- Email: [email protected]
Bricker Conduit for Pediatric Urinary Diversion—Should we Still Offer It?
Bricker Conduit for Pediatric Urinary DiversiondShould we Still Offer It? Ahmed Abdelhalim,* Ahmed M. Elshal, Amr A. Elsawy, Tamer E. Helmy, Hesham A. Orban, Mohamed E. Dawaba and Ashraf T. Hafez From the Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
Abbreviations and Acronyms CKD ¼ chronic kidney disease eGFR ¼ estimated glomerular filtration rate QoL ¼ quality of life Accepted for publication May 3, 2015. Study received internal review board approval. * Correspondence: Department of Urology, Urology and Nephrology Center, Mansoura University, Gomhoria S., 35516, Egypt (telephone: 20-10-01349367; FAX: 20-50-2263717; e-mail: [email protected]).
See Editorial on page 1190.
Purpose: We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. Materials and Methods: We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. Results: We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean SD baseline (64.5 46 ml/minute/1.73 m2) and last followup estimated glomerular filtration rate (54.1 44.9 ml/minute/1.73 m2), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications. Conclusions: The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population. Key Words: child, glomerular filtration rate, quality of life, urinary diversion
URINARY diversion has revolutionized the treatment of patients with lower urinary tract dysfunction, anomalies or malignancy. Aimed at preserving
1414
j
www.jurology.com
renal function and achieving dryness, unprecedented advances have been achieved in the field of urinary diversion in the last few decades. The
0022-5347/15/1945-1414/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.05.028 Vol. 194, 1414-1419, November 2015 Printed in U.S.A.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
initial enthusiasm for conduit diversion to treat children with lower urinary tract dysfunction has been tempered by the high frequency of complications and the risk of upper tract deterioration.1 Despite the potential risks, conduit diversion remains a reasonable choice for a small subset of patients. Children who are too young to undergo continent urinary reservoir, those lacking reliable family support and those with poor manual dexterity, mental disability or short life expectancy are in need of tubeless, low pressure drainage that does not require intermittent catheterization.2,3 Furthermore, bladder augmentation or continent reservoirs may be problematic in the setting of renal insufficiency,4 and recalls the use of conduit diversion. Several studies have shown high complication rates when ileal conduits are used in children with neuropathic bladder, including renal deterioration, upper tract calculi, pyocystitis and peristomal complications.1 However, the majority of these studies, conducted several decades ago, have focused on morphological renal deterioration and the crude measurement of serum creatinine without accurate estimation of renal function. In addition, the impact of diversion on growth trends and quality of life in patients and their caregivers have not been adequately investigated. We evaluated whether the Bricker conduit diversion could reliably protect the upper tract and prevent the steep decline in renal function in children offered the procedure. Moreover, the potential impact on linear growth and QoL, and anticipated long-term complications were weighed against renal function outcome.
PATIENTS AND METHODS Following internal review board approval we retrieved the electronic files of children who underwent ileal conduit for urinary diversion at a pediatric urology tertiary referral unit between 1981 and 2011. Patient files were reviewed for gender, age at surgery, indication for diversion, baseline renal function, preoperative imaging studies, surgical details, postoperative recovery, readmission rates and followup data. Furthermore, patients were invited to up-to-date followup visits. Patients who were older than 18 years at surgery and those with less than 1 year of followup were excluded from analysis. Renal function was the primary outcome of the study, while diversion related complications, linear growth effect, readmission rates and quality of life were considered secondary outcomes. End points of the study were death, undiversion to continent reservoir and last followup date.
Procedure After sparing the last 10 cm of the terminal ileum a 15 to 20 cm ileal segment was isolated. The bowel continuity was reestablished and the mesenteric defect was closed. The distal end of the isolated bowel segment was
1415
mobilized and exteriorized at a predetermined site on the abdominal wall. An everting nipple was created. The ureters were mobilized and anastmosed to the proximal end of the conduit using either the Bricker or Wallace technique. The conduit was drained using a Foley catheter for 5 days and the ureteroileal anastmoses were stented for 7 to 8 days.
Outcome Measures Baseline and followup renal function was evaluated using eGFR or 99mtechnetium mercaptoacetyltriglycine isotope renal scans, if available. eGFR was calculated using an online calculator (http://nkdep.nih.gov/lab-evaluation/ gfr-calculators.shtml) based on the modified Schwartz formula or MDRD formula for patients entering adulthood at followup. The mean of 3 sequential eGFR measurements was used to study the outcome. The severity of chronic kidney disease was staged according to the National Kidney FoundationÒ Kidney Disease Outcomes Quality Initiative staging system.5 The Society for Fetal Urology grading system was used to assess severity of hydronephrosis.6 Patient growth charts were reviewed to observe growth trends. Egyptian children’s growth (height-for-age) charts served as a reference. Linear growth was considered stunted if patient height was below the 10th percentile for age and gender, or crossing 2 or more major percentile curves on the charts. The Mansoura QoL questionnaire was used to evaluate patient and family satisfaction regarding the procedure.7,8 The questionnaire has been modulated to fit the method of urine evacuation. The modified version of the questionnaire consists of 6 items, each assigned a score of 1 to 3 (supplementary table 1, http://jurology.com/), giving a possible maximum of 18 points (excellent degree of wellbeing). Poor QoL was defined as a QoL questionnaire score of 12 or less. A neutral third party (stoma therapist) questioned the children and their caregivers about the questionnaire items through direct interview at last followup visit. Although the questionnaire is not validated, it gave a meaningful idea about the satisfaction of patients and families regarding urinary diversion.
Statistical Analysis Continuous variables were expressed as mean SD or median (range) according to normality, while categorical variables were described as frequencies (percentages) in each category. Paired t-test and repeated measures ANOVA were used when indicated for comparison of continuous variables across time intervals. Statistical analysis was done using SPSSÒ, version 20. All tests were 2-tailed with statistical significance considered at p <0.05.
RESULTS A total of 36 children underwent Bricker conduit at our institution between 1981 and 2011. After exclusion of patients with less than 1 year of followup 29 patients were included in the analysis. Of these patients 19 (65.5%) were male. Neuropathic bladder was the underlying diagnosis in 21 patients (72.4%). Median age at surgery was 10 years (range
1416
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
2 to 18). Ureteroileal anastomosis was done using the Bricker technique in 17 patients (58.6%) and the Wallace technique in the remainder. Patients were followed for a median of 91 months (range 16 to 389). Baseline demographics are outlined in table 1. At last followup hydronephrosis improved or remained stable in 39 of 55 renal units (70.9%; 3 patients had solitary kidneys at diversion). No statistically significant difference was observed when comparing mean SD baseline (64.5 46 ml/ minute/1.73 m2) and last followup eGFR (54.1 44.9 ml/minute/1.73 m2, p ¼ 0.073). Furthermore, patients with stage 4 or 5 CKD had no statistically significant difference in median percent change in eGFR (median 25%, range 1.8% to 77%) compared to those with lower baseline CKD stages (21%, 1.7% to 88%, p ¼ 0.72). However, 13 patients (44.8%) had worsening of CKD by 1 or more stages, compared to only 4 (13.8%) who had improvement of preoperative CKD stage. Prevalence of CKD stages in the study cohort at baseline and last followup is illustrated in the figure. Eventually 11 patients (37.9%) had stage 5 CKD, of whom 2 received renal allotransplantation. Metabolic acidosis was observed in 11 patients, all with end-stage kidney disease. Nine patients were deceased at the study conclusion, of whom 7 died of chronic renal failure, 1 of recurrent malignant disease and 1 of unknown cause. After stabilization of Table 1. Baseline patient characteristics Median yrs age (range) No. gender (%): Male Female No. indication for diversion (%): Neuropathic bladder Bladder exstrophy/epispadias Rhabdomyosarcoma of bladder/prostate Hypoplastic bladder Nonreconstructable bladder/urethral injuries Posterior urethral valves No. previous augmentation/diversion (%): Augmentation ileocystoplasty Cutaneous vesicostomy Rectal diversion Cutaneous ureterostomy Median mg/dl baseline serum creatinine (range) Median ml/min/1.73 m2 baseline eGFR (range) No. baseline CKD stage (%): 0 1 2 3 4 5 No. preop hydronephrosis grade (%):* 0 I II III IV Median mos followup (range) * Three patients had solitary kidneys at diversion.
10
(2e18)
19 10
(65.5) (34.5)
21 2 2 2 1 1
(72.4) (6.9) (6.9) (6.9) (3.4) (3.4)
2 (6.9) 2 (6.9) 2 (6.9) 1 (3.4) 1.6 (0.3e9.3) 44.6 (9.7e178) 4 3 6 8 6 2
(13.8) (10.3) (20.7) (27.6) (20.7) (6.9)
9 9 10 12 15 91
(16.4) (16.4) (18.2) (21.8) (27.3) (16e389)
renal function 6 patients underwent augmentation ileocystoplasty and continent cutaneous diversion at a median age of 9.3 years (range 3.4 to 16.9) after a mean of 118 months of conduit diversion (46 to 180). At undiversion the median eGFR was 105.5 ml/ minute/1.73 m2 (range 60 to 178). All of these patients fared well after undiversion except for 1 who had progressive renal deterioration and eventually underwent living donor renal transplantation. When patient growth charts were reviewed, 10 patients (34.5%) were below the 10th percentile of height for age and gender, and 2 additional patients crossed 2 or more major percentile curves toward stunting. Mean SD QoL questionnaire score was 13.1 2.3. Based on our QoL questionnaire, 17 of 20 patients who completed the questionnaire (85%) reported poor QoL. A total of 19 hospital readmissions were reported in 14 patients for treatment of diversion related complications. Table 2 lists early and late complications of Bricker conduit diversion (graded according to modified Clavien system) and their management.
DISCUSSION Ileal conduit diversion was initially described in 1935 and popularized by Bricker in 1950.9 The technique has gained wide acceptance due to its simplicity and the relatively low complication rate. It is the most commonly used urinary diversion technique worldwide and is still considered the standard diversion method for adults with muscle invasive bladder cancer against which all other methods are compared.10 In the 1970s conduit diversion was widely adopted to treat children with neuropathic lower urinary tract dysfunction. Unfortunately the results did not meet expectations, and the use of conduit diversion was largely abandoned in children due to the risk of renal deterioration and the increased number of complications. Before the final endorsement of urinary diversion in a child the simplicity of the diversion technique should be weighed against the expected shortcomings. In other words, some critical points should always be considered, including the impact on renal function, the long-term consequences of urinary diversion such as electrolyte imbalance and effect on linear growth, achievement of independence as children grow into adulthood and the need for revision surgery. Some clinical studies conducted several decades ago assessed the outcome of Bricker conduit diversion in children. The majority of these studies centered on renal deterioration based on radiological criteria, omitting functional assessment. Moreover, the effect on linear growth and the impact of diversion on patient and family QoL were overlooked.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
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Prevalence of CKD stages at baseline and at last followup
Despite the simplicity of the Bricker conduit diversion, the detrimental effect on renal function remains a potential concern. Intractable upper tract dilatation was reported in up to 60% of renal units in children with a Bricker conduit, especially with longer followup.11e14 Even previously normal renal units were not protected against deterioration. Interestingly deterioration was sometimes not attributable to ureteroileal strictures or loop Table 2. Early and late postoperative complications based on modified Clavien grading system Complications Grade I (transient increase in serum creatinine) Grade II: Early postop sepsis Pyelonephritis Prolonged ileus Intestinal obstruction Upper tract stones Peristomal dermatitis Grade IIIa: Pyonephrosis Upper tract stones Grade IIIb: Intestinal obstruction Upper tract stones Stomal prolapse Grade IVa (end-stage kidney disease)* Grade V (death)†
No. Episodes (No. cases)
Management
5 (4)
Adequate hydration, discontinuation of nephrotoxic drugs, monitoring
4 4 3 1 2
6 (6)
Antibiotic treatment Antibiotic treatment Suction þ drip Suction þ drip Oral dissolution therapy (potassium citrate) Skin care
1 (1) 1 (1)
Nephrostomy tube drainage Extracorporeal shock wave lithotripsy
1 2 1 9
Abdominal exploration þ adhesiolysis Pyelolithotomy Revision of stoma Renal replacement therapy (dialysis or renal transplantation)
(4) (2) (3) (1) (2)
(1) (1) (1) (9)
7 (7)
* eGFR less than 15 ml/min/1.73 m2. † Seven patients died of chronic renal failure complications after a median of 80 months (range 4 to 248).
redundancy. Some authors claim that the use of nonrefluxing colon conduit may offer a more favorable renal function outcome.15 However, this claim has been refuted by others.16,17 Nonetheless, more than 1 clinical study supports that enterocystoplasty is not inherently deleterious to the upper tracts, even in patients with impaired renal function.18 In this study worsening of hydronephrosis was observed in 16 of 55 renal units (29.1%) after an average followup of more than 7 years. Only 1 previously normal renal unit exhibited new onset hydronephrosis at followup. While no statistically significant difference was observed between baseline and followup eGFR, conduit diversion failed to halt the progression of renal insufficiency in 3 patients with stage 3 and 5 with stage 4 CKD. Endstage kidney disease ultimately developed in those patients, who consequently required dialysis or renal transplantation. However, progression of the preexisting renal damage and exposure to nephrotoxic agents in patients with malignant disease could have contributed to the worsening renal failure in addition to conduit diversion. The effect on linear growth is another issue of potential concern when considering incorporation of intestinal segments into the urinary tract of growing children, even with incontinent diversion.14,19 Of a series of 183 children treated with intestinal cystoplasty linear growth retardation was noted in 20%. These changes occurred even in the absence of serious metabolic derangements.20 Similar results
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BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
were observed in patients with exstrophy treated with enterocystoplasty.21 In contrast, Taskinen et al found no adverse effects of enterocystoplasty on linear growth.22 In another large series of enterocystoplasty half of the patients with initial growth retardation regained or surpassed their preoperative position on the growth charts on subsequent followup. Furthermore, enterocystoplasty could not be considered the sole cause in patients with a clinically significant effect on growth.23 There has been recent evidence that continued normal or near normal linear growth may be maintained in children with urinary diversion at the expense of bone demineralization.24 In our series linear growth was negatively impacted in 12 patients, including 10 with a neuropathic bladder, 1 with rhabdomyosarcoma and 1 with posterior urethral valves. However, it is difficult to attribute stunting solely to ileal conduits, because a similar growth effect was documented in other series in controls with myelodysplasia and bladder exstrophy.22 Additionally stunted growth may be explained by familial factors, renal failure, repeated urinary tract infections and administration of chemotherapy and/or radiotherapy in patients with rhabdomyosarcoma. By comparison, 5 patients had surpassed their preoperative position on the growth charts at last followup. Finally, body image, general well-being and patient independence should not be overlooked when considering urinary diversion in a child, due to the fact that QoL of patients and/or their families might be severely impacted by the diversion technique. Despite the presence of a large body of literature addressing health related QoL after urinary diversion in adults, these studies have not reliably shown that conduit diversion is inferior to other diversion methods, including orthotopic and continent cutaneous diversion, in terms of QoL.25 In the absence of a standard assessment tool, and due to the paucity of literature addressing QoL issues in pediatric urinary diversion, we used a simple internally designed QoL questionnaire to measure overall patient satisfaction regarding diversion, independence in caring for the stoma and appliance, and impact on physical and social wellbeing. Of the 20 patients who responded to the questionnaire 17 (85%) reported poor QoL and 19 expressed a desire to undergo another method of
diversion. In addition to distorted body image, progressive renal deterioration with the need for dialysis or transplantation, recurrent pyelonephritis and peristomal complications, and the need for revision surgery have all contributed to poor QoL. Conversely 84% of our patients treated with continent catheterizable stomas reported good QoL and satisfaction with the procedure.7 Similarly high levels of satisfaction have been reported in the majority of clinical studies assessing QoL in children with continent urinary diversion. Supplementary table 2 (http://jurology.com/) summarizes the results of the current study and other series addressing urinary diversion in children, with special emphasis on renal function outcomes and QoL issues.7,8,11,12,14,16,17,26e30 Some limitations of our study must be acknowledged. Selection bias and missing data points are inherent defects of any retrospective study. The smaller number of patients and the relatively shorter followup compared to other series may underestimate the complications and the risk of renal deterioration. However, these studies were performed several decades ago and lacked proper functional assessment of the upper tracts and QoL evaluation. Growth pattern and renal function deterioration may be influenced by a number of factors that have not been controlled for in this retrospective study. Because the procedure is rarely performed in the modern era, a valid subgroup analysis to eliminate confounders was not possible. Finally, a nonvalidated questionnaire was used to assess QoL. However, despite these shortcomings, this study offers valuable data in the absence of contemporary evaluations of ileal conduit diversion in children.
CONCLUSIONS The Bricker conduit does not seem to guard against renal deterioration in predisposed patients. Therefore, compromised renal function does not seem to be a justifiable indication for ileal conduit diversion in children with lower urinary tract dysfunction. Significant burdens of the procedure on patient growth, body image and QoL place the Bricker conduit at the bottom of the list among urinary diversion techniques. Whenever used, dedicated, lifelong, close followup is warranted.
REFERENCES 1. Cass AS, Luxenberg M, Gleich P et al: A 22-year followup of ileal conduits in children with a neurogenic bladder. J Urol 1984; 132: 529.
2. Cain MP, Metcalfe PD and Rink RC: Urinary diversion. In: The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, 5th ed. Edited by
SG Docimo, DA Canning and AE Khoury. London: Informa Healthcare UK Ltd 2007; chapt 57, pp 911e946.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
3. Westney OL: The neurogenic bladder and incontinent urinary diversion. Urol Clin North Am 2010; 37: 581.
13. Graham AG: Long-term results of ileal conduit diversion in childrenda brighter picture? Br J Urol 1982; 54: 632.
4. Alfrey EJ, Salvatierra O Jr, Tanney DC et al: Bladder augmentation can be problematic with renal failure and transplantation. Pediatr Nephrol 1997; 11: 672.
14. Koch MO, McDougal WS, Hall MC et al: Long-term metabolic effects of urinary diversion: a comparison of myelomeningocele patients managed by clean intermittent catheterization and urinary diversion. J Urol 1992; 147: 1343.
5. Whyte DA and Fine RN: Chronic kidney disease in children. Pediatr Rev 2008; 29: 335. 6. Fernbach SK, Maizels M and Conway JJ: Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol 1993; 23: 478. 7. Elshal AM, Abol-Enein H, Sarhan O et al: Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail. J Urol 2011; 185: 1083. 8. Elshal AM, Abdelhalim A, Hafez AT et al: Ileal urinary reservoir in pediatric population: objective assessment of long-term sequelae with time-to-event analysis. Urology 2012; 79: 1126. 9. Bricker EM: Bladder substitution after pelvic evisceration. Surg Clin North Am 1950; 30: 1511. 10. Hautmann RE, Abol-Enein H, Lee CT et al: Urinary diversion: how experts divert. Urology 2015; 85: 233. 11. Shapiro SR, Lebowitz R and Colodny AH: Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology. J Urol 1975; 114: 289. 12. Pitts WR Jr and Muecke EC: A 20-year experience with ileal conduits: the fate of the kidneys. J Urol 1979; 122: 154.
15. Stein R, Wiesner C, Beetz R et al: Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience. Part III: colonic conduit. Pediatr Nephrol 2005; 20: 932. 16. Elder DD, Moisey CU and Rees RW: A long-term follow-up of the colonic conduit operation in children. Br J Urol 1979; 51: 462. 17. Husmann DA, McLorie GA and Churchill BM: Nonrefluxing colonic conduits: a long-term lifetable analysis. J Urol 1989; 142: 1201. 18. Ivancic V, Defoor W, Jackson E et al: Progression of renal insufficiency in children and adolescents with neuropathic bladder is not accelerated by lower urinary tract reconstruction. J Urol, suppl., 2010; 184: 1768. 19. McDougal WS: Metabolic complications of urinary intestinal diversion. J Urol 1992; 147: 1199. 20. Wagstaff KE, Woodhouse CR, Duffy PG et al: Delayed linear growth in children with enterocystoplasties. Br J Urol 1992; 69: 314. 21. Feng AH, Kaar S and Elder JS: Influence of enterocystoplasty on linear growth in children with exstrophy. J Urol 2002; 167: 2552. 22. Taskinen S, M€akitie O and Fagerholm R: Intestinal bladder augmentation at school age
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has no adverse effects on growth. J Pediatr Urol 2008; 4: 40. 23. Gerharz EW, Preece M, Duffy PG et al: Enterocystoplasty in childhood: a second look at the effect on growth. BJU Int 2003; 91: 79. 24. Hensle TW, Mingin G and Fam M: Metabolic bone loss after urinary diversion in children. Curr Opin Urol 2014; 24: 619. 25. Gerharz EW, M ansson A, Hunt S et al: Quality of life after cystectomy and urinary diversion: an evidence based analysis. J Urol 2005; 174: 1729. 26. Hoebeke P, De Kuyper P, Goeminne H et al: Bladder neck closure for treating pediatric incontinence. Eur Urol 2000; 38: 453. 27. Abd-el-Gawad G, Abrahamsson K, Hellstr€om AL et al: Health-related quality of life after 5-12 years of continent ileal urostomy (Kock reservoir) in children and adolescents. Scand J Urol Nephrol 2002; 36: 40. 28. Bastian PJ, Albers P, Hanitzsch H et al: Health-related quality-of-life following modified ureterosigmoidostomy (Mainz pouch II) as continent urinary diversion. Eur Urol 2004; 46: 591. 29. Merenda LA, Duffy T, Betz RR et al: Outcomes of urinary diversion in children with spinal cord injuries. J Spinal Cord Med, suppl., 2007; 30: S41. 30. Abdallah MM, Bissada NK, Hamouda HM et al: Long-term multi-institutional evaluation of Charleston pouch I continent cutaneous urinary diversion. J Urol 2007; 177: 2217.
Abbreviations and Acronyms CKD ¼ chronic kidney disease eGFR ¼ estimated glomerular filtration rate QoL ¼ quality of life Accepted for publication May 3, 2015. Study received internal review board approval. * Correspondence: Department of Urology, Urology and Nephrology Center, Mansoura University, Gomhoria S., 35516, Egypt (telephone: 20-10-01349367; FAX: 20-50-2263717; e-mail: [email protected]).
See Editorial on page 1190.
Purpose: We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. Materials and Methods: We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. Results: We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean SD baseline (64.5 46 ml/minute/1.73 m2) and last followup estimated glomerular filtration rate (54.1 44.9 ml/minute/1.73 m2), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications. Conclusions: The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population. Key Words: child, glomerular filtration rate, quality of life, urinary diversion
URINARY diversion has revolutionized the treatment of patients with lower urinary tract dysfunction, anomalies or malignancy. Aimed at preserving
1414
j
www.jurology.com
renal function and achieving dryness, unprecedented advances have been achieved in the field of urinary diversion in the last few decades. The
0022-5347/15/1945-1414/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.05.028 Vol. 194, 1414-1419, November 2015 Printed in U.S.A.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
initial enthusiasm for conduit diversion to treat children with lower urinary tract dysfunction has been tempered by the high frequency of complications and the risk of upper tract deterioration.1 Despite the potential risks, conduit diversion remains a reasonable choice for a small subset of patients. Children who are too young to undergo continent urinary reservoir, those lacking reliable family support and those with poor manual dexterity, mental disability or short life expectancy are in need of tubeless, low pressure drainage that does not require intermittent catheterization.2,3 Furthermore, bladder augmentation or continent reservoirs may be problematic in the setting of renal insufficiency,4 and recalls the use of conduit diversion. Several studies have shown high complication rates when ileal conduits are used in children with neuropathic bladder, including renal deterioration, upper tract calculi, pyocystitis and peristomal complications.1 However, the majority of these studies, conducted several decades ago, have focused on morphological renal deterioration and the crude measurement of serum creatinine without accurate estimation of renal function. In addition, the impact of diversion on growth trends and quality of life in patients and their caregivers have not been adequately investigated. We evaluated whether the Bricker conduit diversion could reliably protect the upper tract and prevent the steep decline in renal function in children offered the procedure. Moreover, the potential impact on linear growth and QoL, and anticipated long-term complications were weighed against renal function outcome.
PATIENTS AND METHODS Following internal review board approval we retrieved the electronic files of children who underwent ileal conduit for urinary diversion at a pediatric urology tertiary referral unit between 1981 and 2011. Patient files were reviewed for gender, age at surgery, indication for diversion, baseline renal function, preoperative imaging studies, surgical details, postoperative recovery, readmission rates and followup data. Furthermore, patients were invited to up-to-date followup visits. Patients who were older than 18 years at surgery and those with less than 1 year of followup were excluded from analysis. Renal function was the primary outcome of the study, while diversion related complications, linear growth effect, readmission rates and quality of life were considered secondary outcomes. End points of the study were death, undiversion to continent reservoir and last followup date.
Procedure After sparing the last 10 cm of the terminal ileum a 15 to 20 cm ileal segment was isolated. The bowel continuity was reestablished and the mesenteric defect was closed. The distal end of the isolated bowel segment was
1415
mobilized and exteriorized at a predetermined site on the abdominal wall. An everting nipple was created. The ureters were mobilized and anastmosed to the proximal end of the conduit using either the Bricker or Wallace technique. The conduit was drained using a Foley catheter for 5 days and the ureteroileal anastmoses were stented for 7 to 8 days.
Outcome Measures Baseline and followup renal function was evaluated using eGFR or 99mtechnetium mercaptoacetyltriglycine isotope renal scans, if available. eGFR was calculated using an online calculator (http://nkdep.nih.gov/lab-evaluation/ gfr-calculators.shtml) based on the modified Schwartz formula or MDRD formula for patients entering adulthood at followup. The mean of 3 sequential eGFR measurements was used to study the outcome. The severity of chronic kidney disease was staged according to the National Kidney FoundationÒ Kidney Disease Outcomes Quality Initiative staging system.5 The Society for Fetal Urology grading system was used to assess severity of hydronephrosis.6 Patient growth charts were reviewed to observe growth trends. Egyptian children’s growth (height-for-age) charts served as a reference. Linear growth was considered stunted if patient height was below the 10th percentile for age and gender, or crossing 2 or more major percentile curves on the charts. The Mansoura QoL questionnaire was used to evaluate patient and family satisfaction regarding the procedure.7,8 The questionnaire has been modulated to fit the method of urine evacuation. The modified version of the questionnaire consists of 6 items, each assigned a score of 1 to 3 (supplementary table 1, http://jurology.com/), giving a possible maximum of 18 points (excellent degree of wellbeing). Poor QoL was defined as a QoL questionnaire score of 12 or less. A neutral third party (stoma therapist) questioned the children and their caregivers about the questionnaire items through direct interview at last followup visit. Although the questionnaire is not validated, it gave a meaningful idea about the satisfaction of patients and families regarding urinary diversion.
Statistical Analysis Continuous variables were expressed as mean SD or median (range) according to normality, while categorical variables were described as frequencies (percentages) in each category. Paired t-test and repeated measures ANOVA were used when indicated for comparison of continuous variables across time intervals. Statistical analysis was done using SPSSÒ, version 20. All tests were 2-tailed with statistical significance considered at p <0.05.
RESULTS A total of 36 children underwent Bricker conduit at our institution between 1981 and 2011. After exclusion of patients with less than 1 year of followup 29 patients were included in the analysis. Of these patients 19 (65.5%) were male. Neuropathic bladder was the underlying diagnosis in 21 patients (72.4%). Median age at surgery was 10 years (range
1416
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
2 to 18). Ureteroileal anastomosis was done using the Bricker technique in 17 patients (58.6%) and the Wallace technique in the remainder. Patients were followed for a median of 91 months (range 16 to 389). Baseline demographics are outlined in table 1. At last followup hydronephrosis improved or remained stable in 39 of 55 renal units (70.9%; 3 patients had solitary kidneys at diversion). No statistically significant difference was observed when comparing mean SD baseline (64.5 46 ml/ minute/1.73 m2) and last followup eGFR (54.1 44.9 ml/minute/1.73 m2, p ¼ 0.073). Furthermore, patients with stage 4 or 5 CKD had no statistically significant difference in median percent change in eGFR (median 25%, range 1.8% to 77%) compared to those with lower baseline CKD stages (21%, 1.7% to 88%, p ¼ 0.72). However, 13 patients (44.8%) had worsening of CKD by 1 or more stages, compared to only 4 (13.8%) who had improvement of preoperative CKD stage. Prevalence of CKD stages in the study cohort at baseline and last followup is illustrated in the figure. Eventually 11 patients (37.9%) had stage 5 CKD, of whom 2 received renal allotransplantation. Metabolic acidosis was observed in 11 patients, all with end-stage kidney disease. Nine patients were deceased at the study conclusion, of whom 7 died of chronic renal failure, 1 of recurrent malignant disease and 1 of unknown cause. After stabilization of Table 1. Baseline patient characteristics Median yrs age (range) No. gender (%): Male Female No. indication for diversion (%): Neuropathic bladder Bladder exstrophy/epispadias Rhabdomyosarcoma of bladder/prostate Hypoplastic bladder Nonreconstructable bladder/urethral injuries Posterior urethral valves No. previous augmentation/diversion (%): Augmentation ileocystoplasty Cutaneous vesicostomy Rectal diversion Cutaneous ureterostomy Median mg/dl baseline serum creatinine (range) Median ml/min/1.73 m2 baseline eGFR (range) No. baseline CKD stage (%): 0 1 2 3 4 5 No. preop hydronephrosis grade (%):* 0 I II III IV Median mos followup (range) * Three patients had solitary kidneys at diversion.
10
(2e18)
19 10
(65.5) (34.5)
21 2 2 2 1 1
(72.4) (6.9) (6.9) (6.9) (3.4) (3.4)
2 (6.9) 2 (6.9) 2 (6.9) 1 (3.4) 1.6 (0.3e9.3) 44.6 (9.7e178) 4 3 6 8 6 2
(13.8) (10.3) (20.7) (27.6) (20.7) (6.9)
9 9 10 12 15 91
(16.4) (16.4) (18.2) (21.8) (27.3) (16e389)
renal function 6 patients underwent augmentation ileocystoplasty and continent cutaneous diversion at a median age of 9.3 years (range 3.4 to 16.9) after a mean of 118 months of conduit diversion (46 to 180). At undiversion the median eGFR was 105.5 ml/ minute/1.73 m2 (range 60 to 178). All of these patients fared well after undiversion except for 1 who had progressive renal deterioration and eventually underwent living donor renal transplantation. When patient growth charts were reviewed, 10 patients (34.5%) were below the 10th percentile of height for age and gender, and 2 additional patients crossed 2 or more major percentile curves toward stunting. Mean SD QoL questionnaire score was 13.1 2.3. Based on our QoL questionnaire, 17 of 20 patients who completed the questionnaire (85%) reported poor QoL. A total of 19 hospital readmissions were reported in 14 patients for treatment of diversion related complications. Table 2 lists early and late complications of Bricker conduit diversion (graded according to modified Clavien system) and their management.
DISCUSSION Ileal conduit diversion was initially described in 1935 and popularized by Bricker in 1950.9 The technique has gained wide acceptance due to its simplicity and the relatively low complication rate. It is the most commonly used urinary diversion technique worldwide and is still considered the standard diversion method for adults with muscle invasive bladder cancer against which all other methods are compared.10 In the 1970s conduit diversion was widely adopted to treat children with neuropathic lower urinary tract dysfunction. Unfortunately the results did not meet expectations, and the use of conduit diversion was largely abandoned in children due to the risk of renal deterioration and the increased number of complications. Before the final endorsement of urinary diversion in a child the simplicity of the diversion technique should be weighed against the expected shortcomings. In other words, some critical points should always be considered, including the impact on renal function, the long-term consequences of urinary diversion such as electrolyte imbalance and effect on linear growth, achievement of independence as children grow into adulthood and the need for revision surgery. Some clinical studies conducted several decades ago assessed the outcome of Bricker conduit diversion in children. The majority of these studies centered on renal deterioration based on radiological criteria, omitting functional assessment. Moreover, the effect on linear growth and the impact of diversion on patient and family QoL were overlooked.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
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Prevalence of CKD stages at baseline and at last followup
Despite the simplicity of the Bricker conduit diversion, the detrimental effect on renal function remains a potential concern. Intractable upper tract dilatation was reported in up to 60% of renal units in children with a Bricker conduit, especially with longer followup.11e14 Even previously normal renal units were not protected against deterioration. Interestingly deterioration was sometimes not attributable to ureteroileal strictures or loop Table 2. Early and late postoperative complications based on modified Clavien grading system Complications Grade I (transient increase in serum creatinine) Grade II: Early postop sepsis Pyelonephritis Prolonged ileus Intestinal obstruction Upper tract stones Peristomal dermatitis Grade IIIa: Pyonephrosis Upper tract stones Grade IIIb: Intestinal obstruction Upper tract stones Stomal prolapse Grade IVa (end-stage kidney disease)* Grade V (death)†
No. Episodes (No. cases)
Management
5 (4)
Adequate hydration, discontinuation of nephrotoxic drugs, monitoring
4 4 3 1 2
6 (6)
Antibiotic treatment Antibiotic treatment Suction þ drip Suction þ drip Oral dissolution therapy (potassium citrate) Skin care
1 (1) 1 (1)
Nephrostomy tube drainage Extracorporeal shock wave lithotripsy
1 2 1 9
Abdominal exploration þ adhesiolysis Pyelolithotomy Revision of stoma Renal replacement therapy (dialysis or renal transplantation)
(4) (2) (3) (1) (2)
(1) (1) (1) (9)
7 (7)
* eGFR less than 15 ml/min/1.73 m2. † Seven patients died of chronic renal failure complications after a median of 80 months (range 4 to 248).
redundancy. Some authors claim that the use of nonrefluxing colon conduit may offer a more favorable renal function outcome.15 However, this claim has been refuted by others.16,17 Nonetheless, more than 1 clinical study supports that enterocystoplasty is not inherently deleterious to the upper tracts, even in patients with impaired renal function.18 In this study worsening of hydronephrosis was observed in 16 of 55 renal units (29.1%) after an average followup of more than 7 years. Only 1 previously normal renal unit exhibited new onset hydronephrosis at followup. While no statistically significant difference was observed between baseline and followup eGFR, conduit diversion failed to halt the progression of renal insufficiency in 3 patients with stage 3 and 5 with stage 4 CKD. Endstage kidney disease ultimately developed in those patients, who consequently required dialysis or renal transplantation. However, progression of the preexisting renal damage and exposure to nephrotoxic agents in patients with malignant disease could have contributed to the worsening renal failure in addition to conduit diversion. The effect on linear growth is another issue of potential concern when considering incorporation of intestinal segments into the urinary tract of growing children, even with incontinent diversion.14,19 Of a series of 183 children treated with intestinal cystoplasty linear growth retardation was noted in 20%. These changes occurred even in the absence of serious metabolic derangements.20 Similar results
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BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
were observed in patients with exstrophy treated with enterocystoplasty.21 In contrast, Taskinen et al found no adverse effects of enterocystoplasty on linear growth.22 In another large series of enterocystoplasty half of the patients with initial growth retardation regained or surpassed their preoperative position on the growth charts on subsequent followup. Furthermore, enterocystoplasty could not be considered the sole cause in patients with a clinically significant effect on growth.23 There has been recent evidence that continued normal or near normal linear growth may be maintained in children with urinary diversion at the expense of bone demineralization.24 In our series linear growth was negatively impacted in 12 patients, including 10 with a neuropathic bladder, 1 with rhabdomyosarcoma and 1 with posterior urethral valves. However, it is difficult to attribute stunting solely to ileal conduits, because a similar growth effect was documented in other series in controls with myelodysplasia and bladder exstrophy.22 Additionally stunted growth may be explained by familial factors, renal failure, repeated urinary tract infections and administration of chemotherapy and/or radiotherapy in patients with rhabdomyosarcoma. By comparison, 5 patients had surpassed their preoperative position on the growth charts at last followup. Finally, body image, general well-being and patient independence should not be overlooked when considering urinary diversion in a child, due to the fact that QoL of patients and/or their families might be severely impacted by the diversion technique. Despite the presence of a large body of literature addressing health related QoL after urinary diversion in adults, these studies have not reliably shown that conduit diversion is inferior to other diversion methods, including orthotopic and continent cutaneous diversion, in terms of QoL.25 In the absence of a standard assessment tool, and due to the paucity of literature addressing QoL issues in pediatric urinary diversion, we used a simple internally designed QoL questionnaire to measure overall patient satisfaction regarding diversion, independence in caring for the stoma and appliance, and impact on physical and social wellbeing. Of the 20 patients who responded to the questionnaire 17 (85%) reported poor QoL and 19 expressed a desire to undergo another method of
diversion. In addition to distorted body image, progressive renal deterioration with the need for dialysis or transplantation, recurrent pyelonephritis and peristomal complications, and the need for revision surgery have all contributed to poor QoL. Conversely 84% of our patients treated with continent catheterizable stomas reported good QoL and satisfaction with the procedure.7 Similarly high levels of satisfaction have been reported in the majority of clinical studies assessing QoL in children with continent urinary diversion. Supplementary table 2 (http://jurology.com/) summarizes the results of the current study and other series addressing urinary diversion in children, with special emphasis on renal function outcomes and QoL issues.7,8,11,12,14,16,17,26e30 Some limitations of our study must be acknowledged. Selection bias and missing data points are inherent defects of any retrospective study. The smaller number of patients and the relatively shorter followup compared to other series may underestimate the complications and the risk of renal deterioration. However, these studies were performed several decades ago and lacked proper functional assessment of the upper tracts and QoL evaluation. Growth pattern and renal function deterioration may be influenced by a number of factors that have not been controlled for in this retrospective study. Because the procedure is rarely performed in the modern era, a valid subgroup analysis to eliminate confounders was not possible. Finally, a nonvalidated questionnaire was used to assess QoL. However, despite these shortcomings, this study offers valuable data in the absence of contemporary evaluations of ileal conduit diversion in children.
CONCLUSIONS The Bricker conduit does not seem to guard against renal deterioration in predisposed patients. Therefore, compromised renal function does not seem to be a justifiable indication for ileal conduit diversion in children with lower urinary tract dysfunction. Significant burdens of the procedure on patient growth, body image and QoL place the Bricker conduit at the bottom of the list among urinary diversion techniques. Whenever used, dedicated, lifelong, close followup is warranted.
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SG Docimo, DA Canning and AE Khoury. London: Informa Healthcare UK Ltd 2007; chapt 57, pp 911e946.
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