Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty.
OBJECTIVE
Previous studies have described placement of an artificial urinary sphincter and simultaneous augmentation cystoplasty with a segment of bowel. Conclusions from these studies indicated that infection rates were higher and a staged approach should be undertaken. Others have suggested that concurrent urinary reconstruction with stomach and sphincter placement can be performed safely. Results comparing infection rates of simultaneous sphincter placement and gastrocystoplasty versus staged sphincter placement and augmentation cystoplasty using a segment of ileum or stomach versus sphincter placement alone in a pediatric population have not been previously described to our knowledge. We reviewed these various groups of patients to determine if the difference in infectious complications were clinically and statistically significant.


METHODS
A retrospective review of medical records from 1986 to 1999 identified 28 pediatric patients (age 18 years or less) who had undergone placement of an AS800dagger artificial urinary sphincter. Data points were collected focusing on etiology of the neurogenic bladder, age at time of surgery, types of surgery performed, length of followup and complication rates.


RESULTS
Complete data were available for 27 of the 28 patients. Neurogenic bladder was secondary to myelomeningocele in 25 cases, transverse myelitis in 1 and spinal cord injury in 2. Mean patient age at surgery was 12.7 years (range 6.1 to 18.2) and mean followup was 4.3 years (range 1 month to 13 years). Simultaneous gastrocystoplasty was performed in 7 cases (group 1), staged sphincter placement followed by augmentation cystoplasty with a segment of ileum or stomach was done in 8 (group 2) and 12 did not require bladder augmentation (group 3). Urethral device erosion requiring explantation was the most common complication, occurring in 3 patients in group 1 and 2 in group 3 (p = 0.101). Mean time to erosion was 22.1 months (range 2 to 46.4). Previous surgery (bladder neck or hernia repair) was a common factor in each group with complications. Urine cultures and culture of the explanted device were positive in 2 patients in group 1.


CONCLUSIONS
Simultaneous placement of artificial urinary sphincter at the time of gastrocystoplasty can be performed in carefully selected patients, although those undergoing staged procedures did well without complications. Prior bladder neck surgery seems to be a significant risk for infection. A staged approach to lower urinary tract reconstruction would be more advantageous due to the absence of infection and erosion in those undergoing staged sphincter placement and augmentation cystoplasty.
Holmes
N M
NM
Division of Urology, Albany Medical College, Albany, New York, USA.
Kogan
B A
BA
Baskin
L S
LS
D000293:Adolescent; D000328:Adult; D002648:Child; D015391:Gastroplasty; D006801:Humans; D008591:Meningomyelocele / Q000150:complications; D011183:Postoperative Complications; D012189:Retrospective Studies; D001743:Urinary Bladder / Q000601:surgery*; D001750:Urinary Bladder, Neurogenic / Q000209:etiology / Q000601:surgery*; D014549:Urinary Incontinence / Q000209:etiology / Q000601:surgery; D016741:Urinary Sphincter, Artificial