Bricker Conduit for Pediatric Urinary DiversiondShould we Still Offer It? Ahmed Abdelhalim,* Ahmed M. Elshal, Amr A. Elsawy, Tamer E. Helmy, Hesham A. Orban, Mohamed E. Dawaba and Ashraf T. Hafez From the Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
Abbreviations and Acronyms CKD ¼ chronic kidney disease eGFR ¼ estimated glomerular filtration rate QoL ¼ quality of life Accepted for publication May 3, 2015. Study received internal review board approval. * Correspondence: Department of Urology, Urology and Nephrology Center, Mansoura University, Gomhoria S., 35516, Egypt (telephone: 20-10-01349367; FAX: 20-50-2263717; e-mail: [email protected]).
See Editorial on page 1190.
Purpose: We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. Materials and Methods: We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. Results: We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean SD baseline (64.5 46 ml/minute/1.73 m2) and last followup estimated glomerular filtration rate (54.1 44.9 ml/minute/1.73 m2), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications. Conclusions: The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population. Key Words: child, glomerular filtration rate, quality of life, urinary diversion
URINARY diversion has revolutionized the treatment of patients with lower urinary tract dysfunction, anomalies or malignancy. Aimed at preserving
1414
j
www.jurology.com
renal function and achieving dryness, unprecedented advances have been achieved in the field of urinary diversion in the last few decades. The
0022-5347/15/1945-1414/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.05.028 Vol. 194, 1414-1419, November 2015 Printed in U.S.A.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
initial enthusiasm for conduit diversion to treat children with lower urinary tract dysfunction has been tempered by the high frequency of complications and the risk of upper tract deterioration.1 Despite the potential risks, conduit diversion remains a reasonable choice for a small subset of patients. Children who are too young to undergo continent urinary reservoir, those lacking reliable family support and those with poor manual dexterity, mental disability or short life expectancy are in need of tubeless, low pressure drainage that does not require intermittent catheterization.2,3 Furthermore, bladder augmentation or continent reservoirs may be problematic in the setting of renal insufficiency,4 and recalls the use of conduit diversion. Several studies have shown high complication rates when ileal conduits are used in children with neuropathic bladder, including renal deterioration, upper tract calculi, pyocystitis and peristomal complications.1 However, the majority of these studies, conducted several decades ago, have focused on morphological renal deterioration and the crude measurement of serum creatinine without accurate estimation of renal function. In addition, the impact of diversion on growth trends and quality of life in patients and their caregivers have not been adequately investigated. We evaluated whether the Bricker conduit diversion could reliably protect the upper tract and prevent the steep decline in renal function in children offered the procedure. Moreover, the potential impact on linear growth and QoL, and anticipated long-term complications were weighed against renal function outcome.
PATIENTS AND METHODS Following internal review board approval we retrieved the electronic files of children who underwent ileal conduit for urinary diversion at a pediatric urology tertiary referral unit between 1981 and 2011. Patient files were reviewed for gender, age at surgery, indication for diversion, baseline renal function, preoperative imaging studies, surgical details, postoperative recovery, readmission rates and followup data. Furthermore, patients were invited to up-to-date followup visits. Patients who were older than 18 years at surgery and those with less than 1 year of followup were excluded from analysis. Renal function was the primary outcome of the study, while diversion related complications, linear growth effect, readmission rates and quality of life were considered secondary outcomes. End points of the study were death, undiversion to continent reservoir and last followup date.
Procedure After sparing the last 10 cm of the terminal ileum a 15 to 20 cm ileal segment was isolated. The bowel continuity was reestablished and the mesenteric defect was closed. The distal end of the isolated bowel segment was
1415
mobilized and exteriorized at a predetermined site on the abdominal wall. An everting nipple was created. The ureters were mobilized and anastmosed to the proximal end of the conduit using either the Bricker or Wallace technique. The conduit was drained using a Foley catheter for 5 days and the ureteroileal anastmoses were stented for 7 to 8 days.
Outcome Measures Baseline and followup renal function was evaluated using eGFR or 99mtechnetium mercaptoacetyltriglycine isotope renal scans, if available. eGFR was calculated using an online calculator (http://nkdep.nih.gov/lab-evaluation/ gfr-calculators.shtml) based on the modified Schwartz formula or MDRD formula for patients entering adulthood at followup. The mean of 3 sequential eGFR measurements was used to study the outcome. The severity of chronic kidney disease was staged according to the National Kidney FoundationÒ Kidney Disease Outcomes Quality Initiative staging system.5 The Society for Fetal Urology grading system was used to assess severity of hydronephrosis.6 Patient growth charts were reviewed to observe growth trends. Egyptian children’s growth (height-for-age) charts served as a reference. Linear growth was considered stunted if patient height was below the 10th percentile for age and gender, or crossing 2 or more major percentile curves on the charts. The Mansoura QoL questionnaire was used to evaluate patient and family satisfaction regarding the procedure.7,8 The questionnaire has been modulated to fit the method of urine evacuation. The modified version of the questionnaire consists of 6 items, each assigned a score of 1 to 3 (supplementary table 1, http://jurology.com/), giving a possible maximum of 18 points (excellent degree of wellbeing). Poor QoL was defined as a QoL questionnaire score of 12 or less. A neutral third party (stoma therapist) questioned the children and their caregivers about the questionnaire items through direct interview at last followup visit. Although the questionnaire is not validated, it gave a meaningful idea about the satisfaction of patients and families regarding urinary diversion.
Statistical Analysis Continuous variables were expressed as mean SD or median (range) according to normality, while categorical variables were described as frequencies (percentages) in each category. Paired t-test and repeated measures ANOVA were used when indicated for comparison of continuous variables across time intervals. Statistical analysis was done using SPSSÒ, version 20. All tests were 2-tailed with statistical significance considered at p
Abbreviations and Acronyms CKD ¼ chronic kidney disease eGFR ¼ estimated glomerular filtration rate QoL ¼ quality of life Accepted for publication May 3, 2015. Study received internal review board approval. * Correspondence: Department of Urology, Urology and Nephrology Center, Mansoura University, Gomhoria S., 35516, Egypt (telephone: 20-10-01349367; FAX: 20-50-2263717; e-mail: [email protected]).
See Editorial on page 1190.
Purpose: We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. Materials and Methods: We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. Results: We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean SD baseline (64.5 46 ml/minute/1.73 m2) and last followup estimated glomerular filtration rate (54.1 44.9 ml/minute/1.73 m2), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications. Conclusions: The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population. Key Words: child, glomerular filtration rate, quality of life, urinary diversion
URINARY diversion has revolutionized the treatment of patients with lower urinary tract dysfunction, anomalies or malignancy. Aimed at preserving
1414
j
www.jurology.com
renal function and achieving dryness, unprecedented advances have been achieved in the field of urinary diversion in the last few decades. The
0022-5347/15/1945-1414/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.05.028 Vol. 194, 1414-1419, November 2015 Printed in U.S.A.
BRICKER CONDUIT FOR PEDIATRIC URINARY DIVERSION
initial enthusiasm for conduit diversion to treat children with lower urinary tract dysfunction has been tempered by the high frequency of complications and the risk of upper tract deterioration.1 Despite the potential risks, conduit diversion remains a reasonable choice for a small subset of patients. Children who are too young to undergo continent urinary reservoir, those lacking reliable family support and those with poor manual dexterity, mental disability or short life expectancy are in need of tubeless, low pressure drainage that does not require intermittent catheterization.2,3 Furthermore, bladder augmentation or continent reservoirs may be problematic in the setting of renal insufficiency,4 and recalls the use of conduit diversion. Several studies have shown high complication rates when ileal conduits are used in children with neuropathic bladder, including renal deterioration, upper tract calculi, pyocystitis and peristomal complications.1 However, the majority of these studies, conducted several decades ago, have focused on morphological renal deterioration and the crude measurement of serum creatinine without accurate estimation of renal function. In addition, the impact of diversion on growth trends and quality of life in patients and their caregivers have not been adequately investigated. We evaluated whether the Bricker conduit diversion could reliably protect the upper tract and prevent the steep decline in renal function in children offered the procedure. Moreover, the potential impact on linear growth and QoL, and anticipated long-term complications were weighed against renal function outcome.
PATIENTS AND METHODS Following internal review board approval we retrieved the electronic files of children who underwent ileal conduit for urinary diversion at a pediatric urology tertiary referral unit between 1981 and 2011. Patient files were reviewed for gender, age at surgery, indication for diversion, baseline renal function, preoperative imaging studies, surgical details, postoperative recovery, readmission rates and followup data. Furthermore, patients were invited to up-to-date followup visits. Patients who were older than 18 years at surgery and those with less than 1 year of followup were excluded from analysis. Renal function was the primary outcome of the study, while diversion related complications, linear growth effect, readmission rates and quality of life were considered secondary outcomes. End points of the study were death, undiversion to continent reservoir and last followup date.
Procedure After sparing the last 10 cm of the terminal ileum a 15 to 20 cm ileal segment was isolated. The bowel continuity was reestablished and the mesenteric defect was closed. The distal end of the isolated bowel segment was
1415
mobilized and exteriorized at a predetermined site on the abdominal wall. An everting nipple was created. The ureters were mobilized and anastmosed to the proximal end of the conduit using either the Bricker or Wallace technique. The conduit was drained using a Foley catheter for 5 days and the ureteroileal anastmoses were stented for 7 to 8 days.
Outcome Measures Baseline and followup renal function was evaluated using eGFR or 99mtechnetium mercaptoacetyltriglycine isotope renal scans, if available. eGFR was calculated using an online calculator (http://nkdep.nih.gov/lab-evaluation/ gfr-calculators.shtml) based on the modified Schwartz formula or MDRD formula for patients entering adulthood at followup. The mean of 3 sequential eGFR measurements was used to study the outcome. The severity of chronic kidney disease was staged according to the National Kidney FoundationÒ Kidney Disease Outcomes Quality Initiative staging system.5 The Society for Fetal Urology grading system was used to assess severity of hydronephrosis.6 Patient growth charts were reviewed to observe growth trends. Egyptian children’s growth (height-for-age) charts served as a reference. Linear growth was considered stunted if patient height was below the 10th percentile for age and gender, or crossing 2 or more major percentile curves on the charts. The Mansoura QoL questionnaire was used to evaluate patient and family satisfaction regarding the procedure.7,8 The questionnaire has been modulated to fit the method of urine evacuation. The modified version of the questionnaire consists of 6 items, each assigned a score of 1 to 3 (supplementary table 1, http://jurology.com/), giving a possible maximum of 18 points (excellent degree of wellbeing). Poor QoL was defined as a QoL questionnaire score of 12 or less. A neutral third party (stoma therapist) questioned the children and their caregivers about the questionnaire items through direct interview at last followup visit. Although the questionnaire is not validated, it gave a meaningful idea about the satisfaction of patients and families regarding urinary diversion.
Statistical Analysis Continuous variables were expressed as mean SD or median (range) according to normality, while categorical variables were described as frequencies (percentages) in each category. Paired t-test and repeated measures ANOVA were used when indicated for comparison of continuous variables across time intervals. Statistical analysis was done using SPSSÒ, version 20. All tests were 2-tailed with statistical significance considered at p
