Augmentation cystoplasty and the artificial genitourinary sphincter

Simultaneous bladder augmentation and artificial urinary sphincter placement in children with neuropathic urinary incontinence. Is it safe to perform? Long-term results

INTRODUCTION

Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial.

OBJECTIVE

The aim of this study is to describe our very long-term results after a median follow-up of 17 years.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups.

RESULTS

A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p = 0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p = 0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups.

DISCUSSION

There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time.

CONCLUSION

Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times.

Augmentation cystoplasty: Contemporary indications, techniques and complications

Augmentation cystoplasty (AC) has traditionally been used in the treatment of the low capacity, poorly compliant or refractory overactive bladder (OAB). The use of intravesical botulinum toxin and sacral neuromodulation in detrusor overactivity has reduced the number of AC performed for this indication. However, AC remains important in the pediatric and renal transplant setting and still remains a viable option for refractory OAB. Advances in surgical technique have seen the development of both laparoscopic and robotic augmentation cystoplasty. A variety of intestinal segments can be used although ileocystoplasty remains the most common performed procedure. Early complications include thromboembolism and mortality, whereas long-term problems include metabolic disturbance, bacteriuria, urinary tract stones, incontinence, perforation, the need for intermittent self-catheterization and carcinoma. This article examines the contemporary indications, published results and possible future directions for augmentation cystoplasty.

Treatment of neurogenic male urinary incontinence related to intrinsic sphincter insufficiency with an artificial urinary sphincter: a French retrospective multicentre study

OBJECTIVE

To assess results and morbidity of the periprostatic insertion of an artificial urinary sphincter (AUS) in adult male patients with a neurogenic bladder.

PATIENTS AND METHODS

A retrospective study was carried out on 51 adult male patients operated on in four urologic academic wards from April 1988 to January 2008. Among these patients, 31% (16/51) had spina bifida and 69% (35/51) had spinal cord injury. All patients suffered urinary incontinence secondary to sphincteric deficiency, and this was associated with detrusor overactivity in 39% of them (leading in these cases to an added bladder augmentation). Perfect continence was defined as a period of dryness of at least 4 h between two self-intermittent catheterizations (SIC) or spontaneous micturitions, moderate incontinence as nocturnal leakage or need to wear protection once during the day or for stress leakage, while severe incontinence was defined as uncontrollable leakage causing patient discomfort.

RESULTS

Mean age at the procedure was 35 years (18-58). Mean follow-up was 83 months (CI 95%, 65-101). At the end of the study, 15 patients (29.4%) were lost to follow-up. One patient (2%) died shortly after the procedure from a pulmonary infection. Post-operative morbidity was observed in 19% (10/50) of the patients (8 urinary tract infection, 1 failure to perform SIC, 1intracranial hypertension). Of the patients in our study 74% had perfect or moderate continence with a working AUS after a 10-year follow-up

CONCLUSIONS

We present a specific study on adult patients with a neurological lesion leading to bladder dysfunction treated by a periprostatic AUS. This procedure was effective in restoring urinary incontinence in the vast majority of our patients with an acceptable morbidity.

Total continence reconstruction using the artificial urinary sphincter and the Malone antegrade continence enema

PURPOSE

Surgical management of children with myelomeningocele addresses 2 aspects of the disease, neurogenic bladder and neurogenic bowel. Results of total continence reconstruction using an artificial urinary sphincter and Malone antegrade continence enema are presented.

MATERIALS AND METHODS

We performed a retrospective chart review of patients who underwent simultaneous artificial urinary sphincter placement and a Malone antegrade continence enema procedure. From 1997 to 2007 a total of 21 patients with myelomeningocele underwent total continence reconstruction using the artificial urinary sphincter. Mean patient age was 10.4 years (range 6 to 22) and mean followup was 4.7 years (range 0.66 to 11.7). Artificial urinary sphincter cuff was placed around the bladder neck. A Malone antegrade continence enema was performed using appendix in 19 patients and cecal based flaps in 2. Two patients underwent concomitant augmentation cystoplasty. Six patients had concomitant Mitrofanoff vesicostomy using split appendix in 4 and Monti tube in 2.

RESULTS

Immediate postoperative complications were observed in 5 patients, including prolonged ileus (2), urinary tract infection (2) and superficial wound dehiscence (1). Seventeen patients (81%) achieved complete urinary continence and 5 were voiding with sphincter cycling. Improvement in urinary continence with dry intervals greater than 3 hours was reported in 2 patients. There were 19 patients (90%) who reported fecal continence, with 2 reporting soiling 1 to 2 times a week. Malone antegrade continence enema stoma stenosis occurred in 3 patients and 2 required revisions. Sixteen patients (76%) achieved complete continence of stool and urine. During followup 2 artificial urinary sphincters were explanted and 8 patients (38%) underwent bladder augmentation.

CONCLUSIONS

Urinary and fecal continence in patients with myelomeningocele is achievable with a single total continence reconstruction procedure using the artificial urinary sphincter and the Malone antegrade continence enema with durable results.

BLADDER NECK SLING FOR TREATMENT OF NEUROGENIC INCONTINENCE IN CHILDREN WITH AUGMENTATION CYSTOPLASTY: LONG-TERM FOLLOWUP

PURPOSE

We retrospectively reviewed the outcome and long-term followup (mean 4.16 years) of bladder neck slings for the treatment of neurogenic urinary incontinence in 58 patients (15 males) who also underwent bladder augmentation.

MATERIALS AND METHODS

A total of 58 patients with neurogenic bladder (43 females and 15 males, median age 11.4 years) underwent a rectus fascial sling procedure as part of the reconstructive efforts for continence between July 1991 and July 2003. Criteria for enhancement of bladder outlet resistance included a detrusor leak point pressure of less than 45 cm H2O, an open bladder neck during bladder filling at low detrusor pressures and clinical evidence of stress incontinence.

RESULTS

Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). A total of 51 patients (88%) obtained good continence results. Five females and 2 males remained incontinent following the sling procedure. Four females underwent a secondary open bladder neck procedure at a mean of 18 months after the initial procedure (artificial urinary sphincter in 2, bladder neck closure in 2). Two male patients (5 and 17 years old) had daily underwear staining or dampness with exercise or transfer.

CONCLUSIONS

We consider bladder neck slings the procedure of choice for the enhancement of bladder outlet resistance in the majority of patients with neurogenic bladder who need augmentation cystoplasty and whom we do not expect will be capable of voiding spontaneously. In males and females satisfactory long-term continence can be expected with the use of the rectus fascial sling.

SIMULTANEOUS AUGMENTATION CYSTOPLASTY IS ASSOCIATED WITH EARLIER RATHER THAN INCREASED ARTIFICIAL URINARY SPHINCTER INFECTION

PURPOSE

While artificial urinary sphincter infection or erosion occurs in 20% of implantations, the risk factors are poorly understood. One of the most contentious factors reported to increase prosthesis infection is simultaneous sphincter implantation and augmentation cystoplasty. In contrast to some reports, to date our results have not shown an increased infective risk with the simultaneous procedure. We reviewed the long-term infective complications of 195 sphincters to investigate for predisposing infective factors and review the role of augmentation cystoplasty.

MATERIALS AND METHODS

We performed a retrospective case note review of 144 patients with a median followup of 112 months. Augmentation cystoplasty performed in 86 patients (60%) and was simultaneous in 56. All patients were reviewed within the last year or followed until death or sphincter failure. Patient, surgical and treatment factors were statistically analyzed for associations with prosthesis infection.

RESULTS

A total of 108 sphincters failed from infection (25%), tissue atrophy (5%) or mechanical reasons (25%). The overall infective failure rate was similar in patients who underwent simultaneous augmentation (30%) compared with the other patients (23%), although there was a statistically significant difference within the first 3 postoperative years (log rank p = 0.009). While no other variables were significantly associated with sphincter infection, intermittent self-catheterization did not increase sphincter infection and females appeared to have more prosthesis infections.

CONCLUSIONS

Our results suggest that, while simultaneous augmentation cystoplasty and artificial urinary sphincter implantation lead to an initial increase in prosthesis infection, this difference disappears after 3 years.

Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty

PURPOSE

Previous studies have described placement of an artificial urinary sphincter and simultaneous augmentation cystoplasty with a segment of bowel. Conclusions from these studies indicated that infection rates were higher and a staged approach should be undertaken. Others have suggested that concurrent urinary reconstruction with stomach and sphincter placement can be performed safely. Results comparing infection rates of simultaneous sphincter placement and gastrocystoplasty versus staged sphincter placement and augmentation cystoplasty using a segment of ileum or stomach versus sphincter placement alone in a pediatric population have not been previously described to our knowledge. We reviewed these various groups of patients to determine if the difference in infectious complications were clinically and statistically significant.

MATERIALS AND METHODS

A retrospective review of medical records from 1986 to 1999 identified 28 pediatric patients (age 18 years or less) who had undergone placement of an AS800dagger artificial urinary sphincter. Data points were collected focusing on etiology of the neurogenic bladder, age at time of surgery, types of surgery performed, length of followup and complication rates.

RESULTS

Complete data were available for 27 of the 28 patients. Neurogenic bladder was secondary to myelomeningocele in 25 cases, transverse myelitis in 1 and spinal cord injury in 2. Mean patient age at surgery was 12.7 years (range 6.1 to 18.2) and mean followup was 4.3 years (range 1 month to 13 years). Simultaneous gastrocystoplasty was performed in 7 cases (group 1), staged sphincter placement followed by augmentation cystoplasty with a segment of ileum or stomach was done in 8 (group 2) and 12 did not require bladder augmentation (group 3). Urethral device erosion requiring explantation was the most common complication, occurring in 3 patients in group 1 and 2 in group 3 (p = 0.101). Mean time to erosion was 22.1 months (range 2 to 46.4). Previous surgery (bladder neck or hernia repair) was a common factor in each group with complications. Urine cultures and culture of the explanted device were positive in 2 patients in group 1.

CONCLUSIONS

Simultaneous placement of artificial urinary sphincter at the time of gastrocystoplasty can be performed in carefully selected patients, although those undergoing staged procedures did well without complications. Prior bladder neck surgery seems to be a significant risk for infection. A staged approach to lower urinary tract reconstruction would be more advantageous due to the absence of infection and erosion in those undergoing staged sphincter placement and augmentation cystoplasty.

Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty

PURPOSE

Previous studies have described placement of an artificial urinary sphincter and simultaneous augmentation cystoplasty with a segment of bowel. Conclusions from these studies indicated that infection rates were higher and a staged approach should be undertaken. Others have suggested that concurrent urinary reconstruction with stomach and sphincter placement can be performed safely. Results comparing infection rates of simultaneous sphincter placement and gastrocystoplasty versus staged sphincter placement and augmentation cystoplasty using a segment of ileum or stomach versus sphincter placement alone in a pediatric population have not been previously described to our knowledge. We reviewed these various groups of patients to determine if the difference in infectious complications were clinically and statistically significant.

MATERIALS AND METHODS

A retrospective review of medical records from 1986 to 1999 identified 28 pediatric patients (age 18 years or less) who had undergone placement of an AS800dagger artificial urinary sphincter. Data points were collected focusing on etiology of the neurogenic bladder, age at time of surgery, types of surgery performed, length of followup and complication rates.

RESULTS

Complete data were available for 27 of the 28 patients. Neurogenic bladder was secondary to myelomeningocele in 25 cases, transverse myelitis in 1 and spinal cord injury in 2. Mean patient age at surgery was 12.7 years (range 6.1 to 18.2) and mean followup was 4.3 years (range 1 month to 13 years). Simultaneous gastrocystoplasty was performed in 7 cases (group 1), staged sphincter placement followed by augmentation cystoplasty with a segment of ileum or stomach was done in 8 (group 2) and 12 did not require bladder augmentation (group 3). Urethral device erosion requiring explantation was the most common complication, occurring in 3 patients in group 1 and 2 in group 3 (p = 0.101). Mean time to erosion was 22.1 months (range 2 to 46.4). Previous surgery (bladder neck or hernia repair) was a common factor in each group with complications. Urine cultures and culture of the explanted device were positive in 2 patients in group 1.

CONCLUSIONS

Simultaneous placement of artificial urinary sphincter at the time of gastrocystoplasty can be performed in carefully selected patients, although those undergoing staged procedures did well without complications. Prior bladder neck surgery seems to be a significant risk for infection. A staged approach to lower urinary tract reconstruction would be more advantageous due to the absence of infection and erosion in those undergoing staged sphincter placement and augmentation cystoplasty.

Reconstructive surgery in voiding dysfunction: experience with 69 patients

OBJECTIVES

To present our reconstructive surgery experience with voiding dysfunction due to both neurologic and non-neurologic etiology.

METHODS

From March 1993 to January 2000, 69 patients (43 men and 26 women) with voiding dysfunction underwent lower urinary tract reconstruction. Mean patient age at the time of surgery was 34. 5 years (range 9 to 75). Voiding dysfunction had a neurologic etiology in 65.2% of the patients and a non-neurologic etiology in 34.8%. Urodynamic investigation revealed poor bladder compliance in 52%, detrusor hyperreflexia in 19%, and a combination of the two in 29% of the patients. Thirteen patients (19%) had coexistent intrinsic sphincteric deficiency. A total of 56.5% of the patients had upper urinary tract deterioration. Most patients (78%) had severe urinary incontinence. Augmentation cystoplasty was performed in 60 patients. Nine patients had augmentation cystoplasty with a continent stoma. Concomitant procedures were performed in 11 patients.

RESULTS

Mean follow-up was 36.6 months (range 8 to 108). Marked improvement of the upper tracts was documented in 79% of the patients in the neuropathic and 73% in the non-neuropathic group. High continence rates were achieved in both groups (82% and 94%, respectively). Intermittent catheterization rate was 88.6% in the neuropathic and 44% in the non-neuropathic groups and patient satisfaction rate was 84% and 94%, respectively. Three major complications in 2 patients required surgery.

CONCLUSIONS

Surgical reconstruction to treat urinary incontinence and upper urinary tract deterioration gives satisfactory results in voiding dysfunction in the case of medical treatment failure.

Bladder augmentation: does it predispose to prosthetic infection of simultaneously placed artificial genitourinary sphincters or in situ ventriculoperitoneal shunts?

OBJECTIVE

To review previous reports and our experience in assessing the risk of prosthetic infections in patients undergoing bladder augmentation simultaneously with artificial genitourinary sphincter (AGUS) implantation, and in patients with in situ ventriculoperitoneal (VP) shunts, implicated as a cause of shunt infection.

PATIENTS AND METHODS

The literature was searched to identify the number of prosthetic infections (AGUS or VP shunt) reported in patients who have undergone bladder augmentation. Additionally, the records of 53 myelodysplastic patients at our institution who had undergone bladder augmentation were reviewed to determine the incidence of AGUS and/or VP shunt infections. An AGUS was placed in 17 of these patients, who were then divided into three groups based upon the timing of their AGUS placement relative to bladder augmentation. Of the 53 patients, 47 had an in situ VP shunt at the time of their augmentation. All patients were followed for at least 12 months.

RESULTS

The reported rate of AGUS infection at the time of simultaneous bladder augmentation was not significantly different from that when these procedures were staged. In the present series, the AGUS became infected in two patients (12%); one infection occurred in each of 10 patients undergoing simultaneous procedures (10%) and one developed in each of the seven patients undergoing staged procedures (14%). Although VP shunt infections have been reported after bladder augmentation, none of the present patients had a VP shunt infection after bladder augmentation.

CONCLUSION

These results suggest that bladder augmentation is not associated with an increased risk of prosthetic infection in patients undergoing simultaneous placement of an artificial sphincter or in those who have an in situ VP shunt.

Reconstructive surgery for urinary incontinence

The clinical urologist often is faced with the referral of a patient with urinary incontinence refractory to conservative measures. Given the broad spectrum of causes of urinary incontinence, the clinician must base evaluation and therapeutic management on current principles of urinary tract pathophysiology. This article organizes the pertinent diagnostic considerations that must be addressed in guiding the clinician to the appropriate surgical treatment option.

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement: infection rates and voiding mechanisms

PURPOSE

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement have recently been reported to be associated with a high incidence of infection. We reviewed our results to define the infection rate and outline the mechanisms of voiding in our patient population.

MATERIALS AND METHODS

A total of 29 patients underwent a simultaneous procedure. The etiology of lower urinary tract disease was exstrophy in 14 patients, myelomeningocele in 10, lipomeningocele in 3, spinal cord injury in 1 and radical retropubic prostatectomy in 1. We used 19 gastric, 5 ileal and 5 colonic intestinal segments. Average followup was 33 months. All patients were followed for a minimum of 2 years. Preoperatively all cases had mechanical bowel preparation and documented sterile urine cultures or treated bacteriuria.

RESULTS

Infection developed in 2 patients (6.9%) necessitating artificial urinary sphincter removal at 1 week and 9 months. There were no infections associated with gastrocystoplasty. Clean intermittent catheterization was required in 21 patients, while the remaining 8 voided spontaneously. Of the 8 patients 4 were catheterized at least once daily to monitor residual urine volumes. Of all patients 5 were catheterized with a gastric tube, 5 with an appendicovesicostomy and 14 per urethra.

CONCLUSIONS

A simultaneous procedure was associated with an acceptable prosthetic infection rate and gastric segments were associated with the lowest incidence of infection. The minority of patients voided spontaneously. The combination procedure was effective in achieving continence. However, in the future a nonprosthetic means of providing urethral resistance may provide better treatment.

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement: infection rates and voiding mechanisms

PURPOSE

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement have recently been reported to be associated with a high incidence of infection. We reviewed our results to define the infection rate and outline the mechanisms of voiding in our patient population.

MATERIALS AND METHODS

A total of 29 patients underwent a simultaneous procedure. The etiology of lower urinary tract disease was exstrophy in 14 patients, myelomeningocele in 10, lipomeningocele in 3, spinal cord injury in 1 and radical retropubic prostatectomy in 1. We used 19 gastric, 5 ileal and 5 colonic intestinal segments. Average followup was 33 months. All patients were followed for a minimum of 2 years. Preoperatively all cases had mechanical bowel preparation and documented sterile urine cultures or treated bacteriuria.

RESULTS

Infection developed in 2 patients (6.9%) necessitating artificial urinary sphincter removal at 1 week and 9 months. There were no infections associated with gastrocystoplasty. Clean intermittent catheterization was required in 21 patients, while the remaining 8 voided spontaneously. Of the 8 patients 4 were catheterized at least once daily to monitor residual urine volumes. Of all patients 5 were catheterized with a gastric tube, 5 with an appendicovesicostomy and 14 per urethra.

CONCLUSIONS

A simultaneous procedure was associated with an acceptable prosthetic infection rate and gastric segments were associated with the lowest incidence of infection. The minority of patients voided spontaneously. The combination procedure was effective in achieving continence. However, in the future a nonprosthetic means of providing urethral resistance may provide better treatment.

The development and evolution of artificial urethral sphincters

This history and evolution of mechanical devices designed to achieve urinary continence are reviewed. The following devices were studies: Foley clamp, Kaufman prosthesis, Giori, Summers and Rosen sphincters, Gruneberger and Cleveland Clinic magnetic designs, Craggs sphincter and the AMS family of sphincters (AMS 721, AMS 761, AMS 742 (A, B, C), AMS 792, AMS 800). The design of active hydraulic devices is discussed in more detail. This review analyses the problems relating to the application of pressure and the presence of foreign material around the urethra. 'Volume set' devices are universally unsuccessful and detrimental for urethral integrity as opposed to 'pressure set' hydraulic sphincters (e.g. AMS 800). The implications for the design of artificial implants are discussed.

Clinical outcome and quality of life following enterocystoplasty for idiopathic detrusor instability and neurogenic bladder dysfunction

OBJECTIVE

To study the long-term outcome of patients undergoing enterocystoplasty.

PATIENTS AND METHODS

The study comprised 48 patients (17 men and 31 women; mean age 46 years) who underwent enterocystoplasty for idiopathic detrusor instability (DI, 35 patients) or neurogenic bladder dysfunction (13 patients). Symptoms were scored from 0 to 14 and the overall outcome and generic quality of life were assessed using a Visick grading system (groups A to E) and the Nottingham Health Profile (NHP). These assessments were carried out before, 3 months after operation and at the final follow-up (38 +/- 18 months, range 13-78). Urodynamic studies were performed before and after operation.

RESULTS

No patient died after operation and there was minimal early morbidity. Late complications (> 30 days) included incisional hernia (3), anastomotic perforation (1), calculus formation (1) and urethral stricture (1). Clean intermittent self-catheterization (CISC) was performed by 36 (75%) patients. Early symptomatic outcome was good in 40 (83%) patients, moderate in seven (15%) and unsatisfactory in one (2%) patient. The mean symptom scores before and 3 months after surgery were 10 (range 2-14) and 3 (range 2-14), respectively (P < 0.001). There was a significant increase in total bladder capacity (307 +/- 140 to 588 +/- 217 mL; P < 0.001) and bladder compliance (37 +/- 50 to 169 +/- 162 mL/cm H2O; P < 0.001). DI persisted in 15 (31%) patients. NHP scores revealed significant improvements in all domains. Final assessment showed a less satisfactory situation, with recurrent urinary tract infection (UTI) in 17 (37%) patients, a need for long-term antibiotic therapy in seven (15%) and a change in bowel habit in 15 (33%) (13 DI, two with neurogenic bladder dysfunction). CISC was performed by 39 (85%) patients. The long-term outcome was good or moderate in 12 patients (92%) with neurogenic bladder dysfunction and good or moderate in only 19 patients (58%) with DI.

CONCLUSION

Clam enterocystoplasty remains an effective management option in some patients with DI, but most patients with neurogenic bladder dysfunction do well. The procedure is, however, associated with long-term complications such as disturbance of bowel habit and recurrent UTIs, which impair the outcome in the long-term in patients with DI despite general improvements in irritative bladder symptoms.

Experience with augmentation cystoplasty. A review

Good experience with clam cystoplasty is reported for 28 patients (14 female), 89% of whom had a neuropathic bladder. Prolonged conservative treatment had failed in all cases. The efficacy of the operation in terms of continence, increased bladder compliance, and bladder capacity was confirmed. Complications were common and included inability to void (70%) requiring clean intermittent catheterisation (CIC), recurrent urinary tract infection (59%) and stone formation (22%). Due to these complications, further surgery was required for 44% of the patients. Although clam enterocystoplasty is an efficient way to reconstruct a functionally disturbed urinary tract, careful patient selection is essential. Lifetime follow-up and recognition of the most frequent complications is mandatory.

Combined use of bowel and the artificial urinary sphincter in reconstruction of the lower urinary tract: infectious complications

Combined use of the artificial urinary sphincter and bowel in reconstruction of the lower urinary tract is currently being performed with increasing frequency. We reviewed our experience with 31 patients undergoing augmentation cystoplasty and insertion of the artificial urinary sphincter with respect to device infections to determine if a single operation was associated with increased morbidity compared to staged procedures. Of the patients who underwent simultaneous reconstruction 50% had prosthetic infections as opposed to 9.5% when the procedure was staged. More than half of the infections presented longer than 1 year after placement of the artificial urinary sphincter. The lowest incidence of device infection occurred in patients who underwent a staged procedure with implantation of the artificial urinary sphincter initially followed by augmentation cystoplasty. The discrepancy in infection rates between single and staged procedures is dramatic in this series and, therefore, a staged approach is recommended to decrease infectious complications.

Enterocystoplasty in the neuropathic bladder

Patients with neuropathic bladders who have intractable hyperreflexia often require cystoplasty and in patients adequately motivated and counselled, continence rates in excess of 90% can be achieved. Seventy-eight patients with neurological disease have undergone enterocystoplasty and are presented. Twenty-two patients had acquired cord lesions of which 17 were traumatic. Of the 56 patients with congenital myelodysplasia, 49 were meningomyelocele, 5 had sacral agenesis, and 2 lipoma of cauda equina. The mean age was 26 (range 13-61) years with 48 male and 30 females. Pre-operative video urodynamics showed sphincter weakness in 54 patients, all patients had intermediate type bladders; hyperreflexia in 52, reduced compliance in 17, and in 7 a combination of both. Forty-seven patients had ileal, 20 had sigmoid, and 11 had ileocaecal cystoplasty. Fifty-two patients had an artificial urinary sphincter inserted, 9 had a colposuspension, and 1 had both for concurrent sphincter weakness incontinence. Acceptable continence has been achieved in 73 (93.6%) patients, 65 claiming complete continence with no pads or incontinence episodes and the 8 others needing pharmacotherapy or pads. Two of our 5 failures have been converted to an ileal loop, 2 are awaiting further surgery, and 1 is wet despite normal urodynamics. Our threshold for initiating intermittent catheterisation is low and 63 (81%) of our patients catheterise. Complications in these patients are few and the only one of note is persistent bowel problems in 30% of our patients. Cystoplasty is recommended as safe and reliable in the treatment of neurogenic detrusor over activity with a continence rate of 93% being achieved.(ABSTRACT TRUNCATED AT 250 WORDS)

Success of the narrow-backed cuff design of the AMS800 artificial urinary sphincter: analysis of 144 patients

The narrow-backed cuff design of the AMS800 artificial urinary sphincter was introduced to improve transmission of cuff pressure to underlying tissue and, theoretically, to decrease the incidence of cuff erosion. The AMS800 urinary sphincter with this design change was implanted in 136 male and 8 female patients (mean age 57 years). Mean followup was 28 months. The cuff was placed around the bladder neck in all 8 female and in 29 male patients, and it was implanted around the bulbous urethra in the remaining 107. The 4.5 cm. cuff in combination with the 61 to 70 cm. pressure balloon was implanted in 109 patients. There were 12 device failures and 12 surgical complications. Five patients required cuff removal and none required reoperation for inadequate cuff pressure. Postoperatively, 132 patients reported satisfactory continence. The design change of the AMS800 and the use of the 4.5 cm. cuff with the 61 to 70 cm. pressure balloon decreased the incidence of cuff erosion and the need for reoperation for inadequate cuff pressure.

Experience with AS 800 artificial sphincter in pediatric and young adult patients

Congenital or acquired sphincteric urinary incontinence in children and young adults is a severe social and physical burden. As a therapeutic option, we implanted 61 AS 800 artificial sphincters in 59 patients (46 males and 13 females). The mean age of the patients was 17.5 years (range, 6 to 34 years), and mean follow-up was forty-three months (range, 5 to 84 months). In addition to artificial sphincter implantation, intestinal cystoplasty was required in 22 patients to obviate problems of increased detrusor contractility or decreased detrusor compliance, or both. Continence was good in 47 patients (80%) and fair in 8 (14%). Four patients (7%) were awaiting sphincter modification or cystoplasty, or both. Careful and prolonged follow-up is mandatory in all patients managed in this fashion to preclude the deleterious effects of subtle changes in detrusor or ureteral function on the integrity of the upper urinary tracts.

Experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma

We describe our experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma as an alternative to an indwelling catheter or supravesical diversion in 14 women and 4 men with various problems who could not perform intermittent urethral self-catheterization. The aim of management was also to provide, if possible, a competent urethra for additional access. Mean patient age was 37 years (range 22 to 75) and mean followup was 26 months (range 5 to 58). Preoperative management in the 11 wheelchair dependent women with neurological disease was an indwelling catheter in 7, urethral intermittent catheterization with the patient in the supine position in 3 and diapers in 1. Two women with a nonneurogenic bladder and a grossly incompetent urethra (1 after multiple incontinence and fistula repairs, and 1 after severe obstetrical trauma) wore diapers, while 1 with urinary retention and inability to perform self-catheterization had an indwelling catheter. The 4 men included 2 wheelchair dependent incontinent spinal cord injury patients who could not be managed with condom drainage, 1 with multiple anomalies who had trouble with self-catheterization, and 1 with an impassable postoperative stricture and a suprapubic tube. Surgery included anti-incontinence procedures in 10 patients and bladder neck closure in 3. A total of 15 patients required bladder augmentation in addition to the stoma and 3 had a stoma alone. Postoperative intervention was necessary in 4 women for stomal incontinence and in 2 of these bladder stones were removed simultaneously. One of these women was later treated for recurrent stones cystoscopically through the stoma. Overall, 17 of 18 patients are dry on intermittent stomal catheterization, with 1 lost to followup. We conclude that this procedure is a good alternative in patients with an end stage urethra or who cannot perform urethral catheterization because of physical disability. Establishing urethral continence and maintaining patency leaves a safety valve should the stoma fail. Since the bladder remains as a reservoir no ureteral surgery is necessary.

Ambulatory monitoring of bladder pressure in low compliance neurogenic bladder dysfunction

Upper tract dilatation is an important complication of neurogenic bladder dysfunction. Risk factors include incomplete bladder emptying with large residual volumes of urine and high tonic increases in bladder pressures during artificial filling. However, on natural bladder filling many of these patients do not have high tonic increases in detrusor pressures. We compared conventional urodynamic studies with ambulatory monitoring during natural bladder filling in 66 patients with low compliance neurogenic bladder dysfunction. There were marked differences in the tonic increase in bladder pressure during filling and in compliance during artificial bladder filling compared with ambulatory monitoring. Faster filling rates during artificial filling resulted in greater end filling pressures and lower compliance but the lowest increases in bladder pressure were found during ambulatory monitoring with natural bladder filling. During natural bladder filling significantly more patients had phasic changes in detrusor pressure; a high intensity of phasic activity during ambulatory monitoring correlated with high end filling pressures during artificial bladder filling. Upper tract dilatation was associated with large volumes of residual urine, high resting bladder pressures and low bladder compliance on filling at 100 ml. per minute. However, upper tract dilatation was most strongly associated with high intensity phasic pressure activity during natural bladder filling in combination with high residual urine volumes and high resting bladder pressures. On multivariate statistical analysis the intensity of phasic pressure activity during ambulatory monitoring was the best discriminator between patients with dilated and normal upper tracts. Our study has highlighted important differences in the results obtained by artificial filling cystometry and ambulatory monitoring during natural bladder filling. In particular, high increases in pressure did not occur during natural bladder filling, apparently being replaced by phasic activity. Within this group of patients who had the high risk factor of low bladder compliance measured during artificial bladder filling, a combination of greater residual urine volumes, greater resting pressures and greater phasic activity during natural bladder filling was found in patients with upper tract dilatation.

Management of the bladder outlet in patients requiring enterocystoplasty

We reviewed 30 patients who required augmentation enterocystoplasty and a procedure to modify the bladder outlet for the treatment of intractable incontinence. Of the 30 patients 16 were treated with simultaneous cystoplasty and an outlet procedure, 6 initially underwent an outlet procedure followed by cystoplasty and in 8 cystoplasty was performed first with a subsequent operation to modify the bladder outlet. Continence was achieved in 29 patients. The current methods for evaluation of the bladder and its outlet are reviewed, focusing on the predictive value of preoperative testing to determine which patients require cystoplasty and an outlet modifying procedure.