| Background:The main causes of neurogenic bladder in children are spina bifida and sacrococcygeal teratoma,and the clinical symptoms vary.Due to detrusor overactivity,urethral sphincter insufficiency,or the uncoordinated action of bladder detrusor and the sphincter,the symptoms can manifest as incontinence,dysuria,urinary retention,urinary drip,repeated urinary tract infections,upper urinary tract dysfunction,and even renal failure.The dysfunction of urination and incontinence seriously affects normal quality of life and mental health.Renal damage can progress to renal failure,endangering the lives of children.The widespread use of clean intermittent catheterization and bladder augmentation has greatly reduced the mortality of patients with neurogenic bladder.Presently,the main management strategy of the disease is prevention,including oral folic acid during pregnancy to prevent meningocele and B-ultrasound screening during pregnancy.There is no effective treatment for the etiology;the clinical focus is on symptomatic treatment.The main treatment goal is to protect upper urinary tract function and alleviate incontinence,including behavioral habits,urination training,clean intermittent catheterization,oral anticholinergic drugs,intravesical injection of botulinum toxin,surgery and psychological counseling.Different conservative treatment methods are selected according to the situation of the disease,and many children can avoid subsequent operations.For children with poor outcomes of conservative treatment and severe bladder fibrosis,bladder augmentation remains the most effective treatment that can protect upper urinary tract function,improve urodynamic parameters,and relieve urinary incontinence.Many perioperative and long-term complications occur,but the treatment is still worthwhile to improve the quality of life and protect upper urinary tract function.The main indications for bladder augmentation are as follows:small bladder volume,low compliance,unsafe bladder hypertension caused by detrusor overactivity,progressive deterioration of upper urinary tract function,persistent incontinence with oral medications and intermittent catheterization.Bladder augmentation using the gastrointestinal tract is the most widely used operation.The materials used are elastic,low in tension,and sufficient in length.Resection of part of the intestinal tube has little effect on the patient's nutrient absorption function.The bladder volume expands significantly after surgery,the urodynamic parameters are improved,and urinary incontinence can be alleviated.However,many postoperative complications occur,such as bacteriuria and mucus urine,urinary tract infections,bladder stones,cancer,electrolyte disorders,acidosis,metabolic abnormalities,and vitamin B12 deficiency.Urinary tract infections and bladder stones occur frequently,causing great distress to children and their families.To avoid complications related to the integration of the intestinal mucosa into the bladder,various surgical procedures have been attempted.The main changes include keeping the bladder mucosa intact,removing the intestinal mucosa and retaining the seromuscular layer,covering the bladder mucosa with seromuscular layer,and so on.Seromuscular cystoplasty lined with urothelium(SCLU),autoaugmentation(AA),and seromuscular bladder augmentation(SMBA)are the commonly used procedures.Compared with SC,some studies have reported good results.Because no intestinal mucosa was present,the incidence rates of mucus urine,urinary tract infection and bladder stones were lower,but other studies have reported negative results.There have been researches on the outcomes and complications of the four procedures of SC,SCLU,AA and SMBA.However,how to choose the best procedure for different patients and how to minimize the long-term complications while ensuring the surgical effect are still controversial.The four surgical procedures are not totally different.For example,the difference between SC and SMBA is whether to preserve the intestinal mucosa,that between SCLU and AA is whether to apply the gastrointestinal seromuscular layer,and that between SMBA and SCLU is whether to maintain the integrity of the bladder mucosa.However,no report has compared SCLU,AA and SMBA in the literature.Therefore,the roles of retaining the intestinal mucosa,covering the bladder mucosa with seromuscular layer and maintaining the integrity of the bladder mucosa in bladder augmentation remain to be clarified.Purpose:To evaluate the functional outcomes of SCLU,AA and SMBA compared with SC.Compare the outcomes of SC and SMBA to clarify the roles of preserving the intestinal mucosa,compare the outcomes of SCLU and AA to clarify the roles of covering the bladder mucosa with gastrointestinal seromuscular layer,and compare the outcomes of SCLU and SMBA to clarify the roles of maintaining the integrity of bladder mucosa in improving bladder function and reducing complications after surgery.Methods:A retrospective analysis was performed on the clinical data of children with various bladder augmentation procedures completed at the Second Hospital of Shandong University from August 2003 to December 2018,and the children were divided into four groups—SC,SCLU,AA,and SMBA—according to the different augmentation procedures.The urodynamic parameters,clinical symptoms and postoperative complications of each group before and after the operation were compared.The urodynamic parameters included the maximum bladder capacity,bladder compliance and end-filling detrusor pressure.The clinical symptoms observed were urinary incontinence,the number of clean intermittent catheterizations,and the proportion of patients with oral anticholinergic drugs.Postoperative complications included recurrent urinary tract infections,bladder stones and expansion failure.The urodynamic parameters before and after the operation were compared to evaluate the improvement of bladder function after surgery.A comparison of the urodynamic parameters between SC and SMBA was performed to evaluate the effect of preserving the intestinal mucosa,a comparison between SCLU and AA was performed to evaluate the effect of covering the bladder mucosa with gastrointestinal seromuscular layer,and a comparison between SCLU and SMBA was performed to evaluate the effect of maintaining the integrity of the bladder mucosa.Results:1.To evaluate the functional outcomes of SCLU,AA and SMBA compared with SC.One hundred seventeen children had undergone bladder augmentation.The numbers of cases in the SC,SCLU,AA,and SMBA groups were 46,37,13,and 21,respectively;the mean ages at surgery in the four groups were 10.6 years,7.5 years,4.8 years,and 7.6 years,respectively;the durations of follow-up in the four groups were 36 months,60.8 months,36.4 months,and 29.7 months,respectively.Autoaugmentation demonstrated the shortest operation time and least volume of blood loss.The other three groups had the same complexity,and no significant differences were found in the operation time and blood loss.In the SC group,the sigmoid colon patch was used in 3 cases and ileum patch in 43 cases.In the SCLU group,the sigmoid colon seromuscular layer patch was used in 11 cases,the gastric seromuscular layer patch was used in 1 case,and ileum seromuscular layer patch in 25 cases.In the SMBA group,the sigmoid colon seromuscular layer patch was used in 10 cases,gastric seromuscular layer patch in 2 cases,and ileum seromuscular layer patch in 9 cases.Intraoperative concomitant surgery included bladder outlet surgery,ureteric reimplantation,and continent urinary stoma.The postoperative bladder volume in the SC group increased by 123%compared with that before the operation,and bladder compliance,end-filling detrusor pressure and urinary incontinence were also improved significantly.The bladder volumes in the SCLU and AA groups also improved after surgery,increasing by 45%and 31%,respectively,compared with those preoperatively.The bladder volume in the SMBA group did not improve significantly after surgery and only increased by 9.7%.The bladder pressure in the SC group decreased significantly after the operation,and the average value decreased to close to 20 cm H2O,reaching a relatively safe level.The pressure in the AA and SMBA groups also decreased while that in the SCLU group did not decrease significantly,requiring oral anticholinergic drugs.The improvement of the urodynamic parameters in the SC group was significantly better than that in the other three groups in all aspects.The postoperative bladder volume in the SCLU group was 62%of that in the SC group,the postoperative bladder volume in the AA group was 46.9%of that in the SC group,and the postoperative bladder volume in the SMBA group was 37.1%of that in the SC group.After SC,SCLU,AA,and SMBA,urinary incontinence improved to various degrees.The numbers of clean intermittent catheterizations after surgery were 5.6,7.8,8.2,and 7.6,respectively.The proportions of children who needed oral anticholinergic drugs were 17.4%,67.6%,76.9%and 81.0%,respectively.No cancer was found in any group after the operation.The main long-term complications after surgery in the SC group were recurrent urinary tract infections and bladder stones,with incidences of 8.7%and 6.5%,respectively,and the overall complication rate was 17.2%.No children had undergone reaugmentation for failure to enlarge the bladder capacity.The main complications after SCLU,AA and SMBA were residual ureteral reflux and failure of expansion,and the incidences in the three groups were 13.5%and 21.6%,23.1%and 23.1%,33.3%and 28.6%,respectively.The SC procedure was chosen for reaugmentation.The reason for the failure of expansion in the SMBA group was contracture of the patch.During the reoperation,contracture and fibrosis of the patch were observed,and the 6 patients with failure of expansion all used the ileal seromuscular layer patch for augmentation.2.Compare the functional outcomes between SC and SMBA,SCLU and AA,SCLU and SMBA,to evaluate the significance of key surgical steps.The bladder volume after SMBA was only 37.1%of that in the SC group,and the postoperative bladder pressure and compliance were also worse than that in the SC group.The improvement of postoperative urinary incontinence and the proportion of patients with anticholinergic drugs were significantly different between the two groups(P<0.05).No mucus urine occurred after SMBA,but the rate of recurrent urinary tract infection and expansion failure were higher than those in the SC group.The difference in urodynamic parameters between the SCLU and AA groups before and after surgery was not significant,except that the postoperative bladder volume in the SCLU group was slightly higher than that in the AA group,.but the duration of follow-up after SCLU was longer.There was no significant difference in the rate of urinary incontinence and patients with anticholinergic drugs between the two groups before and after surgery.No significant difference was found in the preoperative urodynamic parameters between SCLU and SMBA,and the postoperative bladder volume in the SCLU group was higher than that in the SMBA group(P<0.05).There was no significant difference in the rate of urinary incontinence and patients with anticholinergic drugs between the two groups before and after surgery.The incidence of complications after SMBA was higher than that in the SCLU group,but it was not statistically significant(P>0.05).Conclusions:1.SC was effective in improving urodynamic parameters,relieving bladder hypertension,protecting upper urinary tract function,relieving urinary incontinence,and improving quality of life.The overall postoperative complication rate was lower than that of the other groups,but the incidence of urinary tract infection and bladder stones was higher.For children with severe bladder fibrosis and low volume,the procedure of SC was the first choice.2.The bladder capacity got limited improvement after SMBA or SCLU,but the bladder hypertension and low compliance could be relieved to a certain extent.There were few complications related to intestinal mucus,and the incidence of postoperative urinary tract infection and bladder stones was lower.The potential rate of cancer was lower.These two procedures could be selected on the premise that the bladder capacity was greater than 75%of the expected capacity.3.The procedure of AA was relatively simple,less traumatic,and could improve bladder function without hindering future operations.For children with bladder capacity greater than 75%of the expected capacity and age of less than 5 years old,the precedure of AA would be a choice.4.The comparison of outcomes between SMBA and SC showed that preserving the intestinal mucosa was of great significance to the blood supply and elasticity of the patch,and could prevent contracture of the patch.The comparison of outcomes between SCLU and AA showed that covering the bladder mucosa with the seromuscular layer patch could not improve bladder function significantly.The comparison of outcomes between SCLU and SMBA showed that keeping the bladder mucosa intact could protect the seromuscular layer patch from contracting caused by urine stimulation. |
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