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. 2016 Apr;8(Suppl 2):S122–S134.

Voiding Dysfunction

PMCID: PMC4869443
Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Modified young-dees-leadbetter bladder neck reconstruction in bladder exstrophy and episdadias

Mostafa K. Mansi, S. Aluned

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Fifteen patients had Young-Dees-Leadbetter bladder neck reconstruction, including seven females and two males with exstrophy and four females and two males with epispadias. Eight patients had previous unsuccessful reconstructions, including three with failed artificial urinary sphincters. The reconstruction technique was modified, using one layer of interrupted mattress sutures, instead of the two layer double-breasting technique. Simultaneous augmentation cystoplasty was performed in 12 patients (9 exstrophy, 3 female epispadias). Six female and two male exstrophy patients and one female epispadias patient are continent. Five females and one male are managed by clean intermittent catheterisable stoma (Mitrofanoff). Two male and one female epispadias patients are incontinent due to small bladder capacity and will require secondary augmentation. The other three incontinent patients may have inadequate tubularized segments, the problem being compounded by non-compliance with CIC. Overall continence rate was 60% but 75% in augmentation patients. Young-Dees-Leadbetter bladder neck reconstruction using a modified one layer tubularization is a satisfactory operation and may be performed when previous surgical procedures have been unsuccessful. However, bladder capacity may be considerably reduced after reconstruction and simultaneous augmentation should be considered, not only in exstrophy patients, but also in patients with epispadias.

Presented at the: 8th Saudi Urological Conference King Fahd Military Medical Complex 9-10 November 1993

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Hinman's syndrome: Experience in the management of two cases

Farouq Osman, Reda Hassan

Department of Urology, King Abdulaziz Airbase Hospital, Dhahran, Saudi Arabia

Hinman's syndrome “non-neurogenic bladder” is the most severe form of vesico-urethral dysfunction during voiding in childhood. It is claimed to be an acquired functional disturbance and not a neuropathy. It could result in vesica-ureteric reflux, ureteric dilatation and hydronephrosis. Any of these complications could present as the primary disease which warrants surgical implication before identifying the primary bladder sphincter dysfunction. This usually results in high surgical complications and failure rate.

We present our experience in treating two cases detected over the last ten years in our hospital.

Presented at the: 8th Saudi Urological Conference King Fahd Military Medical Complex 9-10 November 1993

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Urinary diversion in pediatrics

A. Al Ghamdi, A. Shaaban, M. S. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

A review of 25 cases of pediatric urinary diversion managed in Riyadh Armed Forces Hospital between 1983 and 1995 was carried out. The initial diagnosis were PUV in 7 patients, ectopia vesicae in 6, vesico-renal reflux in 5, neurogenic bladder in 6 and 1 patient had rhabdomyosarcoma of the genital tract. Of the total number of patients, 16 patients were referred to Riyadh Armed Forces Hospital for further management. The age of presentation was between 2 days and 7-1/2 years. 23 patients were Saudi and 2 patients non-Saudi. Type of treatment performed were cutaneoureterostomy in 10 patients, ureterosigmoidostomy in 6, vesicostomy in 3, colonic conduit in 2 and suprapubic and urethral catheter in 2 patients. All patients were followed up except one. The complication and outcome of patients will be presented.

Presented at the: 9th Saudi Urology Conference King Fahad Hospital - Jeddah 14-16 November 1995

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Reconstruction in bladder exstrophy

Robert D. Jeffs

Department of Urology, John Hopkins Hospital, Baltimore, USA

There have been many refinements in the management of bladder exstrophy in the last 40 years. Including all the variants of the exstrophy epispadias syndrome this unit has treated or consulted on more than 500 patients. Central and most common in this group of patients is classical bladder exstrophy. The present approach to management is illustrated by 70 patients seen in the last 20 years who were untreated at presentation. The lessons learned, the new knowledge acquired and the present outcome in these 70 patients will be reviewed.

Presented at the: 9th Saudi Urology Conference King Fahad Hospital – Jeddah 14-16 November 1995

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Experiences with single stage correction of ectopia vesica

K. S. Abdulwahab, C. Krishnappa, A. Jha, Said Roshdi, Thomson Jacob

Department of Urology, King Fahd Central Hospital, Gizan, Saudi Arabia

Introduction and Aims: Ectopia Vesica or Exstrophy of the bladder is one of the rarest Genitourinary abnormalities. We have seen and operated 8 cases in 5 years. Primary closure of the defect and reconstruction were done without inanimate osteotomy in all cases. The long term follow up and the complications are discussed.

Materials and Methods: All the children were operated in Neonatal period. The age at the time of presentation were 3 days to 40 days. Surprisingly all the cases were female. Only one child had vaginal opening, the vagina was absent in 5 cases. All the children had Grade I to Grade II hydronephrosis and hydroureter. Renal functional testes were within normal limits. Split clitoris were found in all the cases. Total success as far as midline closure were concerned, was achieved in 7 cases. One case was total failure, all sutures gave way on the 3rd postoperative day. The children are followed up now for the past 6 years. The eldest child is six years and the youngest 3 months only. Urinary continent was achieved in two cases. During the follow up two children developed vesical stones repeatedly. 3 children had repeated urinary tract infection. Prolapse of the rectum corrected spontaneously in all cases. No attempt was made to construct vagina till now.

Summary and Conclusion: Single stage correction is highly successful. Complications are discussed and the ways to minimise and prevent complication are discussed.

Presented at the: 9th Saudi Urology Conference King Fahad Hospital - Jeddah 14-16 November 1995

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Bladder augmentation in children

Robert D. Jeffs

Department of Urology, John Hopkins Hospital, Baltimore, USA

Bladder augmentation to enlarge the bladder is used in patients with hyper tonic neurogenic bladder, non compliant urethral valve bladders, exstrophy bladders failing primary reconstruction and other rare anomalies or injuries to the bladder. The present status and complications in 62 patients in reviewed. All of these 62 patients received augmentation when the bladder could not be functionally reconstructed. All patients perform clean intermittent catheterisation either through an abdominal stoma or through the reconstructed urethra. None void spontaneously even by valsalva because of the abnormal outlet. The abdominal stoma was created using the Mitrofanoff principle in 16 patients and by use of the Benchekroun procedure in 14 patients. Other types of continent stomata were used occasionally but urethral catheterisation for evacuation was used in most of the remaining patients. A variety of bowel segments were used in the augmentation.

Upper tract deterioration was infrequent as reflux was corrected at time of augmentation. All patients were continent on clean intermittent catheterisation. Stoma revision was frequently needed in the Benchekroun stomata. Bladder stone formation was the most frequent complication. Except in patients with prior renal insufficiency, electrolyte disturbances were infrequent. Vitamin B deficiency, fat mal-absorption and steatorrhea did not occur. New approaches to augmentation and techniques to avoid complications will be discussed. Long-term follow up is essential in all patients with augmentation considering the possibility of malignancy.

Presented at the: 9th Saudi Urology Conference King Fahad Hospital – Jeddah 14-16 November 1995

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Bladder neck reconstruction in bladder exstrophy

S. Ahmed, K. Fouda-Neel, M. Borghol

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Nine female and four male patients with repaired bladder exstrophy had modified Young-Dees-Leadbetter bladder neck reconstruction together with augmentation cystoplasty (colon 12, ileum 1).

Eight females are continent, seven being managed by clean intermittent catheterization (CIC), including one Mitrofanoff procedure and one voids normally. One girl who would not allow CIC is incontinent. Two males are continent (one normal voiding, one CIC).

Two are incontinent although one has improved control. The pubic diastasis which ranged from 3 cm (mean 5.5 cm) did not have any bearing on the result. Thus, the 3 incontinent patients had with diastasis ranging from 4-9 cm.

Young-Dees-Leadbetter bladder neck reconstruction with augmentation cystoplasty is a satisfactory operation in bladder exstrophy patients. We believe that the 77% is a continence rate is reflection of a competent tubularization with an adequate bladder capacity. A closed pelvis with approximated pubic bones is not necessary to achieve this objective.

Presented at the: 9th Saudi Urology Conference King Fahad Hospital - Jeddah 14-16 November 1995

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Congenital and iatrogenic malformations and deformalities of the male genitalia: Recent personal experience in 56 patients

Nabil K. Bissada

Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Fifty-six personal cases with congenital malformation (48) and eight with iatrogenic deformities managed in the last 3 years are described. These include 26 patients with hypospadias, 4 with pure hypospadias, 10 with epispadias exstrophy complex, 5 with ventral chordee without hypospadias and 1 with dorsal chordee and 1 with penile hemangiomas and 1 with isolated torsion. The 8 iatrogenic cases resulted from circumcision in 4, failed corrections of chordee without hypospadias (2) and of urethral stricture (2).

Patient with mild hypospadias and those with iatrogenic complications have done well with one-stage correction. Those with severe hypospadias were also managed by one-stage correction with satisfactory results. Patients with epispadias and exstrophy epispadias complex required multi stage correction to achieve satisfactory results.

Presented at the: 4th Saudi Urological Conference Riyadh Central Hospital 18 September 1986

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

The child with ambigious genitalia background, evaluation and management

Nadia Sakati

Department of Pediatrics, King Faisal Specialist Hospital, Riyadh, Saudi Arabia

The embryology of the external genitalia and the internal ductal system is reviewed. Abnormal development and the pathogenesis of different intersex states is described. The systematic diagnostic work up and differential diagnosis of the child with ambigious genitalia is described. The management of different intersex conditions is outlined.

Presented at the: 4th Saudi Urological Conference Riyadh Central Hospital 18 September 1986

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Randomized prospective study to see the effect of botulinum: A toxin intravesically as a solo treatment for non-compliant neuropathic bladder

Khalid Fouda, Sherif Soliman, Hamdan Al Hazmi, Mohamed Seida, Amenah Khatab

Department of Surgery, Division of Urology, College of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

Introduction: Botulinum toxin, first isolated by Van Emengem in 1897, is the most potent biological toxin known to man. Through basic research, clinicians have been able to transform this lethal toxin into a health benefit. In urology it was initially used to treat spinal cord injured patients who suffers from detrusor external sphincter dyssnergia. More recently Schurch and colleagues reported successful treatment of detrusor hyper-reflexia using intravesical botulinum toxin type-A (Botox®) which was followed by the initial clinical application in children suffering from neuropathic bladder with encouraging result.

Aim of the Study: In this study, we examined the effect of botulinum-A toxin on children with neuropathic bladder, and to see whether botulinum-A toxin can be used alone in the management of refractory neuropathic bladder or better in conjunction with oxybutinin.

Materials and Methods: Between October 2003 and October 2005, 20 children with mean age of 5.7 years (2-10 + SD2.2) had botulinum toxin type A (Botox®) injection for the treatment of neuropathic bladder secondary to myelomeningiocele. All patients were on clean intermittent catheterization and anti-cholenergic medication, but are still showing a non-compliant bladder. The 20 patients were randomized divided into two groups. In group 1 (10 patients) oxybutinin was continued throughout the study and in group 2 (10 patients) oxybutinin was stopped at the day of the (Botox®)) injection and continued off oxybutinin through out the study. A urodynamic study was repeated within a week before the procedure and cystoscopic injection of 12 u/kg of (Botox®)) (maximum 300 u) was done in an infection free bladder. A follow up urodynamic study was done at one month, 3 months, and 6 months follow up.

Results: The maximum bladder capacity increased from 105 ml ± 66 (range 15 to 277) to 156 ml ± 106 (range 50 to 500) (p < 0.012), 143 ± 107 (45-450) (NS) and 135 (21-250) (p < 0.014) at 1, 3, and 6 months respectively. The maximal detrusor pressure decreased significantly from 79 cm H2O ± 39 (36-209) to 56 cm H2O ± 22 (20-100) (p < 0.010), 52 cm H2O ± 18 (22-90) (p < 0.005), and 51 cm H2O ± 16 (18-95) (p < 0.007) at 1, 3, and 6 months respectively. Comparing group 1 and 2 there was no statistical difference in all parameters at any point. From the clinical point of view, out of 14 incontinent patients, 8 (57.1%) patients showed complete continence after treatment, while 3 (21.4%) reported mild to moderate improvement and 3 (21.4%) showed no improvement. None of our patients had side effects related to the procedure or the material used.

Conclusion: Botulinum A toxin injection into the hyper reflexive detrusor muscle seems to cause significant improvement of the bladder function in both urodynamic and clinical parameters. There was no clinical or urodynamic sequel from stopping oxybutinin chloride during the study. Accordingly our results confirm that this new treatment is safe and valuable and can be used as a solo treatment for refractory cases of neuropathic bladder.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Botulinum a toxin urethral sphincter injection in children with non-neurogenic neurogenic bladder

Salah Gaafar

Department of Urology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt

Purpose: To evaluate Botulinum A toxin (Botox®) injection into the external urethral urinary sphincter in children with non-neurogenic neurogenic bladder to reduce urethral resistance and improve voiding as an alternative to alpha blocker medications and biofeedback.

Materials and Methods: A prospective study was performed on 10 children with non-neurogenic neurogenic bladder whose age ranged between 6-17 years (mean age=8) using Botulinum A toxin (Botox®). Preoperatively, all children were evaluated by U/S, VCUG, IVP, MRI and urodynamic studies including pressure flow, EMG and uroflowmetry. One patient had unilateral reflux G3 and four patients had bilateral hydronephrosis (G1 to G4). Using a rigid pediatric endoscope and a 4 Fr injection needle, 50 to 100 I.U. of Botulinum A toxin were injected into the external sphincter at the 3, 6 and 9 o’clock positions. Follow up ranged from 3 to 6 months. Repeated injections every month were given according to the response with a maximum of 3 injections.

Results: Immediately after Botulinum A toxin injection all but 1 patient were able to void without catheterization. No acute complications were encountered. Three patients with bilateral hydronephrosis and the patient with the refluxing unit showed regression. Postoperative post-voiding residual urine decreased by 81% maximum voiding pressure decreased significantly (75 ± 40 vs 30 ± 23 cm H2O) and uroflowmetry showed marked increase in Qmax (4 ± 4 vs 18 ± 8 ml/sec). One patient needed 3 injections to reach the desired response.

Conclusions: Urethral sphincter Botulinum A toxin (Botox®) injection could be considered as a reliable treatment modality in children with non-neurogenic neurogenic bladder.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Minimally invasive surgery in children

Khalid Fouda Neel

Department of Urology, Kind Khalid University Hospital, Riyadh, Saudi Arabia

The current trend in the use of minimally invasive therapy has its roots in endoscopy, which in turn derived its historical roots from inspection of body cavities using specula and other similar instruments. Management of urolithiasis and secondary ureteric obstruction, endourology in pediatric urology became an intimate part of managing different pathologies, particularly vesicoureteric reflux. Since Puri and Donnel reported their experience with the endoscopic correction of VUR (STING procedure) in the early 80's of the last century, this technique have evolved and gained wide acceptance, particularly with the introduction of a more safe injectable materials.

Further advances in minimally invasive procedures included managing children with neuropathic bladder, after the encouraging initial experience with intravesical injection of Botulinum toxin (BOTOX®) in adults, were it shopped with further research and standardization; bladder reconstruction procedures in patients with neuropathic bladder will be reduced. Minimally invasive surgery in urology is gaining wide acceptance, particularly in children, were their perception of an open procedure is quite different, and the long term effect of many open procedures is yet to be determined. In 1976 laparoscopy was introduced to urology by Cortesi when they performed laparoscopy for a nonpalpable testis. Then after a period stagnation, pelvic lymphadenectomy and nephrectomy were performed in adult patients. In consequence, laparoscopy regained access into pediatric urology and has evolved to therapeutic approaches as well. The evolution of endourology has preceded that of laparoscopy in pediatric urology. Together with shared procedures with adult urologist, naming a few.

Presented at the: 17th Saudi Urological Conference King Fahd Military Medical Complex 8-10 March 2005

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Neuropathic bladder as a cause of chronic renal failure in children

Jameela A. Kari

Department of Pediatric, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Objectives: Neuropathic bladder is considered as threaten to the kidneys if not managed appropriately. Early interference by keeping the bladder empty, at low pressure, and free of infection, would preserve renal function. In this study, we report our experience at King Abdulaziz University Hospital (KAUH), with neuropathic bladder as a cause of chronic renal failure (CRF) in pediatrics age group.

Patients and Methods: A retrospective study of all pediatric cases diagnosed as a neurogenic bladder and presented with CRF (GFR <50 ml/minute/1.73 M2) from December 2000 to December 2004. Fifteen patients were diagnosed as neuropathic bladder, group A: 10 spina bifida and 1 sacral agenesis and group B: 4 non-neurogenic neurogenic bladder (NNNB).

Results: The mean age + SD at presentation 6.2 + 3.8 years, GFR 24.2 + 12.4 ml/minute/1.73 M2 and creatinine 289.9 + 253.2 mmol/l. There was no difference in the age of presentation to pediatric nephrologists or the degree of renal failure at presentation between the two groups. All children with NNNB, in group (B) presented with recurrent urinary tract infection (UTI) and the two older children were also reported as wet during the day. Clean intermittent catheterization (CIC) was not started in all patients before presentation to KAUH except in 2 children, in whom it was started by urologists. Five children required dialysis as they were in end stage renal failure (ESRF); 4 in group (A) and one in group (B). All except one received peritoneal dialysis (PD). Their mean age at the start of dialysis was 10.8 + 1.7 years. Two children with shunted hydrocephalus were dialyzed peritoneally; one of them had peritonitis and complicated with a staph epidermis shunt infection and therefore, she was shifted to hemodialysis and required externalization of the V-P shunt for few weeks. Only one patient was started on hemodialysis from the start because of social reasons.

Conclusion: Neuropathic bladder due to spina bifida or NNNB is an importance cause of CRF in the third world. There was a considerable delay in the diagnosis of NNNB and a significant delay in starting CIC in all neuropathic patients. More awareness is required among pediatricians about NNNB and about the risk to the kidneys caused by neuropathic bladder. Specialized spina bifida clinic with multi-disciplinary approach will help to reduce the observed delay in commencing the appropriate management to the urinary tract.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Minimally invasive management of ureterocele in children

Jeff-Stephane Valla

Department of Pediatric Surgery, Fondation LENVAL, Nice, France

Opinion is divided on the management of ureterocele which is influenced by a number of factors, including anatomical type (simple or duplex system, orthotopic, ectopic) mode of presentation (age, infection) effects on renal parenchyma (dysplasia), effects on upper urinary tract (obstruction, reflux), effects on bladder outflow (obstruction).

Our philosophy since 10 years is to adapt the treatment to each case and to use the less invasive method; a video will illustrate each step:

  • Watchful observation could be advocated for small asymptomatic ureterocele (2 cases)

  • Endoscopic ureterocele incision (20 cases) represents the least invasive form of intervention and may be an adequate definitive treatment in some selected cases, but more than often a temporizing measure in neonatal period to treat a gross upper polar sepsis or to assess the upper polar function; the technique of incision is variable according to the kind of ureterocele. Ureterocele incision was curative in 3/4¼ cases with single system and in 7/16 cases with duplex system

  • The “simplified approach” (20 cases), upper pole nephrectomy + ureterocele left in situ, is indicated if upper polar function is severely compromised. This partial nephrectomy is now performed with laparoscopic technique using a retroperitoneal approach; the conversion rate is 10%; no case of secondary atrophy of the lower pole was observed

Ureterocele excision + bladder trigonal reconstruction + ureteral reimplantation (4 cases) is the most extensive operation, often combined with an upper pole nephrectomy. This challenging procedure could be performed today under pneumovesicoscopy. The conversion rate is 1/4¼ in our preliminary experience. No specific complications related to laparoscopic technique were recorded. These results (38 cases in the last 10 years) are comparable to those of conventional open surgery.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Spina bifida management, how far we are?

Ahmad Al Shammari

Department of Urology, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Spina bifida is one of the congenital anomalies with wide spectrum of severity and presentation. If left untreated or improperly managed, will cause tremendous pressure on the health system. The management of spina bifida requires multidisciplinary approach through specialized spina bifida clinics. Early recognition and timely intervention will reduce the complication of this condition, improve the standard of care and reduce the economic pressure on the health system. The spina bifida management programs in Saudi Arabia are still in its infancy compared to the first world. An insight on how far are we in the management of spina bifida will be presented as well as possible future plan based on the local available sources.

Presented at the: 17th Saudi Urological Conference King Fahd Military Medical Complex 8-10 March 2005

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Complete repair of bladder exstrophy: Single-center experience with 50 cases

Ashraf Tarek Hafez1,2

1Department of Pediatric Urology, Mansoura Urology and Nephrology Center, Mansoura, Egypt, 2Department of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Purpose: Complete primary repair (CPR) of bladder extrophy using Mitchell's technique gained wide popularity. We present a single center experience with CPR in 50 children.

Materials and Methods: Between November 1998 and December 2004, 50 patients (36 boys and 14 girls) underwent CPR of bladder extrophy using Mitchell's technique. 30/50 patients presented beyond the age of 1 year. Of the 30 patients 19 (63%) had a history of failed extrophy closure with mean patient age at surgery of 3.2 years. Ultrasound was performed before surgery and 3 months thereafter in all patients. Voiding cystourethrography was obtained at 3 months and then annually. Continence was defined as dry intervals of 3 hours or more.

Results: Mean follow up is 40 months (range 12 to 77). Concomitant intestinal bladder augmentation was performed in 5 children (10%). The repair resulted in hypospadias in 17 of 36 boys (47%). Following catheter removal 7 patients (14%) had suprapubic urine leakage that ceased spontaneously in all. Early postoperative hydronephrosis was present in 28 of the 50 children (56%) and resolved spontaneously in all. Six patients (12%) had febrile urinary tract infection that was treated conservatively. Vesicoureteral reflux was present in 34 children (68%). Of the 5 patients treated with concomitant bladder augmentation 2 are continent, 2 underwent bladder neck closure and 1 underwent bladder neck reconstruction (BNR). All 5 patients are currently dry. The remaining 45 patients had a mean bladder capacity of 90 ml (range 30 to 200). Continence was achieved in 60% of girls and 25% of boys following CPR.

Conclusions: CPR of bladder extrophy is feasible in both neonates and children presenting late or after failed initial closure. Concomitant intestinal bladder augmentation was required in 10% of our patients. The procedure resulted in hypospadias in half of boys. Continence rates are favorable in girls while most boys would require auxiliary procedures for achievement of volitional voiding.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Endoscopic polydimethylsiloxane treatment of intractable sphincteric urinary incontinence

Hamdan Al Hazmi, Cedric Andres, Ann-Marie Houle, Julie Franc-Guimond, Diego Barrieras

CHU Sainte-Justine, Division d’Urologie Pediatrique, Universite de Montreal and AI duPont Hospital for Children, Division of Pediatric Urology, Thomas Jefferson University, Wilmington, Delaware, USA

Purpose: Treatment of type III (sphincteric) urinary incontinence in children is challenging due to its various etiologies. It frequently involves complex reconstruction to attain continence. We present our result with the use of endoscopic polydimethysiloxane (Macroplastique, Uroplasty Inc.) injection for treatment of intractable type III incontinence.

Materials and Methods: We studied 12 patients (8 males, 4 females) age 3-18 years (7 myelomeningocele, 3 exstrophy/epispadias complex, 1 cloacal exstrophy, and 1 urogenital sinus malformation). Inclusion criteria were type III incontinence with leak point pressure (LPP) <20 cm H2O, failure of medical treatment and/or failed attempt at incontinence surgery. Treatment was done on an outpatient basis. Follow up involved urodynamic studies, voiding and incontinence diary and ultrasound carried at 3 and 12 months postoperatively.

Results: The 12 patients underwent 18 procedures with a total of 1.5 to 5 ml of polydimethylsiloxane per procedure. All patients were wearing 2 or more diapers per day pre-operatively. Post-operatively, 9 patients (75%) have greatly improved (0, 1 or 2 pads per day). Post-operative urodynamic studies revealed increased LPP to >50 cm H2O in these 9 patients. 3 patients have had only minimal subjective and no objective (urodynamics) improvement (awaiting second attempt). There were no intra or post-operative complications.

Conclusions: Endoscopic polydimethylsiloxane treatment of intractable type III incontinence in children is simple, minimally invasive, safe, and short term results are encouraging. Long term results in a larger cohort are warranted before this is considered standard treatment in the pediatric urologist armamentarium.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Nocturnal enuresis

Salah Gaafar

Department of Urology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt

Nocturnal enuresis or bedwetting the age of 5 or 6 years may primary or secondary; may be monosymptomatic or associated with diurnal voiding symptoms. The basic pathophysiology is a mismatch between nocturnal urine production and the nocturnal bladder capacity in the presence of an arousal defect. Defective toilet training plays a crucial role in the etiology of nocturnal enuresis. The etiological factors also include psycho-social and hereditary factors in addition to, upper respiratory tract lesions and constipation.

The diagnostic workup starts by clinical evaluation, routine laboratory tests and ultrasonography of the kidney and urinary tract. Older children, cases of secondary enuresis, treatment-failures, and those with evident neurological lesions will need urodynamic studies and detailed imaging studies, e.g. IVU, VCUG, and/or MRI.

The management of primary monosymptomatic nocturnal enuresis is based on counseling the child and his parents with some modifications in life style, in addition to pharmacological therapy in the form of anti-diuretic hormone analogues, and/or anticholinergics. Tricyclic antidepressants, e.g. imipramine are not recommended because of their serious side effects. Alarms may be useful in some cases.

Presented at the: 18th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Extramural serous lined tunnel, an alternative technique to do mitrofanoff (continent catheterizable outlet stoma). Single center experience

F. Al Kawai, K. Fouda, H. Al Hazmi, M. Salem, A. Gomha

Department of Urology, King Fahd Specialist Hospital, Dammam, Saudi Arabia

Objective: To study the difference in the outcome of Mitrafanoff construction using direct bladder submucosal tunnel anastomosis versus extramural serous lined tunnel.

Patients and Methods: We retrospectively reviewed the medical records of 27 patients who underwent continent catheterizable stoma construction between 2003 and 2008. 23 patients who had Mitrofanoff (appendico-vesicostomy) were included in the study, and 4 patients who had Monti (ileo-vesicostomy) were excluded. Medical records were reviewed for late complication rates of stoma leaking and stoma stenosis.

Results: Patient median age was 10.1 year (5–18 years), 10 males and 13 females. The indication for stoma construction was neuropathic bladder in 15 patients, bladder exstrophy epispadias complex in 5, and valve bladder in 3 patients. 10 patients (43.5%) had direct bladder submucosal tunnel anastomosis, of which 2 (8.69%) had a leaking stoma; both were endoscopically managed but were still leaking. One patient (4.3%) had stoma stenosis corrected by dilatation and Z – Y plasty at the skin level. 13 patients (56.5%) with extramural serous lined tunnel Mitrofanoff, only one patient (4.3%) needed t do strict Q3 hours CIC to remain dry.

Conclusion: Continent outlet catheterizable extramural serous line channel stoma construction is a demanding and challenging procedure. Our study showed that construction of stoma using extramural serous line tunnel (Mansoura technique) was associated with less stoma complications compared to direct bladder tunnel anastomosis.

Presented at the: 21st Saudi Urological Conference North West Armed Forces Hospital – Tabuk 14-16 April 2009

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Mitchell's detrusor wrap-around bladder neck, ileocystoplasty, and the extramural serous-lined continent outlet: An optimal triad

A. Hafez, F. Al Kawai, M. Al Ghanbar, A. Abdulbasit, Z. Nakshabandi

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Objective: Providing continence for children with non-compliant bladder and low detrusor leak point pressure secondary to neuropathic dysfunction or bladder exstrophy is a challenging task. A one stage reconstruction triad is presented.

Materials and Methods: Between May 2005 to July 2008, 21 patients underwent DWBN, ileocystoplasty, and extramural serous lined tunnel as continent outlet in one stage. Patients included 15 boys and 6 girls with mean age of 7.6 years. Nine patients had previous complete repair of bladder exstrophy, 4 had staged repair and 8 had neuropathic bladder dysfunction. The ileum was fashioned in the shape of U in 4, S in 13, and W in 4. The appendix was used in 17 and Monti was used in 4. Neo umbilicus was constructed for the outlet in 13. In all patients the continent outlet was located in the umbilicus or a neo-umbilicus.

Results: Mean follow up duration was 19 months (range 4-39). Early postoperative complications included prolonged ileus in 1 and urine leak in 1 and both were conservatively managed. Vesicoureteral reflux persisted in 13/21 (62%) patients. All patients were completely dry on CIC except 1. The leakage was through the urethra and was successfully managed by macroplastique injection at the bladder neck. No patient leaked through the continent outlet. Stomal stenosis was encountered in 2 patients with neo-umbilicus and both had stomal revision. No patient had bladder stones or perforation during follow up.

Conclusions: Children with urinary incontinence secondary to the combination of a non-compliant bladder and sphincteric deficiency could be optimally managed with this triad. The DWBN provides optimal bladder neck reconstruction. The extramural serous-lined technique has the advantages of a leak-proof continent outlet, ease of catheterization through a straight channel, and the orthotopic position of the outlet in the umbilicus/neo-umbilicus in all patients.

Presented at the: 21st Saudi Urological Conference North West Armed Forces Hospital – Tabuk 14-16 April 2009

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Augmentation of non-compliant bladder with associated vesicouretral reflux: Is concomitant antireflux surgery mandatory?

Abdulhakim Al Otay, Ziad Nakshabandi, Ashraf T. Hafez

Department of Urology, Riyadh Military Hospital, Riyadh, Saudi Arabia

Introduction: We studied VUR resolution and risk of pyelonephritis following bladder augmentation.

Methods: Between February 2005 and March 2009, 42 patients underwent ileocystoplasty for non-compliant bladder at a mean age of 9 years (range 4-17). Patients included 29 boys and 13 girls. The indications are neuropathic bladder (NB) in 19, posterior urethral valves (PUV) in 12, and bladder exstrophy (BE) in 11. Bladder neck reconstruction was performed for 21 patients (50%). VUR was low-grade in 15 (34%), high-grade in 27 (64%), unilateral in 18 (43%), and bilateral in 24 (57%). All patients were kept on oral antibiotic prophylaxis. Patients were followed up with renal/bladder ultrasound and voiding cystourethrography at 3 months postoperatively and annually thereafter.

Results: Mean follow up duration was 20 months (range 8-48). VUR resolved in 21 patients (50%). During follow up 6 patients (14%) had documented one or more attacks of break-through pyelonephritis. For PUV patients, VUR resolution rate was 83% and pyelonephritis rate was 8%. For BE, VUR resolution rate was 18% and pyelonephritis rate was 9%. For NB, VUR resolution rate was 47% and pyelonephritis rate was 21%. For patients with initial low-grade VUR, resolution rate was 33% and rate of pyelonephritis was 0%. Although patients with initial high-grade VUR had higher resolution rate of 59%, the rate of pyelonephritis was 22%, which is of statistical significance (p < 0.05). Lower resolution rate of low-grade VUR could be attributed to the fact that most BE patients had low-grade initial VUR which is an inherent anatomical defect of the ureterovesical junction.

Summary and Conclusion: At time of bladder augmentation, concomitant anti-reflux surgery should be performed for all patients with initial high grade VUR regardless of etiology. If left uncorrected, the risk of pyelonephritis and subsequent need for a difficult anti-reflux surgery is 22%.

Presented at the: 22nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Augmentation uretrocystoplasty

Hassan Abol-Enein

Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Introduction: Augmentation cystoplasty is frequently indicated in children. The available tissue for augmentation is the bowel. Bowel is associated with some complications like acidosis, stones, infections, etc…. when a dilated ureter of nonfunctioning kidney is available, uretero-cystoplasty becomes the technique of choice.

Surgical Technique: The bladder is opened, the dieted ureter is dissected keeping its blood supply and the adventitia intact. Nephrectomy is performed. The ureter is opened and the ureteral plate is augmented to the bladder.

Results: The catheters are removed after 10 days. Cystogram showed increased capacity. The bowel complication is thus avoided.

Conclusion: Augmentation uretro-cystoplasty is a viable alternative whenever the ureter is dilated and nephrectomy is indicated.

Presented at the: 23rd Saudi Urological Conference King Fahd Specialist Hospital – Dammam 21-24 February 2011

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

The spectrum of management of bladder exstrophy, options for the patient in late presentation

M. H. Abdulwahab, H. A. Mosli, A. M. Altayib

Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia

In experienced hands, functional repair of bladder exstrophy at an early neonatal age may restore a near normal micturition cycle. Repair of a reasonable size exstrophied bladder may allow satisfactory storage capacity. The achievement of sphincteric functional control requires considerable efforts that are combined from all players: members of the health care team, the patient and his or her family. In this paper we present our 21 years of experience with the management of 26 cases of exstrophy-epispadias spectrum seen in patients at different ages. The cooperation between the urologic and the interested orthopedic surgeon is crucial for the success of the reconstruction of this congenital anomaly. The major recent advances in the performance of adequate osteotomy for effective pelvic closure and the collaboration of the orthopedic team made an observed difference that needs to be further documented with larger series of patients. Becoming a referral center in the region for the management of such cases allows expansions of the experience and the subsequent enhance for the patient to enjoy better outcome. Other options for the patients who present at older ages should be considered if achieving the same goals of early repair is kept6 in mind. Those goals are: maintain normal upper urinary tracts, obtain social continence of urine and acceptable function and cosmetic appearance of the external genitalia.

Presented at the: 19th Saudi Urological Conference King Khalid University Hospital – Riyadh 26 February – 01 March 2007

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Detrusor wrap-around bladder neck for treatment of urinary incontinence following bladder exstrophy closure

Mostafa Al Ghanbar, Ziad Nakshabandi, Ashraf T. Hafez

Department of Urology, Riyadh Military Hospital, Riyadh, Saudi Arabia

Introduction: The use of a demucosalized detrusor pedicle flap as a bladder neck wrap was described by Mitchell. The outcome of this novel technique of bladder neck reconstruction (BNR) in 28 children with bladder exstrophy is presented.

Methods: The records of all patients who underwent bladder neck reconstruction using DWBN were reviewed. A total of 28 patients were identified and included 21 boys and 7 girls with mean age at surgery of 8.3 years. All patients had previous exstrophy closure (17 staged and 11 complete). Eight patients (29%) had previous endoscopic injection of bulking agent at the bladder neck. At time of surgery, 13 patients (46%) required concomitant augmentation ileocystoplasty and continent catheterizable outlet. Ureteral reimplantation was not performed in any patient. Continence was defined as complete dryness for a minimum of 4 hours.

Results: Mean follow up duration is 31 months (range 13–48). All augmented patients were on CIC through the continent outlet. Complete dryness was achieved in 20/28 patients (71%). However, continence rate was only 47% in the non-augmented group compared to 100% in the augmented group. Six of the incontinent children underwent bladder neck injection using bulking agent but dryness was achieved only 1 (17%).

Summary and Conclusion: DWBN is a viable option for bladder neck reconstruction for incontinent children after exstrophy closure. However, bladder augmentation and continent outlet construction are the pillars of optimal success. Injection of bulking agent at the bladder neck for failures has poor success.

Presented at the: 22nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Total endoscopic management (tem approach) of children with non compliant neuropathic bladder

Khalid Fouda, Mahmoud Salem, Sherif Soliman

Department of Surgery, Division of Urology, King Saud University, Riyadh, Saudi Arabia

Purpose: We prospectively evaluated the efficacy and durability of combined intradetrusor Botulinum-A Toxin (BTX) and endoscopic treatment of VUR (Sting) in the management of children with myelomeningocele (MMC) and noncompliant refluxing bladders not responding to standard conservative therapy. And if this combination therapy can lower the intravesical pressure, increase the bladder capacity, gain social continence, and protect the upper tract from recurrent urinary tract infection.

Materials and Methods: A total of 23 patients, with MMC (13 female and 10 males) were prospectively involved in the study. All patients were fully compliant to clean intermittent catheterization and all were non-responders to maximum tolerate dose of anticholinergics and CIC. All patients were subjected to cystoscopic intradetrusor injection of 12 u/kg (maximum 300 u) of Botulinum-A toxin in an infection free bladder. 9 patients with VUR (15 refluxing ureters, 6 patients with bilateral VUR) and didn’t show resolution in the pretreatment voiding cystourethrogram underwent submucosal injection of Deflux either with 2nd treatment (initial 4 patients) or with 1st BTX-A treatment (the other 5 patients). The grade of reflux was G III, IV, and V in 3, 7 and 5 ureters respectively.

Results: The maximum bladder capacity increased significantly and the maximum detrusor pressure decreased significantly. Thirteen (86.6%) out of 15 refluxing ureters were completely resolved and 2 (13.4%) (both were GV and in one patient), were unchanged.

Conclusions: Botulinum-A toxin is a safe and simple alternative line of treatment that can postpone or avoid major reconstructive procedure in large number of children with MMC not responding to standard conservative medical treatment. Combination of BTX-A and STING procedures is a simple and effective way to overcome the increased risk of high intravesical pressure and recurrent UTI and can decrease the incidence of renal damage in these children.

Presented at the: 19th Saudi Urological Conference King Khalid University Hospital – Riyadh 26 February – 01 March 2007

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Intra-detrusor injection of botulinum: A toxin, is it the magic needle for children with refractory neuropathic bladder?

M. Salem, K. Fouda, S. Soliman, H. Al Hazmi, A. Gomha, A. Khatab

Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Aim of the Work: To evaluate the long term outcome of our subgroup of patients with refractory neuropathic bladder managed by multiple intra-detrusor Botox injection.

Patients and Methods: Between October 2003 to October 2007, 31 patients with refractory neuropathic bladder and myelomeningocele (MMC) were managed by intra-detrusor Botox injection. This subgroup of patients, despite being fully compliant to clean intermittent catheterization, and on maximum tolerable dose of anticholinergics, showed signs of refractory neuropathic bladder. Botox injection was done Q 6-12 months.

Results: 31 patients (16 F and 15 M) mean age 6.8 + 3 (2–14 years) were included in our protocol. None had side effects related to the toxin or the procedure. None had deterioration of the renal function or the upper tract status, during their follow up period. 3 patients were lost for follow up, 15 patients (average 3 injections) were stable (dry in between catheterization, stable or improved upper tract status and with safe intra-detrusor pressure), their mean leak point pressure was 36 + 13.2 cm H2O (15–59) and they are for further injections every 6–12 months. 13 patients needed augmentation cystoplasty due to persistent severe non-compliance of the bladder, persistence severe hydronephrosis, or leakage between catheterization despite low intravesical pressure in 4, 3 and 6 patients, respectively.

Conclusions: Intra-detrusor injection of Botulinum-A toxin is a safe and effective modality of management of refractory neuropathic bladder in most but not all of the cases. We were able to protect the upper tract in 75% of this subgroup of patients, and 54% were kept dry after extended follow up. Close follow up is highly recommended for them.

Presented at the: 20th Saudi Urological Conference King Fahad Hospital of the University – Tabuk 18-20 March 2008

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Urological problems in anorectal malformations, and effect of anorectoplasty on lower urinary tract function

S. Abou Hashem, T. Gobran

Department of Urology, Zagazig University, Zagazig, Egypt

Aim of the Work: Children with anorectal malformation (ARM) have urinary tract dysfunction that causes significant urologic problems and the morbidity often exceed that of (ARM) itself and also urinary complications may follow surgical management of ARM. The aim of this study is to evaluate the urinary problems that may be associated with ARM or complicate its surgical management of children born with ARM.

Patients and Methods: This study included 35 patients with ARM; these patients were evaluated preoperatively by clinical and radiological examinations and urodynamic studies as indicated. Posterior sagittal anorectoplasty (PSARP) was done to all patients. Postoperatively all patients were re-evaluated.

Results: Genitourinary anomalies other than recto-urinary fistula were present in 50% of cases. The commonest was vesicoureteral reflux which was found in 10 patients. Two patients had inactive detrusor muscle (both had abnormal sacrum) and 10 patients had overactive bladder, 2 of them had normal sacrum. Five patients with preoperative normal bladder developed inactive detrusor hypocontractility.

Conclusions: All patients with ARM should be investigated for sacral and urologic anomalies, and the lower urinary function should be evaluated preoperatively to prevent upper urinary tract deterioration. Also special attention must be given to careful surgery and gentle dissection to avoid injury to the innervations of the genitourinary tract following PSARP.

Presented at the: 20th Saudi Urological Conference King Fahad Hospital of the University – Tabuk 18-20 March 2008

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Comprehensive analysis of the clinical and urodynamic outcome of spinal cord untethering

A. Al Zahrani, R. Jednak, J. P. Capolicchio, M. El Sherbiny

McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada

Objective: To evaluate the short and long-term clinical and urodynamic outcomes following spinal cord untethering (SCU).

Materials and Methods: The charts of 46 patients undergoing spinal cord untethering between January 1998 and December 2006 were reviewed. Analysis was performed on 2 groups. Group I included 23 patients with a primary tethered cord (8M:15F; mean age 4.6 years). Group II included 23 patients with secondary cord tethering (13M:10F; mean age 8.6 years). Preoperative and postoperative clinical and urodynamic data were compared 6-12 months post-operatively (mean 9 and #61617; 2 and 9 and #61617; 3 months for group I and II respectively) and at long-term follow up (mean 58 and #61617; 32 and 58 and #61617; 38 months for group I and II, respectively).

Results: Urological and neuro-orthopedic symptoms were initially reported in 7 (30%) and 13 (61%) patients, respectively in Group I. At early and late follow up urological symptoms persisted in only 1 patient (4%). Neuro-orthopedic symptoms persisted in 3 patients at early follow up. Five patients (21%) were symptomatic at the last follow up. Total cystometric bladder capacity (TCC) increased from 108 and #61617; 88 to 155 and #61617; 126 ml (P < 0.00), and to 228 and #61617; 107 ml (P < 0.00) in early and late follow up respectively. The pressure at maximum capacity (PMC) decreased from 40 and #61617; 23 to 28 and #61617; 17 cm H2O (P > 0.05) to 26 and #61617; 19 cm H2O (P < 0.04) in early and late follow up, respectively.

Urological and neuro-orthopedic symptoms were initially reported in 13 (56%) and 19 (83%) patients respectively in Group II. Urological symptoms persisted in 7 patients (30%) at early and late follow up while 3 (13%) patients developed new symptoms. Neuro-orthopedic symptoms persisted in 6 (26%) at early and late follow up while 1 patient (4%) developed new symptoms. TCC improved from 223 and #61617; 118 to 234.5 and #61617; 126 ml (P < 0.02) to 321 and #61617; 137 ml (P < 0.00) at early and late follow up, respectively. PMC changed from 35 and #61617; 19 to 33 and #61617; 19 cm H2O (P > 0.05) to 36 and #61617; 26 cm H2O (P > 0.05) at early and late follow up, respectively.

Summary and Conclusion: SCU of the primary tethered cord was associated with long-term clinical and urodynamic improvements. SCU of the secondary tethered cord was associated with 63% overall long-term improvement in the neuro-orthopedic symptoms. Long-term urological improvement was only 23%. Moreover, the PMC did not improve.

Presented at the: 22nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Management of neuropathic bowel dysfunction with transanal irrigation system

Mahmoud S. Trbay, Khalid Fouda, Hamdan Al Hazmi, Ahmad Elderwy, Abdulmoneum Gomha

Department of Surgery, Urology Unit, King Khalid University Hospital, Riyadh, Saudi Arabia

Aim of the Work: To evaluate the efficacy of the Peristeen® transanal irrigation (TI) system in children with neuropathic bowel dysfunction (NBD).

Methods: We prospectively evaluated children with myelomeningocele and NBD who have achieved complete urinary continence (dryness in between catheterization) but have poor bowel control. All patients were started on transanal irrigation using Peristeen® (Coloplast-Denmark). The children's bowel functions, patient's and parent's satisfaction and diaper independency were evaluated.

Results: Forty five (45) patients were included in our protocol (10 underwent augmentation ileocystoplasty as part of managing their neuropathic bladder). There was 23 female and 22 male patients, mean age was 8.4 year +/- 2.4 SD (4-13 years). Average follow-up period 14 months (5-20). The average frequency of usage Peristeen® system was every 3 days. Forty (40) patients (88.8%) showed complete dryness stool wise, with no soiling, 5 patients showed partial improvement with varying degree of faecal soiling. Out of the 45 patients, 31 (68.8%) were able to switch from diapers to underwear completely and 9 (20%) limited their use of diapers only at school or long trips. The observed adverse events were abdominal pain at the start of treatment which disappears after a short time, catheter malfunction and leakage of irrigation fluid were recorded in 4, 7 and 6 patients, respectively.

Summary and Conclusion: In our experience using the Peristeen® system we found it an effective, safe, and easy applicable conservative method of bowel management in patients with NBD.

Presented at the: 22nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Apr;8(Suppl 2):S122–S134.

Total endoscopic and anal irrigation management (team approach) of children with non-compliant neuropathic bladder: Can it be a good alternative way of management? Point of technique

Mahmoud S. Trbay, Khalid Fouda, Hamdan Al Hazmi, Ahmad Elderwy, Abdulmoneum Gomha

Department of Surgery, Urology Unit, King Khalid University Hospital, Riyadh, Saudi Arabia

Purpose: We prospectively evaluated the efficacy and durability of a combination of intradetrusor Botulinum-A toxin (BTX-A) and endoscopic treatment of vesicoureteric reflux (VUR) together with anal irrigation program as a Total Endoscopic and Anal Irrigation (TEAM approach) minimally invasive protocol to manage children with myelomeningocele (MMC) and non-compliant bladders with VUR who are not responding to standard conservative therapy and has urine and stool incontinence.

Materials and Methods: A total of 13 patients (10 females and 3 males) with a mean age of 5.3 +/- 2.5 years (range 2-12 years) with MMC and VUR who are not responding to standard conservative treatment were prospectively involved in the study. All patients were subjected to cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) of BTX-A in an infection-free bladder. All had VUR (20 refluxing ureters, 7 patients with bilateral VUR) and did not show resolution in the pre-treatment voiding cystourethrogram; accordingly, sub-mucosal injection of Deflux was performed. Most of our patients were still diaper dependent due to stool incontinence. So we extended our management to include complete bowel rehabilitation using a new system of anal irrigation (Peristeen® - Coloplast) to manage their stool incontinence.

Results: The maximum bladder capacity increased significantly from 79 +/- 38 to 155 +/- 45 ml (p < 0.002) and the maximum detrusor pressure decreased significantly from 58 +/- 14 to 36 +/- 7 (p < 0.001) cm H2O. 19 out of 20 (95%) refluxing ureters were completely resolved (one of them on second attempt), and one (5%) (GV reflux) remained unchanged despite of two attempts. Of 8 urinary incontinent patients, 7 (87.5%) reached complete dryness between catheterizations and one showed partial improvement. 10 out of 13 patients achieved stool dryness on one to two times per week anal irrigation and 3 were stool continent with standard enemas and they did not need this irrigation system.

Conclusions: This new “TEAM approach” is a comprehensive minimally invasive way which is safe, simple and effective way that can achieve most of the goals of treatment of this group of patients by protecting the upper tract, keeping the bladder at a safe pressure and providing a satisfactory social life with urine and stool continence.

Presented at the: 22nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

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