Device outcomes in pediatric sacral neuromodulation: A single center series of 187 patients.

INTRODUCTION: Pediatric sacral neuromodulation (SNM) device duration before revision or removal is not well known. Furthermore, secondary surgeries serve as surrogates for key outcomes including complications and symptom improvement. OBJECTIVE: We sought to study the rate and causes of secondary surgeries in pediatric SNM patients. STUDY DESIGN: We assessed our cohort of pediatric SNM patients for secondary surgeries (revision or removal). Baseline patient characteristics associated with secondary surgery were analyzed with Fisher's exact test. Kaplan-Meier analysis was used to describe secondary-surgery-free device survival. RESULTS: 187 pediatric patients underwent sacral neuromodulation at our institution between 2002 and 2019. 7 (4%) patients did not have a permanent device placed due to poor response during an externalized lead trial period, leaving 180 patients with permanent implanted devices. Over a median follow-up of 3.9 years (IQR 2.0 to 6.3), there were 154 total secondary surgeries. There were 83 device revisions, with 89% of revisions for a non-functioning device, 8% for pain, and 2% for infection. Of the non-functioning devices, 11% were due to battery depletion and the rest were due to lead fracture or dislodgement. Permanent device removal was performed in 71 (39%) patients, with 38% of these for unfavorable reasons (6% infection, 8% pain, 24% no longer effective) and 62% for favorable reasons (symptom improvement or resolution). Of patient baseline characteristics, only device duration was associated with favorable removal (p < 0.01). On Kaplan-Meier analysis, 5 year device secondary-surgery-free survival was 32% for any secondary surgery (favorable or unfavorable) and was 47% for unfavorable secondary surgery. At last follow-up, 74% of patients were in a favorable position (using the device, trialing with device off, or device had been removed for improvement) while 26% of patients were requiring other treatments due to device problem or removal. DISCUSSION: Describing the likelihood of subsequent surgery is an important aspect of patient and guardian counseling concerning pediatric SNM. Our cohort had a 68% 5 year all-cause reoperation rate. However, in a theoretical perfect world, pediatric SNM reoperation rate would be 100% after adequate follow-up (either for battery replacement, or device explantation for improvement). CONCLUSIONS: While sacral neuromodulation in our cohort of children carried a high (68% 5-year) reoperation rate (whether for complication or symptom improvement), the majority (74%) of these patients with previously refractory symptoms either continue to use their device or have had significant symptom improvement to permit device removal at moderate-term (median 3.9 year) follow-up.

Sacral neuromodulation for the dysfunctional elimination syndrome: a 10-year single-center experience with 105 consecutive children.

OBJECTIVE: To evaluate our initial experience using sacral neuromodulation via implanted pulse generator as a treatment for children with dysfunctional elimination syndrome and symptoms refractory to maximum medical therapy. MATERIALS AND METHODS: There were 105 consecutive patients who underwent a 2-stage procedure with a trial period (n = 89) or a single procedure (n = 16) for device implantation. They were followed up prospectively for a median of 2.72 years (average, 3.18 years; range, 0.01-9.63 years) for symptom improvement and resolution. RESULTS: Nearly all children (99 of 105 [94%]) experienced improvement of at least 1 symptom; 12 of 105 patients (11%) had at least 1 symptom worsen. Urinary incontinence, constipation, frequency and/or urgency, and nocturnal enuresis improved in 89 of 101 (88%), 73 of 92 (79%), 54 of 81 (67%), and 59 of 89 (66%) children, respectively, and resolved in 41 of 101 (41%), 37 of 92 (40%), 23 of 81 (28%), and 25 of 89 (28%) children, respectively. Outcomes among patients who did and did not undergo the trial were not significantly different (P = .19-1.00), and only 2 of 88 patients did not undergo permanent implantation. Reoperations (n = 85) occurred in 59 of 105 children (56%), mainly for device malfunction (n = 42), whereas explantation was performed in 36 of 104 children (35%) at an average of 2.68 years since implantation (median, 2.36 years; range, 0.03-9.04 years), mainly for complete symptom resolution (n = 12). Explantation for any reason was less common after single-stage procedures (1 of 16 [6%] vs 35 of 88 [40%] patients; P = .01). CONCLUSION: Sacral neuromodulation should be considered for children with dysfunctional elimination syndrome whose symptoms are refractory to maximum medical therapy understanding that the risk of reoperation is >50%. Elimination of the trial period reduces the number of general anesthetics without sacrificing outcomes.

Vesicoureteral reflux in children with urachal anomalies.

OBJECTIVE: We report the largest known series of vesicoureteral reflux (VUR) in children with urachal anomalies (UA). METHODS: Two institutions' records were reviewed for children with UA (1951‒2007). RESULTS: Of 30 girls and 36 boys with UA (34 urachal cysts, 14 patent urachus, 10 urachal diverticula, 7 urachal sinuses, and 1 unknown), 57 (86%) underwent surgical resection or drainage. A voiding cystourethrogram was obtained in 22 (33%). VUR was demonstrated in 14 of the 22 children (64%), and rates were similar among the various types of UA. The median age with versus without VUR was not different (1.3 vs 1.7 years, P=0.97). Of 24 refluxing renal units, classification was grade≤3 in 71%, 4‒5 in 12%, and unspecified in 17%. Four children (26%) underwent ureteroneocystostomy and 10 observed patients resolved spontaneously. CONCLUSION: To our knowledge, this is the first series of VUR associated with UA. The increased incidence of VUR (64%) in this small subset of patients warrants prospective studies to determine if there is a positive correlation with UA. We believe thorough genitourinary and family histories are important when evaluating children with UA to help detect clinically significant VUR.

Predicting renal outcomes in children with anterior urethral valves: a systematic review.

PURPOSE: Prognostic information is limited on children with congenital anterior urethral valves or a diverticulum. We reviewed the literature and examined our clinical database to identify clinical features predicting a poor renal outcome, defined as azotemia, renal failure or death. MATERIALS AND METHODS: We reviewed 97 English language studies of patients 18 years old or younger. Seven patients from our institutions were also included in analysis. After data abstraction we used multivariate models to define factors associated with outcomes of interest. RESULTS: We identified 239 male patients with anterior urethral valves, of whom 139 had adequate data available for study inclusion. Of these patients 108 (78%) had normal renal function after treatment. On bivariate analysis vesicoureteral reflux (OR 22.4, p <0.0001), pretreatment azotemia (OR 17.1, p <0.0001), urinary tract infection (OR 3.3, p = 0.006), hydronephrosis (OR 10.0, p = 0.0004) and bladder trabeculation (OR 7.3, p = 0.01) were associated with renal failure or death while treatment method (p = 0.9), obstruction type (valve vs diverticulum, p = 0.4) and valve location (p = 0.6) were not. After adjusting for other factors only pretreatment azotemia (p = 0.0005) and vesicoureteral reflux (p = 0.01) remained associated with renal failure and/or death with a trend toward significance for urinary tract infection (p = 0.06). When all 3 factors were present, the odds of a poor renal outcome increased 25-fold (p = 0.005). CONCLUSIONS: Congenital anterior urethral obstruction in children has a generally good prognosis but may occasionally result in a poor renal outcome. The combination of pretreatment azotemia, vesicoureteral reflux and urinary tract infection is highly predictive of a poor renal outcome.

Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review.

OBJECTIVE: Published success rates of dextranomer/hyaluronic acid (Dx/HA) injection for pediatric vesicoureteral reflux (VUR) vary widely. Our objective of this study was to assess whether underlying patient or study factors could explain the heterogeneity in reported Dx/HA success rates. METHODS: We searched the Cochrane Controlled Trials Register and Medline, Embase, and Scopus databases from 1990 to 2008 for reports in any language, along with a hand search of included study bibliographies. Articles were assessed and data abstracted in duplicate, and differences were resolved by consensus. Conflict of interest (COI) was determined by published disclosure. Meta-regression was performed to adjust for patient as well as study-level factors. RESULTS: We identified 1157 reports, 89 of which were reviewed in full with 47 included in the pooled analysis. Of 7303 ureters that were injected with Dx/HA, 5633 (77%) were successfully treated according to the authors' definition. Injection success seemed to vary primarily on the basis of the preoperative reflux grade. After adjustment for VUR grade, other factors, such as the presence or absence of COI disclosure, were not significant. Studies were markedly heterogeneous overall. CONCLUSIONS: The overall per-ureter Dx/HA success rate was 77% after 3 months, although success rates varied widely among studies. Increased VUR grade negatively affected success rates, whereas COI, patient age, and injected Dx/HA volume were not significantly associated with treatment outcome after adjustment for VUR grade. There is a significant need for improved reporting of VUR treatments, including comparative studies of Dx/HA and other VUR treatments.

Predicting success in the endoscopic management of pediatric vesicoureteral reflux.

Vesicoureteral reflux is a common cause of pediatric morbidity. Though traditionally managed using a limited number of therapeutic modalities, the last decade has witnessed countless surgical innovations for treating reflux. A major force behind this innovation is the increasing use of endoscopic injection, which currently constitutes nearly half of all anti-reflux procedures performed in the United States. However, published success rates for injection vary dramatically. Despite a relative lack of comparative data, multiple studies have attempted to define the most important prognostic factors for injection success. This article is an attempt to summarize these findings.

Sacral neuromodulation in children with dysfunctional elimination syndrome: description of incisionless first stage and second stage without fluoroscopy.

OBJECTIVES: To detail a percutaneous technique of sacral nerve neuromodulation (SN) that eliminates the first-stage incisions and the need for second-stage fluoroscopy. Our group has previously described the results of SN in children with medically refractory dysfunctional elimination syndrome. The drawbacks to SN include the use of fluoroscopy and the need to reopen recent skin incisions during the second stage. This results in increased radiation exposure, poor cosmesis, and possible wound infection. METHODS: The incisionless first stage consisted of percutaneously tunneling the temporary external appliance to the contralateral axillary line at the buttock after localization of the S3 nerve root and placement of a quadripolar tined lead under fluoroscopic guidance. A subcutaneous bolus of methylene blue marked the lead connector site, obviating the need for later fluoroscopic localization to place the implantable pulse generator at the second stage. RESULTS: A total of 27 children with refractory dysfunctional elimination syndrome underwent SN using the InterStim device. Of the 27 patients, 19 underwent our modified technique. The operative time for our modified tunneling and placement technique was < or = 2 minutes. The mean hospital stay was 0.6 day, with no patient requiring postoperative intravenous narcotics. At a mean follow-up of 35.9 months, no wound infections had occurred in the incisionless cohort compared with 1 postoperative wound infection requiring device explantation in the conventional lead placement group. CONCLUSIONS: The incisionless technique of SN device implantation is technically simple, quick to perform, and results in decreased radiation exposure, excellent pain control, and improved cosmesis without compromising the outcomes.

Acute renal infarction due to fungal vascular invasion in disseminated candidiasis.

Disseminated candidiasis occurs almost exclusively in leukemic patients recovering from neutropenia. Although renal involvement can be a sequela of disseminated candidiasis, acute renal infarction secondary to Candida invading the renal vasculature has not previously been reported. Our patient, who was being treated for acute myelogenous leukemia, developed complete obstruction of the right renal vessels during the course of 36 hours as documented by serial renal ultrasound scans with Doppler investigation of the vasculature. Histopathologic examination of the nephrectomy specimen revealed complete infarction of the kidney secondary to Candida spp. infiltrating the parenchyma and occluding the hilar vessels.

Cystic dysplasia of testis associated with ectopic ureter causing chronic orchalgia.

Cystic dysplasia of the testis (CDT) is a rare entity that typically does not present with orchalgia in affected patients. Most patients with CDT are asymptomatic and have ipsilateral renal malformations. Our patient with CDT was referred because of prolonged unilateral orchalgia. Computed tomography demonstrated an ipsilateral atrophic kidney and hydro-ureter traveling posterior to the bladder. Orchalgia resolved with resection of the dysplastic kidney and ectopic ureter, which drained to an enlarged seminal vesicle. Atypical symptoms associated with CDT, such as chronic orchalgia, should prompt additional investigation to rule out concomitant malformations. This is the first report of an ectopic ureter associated with CDT.

Tunneled tunica vaginalis flap for recurrent urethrocutaneous fistulae.

The tubularized incised plate (TIP) hypospadias repair is currently the most widely used urethroplasty technique. The most significant post-TIP complication is urethrocutaneous fistula (UCF) development. Tunneled tunica vaginalis flap (TVF) is a well-described technique for the repair of UCF. We retrospectively reviewed all patients undergoing repeat repair of UCF after TIP repair from 2001 to 2005. Twelve boys underwent TVF repair at our institution for recurrent UCF. Fistulae ranged from distal penile to penoscrotal in location. Median surgical time was 45 minutes and no postoperative complications occurred. After a median follow-up of 32 months (range 16-48 months), no patient has yet had a recurrence of UCF. In conclusion, TVF repair is a successful technique for the treatment of UCF after previous failed repair. TVF is technically simple to perform and should be considered for treating UCF following TIP urethroplasty, particularly in a repeat surgical setting.

Unilateral vesicoureteral reflux: does endoscopic injection based on the cystoscopic appearance of the ureteral orifice decrease the incidence of de-novo contralateral reflux?

OBJECTIVE: In patients with unilateral vesicoureteral reflux (VUR), it has been suggested that injection of a non-refluxing but cystoscopically abnormal contralateral ureteral orifice (UO) with dextranomer/hyaluronic acid (Dx/HA) should be performed to prevent the development of de-novo contralateral VUR. We evaluate the effectiveness of this practice. PATIENTS AND METHODS: Patients with primary unilateral VUR undergoing injection of Dx/HA from 2002 to 2005 at two institutions were eligible. Patients with unilateral VUR with cystoscopically abnormal contralateral UOs were injected with Dx/HA, while patients with normal appearing UOs received no treatment. Multivariate logistic regression models were used to estimate the impact of prophylactic injection on the development of de-novo contralateral VUR. RESULTS: In total, 101 patients with unilateral VUR and an abnormal appearing contralateral UO underwent prophylactic injection of Dx/HA while 45 patients with a normal appearing contralateral UO were untreated. In patients receiving prophylactic Dx/HA, 9% (9/101) of the previously non-refluxing ureters developed de-novo VUR. Similarly, 13% (6/45) of patients with a normal appearing UO treated by observation alone developed de-novo VUR (P=0.55). The overall incidence of 10% (15/146) de-novo contralateral VUR matches published results where this protocol was not followed. CONCLUSIONS: Our findings suggest that cystoscopic assessment and prophylactic treatment of an abnormal appearing, non-refluxing contralateral UO with Dx/HA is of little clinical benefit and should be abandoned.

Sacral neuromodulation for the dysfunctional elimination syndrome: a single center experience with 20 children.

PURPOSE: Recent advances in neuromodulation have demonstrated promise in treating children with the dysfunctional elimination syndrome refractory to medical management. Sacral nerve stimulation with the InterStim implantable device has been used in adults for management of chronic urinary complaints. However, there are few data regarding the usefulness of sacral nerve stimulation in children. We report our experience with sacral nerve stimulation for severe dysfunctional elimination syndrome. MATERIALS AND METHODS: A total of 20 patients 8 to 17 years old with the dysfunctional elimination syndrome refractory to maximum medical treatment underwent sacral nerve stimulation at our institution. Patients were followed prospectively for a median of 27 months after the procedure. RESULTS: Urinary incontinence, urgency and frequency, nocturnal enuresis and constipation were improved or resolved in 88% (14 of 16), 69% (9 of 13), 89% (8 of 9), 69% (11 of 16) and 71% (12 of 17) of the patients, respectively. Urinary retention requiring intermittent catheterization persisted in 75% of the patients (3 of 4) despite sacral nerve stimulation. Complications requiring operative treatment occurred in 20% of the patients (4 of 20). Following marked symptomatic improvement 2 devices were explanted at 20 and 19 months following placement, and both patients have remained symptom-free. CONCLUSIONS: Sacral nerve stimulation is effective in the majority of our patients, and should be considered in children with severe dysfunctional elimination syndrome refractory to maximum medical treatment.

Utility of dextranomer/hyaluronic acid injection in setting of bladder and ureteral anomalies.

OBJECTIVES: Previous studies have shown that the cure rates after dextranomer/hyaluronic acid (Dx/HA) injection can be decreased in patients with neurogenic bladder, previous ureteroneocystostomy, duplicated ureters, or periureteral diverticula. We attempted to determine whether these factors reduce the efficacy of Dx/HA injection compared with that in otherwise normal patients. METHODS: All children with vesicoureteral reflux (VUR) undergoing Dx/HA injection from April 2002 to March 2006 at two institutions were eligible for this study. Multivariate logistic regression models were built to assess the effect of bladder/ureteral anomalies on the success of Dx/HA injection. We adjusted for previously described predictors of injection success, including VUR grade, sex, age, surgeon experience, and injection technique. RESULTS: A total of 543 refluxing ureters (373 patients) were included, of which 145 (27%) had persistent VUR on postoperative voiding cystourethrography; 86 ureters (16%) had anatomic anomalies. On univariate analysis, the most important predictors of injection failure were increasing VUR grade, male sex, younger age, subureteral injection, ureteral duplication anomaly, increasing Dx/HA volume, and surgeon experience. On multivariate analysis, however, the only significant predictors of injection failure were increasing VUR grade, subureteral injection technique, and surgeon experience. No anatomic or functional abnormalities, considered individually or grouped, significantly affected the probability of injection failure. CONCLUSIONS: In our experience, children with functional and anatomic bladder/ureteral anomalies were no more likely to have Dx/HA injection fail than were children with uncomplicated VUR. The most important predictors of Dx/HA success remained VUR grade, injection technique, and surgeon experience. Dx/HA injection in patients with complex bladders could be a reasonable therapeutic option.

Relative contraindication to endoscopic subureteral injection for vesicoureteral reflux: congenital refluxing megaureter with distal aperistaltic segment.

OBJECTIVES: Endoscopic subureteral injection for the management of vesicoureteral reflux has become a well-established first-line minimally invasive treatment strategy. One potential pitfall is the creation of ureteral obstruction. No predictors are available to determine which patients will develop this rare, but real, complication. METHODS: A retrospective evaluation of 2 girls, aged 3 and 4 years, with grade 4 and 3 reflux, respectively, and documented ureteral obstruction after endoscopic treatment with dextranomer/hyaluronic acid copolymer. Before treatment, both patients had had refluxing megaureters with a distal aperistaltic segment. RESULTS: Ultimately, they both required open, cross-trigonal ureteral reimplantation with resolution of vesicoureteral reflux and ureteral obstruction. CONCLUSIONS: Congenital refluxing megaureter with a distal aperistaltic segment might be a relative contraindication to endoscopic subureteral injection of a bulking agent for the management of vesicoureteral reflux.