Journal of Pediatric Surgery VOL. XIV, NO. 2
Ureteral
APRIL
Reimplantation
in Children With Neurogenic
By G. P. Belloli, L. Musi, P. Campobasso,
1979
Bladder
and A. Cattaneo
Vicenza, Italy 0 The treatment of urologic complications from myelomeningocele and especially of vesico-renal reflux is a controversial problem. A series of 26 reimplanted ureters in 17 children, with good results in more than 85 % , is reported. Ureteroneocystostomy. carried out with a few technical innovations, may represent a useful method for the treatment of vesico-renal reflux and obstruction of the ureterovesical junction in neurogenic bladder associated with myelomeningocele. This surgical approach leads to the disappearance of the reflux, decrease of dilatation of the upper urinary tract and preservation of renal function in most cases: moreover, infection can be more easily controlled. Ureteral reimplantation should be preceded by periodic urethral dilatation, external transurethral sphincterotomy, and pharmacologic regulation in order to attempt to decrease urethral resistance. After successful surgery, it is possible to try to reeducate the bladder. Reimplantation should be preferred to permanent urinary diversion even if there is gross refiux. INDEX WORDS: Ureteral reimplantation; neurogenic bladder.
is the most imM YELOMENINGOCELE portant cause of neurogenic bladder in children. In our series of 96 children with neurogenic bladder, 83 patients had myelomeningoceles, almost all of them in the lumbosacral area. At birth, the upper urinary tract of children with myelomeningocele is usually normal. Only a few children, less than lo%, show dilatation of the upper urinary tract;‘.’ in some cases with no relation to bladder dysfunction. In our selected series, only three patients had normal vesical function. About 30% had total urinary incontinence without residual urine. In this group, infection was present in more than 15% of the cases. Vesico-renal reflux occurred rarely and, if present, was of a mild degree. In 65% of the cases, an obstruction of the lower urinary tract gradually developed. The obstruction was always at the level of the external
Journalof Pediatric
Surgery, Vol. 14, No. 2 (April). 1979
sphincter and the amount of residual urine and the gradual changes of the bladder wall were related to the degree of obstruction. Infection was present in 70% of cases with moderate residual urine and in almost 100% of cases with severe residual urine; in this group the upper urinary tract showed dilatation in about 65% of the patients, one-sided in two-thirds and on both sides in one-third. Vesico-renal reflux was present in almost 30% of the cases. In patients with marked urethral resistance, bladder trabeculation and large residual urine, the incidence of reflux was higher, about 50%. Of these patients, 20% showed dilatation of the upper urinary tract of various degree due to an obstruction at the ureterovesical junction. Nonoperative management of vesico-renal reflux in these patients gives poor results. Surgical treatment is still controversial. We report here our experience with ureteral reimplantation in children with neurogenic bladder. MATERIALS
AND
METHODS
From October 1971 to September 1977, ureteral reimplantation was performed in 6 males and 11 females with neurogenic bladder due to myelomeningocele (14 cases), spina trauma (I case), neonatal meningoencephalitis (I case), and occult neuropatbic bladder’ (1 case). The age of children at the time of surgery ranged from 10 mo to 15 yr withan average age of 6 yr and 5 mo. All the children had pyuria and bacteriuria with previous attacks of acute pyelonephritis. All but three had residual urine and mild to marked dilatation and trabeculation of the bladder. Three children had slight impairment of renal function. Of 26 ureters reimplantated in 17 patients, vesicorenal reflux was found in 22 and an obstructed megaureter in
From the Division of PediatricSurgery, Vicenza. Italy. Address reprint requests 10 G. P. Belloli, M.D.. Surgeonin-chief. Division of Pediatric Surgery, Regional Hospital, Vicenza, Italy. 01979 by Grune & Stratton. Inc. 0022-3468/79/I402-oool$0l.00/0
119
Fig. 1. Female, 10 yr old. (A and 61 IVP and cystourethrography showing a III degree bilateral reflux and moderate dilatation of the upper urinary tract; IC and D) IVP and cystourethrography 10 mo after bilateral Cohen’s operation: the reflux is absent and the upper urinary tract normalized.
URETERAL
121
REIMPLANTATION
the remaining 4. One child suffered from congenital obstructed megaureter not secondary to neurogenic bladder. When classified according to Dwoskin and Perlmutter, there was a grade IIb rellux in 3 out of 22 cases, 13 grade III, and 6 grade IV. Bilateral reimplantation was carried out in 8 patients and unilateral in 9. The Glenn-Anderson procedure’ was used in 6 ureters; the Cohen procedure6 in IO, all of them bilateral cases. Six ureters were reimplanted by the Politano-Leadbetter procedure’ and four, grossly dilated, were trimmed at the time of reimplantation.* In these last ten ureters, the procedure was partly modified because the ureteroneccystostomy was placed lower than usual and the ureter was advanced and fixed proximal to the vesical neck and not in its original position; in other words a “low” Politano-Leadbetter procedure was performed using mostly the vesical trigone. Before surgery, children were given intense antibiotic treatment and underwent either short periods of vesical drainage or of intermittent catheterization. In children with severe residual urine, urethral dilation was performed in females and transurethral sphincterotomy in three males. Follow-up examination ranged from IO mo to 5 yr with an average of 2 yr and 3 mo. One case with a Cohen’s bilateral ureteroneocystostomy is not included in this series because the follow-up is too short. RESULTS
Estimation of results was based on x-ray findings. A good result showed the disappearance of reflux on voiding cystourethrogram and regression of dilatation of the upper urinary tract on IVP (Figs. l-4). In 24 reimplantations, there were 21 successful operations in 14 children and 3 unsuccessful ones in 2 children. Poor results were not due to stenosis but to the persistent reflux. In 1 of the 2 unsuccessful cases, even a second operation failed. In the other child there was improvement of the pyelographic findings (even though reflux was still present in two of three ureters), with clear clinical improvement and moderate gain in renal function (Fig. 5). None of the children had to undergo a urinary diversion later. They are closely followed with urine culture every 2 or 3 mo and with IVP (maximal 1 or 2 radiograms) every year. As soon as infection is detected, antibiotic treatment begins. One male and two females are totally incontinent. None of the other children are completely continent, but they can be kept dry for periods varying from 1’/2 to 4 hr. After surgery, all these children underwent repeated periods of bladder reeducation by means of active exercises, scheduled voiding and transurethral vesical electrical stimulation according to Katona.’ Three females with very severe residual
urine had repeated urethral dilations and four are emptied by intermittent catheterization. DISCUSSION
Almost two-thirds of our patients with neurogenic bladder associated with myelomeningocele had a functional obstruction of various degree at the level of the external sphincter. Infection occurred in the large majority of these patients and was responsible, in addition to stasis, for severe urologic complications, especially vesico-renal reflux and, less frequently, obstruction of the uretero-vesical junction. These complications occurred in about 50% of our children with residual urine. In children with total incontinence and no residual urine, the incidence of vesico-renal reflux, usually of mild degree, was little more than 10%; reflux was often transient and chiefly related to infection. Reflux, especially if severe, and infection are responsible for ureteral dilatation and hypotonia, pyelonephritis and progressive impairment of renal function. In infants, suprapubic expression gives good results in the majority of patients. Manual expression of the bladder usually gives poor results after 2 yr of age, especially if the child and his parents are not cooperative; Crede is absolutely contraindicated when reflux is present. Periodic urethral dilation and external sphincterotomy may have a place in helping emptying of the bladder, but their use in preventing or reducing dilatation of the upper urinary tract due to reflux or stenosis is still controversial. Moreover, external sphincterotomy is not easy to perform in small infants and is frequently incomplete. These preventive measures are useful in children with retention”.” and in our experience they do not cause incontinence. Intermittent catheterization is easy in females, but not in males. It is quite successful in preventing dilatation of the upper urinary tract and keeping many children dry. However, it requires the maximum of cooperation from the patient and his family; besides it is not known to which degree it reduces the dilatation of the upper urinary tract and eliminates the reflux.12 In our opinion it is dangerous when the urine is still sterile. Permanent urinary diversion, largely used in
Female, 2 yr old. (A and B) IVP and cystourethrography showing left megaureter and i.v. degree reflux: (C and 0) Fig. 2. IVP and cystourethrography 2 yr after Hendren’s operation: normalization of the upper urinary tract (arrow) and disappearance of the reflux on the left side: small, transient reflux on the right.
Fig. 3. Female, 4 yr old. (A and B) IVP and cystourethrography showing i.v. degree reilux on the left and II b on the right. with clear dilatation of the left escretory system; (C and DI IVP and cystourethrogrsphy 1 yr after bilateral Cohen’s operation: disappearance of reflux and almost normal radiologic finding on IVP.
Fig. 5. Female. 8 yr old. (A and 8) IVP and cystourethrography showing bilateral dilatation of the upper urinary tract and gross reflux in all three ureters. BUN 41 mg/ 100 ml (N.V. 20-22 mg / 100 ml, Benurn creatinine mg / 100 ml.) (C and D) IVP and cystourethrography 22 mo after Politano-Leadbetter operation: persistent reflux in two ureters but clear radiologic improvement of the upper urinary tract. BUN 32 mg/lOO ml, serum creatinine mg 1,20 % . Marked clinical improvement.
126
BELLOLI ET AL.
is still advocated by several the past, authors,2*‘3.‘4 even though more recently conservative management without permanent diversion is often preferred. Review of the literature shows that permanent urinary diversion in children has an incidence of urologic complications of 48.6% including, in order of declining frequency, pyelonephritis, pyocystis, stones, ureteroileal stenosis, and postoperative stoma1 stenosis in 14.8% of cases.‘5V’6 We strongly believe, as do several other authors, that permanent urinary diversion is not the ideal procedure for neurogenic bladder. Cutaneous vesicostomy is a temporary diversion and provides tubeless drainage of the bladder; it has been found satisfactory to reduce or stabilize dilatation of the upper urinary tract and to control infection.‘2+‘7’8 The main inconveniences of cutaneous vesicostomy are stenosis of the stoma1 site, difficult application of the collecting bag, occurrence of stones and frequent bacteriuria. When maintained for a long time, it may cause contraction of the bladder. The use of ureteral reimplantation in children with neurogenic bladder associated with vesicorenal reflux or obstruction of the uretero-vesical junction is still controversial. Although several authors had moderate or good results,9-24 other authors believe that ureteral reimplantation has little or no place in the treatment of neurogenic bladder.‘9*2s-27 Few cases have been reported and the effectiveness of this procedure has still to be proved. Our experience is limited and the follow-up is still short. Nevertheless, we believe that ureteral reimplantation is a justified surgical treatment for vesico-renal reflux and obstruction of the uretero-vesical junction when the urethral functional obstruction can be removed, and when there is a possibility of a later reeducation of the bladder. In neurogenic bladder from myelomeningocele with high urethral resistance, gradual appearance of progressive trabeculation of the
detrusor occurs, but leaves the vesical trigone undamaged. For this reason, the operative procedure should displace the ureteral opening and the tunnel should be laid under the trigonal mucosa. When a thinning of the dilated ureter or a Politano procedure are necessary, it is better to avoid high reimplantation by advancing the ureteral orifice down into the trigone. We believe that this procedure may give better immediate and long-term results. Surgery is not contraindicated in presence of trabeculation of the bladder; *’ it is also not contraindicated in case of severe reflux and marked dilatation of the upper urinary tract. Before surgery, we advise a trial to control urinary infection by means of antibiotic treatment associated with intermittent catheterization. Chronic infection makes the operation difficult and the result uncertain. These children need frequent evaluation for early diagnosis of infection, reflux, and dilatation of the upper urinary tract. The persistence of infection and reflux is, in our opinion, a clear indication for ureteral reimplantation without undue delay. A careful follow-up is necessary after surgical correction in order to keep the urine sterile and promote the emptying of the bladder by the methods described above. In successfully operated children, the urine remained sterile for quite long periods and attacks of acute pyelonephritis diminished. In unsuccessful cases reimplantation and/or ureteroureterostomy may be tried; or a temporary diversion with cutaneous vesicostomy may be performed. Intermittent catheterization may avoid reoperation and allow the patient a satisfactory life. Permanent urinary diversion should be considered as the last resort. Conservative surgical treatment as described above gives better results and better preservation of renal function. In females with total incontinence, diversion using a sigmoid conduit and an antireflux procedure are carried out when requested by the child and her parents.
REFERENCES I. Ericsson NO, Hellstriim B, Nergardh A, et al: Micturition urethrocystography in children with myelomeningocele. A radiologic and clinical investigation. Acta Radio1 Diagn [Stockh] 11:321-336, 1971 2. Smith ED: Urinary prognosis in spina bifida. J Urol 108:815-817,1972b
3. Williams DI, Hirst G, Doyle D: The occult neuropathic bladder. J Pediatr Surg 9:35-41, 1974 4. Dwoskin JY, Perlmutter AD: Vesico-ureteral reflux in children: A computerized review. J Urol 109:888-890. 1973 5. Glenn JF, Anderson EE: Distal tunnel ureteral reimplantation. J Urol97:623, 1962
127
6. Cohen J: V&co-ureteral reflux: A new surgical approach. Int Urol Pediatr 6:2&24, 1975 7. Politano VA, Leadbetter WF: An operative technique for the correction of vcsico-ureteral reflux. J Ural 79:932, 1958 8. Hendren WH: Operative repair of megaureter in children. J Ural 101:491-495, 1969 9. Katona F, Benyo L, Lang I: Uber intraluminiire Elektrotherapie von verschiedenen paralytischen Zustiinden des gastrointestinalen Traktes mit Quadrangulastrom. Zentralbl Chir 84:929-933, 1959 10. Koontz WW Jr, Smith MJV, Currie RJ: External sphincterotomy in boys with memingomyelocele. J Ural 108:649651, 1972 11. Mallard P, Romagny G, Monfort G, et al: Traitement des obstacles infravtsicaux des vessies neurologiques du spina bilida. J Urol NCphrol81:349-358, 1975 12. Lapides J: Intermittent catheterization and vesicostomy in the management of traumatic neurogenic bladder, in Scott R (ed): Current controversies in Urological Management. Philadelphia, Saunders, 1972, ~~186-191 13. Eckstein HB: Neuropathic bladder, in Williams DI (ed): Urology in Childhood. New York, Springer-Verlag, 1974, ~~249-265 14. Mebust WK, Foret JD, Valk WL: Fifteen years of experience with urinary diversion in myelomeningocele patients. J Urol 101:177-182, 1969 15. Belloli G: Relazione sulla vescica neurogena da mielomeningocele-1 lo Congress0 Societl Italiana di Chirurgia PediatricaMielomeningocele-Palermo, Ottobre 1975 16. Belloli G: Relazione su: Studio diagnostic0 e trattamento della vescica neurogena nel bambino. Corso di Aggiornamento in Chirurgia Pediatrica, Roma, Aprile 1976 17. Duckett JW Jr: Cutaneous vesicostomy in childhood: the Blocksom technique. Ural Clin North Am 1:485, 1974
18. Duckett JW Jr, Raezer DM: Neuromuscular dysfunction of the lower urinary tract, in Kelalis PP, King LR (eds): Clinical Pediatric Urology (vol 1). Philadelphia, Saunders, 1976, ~~401-426 19. Archimbaud JP: Les dysfonctionnements sphincteriens neurologiques-68’ Session A.F.U. Ural NCphrol Tome 80, no 9 bis, 1974
vesico1974. J
20. Hucth JA: Vesic+ureteral reflux in the paraplegic: Cause and correction. J Urol 68:457, 1952 21. Jeffs RD, Jonas P, Schillinger JF: Surgical correction of vesico-ureteral reflux in children with neurogenic bladder. J Ural 115:44945 1, 1976 22. King LR: Comment, in Jeffs RD, Jonas P, Schillinger JF (eds): Surgical Correction of Vesico-Ureteral Reflux in Children with Neurogenic Bladder. J Urol 115:449451, 1976 23. Monfort G: Reimplantation International course of pediatric 24-27, 1977
in neurogenic bladderurology. Barcellona, July
24. Tarabulcy E, Morales PA, Sullivan JF: Vesicoureteric rellux in paraplegia: Results of various form of management. Paraplegia 10:44-49, 1972 25. Bitker MP: Colocystoplastie NCphrol72:789-794, 1966
et spina
26. Bors E, Comar AE: Neurological University Park Press, 197 1, ~~320-328
bifida.
Urology.
J Ural
Baltimore,
27. Cukier J, Beurton D: Le role de I’urologue dans le traitement des obstructions du bas appareil urinarie de l’enfant atteint de vessie neurogene. J Urol Ntphrol 78:207215, 1972 28. Scetbon V, Derhy J: Les &implantations des urettres dans les vessies neurogbnes; Pro& verbaux, mtmoires et discussions. 66’ Congrts A.F.U. 1972, J Urol NCphrol
Ureteral
APRIL
Reimplantation
in Children With Neurogenic
By G. P. Belloli, L. Musi, P. Campobasso,
1979
Bladder
and A. Cattaneo
Vicenza, Italy 0 The treatment of urologic complications from myelomeningocele and especially of vesico-renal reflux is a controversial problem. A series of 26 reimplanted ureters in 17 children, with good results in more than 85 % , is reported. Ureteroneocystostomy. carried out with a few technical innovations, may represent a useful method for the treatment of vesico-renal reflux and obstruction of the ureterovesical junction in neurogenic bladder associated with myelomeningocele. This surgical approach leads to the disappearance of the reflux, decrease of dilatation of the upper urinary tract and preservation of renal function in most cases: moreover, infection can be more easily controlled. Ureteral reimplantation should be preceded by periodic urethral dilatation, external transurethral sphincterotomy, and pharmacologic regulation in order to attempt to decrease urethral resistance. After successful surgery, it is possible to try to reeducate the bladder. Reimplantation should be preferred to permanent urinary diversion even if there is gross refiux. INDEX WORDS: Ureteral reimplantation; neurogenic bladder.
is the most imM YELOMENINGOCELE portant cause of neurogenic bladder in children. In our series of 96 children with neurogenic bladder, 83 patients had myelomeningoceles, almost all of them in the lumbosacral area. At birth, the upper urinary tract of children with myelomeningocele is usually normal. Only a few children, less than lo%, show dilatation of the upper urinary tract;‘.’ in some cases with no relation to bladder dysfunction. In our selected series, only three patients had normal vesical function. About 30% had total urinary incontinence without residual urine. In this group, infection was present in more than 15% of the cases. Vesico-renal reflux occurred rarely and, if present, was of a mild degree. In 65% of the cases, an obstruction of the lower urinary tract gradually developed. The obstruction was always at the level of the external
Journalof Pediatric
Surgery, Vol. 14, No. 2 (April). 1979
sphincter and the amount of residual urine and the gradual changes of the bladder wall were related to the degree of obstruction. Infection was present in 70% of cases with moderate residual urine and in almost 100% of cases with severe residual urine; in this group the upper urinary tract showed dilatation in about 65% of the patients, one-sided in two-thirds and on both sides in one-third. Vesico-renal reflux was present in almost 30% of the cases. In patients with marked urethral resistance, bladder trabeculation and large residual urine, the incidence of reflux was higher, about 50%. Of these patients, 20% showed dilatation of the upper urinary tract of various degree due to an obstruction at the ureterovesical junction. Nonoperative management of vesico-renal reflux in these patients gives poor results. Surgical treatment is still controversial. We report here our experience with ureteral reimplantation in children with neurogenic bladder. MATERIALS
AND
METHODS
From October 1971 to September 1977, ureteral reimplantation was performed in 6 males and 11 females with neurogenic bladder due to myelomeningocele (14 cases), spina trauma (I case), neonatal meningoencephalitis (I case), and occult neuropatbic bladder’ (1 case). The age of children at the time of surgery ranged from 10 mo to 15 yr withan average age of 6 yr and 5 mo. All the children had pyuria and bacteriuria with previous attacks of acute pyelonephritis. All but three had residual urine and mild to marked dilatation and trabeculation of the bladder. Three children had slight impairment of renal function. Of 26 ureters reimplantated in 17 patients, vesicorenal reflux was found in 22 and an obstructed megaureter in
From the Division of PediatricSurgery, Vicenza. Italy. Address reprint requests 10 G. P. Belloli, M.D.. Surgeonin-chief. Division of Pediatric Surgery, Regional Hospital, Vicenza, Italy. 01979 by Grune & Stratton. Inc. 0022-3468/79/I402-oool$0l.00/0
119
Fig. 1. Female, 10 yr old. (A and 61 IVP and cystourethrography showing a III degree bilateral reflux and moderate dilatation of the upper urinary tract; IC and D) IVP and cystourethrography 10 mo after bilateral Cohen’s operation: the reflux is absent and the upper urinary tract normalized.
URETERAL
121
REIMPLANTATION
the remaining 4. One child suffered from congenital obstructed megaureter not secondary to neurogenic bladder. When classified according to Dwoskin and Perlmutter, there was a grade IIb rellux in 3 out of 22 cases, 13 grade III, and 6 grade IV. Bilateral reimplantation was carried out in 8 patients and unilateral in 9. The Glenn-Anderson procedure’ was used in 6 ureters; the Cohen procedure6 in IO, all of them bilateral cases. Six ureters were reimplanted by the Politano-Leadbetter procedure’ and four, grossly dilated, were trimmed at the time of reimplantation.* In these last ten ureters, the procedure was partly modified because the ureteroneccystostomy was placed lower than usual and the ureter was advanced and fixed proximal to the vesical neck and not in its original position; in other words a “low” Politano-Leadbetter procedure was performed using mostly the vesical trigone. Before surgery, children were given intense antibiotic treatment and underwent either short periods of vesical drainage or of intermittent catheterization. In children with severe residual urine, urethral dilation was performed in females and transurethral sphincterotomy in three males. Follow-up examination ranged from IO mo to 5 yr with an average of 2 yr and 3 mo. One case with a Cohen’s bilateral ureteroneocystostomy is not included in this series because the follow-up is too short. RESULTS
Estimation of results was based on x-ray findings. A good result showed the disappearance of reflux on voiding cystourethrogram and regression of dilatation of the upper urinary tract on IVP (Figs. l-4). In 24 reimplantations, there were 21 successful operations in 14 children and 3 unsuccessful ones in 2 children. Poor results were not due to stenosis but to the persistent reflux. In 1 of the 2 unsuccessful cases, even a second operation failed. In the other child there was improvement of the pyelographic findings (even though reflux was still present in two of three ureters), with clear clinical improvement and moderate gain in renal function (Fig. 5). None of the children had to undergo a urinary diversion later. They are closely followed with urine culture every 2 or 3 mo and with IVP (maximal 1 or 2 radiograms) every year. As soon as infection is detected, antibiotic treatment begins. One male and two females are totally incontinent. None of the other children are completely continent, but they can be kept dry for periods varying from 1’/2 to 4 hr. After surgery, all these children underwent repeated periods of bladder reeducation by means of active exercises, scheduled voiding and transurethral vesical electrical stimulation according to Katona.’ Three females with very severe residual
urine had repeated urethral dilations and four are emptied by intermittent catheterization. DISCUSSION
Almost two-thirds of our patients with neurogenic bladder associated with myelomeningocele had a functional obstruction of various degree at the level of the external sphincter. Infection occurred in the large majority of these patients and was responsible, in addition to stasis, for severe urologic complications, especially vesico-renal reflux and, less frequently, obstruction of the uretero-vesical junction. These complications occurred in about 50% of our children with residual urine. In children with total incontinence and no residual urine, the incidence of vesico-renal reflux, usually of mild degree, was little more than 10%; reflux was often transient and chiefly related to infection. Reflux, especially if severe, and infection are responsible for ureteral dilatation and hypotonia, pyelonephritis and progressive impairment of renal function. In infants, suprapubic expression gives good results in the majority of patients. Manual expression of the bladder usually gives poor results after 2 yr of age, especially if the child and his parents are not cooperative; Crede is absolutely contraindicated when reflux is present. Periodic urethral dilation and external sphincterotomy may have a place in helping emptying of the bladder, but their use in preventing or reducing dilatation of the upper urinary tract due to reflux or stenosis is still controversial. Moreover, external sphincterotomy is not easy to perform in small infants and is frequently incomplete. These preventive measures are useful in children with retention”.” and in our experience they do not cause incontinence. Intermittent catheterization is easy in females, but not in males. It is quite successful in preventing dilatation of the upper urinary tract and keeping many children dry. However, it requires the maximum of cooperation from the patient and his family; besides it is not known to which degree it reduces the dilatation of the upper urinary tract and eliminates the reflux.12 In our opinion it is dangerous when the urine is still sterile. Permanent urinary diversion, largely used in
Female, 2 yr old. (A and B) IVP and cystourethrography showing left megaureter and i.v. degree reflux: (C and 0) Fig. 2. IVP and cystourethrography 2 yr after Hendren’s operation: normalization of the upper urinary tract (arrow) and disappearance of the reflux on the left side: small, transient reflux on the right.
Fig. 3. Female, 4 yr old. (A and B) IVP and cystourethrography showing i.v. degree reilux on the left and II b on the right. with clear dilatation of the left escretory system; (C and DI IVP and cystourethrogrsphy 1 yr after bilateral Cohen’s operation: disappearance of reflux and almost normal radiologic finding on IVP.
Fig. 5. Female. 8 yr old. (A and 8) IVP and cystourethrography showing bilateral dilatation of the upper urinary tract and gross reflux in all three ureters. BUN 41 mg/ 100 ml (N.V. 20-22 mg / 100 ml, Benurn creatinine mg / 100 ml.) (C and D) IVP and cystourethrography 22 mo after Politano-Leadbetter operation: persistent reflux in two ureters but clear radiologic improvement of the upper urinary tract. BUN 32 mg/lOO ml, serum creatinine mg 1,20 % . Marked clinical improvement.
126
BELLOLI ET AL.
is still advocated by several the past, authors,2*‘3.‘4 even though more recently conservative management without permanent diversion is often preferred. Review of the literature shows that permanent urinary diversion in children has an incidence of urologic complications of 48.6% including, in order of declining frequency, pyelonephritis, pyocystis, stones, ureteroileal stenosis, and postoperative stoma1 stenosis in 14.8% of cases.‘5V’6 We strongly believe, as do several other authors, that permanent urinary diversion is not the ideal procedure for neurogenic bladder. Cutaneous vesicostomy is a temporary diversion and provides tubeless drainage of the bladder; it has been found satisfactory to reduce or stabilize dilatation of the upper urinary tract and to control infection.‘2+‘7’8 The main inconveniences of cutaneous vesicostomy are stenosis of the stoma1 site, difficult application of the collecting bag, occurrence of stones and frequent bacteriuria. When maintained for a long time, it may cause contraction of the bladder. The use of ureteral reimplantation in children with neurogenic bladder associated with vesicorenal reflux or obstruction of the uretero-vesical junction is still controversial. Although several authors had moderate or good results,9-24 other authors believe that ureteral reimplantation has little or no place in the treatment of neurogenic bladder.‘9*2s-27 Few cases have been reported and the effectiveness of this procedure has still to be proved. Our experience is limited and the follow-up is still short. Nevertheless, we believe that ureteral reimplantation is a justified surgical treatment for vesico-renal reflux and obstruction of the uretero-vesical junction when the urethral functional obstruction can be removed, and when there is a possibility of a later reeducation of the bladder. In neurogenic bladder from myelomeningocele with high urethral resistance, gradual appearance of progressive trabeculation of the
detrusor occurs, but leaves the vesical trigone undamaged. For this reason, the operative procedure should displace the ureteral opening and the tunnel should be laid under the trigonal mucosa. When a thinning of the dilated ureter or a Politano procedure are necessary, it is better to avoid high reimplantation by advancing the ureteral orifice down into the trigone. We believe that this procedure may give better immediate and long-term results. Surgery is not contraindicated in presence of trabeculation of the bladder; *’ it is also not contraindicated in case of severe reflux and marked dilatation of the upper urinary tract. Before surgery, we advise a trial to control urinary infection by means of antibiotic treatment associated with intermittent catheterization. Chronic infection makes the operation difficult and the result uncertain. These children need frequent evaluation for early diagnosis of infection, reflux, and dilatation of the upper urinary tract. The persistence of infection and reflux is, in our opinion, a clear indication for ureteral reimplantation without undue delay. A careful follow-up is necessary after surgical correction in order to keep the urine sterile and promote the emptying of the bladder by the methods described above. In successfully operated children, the urine remained sterile for quite long periods and attacks of acute pyelonephritis diminished. In unsuccessful cases reimplantation and/or ureteroureterostomy may be tried; or a temporary diversion with cutaneous vesicostomy may be performed. Intermittent catheterization may avoid reoperation and allow the patient a satisfactory life. Permanent urinary diversion should be considered as the last resort. Conservative surgical treatment as described above gives better results and better preservation of renal function. In females with total incontinence, diversion using a sigmoid conduit and an antireflux procedure are carried out when requested by the child and her parents.
REFERENCES I. Ericsson NO, Hellstriim B, Nergardh A, et al: Micturition urethrocystography in children with myelomeningocele. A radiologic and clinical investigation. Acta Radio1 Diagn [Stockh] 11:321-336, 1971 2. Smith ED: Urinary prognosis in spina bifida. J Urol 108:815-817,1972b
3. Williams DI, Hirst G, Doyle D: The occult neuropathic bladder. J Pediatr Surg 9:35-41, 1974 4. Dwoskin JY, Perlmutter AD: Vesico-ureteral reflux in children: A computerized review. J Urol 109:888-890. 1973 5. Glenn JF, Anderson EE: Distal tunnel ureteral reimplantation. J Urol97:623, 1962
127
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