Augmentation, Diversion, and Catheterization in Bladder Exstrophy
abstract
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Access this abstract nowPURPOSE
We assessed the probability of bladder augmentation/diversion and clean intermittent catheterization in classic bladder exstrophy in a multi-institutional cohort.
MATERIALS AND METHODS
We included children born from 1980 to 2016 with bladder exstrophy and treated across 5 centers (exclusion criteria less than 1 year followup after birth, isolated epispadias, bladder exstrophy variants etc). Outcomes were probability of bladder augmentation/diversion after bladder closure and proportion of patients performing clean intermittent catheterization at last followup. Survival analysis was used.
RESULTS
Of 216 patients 63.4% were male (median followup 14.4 years). Overall 4 patients (1.9%) underwent primary diversion and 212 underwent primary closure (72.6% in first week of life). After primary closure 50.9% underwent augmentation, 4.7% diversion and 44.8% neither. By age 18 years 88.5% underwent a bladder neck procedure (synchronous augmentation 27.3%). On survival analysis the probability of bladder augmentation/diversion was 14.9% by age 5 years, 50.7% by 10 years and 70.1% by 18 years. Probability of bladder augmentation/diversion varied significantly between centers (p=0.01). Probability of bladder augmentation/diversion was 60.7% 10 years after bladder neck procedure. At last followup of the entire cohort 67.4% performed clean intermittent catheterization. Among 95 patients with intact native bladders 30.5% performed clean intermittent catheterization (channel 72.4%). Among 76 adults without a diversion 85.5% performed clean intermittent catheterization (augmented bladder 100.0% clean intermittent catheterization, native bladder 31.3%). Fifteen patients underwent diversion (continent 8, ureterosigmoidostomy 5, incontinent 2).
CONCLUSIONS
On long-term followup probability of bladder augmentation/diversion increased with age, with 1 in 2 patients by age 10 years and the majority in adulthood. Probability of bladder augmentation/diversion differed among institutions. Almost a third of patients, including adults, with a closed native bladder performed clean intermittent catheterization. Considering all adults only 14% did not perform clean intermittent catheterization.
Additional Info
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Probability of Bladder Augmentation, Diversion and Clean Intermittent Catheterization in Classic Bladder Exstrophy: A 36-Year, Multi-Institutional, Retrospective Cohort Study
J Urol 2019 Sep 17;[EPub Ahead of Print], KM Szymanski, M Fuchs, D Mcleod, I Rosoklija, AC Strine, B VanderBrink, B Whittam, E Yerkes, PC GargolloFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This is a very well done and interesting paper from a nice sized group of midwestern children's hospitals on their long-term experience on the application of bladder augmentation, urinary diversion, and intermittent catheterization in the exstrophy population. The beauty of this study was the large numbers and new information; the downside is the fact that it involves both multiple surgeons and institutions.
In the editorial reply by Nelson, he makes mention of the continued key role for data from high-volume centers in addition to collaborative studies. The most compelling data from this paper demonstrated the probability of augmentation after a bladder neck procedure, which increased over the years. In a soon-to-be-published paper from a high-volume, single-center, long-term follow-up of 432 patients, of whom 142 patients underwent only a modified YDL procedure by 1 of 2 surgeons, was reported. Overall, 64% were dry day and night, with 80/91 voiding spontaneously and 11/91 performing IC. Therefore, 40% fell out and required augmentation in 10 years compared with 60% in the reviewed paper. In the overall single-center study on long term follow-up, only 25% voided spontaneously from the urethra without IC, which is not far from the numbers offered in the PUMA study.
These data continue to support the fact that this remains a major birth defect and that voided continence continues to be an achievable goal, but only after multiple operations, and can be achieved but only in about 25% of cases wherever the surgery is performed.
References