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Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years
Journal of Pediatric Urology (2017) 13, 200.e1e200.e5
Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years a
Division of Paediatric Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
Rakan I. Odeh a, Walid A. Farhat a, Frank J. Penna a, Martin A. Koyle a, Linda C. Lee a, Hissan Butt a, Fahad A. Alyami a,b Summary
b
Urology Division, Department of Surgery, King Saud University, King Khalid University Hospital, College of Medicine, Riyadh, Saudi Arabia Correspondence to: F.A. Alyami, Division of Paediatric Urology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada, Tel.: þ1 416 813 6465; fax: þ1 416 813 6461 [email protected] (F.A. Alyami) Keywords Bladder exstrophy/epispadias; Neuropathic bladders; Bladder augmentation Received 17 August 2015 Accepted 3 May 2016 Available online 3 August 2016
Introduction Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report longterm outcomes of SMBA from a single institution compared with standard ileocystoplasty. Methods After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi,
Table
incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen. Results Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p Z 0.06) did not reach statistical significance (Table). Conclusions SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty.
Outcome comparison: SMBA versus standard ileocystoplasty.
Mean preoperative bladder capacity, mL (nA Z 8, nB Z 19) Mean postoperative bladder capacity, mL (nA Z 4, nB Z 14) Mean time of postoperative urodynamics Urinary tract infections Bladder calculi Incontinence Spontaneous bladder perforation Secondary surgery Re-do augmentation Stone surgery Bladder rupture repair
SMBA (n Z 10)
Ileocystoplasty (n Z 30)
p
121 93 400 241 51 44 3 (30%) 0 (0%) 2 (20%) 1 (10%) 1 (10%) 0 (0%) 0 (0%) 1 (10%)
153 130 378 153 50 28 8 (27%) 8 (27%) 11 (37%) 0 (0%) 7 (23%) 2 (7%) 5 (17%) 0 (0%)
0.26 0.42 0.47 0.8 0.06 0.3 0.07 0.4
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2016.05.030. http://dx.doi.org/10.1016/j.jpurol.2016.05.046 1477-5131/ª 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Outcomes of seromuscular bladder augmentation
200.e2
Introduction Bladder augmentation is one of the major surgical challenges in pediatric urology. The aim of the procedure is to create a capacious, low-pressure reservoir with improved compliance, in order to achieve continence and protect the upper urinary tract. Ileocystoplasty is the standard technique for bladder augmentation [1] and has been used widely for decades. However, it has been associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections (UTIs), intestinal obstruction, and a long-term risk of bladder cancer [2]. These complications have spurred investigation into alternative techniques for bladder augmentation, including seromuscular bladder augmentation (SMBA). In this technique, a portion of the sigmoid colon is used as the source of the augmented patch after removal of the mucosal layer. Using the remaining seromuscular layer, it may help to minimize the risk of mucosa-related complications, including excessive mucus production and subsequent stone formation. Short and intermediate outcomes of this procedure in adults have been published, but data on long-term outcomes in children are very limited. Gonza ´lez and colleagues [3] presented the outcomes of 20 patients who underwent SMBA and compared them with both adult and pediatric patients who underwent augmentation with various intestinal patches with a mean follow-up of under 2 years. They demonstrated an overall low rate of surgical complications and no incidence of bowel obstruction or perforation [3]. Herein, we present our outcomes of all patients who underwent SMBA compared with controls of children who underwent standard ileocystoplasty.
Methods Ethics approval was obtained from the Institutional Review Board, and a retrospective review was conducted on all patients who underwent SMBA at our institution between March 2001 and May 2014. The patients were compared for age, sex, and diagnosis (in 1:3 fashion) with patients who underwent standard ileocystoplasty over the same period. Patients with other forms of bladder augmentation and patients diagnosed with diseases other than neurogenic bladder or bladder exstrophy were excluded. Parameters included age, sex, initial diagnosis, follow-up duration, pre- and postoperative bladder capacity as assessed by urodynamic studies, postoperative outcomes such as UTIs, calculi formation, continence, spontaneous bladder perforation, and the need for secondary surgical procedures. In our study, UTI was defined as a positive urine culture with signs and symptoms of infection, including fever. Incontinence was defined subjectively as episodes of leakage in compliant patients between regular catheterizations that required at least one pad per day. Statistical analysis was performed using the chi-square test for categorical variables and the t test for numerical variables. A p-value < 0.05 was considered statistically significant. Fig. 1 describes the technique of SMBA.
Figure 1 Detailed technique for seromuscular bladder augmentation. The technique is approached through a lower midline or transverse incision. The peritoneum is opened and 20 cm of sigmoid colon is resected (A). Bowel continuity is reestablished. The segment is detubularized along its antimesenteric border (B), the mucosa layer is stripped off using a scalpel and the mucosal crypts were treated with Argon laser to desiccate them. The resected segment is reconfigured into the “U” configuration (C) and brought down to the level of the bladder for suturing it with the incised bladder wall (D).
Results Baseline parameters of the SMBA group and standard ileocystoplasty group are outlined in Fig. 2. The table in the Summary summarizes the outcomes between the two groups. The mean preoperative bladder capacity as estimated by urodynamic studies was similar in the two groups (121 93 vs. 153 130, p Z 0.26). The mean postoperative bladder capacity was also similar between the two groups (400 241 vs. 378 153, p Z 0.42). There was, however, a statistically significant difference in the increase in bladder capacities when comparing the pre- and postoperative results for each group. The rate of recurrent UTIs was the same in both groups, three out of 10 (30%) versus eight out of 30 (27%) in the SMBA and ileocystoplasty groups, respectively (p Z 0.8). There were no reported calculi in the SMBA group and there were eight (27%) in the ileocystoplasty group (p Z 0.06). With regard to continence, two out of 10 (20%) patients were incontinent in the SMBA
200.e3
R.I. Odeh et al.
Figure 2
Baseline parameters.
group, and 11 out of 30 (37%) patients in the ileocystoplasty group were incontinent (p Z 0.3). There was one (10%) case of bladder perforation in the SMBA group (p Z 0.07). Re-do bladder augmentation was performed in zero out of 10 (0%) and two out of 30 (7%) cases in the SMBA and ileocystoplasty groups, respectively (p Z 0.4). The rate of secondary surgeries was one out of 10 (10%) and seven out of 30 (23%) in the SMBA and ileocystoplasty groups, respectively (p Z 0.4) Table 1.
Table 1 Outcome comparison: SMBA versus standard ileocystoplasty.
Mean preoperative bladder capacity, mL (nAZ8, nBZ19) Mean postoperative bladder capacity, mL (nAZ4, nBZ14) Mean time of postoperative urodynamics Urinary tract infections Bladder calculi Incontinence Spontaneous bladder perforation Secondary surgery Re-do augmentation Stone surgery Bladder rupture repair
SMBA (n Z 10)
Ileocystoplasty (n Z 30)
p
121 93
153 130
0.26
400 241
378 153
0.42
51 44
50 28
0.47
3 0 2 1
(30%) (0%) (20%) (10%)
8 (27%) 8 (27%) 11 (37%) 0 (0%)
0.8 0.06 0.3 0.07
1 0 0 1
(10%) (0%) (0%) (10%)
7 2 5 0
0.4
(23%) (7%) (17%) (0%)
Discussion Bladder augmentation was described by Simon [4] 150 years ago. Since then, different techniques have been elucidated, yet ileocystoplasty remains the standard technique. The complications of standard ileocystoplasty are attributed mainly to the absorptive and secretory functions of the bowel mucosa [5] and have motivated surgeons to explore different techniques in an attempt to decrease these complications. SMBA is one of these techniques, which was initially described in animals by Shoemaker et al. in 1955 [6]. It was not until 1981 that it was trialed in humans by Dewan and Stefnak, and showed promising results in terms of increasing bladder capacity and improving continence [7]. Gonza ´lez and colleagues [3] reported 20 patients who underwent SMBA with urothelial lining with lower overall postoperative complications than the standard ileocystoplasty. Herein, we present our long-term outcomes of SMBA in children, evaluating postoperative complications including urinary tract infections, calculi formation, continence, and the need for secondary surgery. In our series, interestingly, no bladder calculi developed in the SMBA group, whereas 27% (8/30) of patients had bladder calculi in the standard ileocystoplasty group (p Z 0.06). Interestingly, only one of the patients with bladder exstrophy from the standard ileocystoplasty group developed stones. All of the other patients that developed stones in the control group had a history of neurogenic bladder, only one of which had a bladder neck procedure. The lower incidence of stone formation in the SMBA group can be attributed to lower mucus production, which has been demonstrated to be a strong contributing factor to calculi formation [8]. Both groups were put on regular clear intermittent catheterization (CIC) and requested to have their bladders irrigated regularly. Despite this intervention, there was still a difference in stone formation between the
Outcomes of seromuscular bladder augmentation two groups. Longer follow-up and a larger series might have detected a statistically significant difference. Gonza ´lez et al. published result that showed only 6% of the patients who underwent SMBA with urothelial lining developed calculi [9]. One of the proposed theoretical limitations for the SMBA technique is bladder augment contraction that results in decreased bladder capacity. Dayanc et al. [10] showed increased bladder capacity with decreased intravesical pressure in all patients who underwent SMBA with urothelial lining. Furthermore, de Badiola et al. [11] showed promising results in terms of improved bladder capacity in patients that underwent SMBA without urothelial lining. The data from our study also confirmed a statistically significant increase in bladder capacity in both the SMBA and the control group as estimated by pre- and postoperative urodynamics studies, with no evidence of bladder contraction postoperative in the SMBA group. In our series, 80% of patients in the SMBA group achieved continence, which can be attributed to a presumed improvement in bladder capacity and compliance with CIC. Two patients in the SMBA group were incontinent: one was not compliant with CIC and ultimately had presented with spontaneous bladder perforation. The other patient was prescribed a higher dose of anticholinergic medication and in response regained continence. Lima et al. [12] showed fewer favorable outcomes in terms of continence in patients that underwent SMBA without urothelial lining with a history of bladder exstrophy. However, in our series, all patients who were incontinent had an initial diagnosis of neurogenic bladder, and none of the bladder exstrophy patients suffered from incontinence. UTI is one of the most common problems after bladder augmentation. About 75% of patients who undergo bladder augmentation develop UTIs [13,14]. Hasan et al. [15] reported that 37% had recurrent UTIs after bladder augmentation even more than 1 year postoperatively. The fact that the patients are on CIC increases the likelihood of bacterial colonization, which can increase the risk of UTIs. Another potential source of infection is urinary stasis, which can be attributed to increased mucus production resulting in poorer drainage even with catheterization. In our study, the rate of UTI was similar in the two groups (30% vs. 27%, p Z 0.8). Our study may be underpowered to demonstrate a significant difference with regard to UTI between the two groups. Bladder perforation, a serious and potentially lifethreatening complication, has been reported to be as high as 13% in bladder augmentation patients [16]. In our SMBA group we had one case of spontaneous bladder perforation in a patient who was poorly compliant with CIC. In a recent large review, the rate of secondary surgery for bladder augmentation was up to 34% [17]. In our series, the secondary surgery rate was not found to be significant between the two groups (10% vs. 23%, p Z 0.4). The only secondary surgery in the SMBA group was related to the spontaneous bladder rupture in a non-compliant patient. In the standard ileocystoplasty group, five patients underwent secondary procedures to treat bladder stones while the other two underwent re-do bladder augmentation for persistent incontinence.
200.e4 The study is limited by the small number of patients in the SMBA group. Despite the lack of statistical significance for the various outcomes, there is clinical significance that warrants consideration, particularly with regard to stone development, continence, and the need for secondary surgery. Another drawback is that our study was conducted retrospectively, and therefore has limitations typically associated with retrospective studies, specifically the lack of data on metabolic abnormalities.
Conclusions Ileocystoplasty remains the standard technique for bladder augmentation, but SMBA is a viable and promising alternative with similar surgical outcomes and a lower rate of stone formation.
Conflicts of interest None.
Funding None.
References [1] Bramble FJ. The treatment of adult enuresis and urge incontinence by enterocystoplasty. Br J Urol 1982;54:693e6. [2] Kispal Z, Balogh D, Erdei O, Kehl D, Juhasz Z, Vastyan AM, et al. Complications after bladder augmentation or substitution in children: a prospective study of 86 patients. BJU Int 2011;108:282e9. [3] Shekarriz B, Upadhyay J, Demirbilek S, Barthold JS, Gonza ´lez R. Surgical complications of bladder augmentation: comparison between various enterocystoplasties in 133 patients. Urology 2000;55:123e8. [4] Simon J. Extropia Vesicae (absence of the anterior walls of the bladder and rubic abdominal parietes): operation for directing the orifices of the ureters into the rectum. Lancet 1852;2:568. [5] Sountoulides P, Laguna MP, de la Rosette JJ. Complications following augmentation cystoplasty; prevention and management. Cent Eur J Urol 2000;62:216e21. [6] Shoemaker WC, Marucci HD. The experimental use of seromuscular grafts in bladder reconstruction; preliminary report. J Urol 1955;73:314e21. [7] Dewan PA. Augmentation colocystoplasty. Pediatr Surg Int 1994;9:526e8. [8] Palmer LS, Franco I, Kogan SJ, Reda E, Gill B, Levitt SB. Urolithiasis in children following augmentation cystoplasty. J Urol 1993;150(Pt 2):726e9. [9] Jednak R, Schimke CM, Barroso UJR, Barthold JS, Gonza ´lez R. Further experience with seromuscular colocystoplasty lined with urothelium. J Urol 2000;164:2045e9. [10] Dayanc ¸ M, Kilciler M, Tan O, Go ¨kalp A, Go ¨ktas‚ S, Peker AF. A new approach to bladder augmentation in children: seromuscular enterocystoplasty. BJU Int 1999;84:103e7. [11] de Badiola F, Ruiz E, Puigdevall J, Caramutti D, Moldes J, Sosa A. Seromuscular colocystoplasty. Pediatrics 1999;104:806S. [12] Lima SV, Arau ´jo LA, Vilar FO, Kummer CL, Lima EC. Nonsecretory sigmoid cystoplasty: experimental and clinical results. J Urol 1995;153:1651e4.
200.e5 [13] Greenwell TJ, Venn SN, Mundy AR. Augmentation cystoplasty. BJU Int 2001;88:511e25. [14] Khoury JM, Timmons SL, Corbel L, Webster GD. Complications of enterocystoplasty. Urology 1992;40:9e14. [15] Hasan ST, Marshall C, Robson WA, Neal DE. Clinical outcome and quality of life following enterocystoplasty for idiopathic detrusor instability and neurogenic bladder dysfunction. Br J Urol 1995;76:551e7.
R.I. Odeh et al. [16] Rushton HG, Woodard JR, Parrott TS, Jeffs RD, Gearhart JP. Delayed bladder rupture after augmentation enterocystoplasty. J Urol 1988;140:344e6. [17] Elder JS, Snyder HM, Hulbert WC, Duckett JW. Perforation of the augmented bladder in patients undergoing clean intermittent catheterization. J Urol 1988;140(Pt 2):1159e62.
Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years a
Division of Paediatric Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
Rakan I. Odeh a, Walid A. Farhat a, Frank J. Penna a, Martin A. Koyle a, Linda C. Lee a, Hissan Butt a, Fahad A. Alyami a,b Summary
b
Urology Division, Department of Surgery, King Saud University, King Khalid University Hospital, College of Medicine, Riyadh, Saudi Arabia Correspondence to: F.A. Alyami, Division of Paediatric Urology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada, Tel.: þ1 416 813 6465; fax: þ1 416 813 6461 [email protected] (F.A. Alyami) Keywords Bladder exstrophy/epispadias; Neuropathic bladders; Bladder augmentation Received 17 August 2015 Accepted 3 May 2016 Available online 3 August 2016
Introduction Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report longterm outcomes of SMBA from a single institution compared with standard ileocystoplasty. Methods After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi,
Table
incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen. Results Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p Z 0.06) did not reach statistical significance (Table). Conclusions SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty.
Outcome comparison: SMBA versus standard ileocystoplasty.
Mean preoperative bladder capacity, mL (nA Z 8, nB Z 19) Mean postoperative bladder capacity, mL (nA Z 4, nB Z 14) Mean time of postoperative urodynamics Urinary tract infections Bladder calculi Incontinence Spontaneous bladder perforation Secondary surgery Re-do augmentation Stone surgery Bladder rupture repair
SMBA (n Z 10)
Ileocystoplasty (n Z 30)
p
121 93 400 241 51 44 3 (30%) 0 (0%) 2 (20%) 1 (10%) 1 (10%) 0 (0%) 0 (0%) 1 (10%)
153 130 378 153 50 28 8 (27%) 8 (27%) 11 (37%) 0 (0%) 7 (23%) 2 (7%) 5 (17%) 0 (0%)
0.26 0.42 0.47 0.8 0.06 0.3 0.07 0.4
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2016.05.030. http://dx.doi.org/10.1016/j.jpurol.2016.05.046 1477-5131/ª 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Outcomes of seromuscular bladder augmentation
200.e2
Introduction Bladder augmentation is one of the major surgical challenges in pediatric urology. The aim of the procedure is to create a capacious, low-pressure reservoir with improved compliance, in order to achieve continence and protect the upper urinary tract. Ileocystoplasty is the standard technique for bladder augmentation [1] and has been used widely for decades. However, it has been associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections (UTIs), intestinal obstruction, and a long-term risk of bladder cancer [2]. These complications have spurred investigation into alternative techniques for bladder augmentation, including seromuscular bladder augmentation (SMBA). In this technique, a portion of the sigmoid colon is used as the source of the augmented patch after removal of the mucosal layer. Using the remaining seromuscular layer, it may help to minimize the risk of mucosa-related complications, including excessive mucus production and subsequent stone formation. Short and intermediate outcomes of this procedure in adults have been published, but data on long-term outcomes in children are very limited. Gonza ´lez and colleagues [3] presented the outcomes of 20 patients who underwent SMBA and compared them with both adult and pediatric patients who underwent augmentation with various intestinal patches with a mean follow-up of under 2 years. They demonstrated an overall low rate of surgical complications and no incidence of bowel obstruction or perforation [3]. Herein, we present our outcomes of all patients who underwent SMBA compared with controls of children who underwent standard ileocystoplasty.
Methods Ethics approval was obtained from the Institutional Review Board, and a retrospective review was conducted on all patients who underwent SMBA at our institution between March 2001 and May 2014. The patients were compared for age, sex, and diagnosis (in 1:3 fashion) with patients who underwent standard ileocystoplasty over the same period. Patients with other forms of bladder augmentation and patients diagnosed with diseases other than neurogenic bladder or bladder exstrophy were excluded. Parameters included age, sex, initial diagnosis, follow-up duration, pre- and postoperative bladder capacity as assessed by urodynamic studies, postoperative outcomes such as UTIs, calculi formation, continence, spontaneous bladder perforation, and the need for secondary surgical procedures. In our study, UTI was defined as a positive urine culture with signs and symptoms of infection, including fever. Incontinence was defined subjectively as episodes of leakage in compliant patients between regular catheterizations that required at least one pad per day. Statistical analysis was performed using the chi-square test for categorical variables and the t test for numerical variables. A p-value < 0.05 was considered statistically significant. Fig. 1 describes the technique of SMBA.
Figure 1 Detailed technique for seromuscular bladder augmentation. The technique is approached through a lower midline or transverse incision. The peritoneum is opened and 20 cm of sigmoid colon is resected (A). Bowel continuity is reestablished. The segment is detubularized along its antimesenteric border (B), the mucosa layer is stripped off using a scalpel and the mucosal crypts were treated with Argon laser to desiccate them. The resected segment is reconfigured into the “U” configuration (C) and brought down to the level of the bladder for suturing it with the incised bladder wall (D).
Results Baseline parameters of the SMBA group and standard ileocystoplasty group are outlined in Fig. 2. The table in the Summary summarizes the outcomes between the two groups. The mean preoperative bladder capacity as estimated by urodynamic studies was similar in the two groups (121 93 vs. 153 130, p Z 0.26). The mean postoperative bladder capacity was also similar between the two groups (400 241 vs. 378 153, p Z 0.42). There was, however, a statistically significant difference in the increase in bladder capacities when comparing the pre- and postoperative results for each group. The rate of recurrent UTIs was the same in both groups, three out of 10 (30%) versus eight out of 30 (27%) in the SMBA and ileocystoplasty groups, respectively (p Z 0.8). There were no reported calculi in the SMBA group and there were eight (27%) in the ileocystoplasty group (p Z 0.06). With regard to continence, two out of 10 (20%) patients were incontinent in the SMBA
200.e3
R.I. Odeh et al.
Figure 2
Baseline parameters.
group, and 11 out of 30 (37%) patients in the ileocystoplasty group were incontinent (p Z 0.3). There was one (10%) case of bladder perforation in the SMBA group (p Z 0.07). Re-do bladder augmentation was performed in zero out of 10 (0%) and two out of 30 (7%) cases in the SMBA and ileocystoplasty groups, respectively (p Z 0.4). The rate of secondary surgeries was one out of 10 (10%) and seven out of 30 (23%) in the SMBA and ileocystoplasty groups, respectively (p Z 0.4) Table 1.
Table 1 Outcome comparison: SMBA versus standard ileocystoplasty.
Mean preoperative bladder capacity, mL (nAZ8, nBZ19) Mean postoperative bladder capacity, mL (nAZ4, nBZ14) Mean time of postoperative urodynamics Urinary tract infections Bladder calculi Incontinence Spontaneous bladder perforation Secondary surgery Re-do augmentation Stone surgery Bladder rupture repair
SMBA (n Z 10)
Ileocystoplasty (n Z 30)
p
121 93
153 130
0.26
400 241
378 153
0.42
51 44
50 28
0.47
3 0 2 1
(30%) (0%) (20%) (10%)
8 (27%) 8 (27%) 11 (37%) 0 (0%)
0.8 0.06 0.3 0.07
1 0 0 1
(10%) (0%) (0%) (10%)
7 2 5 0
0.4
(23%) (7%) (17%) (0%)
Discussion Bladder augmentation was described by Simon [4] 150 years ago. Since then, different techniques have been elucidated, yet ileocystoplasty remains the standard technique. The complications of standard ileocystoplasty are attributed mainly to the absorptive and secretory functions of the bowel mucosa [5] and have motivated surgeons to explore different techniques in an attempt to decrease these complications. SMBA is one of these techniques, which was initially described in animals by Shoemaker et al. in 1955 [6]. It was not until 1981 that it was trialed in humans by Dewan and Stefnak, and showed promising results in terms of increasing bladder capacity and improving continence [7]. Gonza ´lez and colleagues [3] reported 20 patients who underwent SMBA with urothelial lining with lower overall postoperative complications than the standard ileocystoplasty. Herein, we present our long-term outcomes of SMBA in children, evaluating postoperative complications including urinary tract infections, calculi formation, continence, and the need for secondary surgery. In our series, interestingly, no bladder calculi developed in the SMBA group, whereas 27% (8/30) of patients had bladder calculi in the standard ileocystoplasty group (p Z 0.06). Interestingly, only one of the patients with bladder exstrophy from the standard ileocystoplasty group developed stones. All of the other patients that developed stones in the control group had a history of neurogenic bladder, only one of which had a bladder neck procedure. The lower incidence of stone formation in the SMBA group can be attributed to lower mucus production, which has been demonstrated to be a strong contributing factor to calculi formation [8]. Both groups were put on regular clear intermittent catheterization (CIC) and requested to have their bladders irrigated regularly. Despite this intervention, there was still a difference in stone formation between the
Outcomes of seromuscular bladder augmentation two groups. Longer follow-up and a larger series might have detected a statistically significant difference. Gonza ´lez et al. published result that showed only 6% of the patients who underwent SMBA with urothelial lining developed calculi [9]. One of the proposed theoretical limitations for the SMBA technique is bladder augment contraction that results in decreased bladder capacity. Dayanc et al. [10] showed increased bladder capacity with decreased intravesical pressure in all patients who underwent SMBA with urothelial lining. Furthermore, de Badiola et al. [11] showed promising results in terms of improved bladder capacity in patients that underwent SMBA without urothelial lining. The data from our study also confirmed a statistically significant increase in bladder capacity in both the SMBA and the control group as estimated by pre- and postoperative urodynamics studies, with no evidence of bladder contraction postoperative in the SMBA group. In our series, 80% of patients in the SMBA group achieved continence, which can be attributed to a presumed improvement in bladder capacity and compliance with CIC. Two patients in the SMBA group were incontinent: one was not compliant with CIC and ultimately had presented with spontaneous bladder perforation. The other patient was prescribed a higher dose of anticholinergic medication and in response regained continence. Lima et al. [12] showed fewer favorable outcomes in terms of continence in patients that underwent SMBA without urothelial lining with a history of bladder exstrophy. However, in our series, all patients who were incontinent had an initial diagnosis of neurogenic bladder, and none of the bladder exstrophy patients suffered from incontinence. UTI is one of the most common problems after bladder augmentation. About 75% of patients who undergo bladder augmentation develop UTIs [13,14]. Hasan et al. [15] reported that 37% had recurrent UTIs after bladder augmentation even more than 1 year postoperatively. The fact that the patients are on CIC increases the likelihood of bacterial colonization, which can increase the risk of UTIs. Another potential source of infection is urinary stasis, which can be attributed to increased mucus production resulting in poorer drainage even with catheterization. In our study, the rate of UTI was similar in the two groups (30% vs. 27%, p Z 0.8). Our study may be underpowered to demonstrate a significant difference with regard to UTI between the two groups. Bladder perforation, a serious and potentially lifethreatening complication, has been reported to be as high as 13% in bladder augmentation patients [16]. In our SMBA group we had one case of spontaneous bladder perforation in a patient who was poorly compliant with CIC. In a recent large review, the rate of secondary surgery for bladder augmentation was up to 34% [17]. In our series, the secondary surgery rate was not found to be significant between the two groups (10% vs. 23%, p Z 0.4). The only secondary surgery in the SMBA group was related to the spontaneous bladder rupture in a non-compliant patient. In the standard ileocystoplasty group, five patients underwent secondary procedures to treat bladder stones while the other two underwent re-do bladder augmentation for persistent incontinence.
200.e4 The study is limited by the small number of patients in the SMBA group. Despite the lack of statistical significance for the various outcomes, there is clinical significance that warrants consideration, particularly with regard to stone development, continence, and the need for secondary surgery. Another drawback is that our study was conducted retrospectively, and therefore has limitations typically associated with retrospective studies, specifically the lack of data on metabolic abnormalities.
Conclusions Ileocystoplasty remains the standard technique for bladder augmentation, but SMBA is a viable and promising alternative with similar surgical outcomes and a lower rate of stone formation.
Conflicts of interest None.
Funding None.
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