Fewer Augments with Fewer Complications—Laudable, but Likely?

Fewer Augments with Fewer ComplicationsdLaudable, but Likely? IN this issue of The Journal Schlomer et al (page 1352) use the Kids’ Inpatient Database from participating hospitals to evaluate national trends in augmentation cystoplasty in pediatric patients with neuropathic bladder due to various etiologies from 2000 to 2009.1 They observed a trend that fewer children underwent augmentation throughout the study period such that 25% estimated fewer augmentations were performed in 2009 compared to 2000. Unfortunately the authors were unable to explain why this decrease occurred due to the inherent limitations of a retrospective electronic query. The authors speculated that this observed trend could represent changing practice patterns. I hypothesize, as do the authors, that the reasons for these findings are multifactorial. Proactive treatment of infants with spina bifida, which accounted for nearly half of the patient data set, could have affected the number of surgical procedures. The use of clean intermittent catheterization and anticholinergics in infants with spina bifida at high risk for bladder deterioration based on urodynamic findings has also been shown to decrease the need for augmentation cystoplasty.2 Injection of botulinum toxin into the detrusor represents an alternative method of avoiding augmentation cystoplasty in the medically refractory case3 and would not be captured by the authors with an inpatient query as the procedure is often performed on an outpatient basis. An alternative explanation for the study results could be that the same numbers of augmentations are still being performed but the procedure is being delayed until adulthood. Due to data set limitations, the authors could not comment on the rate of augmentation in all patients with neuropathic bladder due to any etiology followed on an outpatient or inpatient basis. A prior study using the Pediatric Health and Information System database with a spina bifida population demonstrated no significant decrease in augmentation rates from 1999 to 2004 in their patient population.4 The authors also observed that inpatient complications, identified only from coding data, were documented in 30% of patients who underwent

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augmentation. A major complication, defined by codes for the conditions small bowel obstruction, blood transfusion, hemorrhagic complication, technical complication or fistulous complication, occurred in 14% of the patients. Complications were observed more frequently in patients with a diagnosis of bladder exstrophy-epispadias complex than in patients with spina bifida. Once again the reason behind this observation was not addressed with the electronic database and was acknowledged by the authors. A single institutional series did not demonstrate a difference in the short term, presumed to include perioperative, complications in neurogenic (spina bifida) vs nonneurogenic (bladder exstrophy-epispadias complex) urinary tract reconstruction in which the majority of patients in both groups underwent augmentation.5 Achieving urinary continence can have a dramatic effect on a child’s self-esteem for obvious reasons. As pediatric urologists we experience tremendous satisfaction in assisting patients and families in attaining continence while preserving renal function. However, the importance of accomplishing this outcome, when surgery is deemed necessary to do so, relative to overall health related quality of life, may be overestimated when using disease specific metrics.6 Augmentation cystoplasty also involves a significant rate of requiring additional surgery, let alone urological followup for life.7 These facts coupled with reports of malignancy in patients with prior augmentation have tempered enthusiasm for the procedure. Therefore, are children with neuropathic bladder better served by avoiding augmentation altogether to avoid the inherent complications associated with enteric augmentation? Or are we exposing them to undue harm because of our inaction in terms of an increased incidence of upper tract injury or decreased quality of life from persistent incontinence? The answers to these questions are not simple and require future clinical studies designed specifically to address these issues. However, what is not controversial is that every child at risk for neuropathic bladder, regardless of the diagnosis, requires regular urological surveillance. A thorough and comprehensive neurourological evaluation to

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TRENDS IN AUGMENTATION CYSTOPLASTY

identify patients with bladder deterioration and intervene when appropriate will hopefully validate the observed trend of fewer augmentations reported by Schlomer et al.

Brian A. VanderBrink Division of Pediatric Urology Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

REFERENCES 1. Schlomer BJ, Saperston K and Baskin L: National trends in augmentation cystoplasty in the 2000s and factors associated with patient outcomes. J Urol 2013; 190: 1352. 2. Kaefer M, Pabby A, Kelly M et al: Improved bladder function after prophylactic treatment of the high risk neurogenic bladder in newborns with myelomeningocele. J Urol 1999; 162: 1068. 3. Riccabona M, Koen M, Schindler M et al: Botulinum-A toxin injection into the detrusor: a safe alternative in the treatment of children with

myelomeningocele with detrusor hyperreflexia. J Urol 2004; 171: 845. 4. Lendvay TS, Cowan CA, Mitchell MM et al: Augmentation cystoplasty rates at children’s hospitals in the United States: a Pediatric Health Information System database study. J Urol 2006; 176: 1716. 5. Novak TE, Salmasi AH, Mathews RI et al: Complications of complex lower urinary tract reconstruction in patients with neurogenic versus

nonneurogenic bladdereis there a difference? J Urol 2008; 180: 2629. 6. MacNeily AE, Jafari S, Scott H et al: Health related quality of life in patients with spina bifida: a prospective assessment before and after lower urinary tract reconstruction. J Urol 2009; 182: 1984. 7. Metcalfe PD, Casale AJ, Kaefer MA et al: Spontaneous bladder perforations: a report of 500 augmentations in children and analysis of risk. J Urol 2006; 175: 1466.