Long-Term Sequela of Pediatric Bladder Reconstruction

Abstract

Children with refractory neurogenic bladder (NGB) who have failed maximal medical management are presented with options for bladder reconstruction. It is critical to understand the long-term sequela of bladder augmentation and bladder neck reconstruction to properly counsel families regarding these procedures. Benefits may include preservation of renal function, continence, reduced risk of renal-related mortality and potential improvements in quality of life (QOL). However, these advantages must be balanced with the risks of bladder calculi, perforation, need for additional surgery, acid/base disturbances, vitamin B12 deficiency and malignancy. Therefore, careful patient selection and preoperative counseling are paramount for those undergoing bladder reconstruction which includes intestinal bladder augmentation, as these patients require lifelong vigilant follow-up. IntroductionChildren with neurogenic bladders (NGB) are initially managed with clean intermittent catheterization (CIC) and anticholinergic medications in order to maintain a sizable, continent, and compliant urinary reservoir. Despite early and aggressive intervention, some patients undergo lower urinary tract reconstruction (bladder augmentation, catheterizable channel and/or bladder neck reconstruction) to protect their upper tracts and achieve continence. In a few select patients with favorable urodynamics (UDS) and low outlet resistance, a bladder neck procedure (BNP) can be performed without bladder augmentation to achieve continence. Myelodysplasia, specifically spina bifida (SB), remains the most common etiology of NGB in the pediatric population. Due to medical advances, particularly in the realm of Urology, more SB patients with bladder reconstruction are surviving into adulthood. We review current literature regarding long-term sequela of bladder reconstruction in pediatric patients with neurogenic bladder, with a primary focus on bladder augmentations for refractory NGB secondary to SB.

Lessons learned from the management of adults who have undergone augmentation for spina bifida and bladder exstrophy: Incidence and management of the non‐lethal complications of bladder augmentation

“…Bladder stone formation after urological reconstruction is directly related to the type of augmentation carried out, the use of a continent catheterizable abdominal stoma, patient compliance with medical directives and length of follow up . It is notable that the most common complication after enteric bladder augmentation in the early 1980s was the development of bladder calculi .…”

“…It is notable that the most common complication after enteric bladder augmentation in the early 1980s was the development of bladder calculi . Indeed, patients undergoing a bladder augmentation in conjunction with a continent abdominal stoma were found to have a 50% incidence of bladder stone formation within 5 years after surgery . Of significant concern within this specific patient population was that 50% of the patients that initially developed a stone acquired a second bladder calculi within 5 years of their first occurrence .…”

“…In addition to the above mentioned metabolic abnormalities, hypercalciura can also occasionally be found in patients with a known neuropathy who have undergone an enteric bladder augmentation. In this patient population, excessive mobilization of calcium phosphate from bony stores develops as a result of either patient immobility or bone absorption used to buffer the metabolic acidosis induced by the enteric augmentation …”

“…The incidence of stomal complications with a continent catheterizable limb are directly related to the type of continent stoma carried out, the surgeons experience, the patient's BMI and length of follow up . Current data suggest that approximately 75% of children undergoing a bladder augmentation will have a simultaneous continent catheterizable stoma placed .…”

“…Bladder stone formation after urological reconstruction is directly related to the type of augmentation carried out, the use of a continent catheterizable abdominal stoma, patient compliance with medical directives and length of follow up. 27,[34][35][36][37][38] It is notable that the most common complication after enteric bladder augmentation in the early 1980s was the development of bladder calculi. 32,39 Indeed, patients undergoing a bladder augmentation in conjunction with a continent abdominal stoma were found to have a 50% incidence of bladder stone formation within 5 years after surgery.…”