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Augmentation Ureterocystoplasty in Bladder Exstrophy: 5-Year Follow-Up in Two Cases
European Urology
European Urology 42 (2002) 631±634
Augmentation Ureterocystoplasty in Bladder Exstrophy: 5-Year Follow-Up inTwo Cases S. Ahmed*, R. De Castro, R.A. Farhoud, A. El Trai® King Faisal Specialist Hospital, Riyadh, Saudi Arabia Accepted 3 September 2002
Abstract Objective: To report two cases of bladder exstrophy managed successfully by augmentation ureterocystoplasty (UCP) together with bladder neck surgery and continent diversion. Patients: Two boys, age 5 and 1 years respectively, had augmentation UCP. The left re¯uxing megaureter was used in the ®rst case together with bladder neck reconstruction. In the second patient, bilateral obstructed magaureters were used in tandem together with bladder neck division. Both patients had appendicovesicostomy according to Mitrofanoff. Results: In follow-up for over 5 years, both patients are continent with improved upper urinary tracts and normal or stable renal function. They are managed by clean intermittent catheterization (CIC) via the continent stoma with bladder capacities of 220 cc and 150 cc, respectively. Cystogram showed no vesicoureteric re¯ux (VUR). The procedures were considered to be successful although one patient was on oxybutinin because urodynamics showed high intravesical pressures. Conclusions: Augmentation UCP should be considered in patients with bladder exstrophy when a suitable megaureter is available. This may be combined with simultaneous bladder neck reconstruction together with a continent diversion. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Bladder exstrophy; Augmentation; Megaureter; Ureterocystoplasty 1. Introduction Bladder exstrophy patients may be managed by the staged approach, the alternative being the single stage complete repair [1,2]. In staged management, bladder augmentation may be necessary [3,4] for which purpose, the megaureter should be considered when available. However, only six cases of ureterocystoplasty (UCP) have been reported in bladder exstrophy including the two in whom we report a 5-year follow-up [5]. 1.1. Case 1 SA, male, had ®rst stage repair of bladder exstrophy at another institution in the ®rst year of life. He was *
Corresponding author. Present address: Department of Surgery, King Khalid National Guard Hospital, P.O. Box 9515, Jeddah 21423, Kingdom of Saudi Arabia. Tel. 966-2-6240000, ext. 1253; Fax: 966-2-6240000, ext. 2071. E-mail address: [email protected] (S. Ahmed).
referred at 5 years of age for management of total urinary incontinence. Voiding cystourethrogram (VCUG) showed a small 40±50 cc bladder with bilateral re¯uxing megaureters and a wide-open bladder neck (Fig. 1A). Modi®ed Young-Dees-Leadbetter bladder neck reconstruction was undertaken by the technique described previously [4,6]. Almost the entire left ureter was used for UCP, the complete reconstruction including right ureteric re-implantation, left to right trans-uretero-ureterostomy (TUU) and the Mitrofanoff procedure. The ureter and the appendix were reimplanted in vertical tunnels in the native bladder. Postoperative recovery was uneventful. Subsequently the patient also had an epispadias repair. In follow-up for over 5 years the patient was continent on clean intermittent catheterization (CIC) via the stoma. Bladder capacity was 155 cc and there was no vesicoureteric re¯ux (VUR) (Fig. 1B). Urodynamics showed high intravesical pressures and the
0302-2838/02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 2 - 2 8 3 8 ( 0 2 ) 0 0 4 4 0 - 2
632
S. Ahmed et al. / European Urology 42 (2002) 631±634
patient was maintained on oxybutinin. The procedure was considered successful as ultrasound showed reduced hydronephrosis with stable renal function (serum creatinine 137 mmol/l). The patient also was continent on CIC. 1.2. Case 2 MH, aged 1 year, was referred for further management of bladder exstrophy. He had primary ®rst stage repair of bladder exstrophy at another institution at a few weeks of age. This was complicated by severe bilateral ureterohydronephrosis secondary to ureterovesical obstruction necessitating bilateral nephrostomy. However, VCUG also showed bladder neck stricture and delayed VUR (Fig. 2A and B). At operation, the bladder neck was severely scarred, not suitable for reconstruction and was therefore divided. Tandem UCP was performed according to the technique described previously [5]. The complete reconstruction included left ureteric re-implantation, right to left TUU and the Mitrofanoff procedure. The ureter and the appendix were re-implanted in vertical tunnels in the native bladder. Postoperative recovery was uneventful. In follow-up for over 5 years the patient was continent on CIC via the stoma. Cystogram showed no VUR and bladder capacity of 220 cc (Fig. 2C). Ultrasound showed resolution of the hydronephrosis and renal function was normal with a normal serum creatinine. 2. Discussion
Fig. 1. (A) Preoperative VCUG showing small bladder with bilateral VUR. The right ureter (pointer) is faintly opaci®ed. (B) Cystogram via the continent stoma shows a good capacity bladder after ureterocystoplasty. There was no VUR.
The principles of management of bladder exstrophy are well de®ned, staged reconstruction being the conventional surgical option [1]. Newer methods include total one stage reconstruction [2]. In staged management, bladder neck reconstruction is usually undertaken around 4 years of age together with bladder augmentation in a signi®cant number of cases [1,3,4,6]. Bowel segments are usually used but because of the known complications, UCP must be considered when a suitable megaureter is available [7]. However, there are only six published cases of UCP in bladder exstrophy in the literature [5,8±10]. Considering the satisfactory long-term progress of our cases, we conclude that UCP should be considered in bladder exstrophy patients when a suitable re¯uxing or obstructed megaureter is available. The procedure may be combined with bladder neck reconstruction or bladder neck division when necessary [5,11].
S. Ahmed et al. / European Urology 42 (2002) 631±634
633
Fig. 2. (A) Preoperative VCUG showing small bladder with markedly strictured bladder neck. There is faint opaci®cation of left ureter. (B) Delayed ®lm of VCUG shows re¯ux into megaureters bilaterally. (C) Cystogram shows a good capacity bladder after ureterocystoplasty. There was no VUR. Black pointer shows Foley's catheter in Mitrofanoff channel used to ®ll the bladder. Note the stumps of the divided ureters at bladder base (light pointers).
634
S. Ahmed et al. / European Urology 42 (2002) 631±634
References [1] Baker LA, Gearhart JP. The staged approach to bladder exstrophy closure and the role of osteotomies. World J Urol 1998;16:205±11. [2] Grady RW, Carr MC, Mitchell ME. Complete primary closure of bladder exstrophy. Urol Clin NA 1999;26:95±107. [3] De Castro R, Pavanello P, Domini R. Indications for bladder augmentation in the exstrophy±epispadias complex. Br J Urol 1994;73: 303±7. [4] Mansi M, Ahmed S. Young-Dees-Leadbetter bladder neck reconstruction for sphincteric urinary incontinence: the value of augmentation cystoplasty. Scand J Urol Nephrol 1993;27:509±17. [5] Ahmed S, Neel KF, Sen S. Tandem ureterocystoplasty. Aust N Z J Surg 1998;68:203±5. [6] Ahmed S, Fouda-Neel K, Borghol M. Continence after bladder neck reconstruction in patients with bladder exstrophy and pubic diastasis. Br J Urol 1996;77:896±9.
[7] Landau EH, Jayanthi VR, Khoury AE, Churchill BM, Gilmour RF, Steckler RE, et al. Bladder augmentation: ureterocystoplasty versus ileocystoplasty. J Urol 1994;152:716±9. [8] Bellinger MF. Ureterocystoplasty: A unique method for vesical augmentation in children. J Urol 1993;149:811±3. [9] Churchill BM, Aliabadi H, Landau EH, McLorie GA, Steckler RE, McKenna PH, Khoury AE. Ureteral bladder augmentation. J Urol 1993;150:716±20. [10] Hitchcock RJI, Duffy PG, Malone PS. Ureterocystoplasty: The bladder augmentation of choice. Br J Urol 1994;73:575± 9. [11] Hoebeke P, De Kuyper P, Goeminne H, Van Laecke E, Everaert K. Bladder neck closure for treating pediatric incontinence. Eur Urol 2000;38:453±6.
European Urology 42 (2002) 631±634
Augmentation Ureterocystoplasty in Bladder Exstrophy: 5-Year Follow-Up inTwo Cases S. Ahmed*, R. De Castro, R.A. Farhoud, A. El Trai® King Faisal Specialist Hospital, Riyadh, Saudi Arabia Accepted 3 September 2002
Abstract Objective: To report two cases of bladder exstrophy managed successfully by augmentation ureterocystoplasty (UCP) together with bladder neck surgery and continent diversion. Patients: Two boys, age 5 and 1 years respectively, had augmentation UCP. The left re¯uxing megaureter was used in the ®rst case together with bladder neck reconstruction. In the second patient, bilateral obstructed magaureters were used in tandem together with bladder neck division. Both patients had appendicovesicostomy according to Mitrofanoff. Results: In follow-up for over 5 years, both patients are continent with improved upper urinary tracts and normal or stable renal function. They are managed by clean intermittent catheterization (CIC) via the continent stoma with bladder capacities of 220 cc and 150 cc, respectively. Cystogram showed no vesicoureteric re¯ux (VUR). The procedures were considered to be successful although one patient was on oxybutinin because urodynamics showed high intravesical pressures. Conclusions: Augmentation UCP should be considered in patients with bladder exstrophy when a suitable megaureter is available. This may be combined with simultaneous bladder neck reconstruction together with a continent diversion. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Bladder exstrophy; Augmentation; Megaureter; Ureterocystoplasty 1. Introduction Bladder exstrophy patients may be managed by the staged approach, the alternative being the single stage complete repair [1,2]. In staged management, bladder augmentation may be necessary [3,4] for which purpose, the megaureter should be considered when available. However, only six cases of ureterocystoplasty (UCP) have been reported in bladder exstrophy including the two in whom we report a 5-year follow-up [5]. 1.1. Case 1 SA, male, had ®rst stage repair of bladder exstrophy at another institution in the ®rst year of life. He was *
Corresponding author. Present address: Department of Surgery, King Khalid National Guard Hospital, P.O. Box 9515, Jeddah 21423, Kingdom of Saudi Arabia. Tel. 966-2-6240000, ext. 1253; Fax: 966-2-6240000, ext. 2071. E-mail address: [email protected] (S. Ahmed).
referred at 5 years of age for management of total urinary incontinence. Voiding cystourethrogram (VCUG) showed a small 40±50 cc bladder with bilateral re¯uxing megaureters and a wide-open bladder neck (Fig. 1A). Modi®ed Young-Dees-Leadbetter bladder neck reconstruction was undertaken by the technique described previously [4,6]. Almost the entire left ureter was used for UCP, the complete reconstruction including right ureteric re-implantation, left to right trans-uretero-ureterostomy (TUU) and the Mitrofanoff procedure. The ureter and the appendix were reimplanted in vertical tunnels in the native bladder. Postoperative recovery was uneventful. Subsequently the patient also had an epispadias repair. In follow-up for over 5 years the patient was continent on clean intermittent catheterization (CIC) via the stoma. Bladder capacity was 155 cc and there was no vesicoureteric re¯ux (VUR) (Fig. 1B). Urodynamics showed high intravesical pressures and the
0302-2838/02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 2 - 2 8 3 8 ( 0 2 ) 0 0 4 4 0 - 2
632
S. Ahmed et al. / European Urology 42 (2002) 631±634
patient was maintained on oxybutinin. The procedure was considered successful as ultrasound showed reduced hydronephrosis with stable renal function (serum creatinine 137 mmol/l). The patient also was continent on CIC. 1.2. Case 2 MH, aged 1 year, was referred for further management of bladder exstrophy. He had primary ®rst stage repair of bladder exstrophy at another institution at a few weeks of age. This was complicated by severe bilateral ureterohydronephrosis secondary to ureterovesical obstruction necessitating bilateral nephrostomy. However, VCUG also showed bladder neck stricture and delayed VUR (Fig. 2A and B). At operation, the bladder neck was severely scarred, not suitable for reconstruction and was therefore divided. Tandem UCP was performed according to the technique described previously [5]. The complete reconstruction included left ureteric re-implantation, right to left TUU and the Mitrofanoff procedure. The ureter and the appendix were re-implanted in vertical tunnels in the native bladder. Postoperative recovery was uneventful. In follow-up for over 5 years the patient was continent on CIC via the stoma. Cystogram showed no VUR and bladder capacity of 220 cc (Fig. 2C). Ultrasound showed resolution of the hydronephrosis and renal function was normal with a normal serum creatinine. 2. Discussion
Fig. 1. (A) Preoperative VCUG showing small bladder with bilateral VUR. The right ureter (pointer) is faintly opaci®ed. (B) Cystogram via the continent stoma shows a good capacity bladder after ureterocystoplasty. There was no VUR.
The principles of management of bladder exstrophy are well de®ned, staged reconstruction being the conventional surgical option [1]. Newer methods include total one stage reconstruction [2]. In staged management, bladder neck reconstruction is usually undertaken around 4 years of age together with bladder augmentation in a signi®cant number of cases [1,3,4,6]. Bowel segments are usually used but because of the known complications, UCP must be considered when a suitable megaureter is available [7]. However, there are only six published cases of UCP in bladder exstrophy in the literature [5,8±10]. Considering the satisfactory long-term progress of our cases, we conclude that UCP should be considered in bladder exstrophy patients when a suitable re¯uxing or obstructed megaureter is available. The procedure may be combined with bladder neck reconstruction or bladder neck division when necessary [5,11].
S. Ahmed et al. / European Urology 42 (2002) 631±634
633
Fig. 2. (A) Preoperative VCUG showing small bladder with markedly strictured bladder neck. There is faint opaci®cation of left ureter. (B) Delayed ®lm of VCUG shows re¯ux into megaureters bilaterally. (C) Cystogram shows a good capacity bladder after ureterocystoplasty. There was no VUR. Black pointer shows Foley's catheter in Mitrofanoff channel used to ®ll the bladder. Note the stumps of the divided ureters at bladder base (light pointers).
634
S. Ahmed et al. / European Urology 42 (2002) 631±634
References [1] Baker LA, Gearhart JP. The staged approach to bladder exstrophy closure and the role of osteotomies. World J Urol 1998;16:205±11. [2] Grady RW, Carr MC, Mitchell ME. Complete primary closure of bladder exstrophy. Urol Clin NA 1999;26:95±107. [3] De Castro R, Pavanello P, Domini R. Indications for bladder augmentation in the exstrophy±epispadias complex. Br J Urol 1994;73: 303±7. [4] Mansi M, Ahmed S. Young-Dees-Leadbetter bladder neck reconstruction for sphincteric urinary incontinence: the value of augmentation cystoplasty. Scand J Urol Nephrol 1993;27:509±17. [5] Ahmed S, Neel KF, Sen S. Tandem ureterocystoplasty. Aust N Z J Surg 1998;68:203±5. [6] Ahmed S, Fouda-Neel K, Borghol M. Continence after bladder neck reconstruction in patients with bladder exstrophy and pubic diastasis. Br J Urol 1996;77:896±9.
[7] Landau EH, Jayanthi VR, Khoury AE, Churchill BM, Gilmour RF, Steckler RE, et al. Bladder augmentation: ureterocystoplasty versus ileocystoplasty. J Urol 1994;152:716±9. [8] Bellinger MF. Ureterocystoplasty: A unique method for vesical augmentation in children. J Urol 1993;149:811±3. [9] Churchill BM, Aliabadi H, Landau EH, McLorie GA, Steckler RE, McKenna PH, Khoury AE. Ureteral bladder augmentation. J Urol 1993;150:716±20. [10] Hitchcock RJI, Duffy PG, Malone PS. Ureterocystoplasty: The bladder augmentation of choice. Br J Urol 1994;73:575± 9. [11] Hoebeke P, De Kuyper P, Goeminne H, Van Laecke E, Everaert K. Bladder neck closure for treating pediatric incontinence. Eur Urol 2000;38:453±6.