Double Layers Of Demucosalized Ileum For Cystoplasty On Children Of Neuropathic Urinary Incontinence: A Long-term Clinical Experience.

Background and ObjectiveMost causes of neurogenic bladder dysfunction in children are congenital diseases on spinal cord and vertebral canal, such as myelodysplasia, dysrhaphism and dysostosis of resurrection bone, etc. Injury of central or peripheral nervous systems which control urination leads to dysfunction of storing urine and urination. If urinary leak is the first apparent symptom, preservation of the upper urinary tract is the main goal of the surgeon.Augmentation of bladder or detrusor muscle reinforcement surgery with double layers of demucosalized ileum has been performed since July 1992 in our department. To evaluate the therapeutic effects of the surgery, we report our follow-up visit.MethodsWe retrospectively reviewed the data of 159 patients (108 males, 51 females) 4 to 14 years old, which are treated with demucosalized ileum for bladder reconstruction alone or in conjunction with various continence techniques since 1992. All patients presented with neurogenic urinary incontinence, of the patients 118 with hyperreflexia, 41 with hyporeflexia. We evaluated the therapeutic effects by comparing clinical symptoms and urodynamic study preoperation and postoperation on follow-up.ResultsAll patients received pathological examinations after surgery. Results of group 1 showed chronic inflammation in transitional epithelium membrane, obvious thickening in muscular layer and lots of eosinophile granulocyte infiltrating muscles. Some could have fibroplasias in interstitium of muscular layer. Results of group 2 showed degenerative atrophy of smooth muscle to different extent in the wall of urinary bladder. The serious patients had extremely small nucleus and muscle theca cell almost disappeared, and they also had unclear muscle fibrous structure.Followup ranged from 3 to 168 months (median 61). All of them had urination with abdominal pressure. Among them, 59 were of hyperreflexia, 19 were of hyporeflexia. The former received augmentation of bladder with seromuscular layer of ileum without mucous membrane. The latter received plasty of bladder with seromuscular layer of ileum patch whose mucous membrane had been removed. Those patients who had concomitant slack muscles on pelvic floor received surgery to reinforce iliopsoas muscle on pelvic floor. ALL cases received urodynamic study before and after surgery. Data was demonstrated by x±s ,compared sample T test was used to analyze the results of group one and Wilcoxon's signed rank test was used for matched-pair samples of group two. Maximum capacity of bladder, compliance of bladder, detrusor pressure at the end of filling period before surgery in group one were (123.8±51.1)ml, (7±4)ml/cmH₂O, (104.7±36.5)ml respectively, and they changed into (276.2±101.1)ml, (22±7) ml/cmH₂O , (212.2±79.3)ml respectively after surgery. Urodynamic parameters were demonstrated significantly improved compared with it before surgery (P <0.01); Maximum capacity of bladder, compliance of bladder, residual urine volume, detrusor pressure at the end of filling period before surgery in group two were (285±64)ml, (3.1±1.2) ml/cmH₂O, (88±69) ml, (2.4±1.3) kPa ,and they changed into (161±117)ml, (6.1±2.1) ml/cmH₂O ,( 34±21)ml, (1.5±0.5)kPa after surgery. The data was considered as significant difference compared with it before surgery too(P<0.0001). B ultrasound and renal function test showed that no upper urinary tract deterioration. There was no mucus formation, electrolyte imbalance, metabolic disturbance and urinary lithiasis. 110 patients had micturition desire and they could hold urine for over 2.5h. 38 patients could hold urine for 1-2.5h. Total effective rate reached 93%.ConclusionAugmentation or plasty of bladder with Double planes of demucosalized ileum alone or in conjunction with various continence techniques was effective in the treatment of neurogenic urinary incontinence in children.