
Bladder capacity at 1 y Mean (SD) Median (range)
Bladder capacity at 5 y Mean (SD) Median (range)
Grade III-V vesicoureteric reflux at 1 y
Grade III-V vesicoureteric reflux at 5 y
A
3 ♂, 2 ♀
2 (40%)
2 ♂, 2 ♀
3 (75%)
3 (75%)
C
3 ♂, 4 ♀
120 120 105 105 164 170
2 (40%)
B
72 60 66 70 85 95
2 (29%)
2 (29%)
(22) (50-100) (24) (35-90) (27) (30-110)
(21) (100-150) (49) (45-165) (32) (120-210)
382 primary goal in BE surgery [7]. Primary urinary diversion, with removal of a small exstrophic template, however, is still considered an option [8]. In this study, the authors used an easy and reproducible technique for evaluating the bladder template in infants with BE. Baird et al [9] showed that 84% were dry after bladder neck reconstruction compared with 29% using a cutoff of 100 mL. Using this criterion of bladder capacity, 94% of the children in our study showed a satisfactory (≥100 mL) capacity at 5 years. Thus, BE infants with small templates have a similar chance to achieve a capacity of 100 mL or greater by 5 years of age than the other groups. Nonetheless, those in group C still have measurably larger bladder capacities at 5 years. This study suggests and the authors believe that a BE template that is too small to close in the newborn period should not be immediately removed or diverted [8]. A very small template may preclude neonatal primary reconstruction, and a “watch and wait” approach could be adopted. A delayed exstrophy closure has been shown to be successful probably because the bladder template grows along with the somatic development of the child [10]. We have presented a preliminary report showing that timing of primary closure does not influence the rate of bladder growth, and leaving the bladder extruded for a period of time may not be harmful to the overall health and development of the detrusor muscle or bladder musculature [11]. For these reasons, a delayed BE closure could be a valid alternative to avoid a high-risk primary closure in small bladder template and to maximize the chances of a successful primary closure.
S. Arena et al.
References [1] Surer I, Baker LA, Jeffs RD, et al. Modified Young-Dees-Leadbetter bladder neck reconstruction in patients with successful primary bladder closure elsewhere: a single institution experience. J Urol 2001;165:2438-40. [2] Gearhart JP, Ben-Chaim J, Sciortino C, et al. The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder? Urology 1996;47:240-3. [3] Purves JT, Baird AD, Gearhart JP. The modern staged repair of bladder exstrophy in the female: a contemporary series. J Pediatr Urol 2008;4: 150-3. [4] Cervellione RM, Bianchi A, Dickson AP. Ideas for an accurate measurement of the bladder plate in babies with bladder exstrophy. Presented at 54th British Association of Paediatric Surgeon, Edinburgh, UK, July; 2007. [5] Palmer JS, Palmer LS. What JJ stent length to use? A simple and reliable formula is patient age + 10. Presented at American Academy of Pediatrics 2006, Atlanta GA, 6th-9th October; 2006. [6] Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardization Committee of the International Children's Continence Society. J Urol 2006;176:314-24. [7] Gearhart JP, Peppas DS, Jeffs RD. The application of continent urinary stomas to bladder augmentation or replacement in the failed exstrophy reconstruction. Br J Urol 1995;75:87-90. [8] Pahernik S, Beetz R, Schede J, et al. Rectosigmoid pouch (Mainz Pouch II) in children. J Urol 2006;175:284-7. [9] Baird AD, Nelson CP, Gearhart JP. Modern staged repair of bladder exstrophy: a contemporary series. J Pediatr Urol 2007;3:311-5. [10] Dodson JL, Surer I, Baker LA, et al. The newborn exstrophy bladder inadequate for primary closure: evaluation, management and outcome. J Urol 2001;165:1656-9. [11] Cervellione RM, Baradaran N, Orosco R, et al. Does neonatal bladder exstrophy closure lead to better bladder growth than delayed closure? (Abstract). Presented at European Society of Pediatric Urology 2010, Antalya,Turkey, April; 2010.
www.elsevier.com/locate/jpedsurg
Relationship between the size of the bladder template and the subsequent bladder capacity in bladder exstrophy Salvatore Arena, Alan P. Dickson, Raimondo M. Cervellione ⁎ Department of Paediatric Urology, Royal Manchester Children's Hospital, Manchester, United Kingdom Received 5 November 2011; accepted 10 November 2011
Key words: Bladder exstrophy; Bladder template; Bladder capacity
Abstract Aim: The aim of this study is to evaluate the relationship between the size of the bladder template in infants born with bladder exstrophy and the subsequent bladder capacity at the age of 1 and 5 years. Materials and Methods: Infants with bladder exstrophy were photographed at birth, and 2 parallel lines were drawn transversally on the photograph across the anterior-superior iliac spines and on the bladder template. The ratio between the 2 lines was calculated, and the bladder templates categorized as (a) small (≥4), (b) medium (3-4), and (c) large (b3). Bladder capacity was subsequently measured at 1 and 5 years and considered satisfactory when 60 mL or greater at the age of 1 year and 100 mL or greater at the age of 5 years. Results: Sixteen patients were identified. At the age of 1 and 5 years, 81% and 94% had achieved a satisfactory bladder capacity, irrespective of their original template group. Nonetheless, those in group C still showed significantly larger capacities at the age of 5 years than those in groups A and B (P b .05). Conclusion: Bladder exstrophy patients, who undergo a successful primary closure, can achieve satisfactory capacities despite smaller bladder templates at birth. © 2012 Elsevier Inc. All rights reserved.
Adequate bladder capacity is considered one of the main goals in the treatment of bladder exstrophy (BE) [1] because it is integral to the achievement of a successful bladder outlet procedure, thereby allowing urethral micturition and continence. A successful initial closure without wound dehiscence, bladder prolapse, or bladder outlet obstruction is the first fundamental step. Previous studies have suggested that after 1 or 2 failed bladder closures, only approximately 60% and 4%, respectively, reach adequate capacity for bladder neck reconstruction [1,2]. Presented at the 58th Annual Meeting of the British Association of Paediatric Surgeons, Belfast, Northern Ireland, July 20-22, 2011. ⁎ Corresponding author. Tel.: +44 161 701 1635; fax: +44 161 701 2928. E-mail address: [email protected] (R.M. Cervellione). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.11.036
“Bladder template” refers to the exposed bladder mucosa in the lower part of the abdomen in patients with BE. It has been suggested that excellent functional results can be expected when the template is “good” [3]. However, no quantitative studies measuring this template have been published. The aim of this study was to obtain an accurate measurement of the bladder template in newborns with BE and to evaluate its relationship with subsequent bladder capacity at the age of 1 and 5 years.
1. Materials and methods Children with classic BE treated at the authors' institution who had preoperative photos taken by the medical illustration service in the newborn period were included in
Size of the bladder template and the subsequent bladder capacity in BE
381
capacity as satisfactory when there was 60 mL or more at the age of 1 year [6] and 100 mL or more at the age of 5 years [3] Nonparametric statistical tests (Kruskal-Wallis, MannWhitney R tests) were used to compare bladder capacities. GraphPad Prism 5 software (GraphPad Software Inc., La Jolla, CA) was used for statistical analysis, and data are quoted as median (range) unless where indicated when a mean (SD) is used. P ≤.05 was considered significant.
2. Results
Fig. 1
Bladder exstrophy ratio.
the study. The infant was kept in supine position, and a standard frontal photo was taken showing abdomen and legs. The picture was printed, and 2 parallel lines were drawn transversally in the image across the anterior-superior iliac spines and on the bladder template (Fig. 1). The ratio between the 2 lines was calculated, and a proportion was given [4]. Infants who experienced a breakdown of the closure were excluded from the study. According to the ratio, infants were divided into 3 groups: group A, small bladder templates with a ratio 4 or more; group B, medium size templates with a ratio 3 or greater, but less than 4; and group C, large templates with a ratio less than 3. Bladder growth was assessed reviewing the cystograms performed at the age of 1 and 5 years. This assessment was done under anesthesia obstructing the bladder neck with a Foley catheter, and the bladder was filled at 20 cm H2O under gravity. When vesicoureteric reflux was present, the volume of the contrast migrated into the ureter was calculated, considering the ureter as a cylinder: (1/2 diameter of the refluxing ureter)2 × π × ureteral length. Ureteral length was calculated using the following formula: 10 + age in years [5]. The diameter of ureter was measured behind the bladder with abdominal ultrasound. The amount of contrast in the ureter in low-grade reflux (grades 1 and 2) was considered irrelevant and was not calculated. The authors considered a bladder Table 1
During the period 2000 to 2005, 24 patients with classic BE were treated, from which 8 were excluded (6 did not have a preoperative photo taken and 2 had failed primary closure). Sixteen (8 males) children from the study group had undergone a modern staged repair with primary neonatal bladder closure with epispadias (in boys) corrected between the age of 24 and 31 months. Vesicoureteric reflux occurred in 8 (50%) at 1 and 5 years. The median (range) ratio between the distance of the anterior-superior iliac spines and the major diameter of the bladder template was 3.16 (1.74-4.85). Their initial bladder template was defined as group A (n = 5), group B (n = 4), and group C (n = 7). At 1 year, 4 (80%) in group A, 3 (75%) in group B, and 6 (86%) in group C had a satisfactory bladder capacity. There was no significant difference between the groups (60 [50-100] vs 70 [35-90] vs and 95 [30-110] mL, respectively; P = .28). At 5 years, 15 (94%) of 16 had a satisfactory bladder capacity. The only patient with an unsatisfactory bladder capacity was originally in group B. There was a significant difference in attained bladder capacity overall with groups A and B being lower than group C (120 [100-150] vs 105 [45165] vs 170 [120-210] mL, respectively [overall P = .04; A vs C, P = .04; B vs C, P = .05]) (Table 1).
3. Discussion The construction of a compliant urinary reservoir of adequate volume preserving the upper urinary tract is the
Demographic details and outcome for infants with classic BE according to initial “bladder template”
Group
Sex
Bladder capacity at 1 y Mean (SD) Median (range)
Bladder capacity at 5 y Mean (SD) Median (range)
Grade III-V vesicoureteric reflux at 1 y
Grade III-V vesicoureteric reflux at 5 y
A
3 ♂, 2 ♀
2 (40%)
2 ♂, 2 ♀
3 (75%)
3 (75%)
C
3 ♂, 4 ♀
120 120 105 105 164 170
2 (40%)
B
72 60 66 70 85 95
2 (29%)
2 (29%)
(22) (50-100) (24) (35-90) (27) (30-110)
(21) (100-150) (49) (45-165) (32) (120-210)
382 primary goal in BE surgery [7]. Primary urinary diversion, with removal of a small exstrophic template, however, is still considered an option [8]. In this study, the authors used an easy and reproducible technique for evaluating the bladder template in infants with BE. Baird et al [9] showed that 84% were dry after bladder neck reconstruction compared with 29% using a cutoff of 100 mL. Using this criterion of bladder capacity, 94% of the children in our study showed a satisfactory (≥100 mL) capacity at 5 years. Thus, BE infants with small templates have a similar chance to achieve a capacity of 100 mL or greater by 5 years of age than the other groups. Nonetheless, those in group C still have measurably larger bladder capacities at 5 years. This study suggests and the authors believe that a BE template that is too small to close in the newborn period should not be immediately removed or diverted [8]. A very small template may preclude neonatal primary reconstruction, and a “watch and wait” approach could be adopted. A delayed exstrophy closure has been shown to be successful probably because the bladder template grows along with the somatic development of the child [10]. We have presented a preliminary report showing that timing of primary closure does not influence the rate of bladder growth, and leaving the bladder extruded for a period of time may not be harmful to the overall health and development of the detrusor muscle or bladder musculature [11]. For these reasons, a delayed BE closure could be a valid alternative to avoid a high-risk primary closure in small bladder template and to maximize the chances of a successful primary closure.
S. Arena et al.
References [1] Surer I, Baker LA, Jeffs RD, et al. Modified Young-Dees-Leadbetter bladder neck reconstruction in patients with successful primary bladder closure elsewhere: a single institution experience. J Urol 2001;165:2438-40. [2] Gearhart JP, Ben-Chaim J, Sciortino C, et al. The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder? Urology 1996;47:240-3. [3] Purves JT, Baird AD, Gearhart JP. The modern staged repair of bladder exstrophy in the female: a contemporary series. J Pediatr Urol 2008;4: 150-3. [4] Cervellione RM, Bianchi A, Dickson AP. Ideas for an accurate measurement of the bladder plate in babies with bladder exstrophy. Presented at 54th British Association of Paediatric Surgeon, Edinburgh, UK, July; 2007. [5] Palmer JS, Palmer LS. What JJ stent length to use? A simple and reliable formula is patient age + 10. Presented at American Academy of Pediatrics 2006, Atlanta GA, 6th-9th October; 2006. [6] Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardization Committee of the International Children's Continence Society. J Urol 2006;176:314-24. [7] Gearhart JP, Peppas DS, Jeffs RD. The application of continent urinary stomas to bladder augmentation or replacement in the failed exstrophy reconstruction. Br J Urol 1995;75:87-90. [8] Pahernik S, Beetz R, Schede J, et al. Rectosigmoid pouch (Mainz Pouch II) in children. J Urol 2006;175:284-7. [9] Baird AD, Nelson CP, Gearhart JP. Modern staged repair of bladder exstrophy: a contemporary series. J Pediatr Urol 2007;3:311-5. [10] Dodson JL, Surer I, Baker LA, et al. The newborn exstrophy bladder inadequate for primary closure: evaluation, management and outcome. J Urol 2001;165:1656-9. [11] Cervellione RM, Baradaran N, Orosco R, et al. Does neonatal bladder exstrophy closure lead to better bladder growth than delayed closure? (Abstract). Presented at European Society of Pediatric Urology 2010, Antalya,Turkey, April; 2010.