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Abstract Urinary bladder dysfunction can be caused by environmental, genetic, and developmental insults. Depending upon insult severity, the bladder may lose its ability to maintain volumetric capacity and intravesical pressure resulting in renal deterioration. Bladder augmentation enterocystoplasty (BAE) is utilized to increase bladder capacity to preserve renal function using autologous bowel tissue as a “patch.” To avoid the clinical complications associated with this procedure, we have engineered composite grafts comprised of autologous bone marrow mesenchymal stem cells (MSCs) co-seeded with CD34+ hematopoietic stem/progenitor cells (HSPCs) onto a pliable synthetic scaffold [poly(1,8-octamethylene-citrate-co-octanol)(POCO)] or a biological scaffold (SIS; small intestinal submucosa) to regenerate bladder tissue in our baboon bladder augmentation model. We set out to determine the global protein expression profile of bladder tissue that has undergone regeneration with the aforementioned stem cell seeded scaffolds along with baboons that underwent BAE. Data demonstrate that POCO and SIS grafted animals share high protein homogeneity between native and regenerated tissues while BAE animals displayed heterogeneous protein expression between the tissues following long-term engraftment. We posit that stem cell-seeded scaffolds can recapitulate tissue that is nearly indistinguishable from native tissue at the protein level and may be used in lieu of procedures such as BAE.

Multiple factors impact ability to achieve urinary continence in cloacal malformation including common channel (CC) and urethral length and presence of spinal cord abnormalities. Few publications describe continence rates and bladder management in this population. We evaluated our cohort of patients with cloacal malformation to describe the bladder management and continence outcomes. We reviewed a prospectively collected database of patients with cloacal malformation managed at our institution. We included girls ≥3 years (y) of age and evaluated their bladder management methods and continence. Dryness was defined as <1 daytime accident per week. Incontinent diversions with both vesicostomy and enterovesicostomy were considered wet. A total of 152 patients were included. Overall, 93 (61.2%) are dry. Nearly half (47%) voided via urethra, 65% of whom were dry. Twenty patients (13.1%) had incontinent diversions. Over 40% of the cohort performed clean intermittent catheterization (CIC), approximately half via urethra and half via abdominal channel. Over 80% of those performing CIC were dry. In total, 12.5% (n = 19) required bladder augmentation (BA). CC length was not associated with dryness (p = 0.076), need for CIC (p = 0.253), or need for abdominal channel (p = 0.497). The presence of a spinal cord abnormality was associated with need for CIC (p = 0.0117) and normal spine associated with ability to void and be dry (p = 0.004) In girls ≥ 3 y of age with cloacal malformation, 61.2% are dry, 65% by voiding via urethra and 82% with CIC. 12.5% require BA. Further investigation is needed to determine anatomic findings associated with urinary outcomes. IV. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the urodynamic changes in patients who have undergone colocystoplasty (CCP), gastrocystoplasty (GCP) and ileocystoplasty (ICP) in a retrospective study. Changes in urinary continence, incidence of pathologic contractions before and after augmentation, alterations of urodynamic parameters were also examined. Methods: Eighty-four patients were included in the study who underwent bladder augmentation between 1987 and 2017. Group I: 35 patients with CCP. Group II: 18 patients with GCP. Group III: 31 patients with ICP. Cystometry was performed at 3, 6, and every 12 months, then biannually after augmentation. Pre- and postoperative urodynamic changes were analysed statistically. Results: In Group I, two patients and in Group III, one patient remained incontinent after CCP and ICP. Bladder capacity increased significantly, maximal intra-vesical pressure decreased and compliance improved in all groups (p < 0.001). Postoperative studies showed pathologic contractions in the augmented bladder in half of the patients with GCP, in 43% of patients after CCP and 26% of patients with ICP. Conclusion: From the urodynamic point of view, ileum is the most adequate option in the long term. Contractions after augmentation might be caused by the remaining peristalsis of the detubularised segment. Further investigations are needed to evaluate pathologic contractions that remained after detubularisation. [ABSTRACT FROM AUTHOR]

Introduction. We present the first case of pediatric ileocystoplasty using a purely robotic approach in Spain. Case report. 12-year-old male with neurogenic bladder of low capacity and high pressures. After failure of conservative treatment, bladder augmentation with ileum patch was decided upon. Surgery was carried out using a purely robotic approach with 4 robotic and 2 accessory ports. Surgery duration was 380 minutes in total, without intraoperative complications. He was discharged 2 weeks after cystographic control. During 32-months follow-up, he has remained continent. Discussion. The minimal invasion, surgical precision and ergonomics made the robotic approach an optimal option for complex surgical techniques. Given the little availability of the robot and the low pediatric volume, its standardization is a challenge. Our accumulated experience is consistent with the current literature and shows promising surgical and esthetic results. We hope this case report will contribute to the divulgation and progressive introduction of robotic surgery in our daily lives. [ABSTRACT FROM AUTHOR]

The conventional approach to managing a newborn with cloacal exstrophy typically includes separating the cecal plate from between the two hemibladders, tubularizing it to be included in the fecal stream, creating an end colostomy, and bringing the two bladder halves together. This study introduces an alternative approach wherein the cecal plate is retained in its original position and designated for future use as an autoaugment of the bladder. Four cases of cloacal exstrophy cases managed between November 2019 and February 2024 are described, with surgical approach and postoperative outcomes reported. Two patients who underwent traditional reconstruction experienced bacterial overgrowth attributed to stasis in the cecal plate, which manifested in increased ostomy output and feeding intolerance. Treatment in these two cases was to remove the cecum from the fecal stream and use it instead for a bladder augment. Learning from these cases, the third and fourth newborn's approach involved retaining the cecum in situ for autoaugmentation of the bladder and performing an ileal to hindgut anastomosis. No postoperative acidosis occurred in these patients. The alternative approach to the newborn management of cloacal exstrophy whereby the cecal plate is left in situ can decrease stasis and postoperative bacterial overgrowth. It allows for an autoaugmentation of the bladder and is technically easier than the traditional rescue of the cecal plate from within the two hemibladders.

Purpose of Review: As patients with spina bifida are living longer, more long-term outcomes are being reported. Today, the conversation surrounding neurogenic bladder care has evolved from reducing mortality to enhancing quality of life, namely, reducing urinary incontinence while still preserving upper tract function. In this paper, we seek to review risks of bladder malignancy in neurogenic bladder patients with history of augmentation or chronic catheters. Recent Findings: Recent data has demonstrated that cancers in bladders with prior augmentation or chronic catheters tend to be advanced, aggressive, and occur at a younger age. However, bladder cancer in this population is difficult to predict and difficult to diagnose before it is too late. Summary: Screening protocols and early diagnostic tools remain elusive as these cancers may present with symptoms that can be easily overlooked or attributed to other disease processes. Current work with biomarkers may yield better diagnostic tools than cystoscopy or cytology. [ABSTRACT FROM AUTHOR]

Abstract Background Perforation of the augmented bladder is a serious and well-known complication of bladder augmentation. The traditional treatment has been emergent surgical exploration and repair of the bladder perforation due to the risk of peritonitis, sepsis and mortality. Some studies have reported successful conservative management by maximizing bladder drainage in patients with stable hemodynamics and limited peritoneal extravasation. Herein, we report the successful conservative management of spontaneous perforation of augmented bladder in a 5-year-old boy with exstrophy-epispadias complex following epispadias repair with significant extravasation. Case presentation A 5-year-old boy had augmentation ileocystoplasty to facilitate repair of failed bladder exstrophy closure. Modified penile disassembly was used for epispadias repair with a transurethral catheter draining the bladder. The patient presented on postoperative day 2 with a non-draining catheter, fever, repeated vomiting and abdominal distension. Leukocytosis and elevated creatinine were evident on laboratory work-up. CT cystogram confirmed the diagnosis of spontaneous perforation of the augmented bladder with significant intraperitoneal extravasation. Conservative management was successful by inserting a suprapubic catheter and an intraperitoneal drain. The patient subsequently underwent creation of Mitrofanoff appendicovesicostomy and bladder neck closure to achieve dryness without recurrence of perforation on follow-up. Conclusions Perforation of the augmented bladder can be managed conservatively even in the presence of significant peritoneal extravasation by maximizing bladder drainage and insertion of an image-guided intraperitoneal drain.

Bilateral single system ectopic ureters are a rare entity in paediatric urology. We report a girl child with bilateral single system ectopic ureters with right system opening into the vagina, who presented at 3.5 years with continuous dribbling of urine & a small capacity bladder. Renal scans and MRI were done which indicated bilateral single system ectopic ureters with hydroureteronephrosis. We managed her surgically by a right nephro-ureterectomy, bladder augmentation, left ureteric reimplantation and Mitrofanoff. Post op patient had acute on chronic renal failure, stabalised by haemodialysis. It is a rare presentation if managed promptly can prevent renal replacement therapy.

Purpose: Cloacal exstrophy (CE) patients may need bladder reconstruction after initially undergoing surgery to obtain continence and improve their quality of life. This study attempts to clarify the clinical features of CE patients who underwent bladder augmentation (BA) and their urinary functional outcomes based on a nationwide survey in Japan. Methods: A questionnaire survey was conducted, and 150 CE patients were enrolled. Their clinical characteristics and urinary outcomes were reviewed. Results: BA was performed in 52 patients (34.7%). Most cases underwent early bladder closure at initial surgery in neonate period. The age at the BA was performed 6.4 [6–9.0] years. Among them, the most used organ for BA was ileum (n = 30, 57.7%). Regarding the outcomes, the age when the renal function was evaluated was 14.0 [10.0–20.5] years and the serum creatinine level was 0.44 [0.36–0.60] (mg/dl). Clean intermittent catheterization was required in 37 (71.2%) patients. On the other hand, no dialysis or kidney transplantation was necessary in any of these patients. Conclusion: The renal function and conditions of patients who underwent BA were relatively well preserved. Individualized management with a stepwise surgical approach for CE patients should thus be considered in the future. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the need and efficacy of treatment of bladder neck procedures in patients with neurogenic bladder and augmentation. Methods: The hospital database was reviewed for patients undergoing enterocystoplasty because of neurogenic bladder during 1990–2019. Diagnoses of patients as well as frequency, type, and efficacy of treatment of sphincter insufficiency were evaluated. Results: Thirty-seven of 87 patients (43%) underwent surgery because of sphincter insufficiency. The median age at bladder augmentation was 11.9 years (IQR 8.5–14.8), and at the last control, 21.8 years (IQR 18.9–31.1). Bladder neck injections (BNI) were performed for 28 patients, fascial sling operation for 14 patients, and bladder neck closure (BNC) was done for five females. Full continence was achieved in 10/28 (36%) patients with one or repeat BNIs and 9/14 (64%) with sling operation. The outcome of BNIs and sling operations was similar in both sexes. All five female patients with BNC became continent. At the end of follow-up, 64 (74%) patients were dry, 19 (22%) had occasional incontinence episodes, and 4 (5%) had daily incontinence episodes necessitating pads. Conclusions: Treatment of sphincter insufficiency is challenging in patients with bladder augmentation and neurogenic disease. Only 74% of our patients became fully continent despite treatments for sphincter insufficiency. [ABSTRACT FROM AUTHOR]

Boys with valve bladder syndrome (PUV) require adequate treatment of the lower urinary tract to preserve renal function and improve long-term outcomes. In some patients, further surgery may be necessary to improve bladder capacity and function. Ureterocytoplasty (UCP) is usually carried out with a small segment of intestine or, alternatively, with a dilated ureter. Our aim was to evaluate the long-term outcomes after UCP in boys with PUV. UCP had been performed in 10 boys with PUV at our hospital (2004–2019). Pre- and postoperative data were evaluated in relation to kidney and bladder function, the SWRD score, additional surgery, complications, and long-term follow-up. The mean time between primary valve ablation and UCP was 3.5 years (SD ± 2.0). The median follow-up time was 64.5 months (IQR 36.0–97.25). The mean increase in age-adjusted bladder capacity was 25% (from 77% (SD ± 0.28) to 102% (SD ± 0.46)). Eight boys micturated spontaneously. Ultrasounds showed no severe hydronephrosis (grade 3–4). The SWRD score showed a median decrease from 4.5 (range 2–7) to 3.0 (range 1–5). No conversion of augmentation was required. UCP is a safe and effective approach to improve bladder capacity in boys with PUV. In addition, the possibility of micturating naturally is still maintained. [ABSTRACT FROM AUTHOR]

Bladder augmentation (BA) maybe required before renal transplantation in children with end stage renal disease (ESRD). Herein we report a case of a 7-year-old boy with ESRD, contracted bladder and severe bilateral reflux secondary to posterior urethral valve (PUV), successfully managed by simultaneous bilateral nephrectomy, bilateral ureterocystoplasty and renal transplantation. [ABSTRACT FROM AUTHOR]

Abstract We assessed the use of common urodynamics (CUD) combined with contrast‐enhanced ultrasound (CEUS) to investigate the efficacy and durability of sigmoid cystoplasty alone in patients with low bladder compliance associated with vesicoureteric reflux (VUR). In this study, we recruited 25 patients with low bladder compliance and VUR who underwent bladder augmentation without antireflux surgery at our institutions between June 2017 and June 2021. The bladder condition and VUR grade were assessed preoperatively and postoperatively via CUD combined with CEUS. The mean follow‐up period was 2.6 years. CUD showed significant improvement in bladder capacity and compliance and a decrease in intravesical pressure after sigmoid cystoplasty. CEUS demonstrated resolution of VUR compared with preoperative assessment. Of the 25 patients who had various degrees of reflux, VUR was eliminated in 18 patients and reduced to a lower grade in the remaining seven patients. CUD combined with CEUS is accurate and safe. They are invaluable and reliable tools for morphological and functional evaluations of the entire urinary tract in patients with low bladder compliance and VUR.

Purpose: To compare the quality of life (QoL) in the same patients first treated with botulinum toxin A (BTA) injections for neurogenic detrusor overactivity (NDO) and then with bladder augmentation (BA)., Method: Retrospective study of patients who had BA after BTA treatment between January 2012 and December 2022. Qualiveen Short Form questionnaires and a 7-level Likert/PGI-I scale to answer the question "How would you describe your quality of life after surgery compared to when you felt your best with BTA injections?" were collated and analyzed., Results: Fifty-two BAs for neurogenic bladder (NDO or low compliance) were performed in patients with a median age of 43years [33; 52] previously treated with BTA. After a median follow-up of 33.5 [13.8; 54.3] months, the median Qualiveen-SF global score after BA was significantly higher than that obtained at best BTA efficacy (1.63 [1; 2.63] vs. 2.63 [1.88; 3], P=0.012), as were the scores for the fear, constraints/restrictions and limitations/inconvenience domains. The median PGI-I score was +3 [2; 3] (truly better QoL) and 85.4% of patients reported a QoL after BA superior to the best QoL under BTA., Conclusion: BA provides a greater range of QoL improvement than BTA injection for patients who have experienced both treatments. Long-lasting effects and absence of need to perform iterative retreatment were the main reasons., (Copyright © 2024. Published by Elsevier Masson SAS.)

The conventional approach to managing a newborn with cloacal exstrophy typically includes separating the cecal plate from between the two hemibladders, tubularizing it to be included in the fecal stream, creating an end colostomy, and bringing the two bladder halves together. This study introduces an alternative approach wherein the cecal plate is retained in its original position and designated for future use as an autoaugment of the bladder. Four cases of cloacal exstrophy cases managed between November 2019 and February 2024 are described, with surgical approach and postoperative outcomes reported. Two patients who underwent traditional reconstruction experienced bacterial overgrowth attributed to stasis in the cecal plate, which manifested in increased ostomy output and feeding intolerance. Treatment in these two cases was to remove the cecum from the fecal stream and use it instead for a bladder augment. Learning from these cases, the third and fourth newborn's approach involved retaining the cecum in situ for autoaugmentation of the bladder and performing an ileal to hindgut anastomosis. No postoperative acidosis occurred in these patients. The alternative approach to the newborn management of cloacal exstrophy whereby the cecal plate is left in situ can decrease stasis and postoperative bacterial overgrowth. It allows for an autoaugmentation of the bladder and is technically easier than the traditional rescue of the cecal plate from within the two hemibladders., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Introduction and Objective: The surgical management of radiation-induced distal ureteral stricture and contracted bladder is challenging. The purpose of this video is to show the feasibility, safety, and functional outcomes of an intracorporeal robot-assisted ileal ureter and bladder augmentation in a modified Studer fashion for a long right ureteral stricture and a small bladder. Methods: A 34-year-old African woman had a history of cervical cancer that was treated with radical surgery and whole pelvis radiation in 2015. She was free of cancer recurrence 6 years after radiotherapy. She developed a long ureteral stricture and a small bladder (188 ml). She was managed with a chronic ureteral stent and complained of urinary frequency, urgency, and nocturia. The International Prostate Symptom Score (IPSS) was 22. A transperitoneal robotic approach was utilized with the Da Vinci Xi™ platform similar to radical cystectomy. The right ureter stricture above the level of the iliac vessels was identified and transected. A 17 cm gap was measured between the proximal ureter and the bladder dome. A segment of 30 cm of terminal ileum was isolated (20 cm for the cystoplasty, 10 cm for the chimney). Intestinal continuity was restored with a side-to-side anastomosis. The inferior 20 cm segment was detubularized and folded into a “U” shape in a modified Studer fashion, leaving 10 cm of superior ileum for creating the afferent chimney. The bladder dome was incised transversely. The posterior cystoplasty was performed by suturing the inferior “U” shape of the ileum patch to the posterior edge of the bladder. A tension-free uretero-ileal Bricker anastomosis was performed in an interrupted fashion using 4-0 PDS sutures. A double-J ureteral stent was placed. The anterior closure of the cystoplasty was completed using running 3-0 V-Loc sutures. Results: The patient was discharged on postoperative day 5. The Foley catheter was removed after 21 days and the ureteral stent was removed 3 months later. A CT Urogram at 6 months showed no hydronephrosis. The patient reported improved urinary symptoms of frequency, urgency, and nocturia. Postoperative urodynamics revealed improved urinary symptoms (IPSS 11), functional capacity (253 ml), low pressure and complete voiding. Conclusions: Robotic ileal ureter with bladder augmentation in a modified Studer fashion is feasible and safe. It offers an excellent functional outcome for patients with a long ureteral stricture and a contracted bladder. This reconstructive approach can be individualized by adjusting the length of chimney and size of bladder augmentation.

We assessed the use of common urodynamics (CUD) combined with contrast‐enhanced ultrasound (CEUS) to investigate the efficacy and durability of sigmoid cystoplasty alone in patients with low bladder compliance associated with vesicoureteric reflux (VUR). In this study, we recruited 25 patients with low bladder compliance and VUR who underwent bladder augmentation without antireflux surgery at our institutions between June 2017 and June 2021. The bladder condition and VUR grade were assessed preoperatively and postoperatively via CUD combined with CEUS. The mean follow‐up period was 2.6 years. CUD showed significant improvement in bladder capacity and compliance and a decrease in intravesical pressure after sigmoid cystoplasty. CEUS demonstrated resolution of VUR compared with preoperative assessment. Of the 25 patients who had various degrees of reflux, VUR was eliminated in 18 patients and reduced to a lower grade in the remaining seven patients. CUD combined with CEUS is accurate and safe. They are invaluable and reliable tools for morphological and functional evaluations of the entire urinary tract in patients with low bladder compliance and VUR. [ABSTRACT FROM AUTHOR]

Background: In this study, we present our long‐term treatment outcomes of bladder augmentation (BA), bladder neck closure, and Mitrofanoff clean intermittent catheterization (CIC) in managing bladder exstrophy (BE). Methods: This was a retrospective medical records' review of 33 children diagnosed as born with BE, followed up at a tertiary pediatric urology clinic from 1988 to 2020. Outcomes such as surgical interventions, presence of renal calculi, hydronephrosis, and continence status were extracted. Results: The median follow‐up of the group was 18.2 (4–26) years. Urinary system stones developed in 10 (30.3%) cases about 8.9 years after BA. Stone development was two times more common in patients who underwent colocystoplasty (33.3%) than those who underwent ileocytoplasty (16.6%). The state of continence of the group was satisfactory in 26 (78.7%; excellent in 23; good in 3 cases) and unsatisfactory (wet) in 6 (18.1%) cases. At the last visit, ultrasonography revealed no hydronephrosis in 23 (69.6%) patients, and the voiding cystourethrogram demonstrated low‐grade vesicoureteral reflux in 10 (30.3%) and high‐grade vesicoureteral reflux in 2 (6%) patients. Conclusions: An elaborated plan of surgical reconstruction for classic BE can lead to satisfactory long‐term urinary continence in most patients. Ultimate predictors of outcome in BE repair are difficult to ascertain. Consistently, BA, bladder neck closure, and Mitrofanoff CIC continue to stand out at a critical point in the management of those patients with classic BE. Our study demonstrated that augmentation is required to achieve acceptable dryness with high satisfactory dryness rates in BE. [ABSTRACT FROM AUTHOR]

Introduction: To assess the long-term effect of bladder augmentation surgery in patients with spina bifida and to identify risk factors for severe bladder dysfunction requiring bladder augmentation. Methods: A retrospective analysis was performed on 178 patients with spina bifida, 23 of them underwent bladder augmentation. Surgery outcome was evaluated according to urodynamic assessments at three follow-up time points per patient up to 120 months postoperatively. The results were compared to the preoperative situation and to the non-operated control group. Bladder function was evaluated using the modified Hostility score. To identify risk factors for bladder dysfunction requiring bladder augmentation, characteristics such as type of spina bifida, lesion level and therapy of bladder dysfunction were analyzed. Results: A high spinal lesion level is a risk factor for requiring bladder augmentation. In the BA group, significantly more thoracic lesions were found than NBA group, BA: 26.1%, NBA: 8.4% (p = 0.021). With bladder augmentation surgery, the modified Hostility score decreased from a preoperative median value of 4.3 ± 1.4 to 1.6 ± 1.0 at the third postoperative follow-up (FU3 = 61–120 months after surgery). In the reference group, the score of the last urological assessment was 2.0 ± 1.5. The age at which clean intermittent catheterization or anticholinergic medication started had no significant influence on the decision to perform bladder augmentation. Discussion/conclusion: Spina bifida patients with bladder augmentation had a significant improvement of the bladder function even at long-term follow-up. A high level of spinal lesion was a predisposing factor for requiring a bladder augmentation. [ABSTRACT FROM AUTHOR]

Introduction: Neurogenic high-pressure bladders may lead to incontinence and upper tract deterioration. Bladder augmentation with creation of a catheterizable channel helps protect the upper tracts and provide patients with a mechanism for social continence. RALIMA offers patients the potential benefits of minimally invasive surgery during major genitourinary reconstruction. We present modifications to our previously described technique to reduce surgical time and for ease of adoption of RALIMA. Patient and Surgical Procedure: An 11-year-old female with a poorly compliant, high pressure, small capacity (73 cc) neurogenic bladder, with detrusor leak point pressure of 8 cm of water, failed conservative measure and subsequently underwent RALIMA, bladder neck reconstruction, and ACE channel creation with cecal flap. Results: Total operative time was 615 minutes, EBL 50 cc, and patient was discharged home on postoperative day 6. Several modifications to our initial technique were utilized to improve operative efficiency, including 1) use of the robotic fourth arm to assist with retraction; 2) relocation of the camera port above the umbilicus to assist with visualization; 3) use of percutaneous stay sutures placed in the ileum to allow for isolation and facilitate bowel-bowel anastomosis; 4) performing the posterior wall bowel anastomosis prior to anterior; 5) utilizing the harmonic scalpel to detubularize ileum, take down bowel mesentery, and perform the cystostomy; and 6) utilizing barbed suture to perform the bowel-bladder anastomosis. Conclusion: The video demonstrates RALIMA with bladder neck reconstruction and ACE channel creation for a high-pressure, refractory neurogenic bladder.

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation.

Intra-detrusor botulinum toxin (Botox) injection is a minimally invasive alternative to augmentation cystoplasty in patients with refractory neurogenic bladder. Botox was first used for neurogenic bladder children two decades ago. However, there are no existing guidelines on indications or use among patients with spina bifida. Furthermore, there are little data regarding its use relative to bladder augmentation and patient volume on a national scale. We sought to investigate the contemporary trends of intra-detrusor Botox injection and augment cystoplasty in free-standing children's hospitals. We queried the Pediatric Health Information System database to identify spina bifida patients from 2016 to 2019 who underwent intra-detrusor Botox injection and augment cystoplasty based on CPT and ICD-10 codes. Total spina bifida population under care in the free-standing children's hospitals was estimated by all inpatient and ambulatory surgery encounters as denominators to calculate frequency by time for both intra-detrusor Botox injections and augmentation cystoplasty. In total, we included 1924 intra-detrusor Botox injections and 842 augmentation cystoplasties. 1413 (51.1%) patients were female. Median age at surgery was 10.0 (interquartile range 6.98–13.5) years. There was a significant increase in intra-detrusor Botox injection frequency (p < 0.001). While there was an overall decreasing, but not significant, trend for augmentation cystoplasty, there was a significant increase in this procedure during the summer months compared to the rest of the year (p < 0.001, Figure 1). Sensitivity analysis using only first intra-detrusor Botox injection per patient demonstrated similarly significant increasing trend. Use of intra-detrusor Botox injection for the management of neurogenic bladder has significantly increased among patients with spina bifida while augmentation cystoplasty has slightly decreased, but not significantly. Over time, practice patterns for the treatments of neurogenic bladder among spina bifida children have favored minimally invasive Botox injections while augmentation cystoplasty use has not significantly changed. [ABSTRACT FROM AUTHOR]

Boys with valve bladder syndrome (PUV) require adequate treatment of the lower urinary tract to preserve renal function and improve long-term outcomes. In some patients, further surgery may be necessary to improve bladder capacity and function. Ureterocytoplasty (UCP) is usually carried out with a small segment of intestine or, alternatively, with a dilated ureter. Our aim was to evaluate the long-term outcomes after UCP in boys with PUV. UCP had been performed in 10 boys with PUV at our hospital (2004–2019). Pre- and postoperative data were evaluated in relation to kidney and bladder function, the SWRD score, additional surgery, complications, and long-term follow-up. The mean time between primary valve ablation and UCP was 3.5 years (SD ± 2.0). The median follow-up time was 64.5 months (IQR 36.0–97.25). The mean increase in age-adjusted bladder capacity was 25% (from 77% (SD ± 0.28) to 102% (SD ± 0.46)). Eight boys micturated spontaneously. Ultrasounds showed no severe hydronephrosis (grade 3–4). The SWRD score showed a median decrease from 4.5 (range 2–7) to 3.0 (range 1–5). No conversion of augmentation was required. UCP is a safe and effective approach to improve bladder capacity in boys with PUV. In addition, the possibility of micturating naturally is still maintained.

Purpose: Enterocystoplasty is adopted for patients requiring bladder augmentation, but significant long-term complications highlight need for alternatives. We established a protocol for creating a natural-derived bladder extracellular matrix (BEM) for developing tissue-engineered bladder, and investigated its structural and functional characteristics. Methods: Porcine bladders were de-cellularised with a dynamic detergent–enzymatic treatment using peristaltic infusion. Samples and fresh controls were evaluated using histological staining, ultrastructure (electron microscopy), collagen, glycosaminoglycans and DNA quantification and biomechanical testing. Compliance and angiogenic properties (Chicken chorioallantoic membrane [CAM] assay) were evaluated. T test compared stiffness and glycosaminoglycans, collagen and DNA quantity. p value of < 0.05 was regarded as significant. Results: Histological evaluation demonstrated absence of cells with preservation of tissue matrix architecture (collagen and elastin). DNA was 0.01 μg/mg, significantly reduced compared to fresh tissue 0.13 μg/mg (p < 0.01). BEM had increased tensile strength (0.259 ± 0.022 vs 0.116 ± 0.006, respectively, p < 0.0001) and stiffness (0.00075 ± 0.00016 vs 0.00726 ± 0.00216, p = 0.011). CAM assay showed significantly increased number of convergent allantoic vessels after 6 days compared to day 1 (p < 0.01). Urodynamic studies showed that BEM maintains or increases capacity and compliance. Conclusion: Dynamic detergent–enzymatic treatment produces a BEM which retains structural characteristics, increases strength and stiffness and is more compliant than native tissue. Furthermore, BEM shows angiogenic potential. These data suggest the use of BEM for development of tissue-engineered bladder for patients requiring bladder augmentation. [ABSTRACT FROM AUTHOR]

Background : The effects of renal transplantation in patients with augmentation cystoplasty are still controversial. We retrospectively analyzed nine patients who underwent renal transplantation after augmentation cystoplasty. Methods : A total of nine patients who underwent augmentation cystoplasty prior to renal transplantation between January 1990 and May 2020 were reviewed. Basic information on augmentation cystoplasty, transplant procedures, and long-term outcomes of renal transplantation were analyzed. Results : The bowel segments utilized for augmentation cystoplasty were the stomach in two patients (one patient needed revision using the ileum), the ileum in four patients, the ileocolic pouch in one patient, the sigmoid in one patient, and the ureter in one patient. All the cystoplasties were performed prior to renal transplantation. The mean follow-up period after transplantation was 161 months (range, 2–341 months). Two patients had an episode of acute rejection each; however, their graft functions were well-maintained. Five patients had recurrent urinary tract infections, and three of these patients progressed to allograft failure. One patient died from bladder cancer with a functioning graft. Five of nine patients showed well-maintained graft function. Conclusions: Renal transplantation after bladder augmentation surgery is a major operation requiring a high level of surgical skill. Based on our long-term experiences, we recommend diligent postoperative monitoring for urinary tract infections, optimal catheter use, and use of appropriate antibiotic prophylaxis to avoid severe complications.

Although enhanced recovery pathways (ERP) provide a safe and effective way to improve the recovery of children undergoing bladder reconstruction, ERPs have not been widely adopted in pediatric urology. We describe a quality improvement initiative and outcomes after implementing a 24-element ERP at a single, freestanding children's hospital. Multiple stakeholder meetings were planned and executed, initially with pediatric practitioners with ERP experience to understand potential implementation barriers then with anesthesiologists, nurses, case managers, and other ancillary staff to draft our institution-specific ERP. A standardized order set was generated to improve ERP adherence. ERP adherence audits and cyclic performance evaluations held every 6–9 months facilitated continuous pathway refinement. Patient outcomes were compared with a pre-ERP historic cohort. Time from initial ERP planning to first implementation was 7 months. ERP was implemented in twenty consecutive patients undergoing bladder reconstruction (median age 11.3 years, range 4.1–21.1) who were compared to twenty consecutive pre-ERP patients (median age 11.4 years, range 7.7–25.1). Median post-operative length of stay (LOS) significantly decreased from 9 days (range 2–31) pre-ERP to 4 days (range 3–29) post-ERP (p < 0.05). A median of 16 (range 12–19) of 24 institutional pathway elements were implemented for each patient. Balancing measures showed no significant increases in highest Clavien complication grade, readmission rate, or unplanned return to the operating room within 30 post-operative days. Implementation of ERP is feasible but requires commitment from multi-disciplinary stakeholders. While we were unable to consistently achieve 80% of the elements, we successfully implemented the pathway and improved our patients' recovery processes (indirectly reflected by a decreased post-operative LOS) with adherence to a median of 67% of elements. Our implementation and effectiveness results are specific to our center and may not be generalizable. However, our experience may offer some insight for others interested in ERP implementation and encourage initiation of their own institutional pathways. Successful ERP implementation at our hospital for children undergoing bladder reconstruction was facilitated by open communication, early stakeholder involvement, and monitoring ERP adherence. ERP implementation significantly decreased LOS without increasing post-operative complications and readmissions (Summary figure). [Display omitted] [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the incidence of lower urinary tract surgery in patients with myelomeningocele (MMC) operated in utero as well as in the subgroup of patients with a minimum age of 5 years. We use a previously published protocol to categorize bladder patterns and propose the treatment: high risk pattern-anticholinergics and clean intermittent catheterization (CIC); incontinent and normal patterns-clinical surveillance and underactivity pattern- CIC. Non-response to clinical treatment with maintenance of detrusor pressure higher than 40 cmH20 with worsening of hydronephrosis or recurrent urinary infection were imperative indications for surgery and urinary incontinence due to sphincter deficiency and leakage pressure below 40 cmH20 in patients aged 5 years and older were possible indications too. We identified the prevalence of urinary tract surgery and concomitant treatment of constipation and refractory fecal incontinence by convenience, the technique performed and surgery outcomes. A total of 122 patients are part of the prospective protocol. The first UE was performed in 119 patients (median age of 4 months). The categorization of the bladder pattern was high risk in 52.1%, incontinent in 25.2%, hypocontractile 4.2% and normal in 18.5%. Current follow-up was 29.9 months (1–99 months). Surgery was performed on 10 patients (8.4%): 3 vesicostomies, 2 surgeries to treat vesicoureteral reflux, 6 bladder augmentations, 3 ACE and a sling surgery. Considering only patients older than 5 years, we identified 65 patients and seven surgeries performed (10.8%). Most bladder reconstruction studies are case series of single institutions or cooperative services, most of which are retrospective. The prospective clinical interpretation and imaging and urodynamic exams over time allowed us prospectively to define the risk of surgery in patients with myelomeningocele operated in utero. It must be considered that the response to the initial urological treatment and even the failure that leads to the need for surgery have to be evaluated in a context of follow-up time. For this reason we have studied separately patients over 5 years-old and also the group considered to be at greatest risk for surgery, the high-risk group of the categorization already described. We found an incidence of 10.8% of surgeries in patients over 5 years-old and 12.9% for the high-risk group. This information may be useful to educate parents when stating urological treatment. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose: The clinician treating patients with neurogenic lower urinary tract dysfunction (NLUTD) needs to balance a variety of factors when making treatment decisions. In addition to the patient's urologic symptoms and urodynamic findings, other issues that may influence management options of the lower urinary tract include cognition, hand function, type of neurologic disease, mobility, bowel function/management, and social and caregiver support. This Guideline allows the clinician to understand the options available to treat patients, understand the findings that can be seen in NLUTD, and appreciate which options are best for each individual patient. This allows for decisions to be made with the patient, in a shared decision-making manner, such that the patient's quality of life can be optimized with respect to their bladder management. Materials and Methods: A comprehensive search for studies assessing patients undergoing evaluation, surveillance, management, or follow-up for NLUTD was conducted from January 2001 through October 2017 and was rerun in February 2021 to capture newer literature. The primary search returned 20,496 unique citations. Following a title and abstract screen, full texts were obtained for 3,036 studies. During full-text review, studies were primarily excluded for not meeting the PICO criteria. One hundred eight-four primary literature studies met the inclusion criteria and were included in the evidence base. Results: This guideline was developed to inform clinicians on the proper evaluation, diagnosis, and risk stratification of adult patients with NLUTD and the non-surgical and surgical treatment options available. Additional statements on urinary tract infection and autonomic dysreflexia were developed to guide the clinician. Conclusions: NLUTD patients may undergo non-surgical and surgical treatment options depending on their level of risk, symptoms, and urodynamic findings. Appropriate follow-up, primarily based on their risk stratification, must be maintained after treatment. [ABSTRACT FROM AUTHOR]

Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated. [ABSTRACT FROM AUTHOR]

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation. [ABSTRACT FROM AUTHOR]

ObjectiveAugmentation cystoplasty (AC) is a major surgery that can be associated with long-term morbidity. This study aimed to describe the cumulative incidence of outcomes and urologic procedures in a large cohort of children who underwent AC, identify significant sources of morbidity, and to evaluate baseline factors associated with outcomes of interest.MethodsChildren≤18 years who underwent AC in the Pediatric Health Information System from 1999 to 2010 were included. All follow-up encounters up to June 2012 were included. Cumulative incidences for 15 outcomes and urologic procedures were calculated using non-informative censoring. Sensitivity analyses were performed to determine effect of censoring assumptions and including hospitals without complete datasets. As an exploratory analysis, baseline patient factors were evaluated for associations with outcomes and urologic procedures of interest using multivariable Cox proportional hazards models adjusted for clustering by hospital.Results2831 AC patients were identified. Based on cumulative incidence calculations and sensitivity analyses; the cumulative incidence ranges of outcomes and procedures at 1, 3, 5, and 10 years were calculated. Examples of 10-year cumulative incidence ranges are given for the following outcomes and procedures: bladder rupture (2.9-6.4%), small bowel obstruction (5.2-10.3%), bladder stones (13.3-36.0%), pyelonephritis (16.1-37.1%), cystolithopaxy (13.3-35.1%), and reaugmentation (5.2-13.4%). The development of chronic kidney disease was strongly associated with a diagnosis of lower urinary tract obstruction (HR 13.7; 95% CI 9.4-19.9). Bladder neck surgery and stoma creation at time of AC were associated with an increased hazard of bladder rupture (HR 1.9; 95% CI 1.1-3.3) and bladder stones (HR 1.4; 95% CI 1.1-1.8) respectively.ConclusionsOutcomes of interest and urologic procedures after AC are common. Results from this large cohort can be used to counsel patients and families about expectations after AC. Pyelonephritis, chronic kidney disease, further reconstructive surgery, and calculus disease appear to cause significant morbidity. Collaborative efforts are needed to further reduce morbidity in this patient population.