Pediatr Surg Int (2011) 27:781785 DOI 10.

1007/s00383-011-2913-5

ORIGINAL ARTICLE

Efcacy of bladder irrigation and surveillance program in prevention of urinary tract infections and bladder calculi in children with an ileocystoplasty and bladder neck repair
Marleen van den Heijkant Nadeem Haider Craig Taylor Ramnath Subramaniam

Accepted: 13 April 2011 / Published online: 8 May 2011 Springer-Verlag 2011

Abstract Purpose In children with bladder augmentation and particularly in those with bladder neck repair (BNR), urinary tract infections (UTI) and bladder calculi are a recognised problem. Bladder irrigation potentially prevents these complications. Our aim was to investigate the efcacy of bladder irrigation supported by a surveillance program in prevention of UTI and bladder calculi in these children. Methods A cohort of children subjected to ileocystoplasty with a stoma for clean intermittent self catheterisation with or without BNR was retrospectively analysed. The children were subjected to bladder irrigation and monitored by Clinical Nurse Specialists (CNS) according to a protocol. Patients demographics, treatment methods and postoperative management were reviewed. Compliance to bladder irrigation was assessed with questionnaires. UTI recurrence and bladder calculi during follow-up were assessed. Results 28 children were included in this study. The median follow-up was 48 months (range 687). Compliance could be assessed in all children, except in one child (3.5%). There was no recurrent UTI reported, bladder calculi occurred in two children (7%). Conclusion Our bladder irrigation regime resulted in a low incidence of calculi by preventing recurrent UTI. The surveillance program resulted in high compliance rates in children with an augmented bladder with or without BNR.

Keywords Bladder augmentation Bladder neck repair Urinary tract infections Bladder calculi Bladder irrigation Acetylcysteine Surveillance

Introduction Bladder augmentation is a well-described treatment option for children with a neuropathic bladder and other bladder anomalies with a decreased bladder capacity [1, 2]. The aim is to create a reservoir, which can store an appropriate bladder volume with low lling pressures. An additional bladder neck repair (BNR) along with a catheterisable abdominal wall stoma (Mitrofanoff or Monti channel) may be required to achieve continence and satisfactory bladder emptying in these children. Various segments of bowel, stomach or urinary tract are used for augmentation cystoplasty [35]. Bowel segments tend to produce large amount of mucous, which can cause bladder outlet obstruction and stone formation in the bladder [611]. Moreover, sedentary and wheelchair-bound myelomeningocele patients with sensory impairment are prone to develop bladder calculi [8, 12]. The incidence of stone formation in this patient population is therefore a common complication and is a source of considerable morbidity with a reported incidence of 1052% [6, 8, 9, 13, 14]. We believe like others that close monitoring of the child and their compliance to a bladder irrigation regimen is crucial [6, 8, 9, 15]. The aim of this study was to demonstrate the efcacy of a bladder irrigation regime and a surveillance program coordinated by a CNS in the prevention of symptomatic UTI and bladder calculi in children with an ileocystoplasty with or without BNR.

M. van den Heijkant N. Haider C. Taylor R. Subramaniam (&) Department of Paediatric Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK e-mail: surgram@btinternet.com

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Subjects and methods A retrospective cohort study was performed in 29 consecutive patients who underwent a bladder augmentation with or without concomitant BNR between 2002 and 2009 at our institution. All procedures were performed by a single surgeon. Patients demographics were obtained from case notes, and treatment methods and postoperative management were reviewed. Bladder irrigation regime

post-discharge allowed early detection of signs of infection or possible complications, taking an appropriate intervention as necessary. Education of community nurses and school staff in proposed treatment plans was addressed and instigated pre-discharge to aid compliance and continuation of care when the child returned to school or education setting. Patients were followed in clinic by the consultant paediatric urologist with ultrasound scans to rule out bladder calculi or upper urinary tract dilatation.

Results Following ileocystoplasty and BNR, postoperative bladder irrigations with 50 ml saline ushes were performed by the children and their caregivers were supervised by the Clinical Nurse Specialists (CNS) 24 times daily as required to keep the catheters patent and draining. For children with severe mucous related problems and catheter blockage acetylcysteine (Parvolex) was used. The recommended dwell time using acetylcysteine is 30 min, if using an indwelling foley catheter and then allowed to drain out. The acetylcysteine solution for bladder irrigation comprises of 10 ml of 20% acetylcysteine solution mixed with 40 ml of saline to make a total of 50 ml instillate. Acetylcysteine is available in vials of 200 mg/ml. This is instilled into the bladder either via the urethral catheter or the abdominal wall stoma (Mitrofanoff or Monti channel). All the patients and their parents were contacted and asked to complete a questionnaire (Fig. 1 of Appendix) relating to bladder washouts done at home. The questionnaire was completed by return of questionnaire or by telephone consultation. Information requested included the frequency of bladder washouts both in the rst month after surgery and thereafter. Besides, the type and the amount of solution used were assessed. Frequency of recurrent urinary tract infections (dened as culture proved bacteriuria [100,000 colony-forming units per ml urine and symptoms specic to the disease, more than twice a year) was evaluated by the CNS and the consultant paediatric urologist in the outpatient clinic. The patients were not placed on antibiotic prophylaxis routinely, as long as they remain free of recurrent urinary tract infections as dened previously and drain their bladder regularly with bladder washouts. All children were subjected to a surveillance program following postoperative discharge home carried out by two CNS. The CNS kept close contact with all patients following their discharge to ensure treatment regimes and management plans were adhered to. Regular telephone calls and visits regarding bladder washouts and general wellbeing were conducted and support provided for them as required. The consultant was regularly updated regarding the follow-up. This surveillance and close monitoring A total of 29 children, who underwent bladder reconstruction surgery were identied. 28 children underwent ileocystoplasty and 1 patient underwent ureterocystoplasty, who was therefore excluded from the study. Questionnaires were completed by all, either by returning the questionnaires (18) or by answering on telephone (10). There were 16 boys and 12 girls, and their median age was 11 years (range 517). Median follow-up was 48 months (range 687). The underlying diagnosis of children who underwent an ileocystoplasty are displayed in Table 1. Three children with a neurogenic bladder were wheelchair bound. The frequency of bladder washouts ranged from once daily (OD) to three times daily (TDS) during the rst 3 months postoperative period. Thereafter the frequency of washouts reduced, ranging from two children performing OD to two children performing rarely. Seven patients used acetylcysteine solution in the rst 8 weeks postoperative period because of severe mucous production.

Table 1 General details of patients in this series No. of boys/girls Median age at ileocystoplasty (years) [range] Median follow up (months) [range] Primary diagnosis Neurogenic Myelomeningocele Ganglioblastoma spinal cord Sacral agenesis Spinal arachnoid cyst excision Anorectal malformation Non neurogenic Epispadias PU valves Bladder extrophy Cloacal extrophy Pelvic malignancy 17 13 1 1 1 1 11 1 2 2 2 4 16/12 11 [517] 48 [687]

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Pediatr Surg Int (2011) 27:781785 Table 2 Results showing incidence of recurrent UTI and bladder calculi in this series

783

Procedure Ileocystoplasty
a

Number of children 1 8 19 3 5 9 1 1 28

Recurrent UTI 0 0 0

Children with bladder calculi (%) 1 (3.5) 1 (3.5) 0

Time to calculi formation (months) 72 8

Ileocystoplasty ? Mitrofanoff Ileocystoplasty ? Mitrofanoff/ Monti ? bladder outlet repair Bladder neck repair AUS cuff Colposuspension TVT sling Closure bladder neck
a

Lost to follow-up

Total

2 (7)

Table 2 outlines the additional BNR done if any, along with the incidence of recurrent urinary tract infections (UTI) and bladder calculi. There were no reports of recurrent UTI. Only two children developed bladder calculi (7%). A 15-year-old boy with a rhabdomyosarcoma of the bladder who underwent an ileocystoplasty did not perform regular bladder washouts, despite attempts for contact by the CNS. He had refused a Mitrofanoff abdominal wall stoma in the rst instance and performed transurethral CISC. He was lost to followup during 2 years and developed bladder calculi 72 months after ileocystoplasty, which were subsequently removed by an open cystolithotomy. The other child, who developed bladder calculi, was a wheelchair-bound girl of 8 years old with a neurogenic bladder who underwent a Mitrofanoff abdominal wall stoma and an ileocystoplasty. She was compliant in performing regular bladder washouts and was in close contact with the CNS. Bladder calculi developed 8 months after the procedure and have been removed by cystolithotrypsy. If we exclude the child lost to follow up, only one child developed bladder calculi (3.6%). In our series, none of our children who underwent a bladder outlet repair developed bladder calculi (Table 2). All children were closely followed by the CNS, except one, despite regular attempts to contact by the CNS.

Discussion Our study highlights that daily bladder irrigation with saline in the postoperative period plays an important role in the prevention of recurrent UTI and bladder calculi in children with ileocystoplasty with or without BNR. To increase compliance to daily bladder irrigation post discharge, we developed an extensive surveillance program coordinated by the CNS. Clinical collaborative pathways

have been described in the literature [16], but as far as we know, surveillance programs including community care have not been published in this chronic patient group. The reported incidence of bladder calculi in bladder augmentation is 1050% and results in considerable morbidity including UTI, haematuria and bladder perforation [6, 8, 9, 13]. In the past, higher incidences have been described, however with increased awareness and less frequent use of staples current incidence is probably decreased [17]. Various bowel segments, stomach and urinary tract can be used for augmentation cystoplasty, though ileum remains popular [7, 9, 18]. The disadvantage of using ileum as an augment is excessive mucus production in the small bowel segment [7, 1922]. Bacteriuria with urease splitting organisms like Proteus mirabilis promotes urinary stone production by altering the urine and mucus composition [13, 22]. Recurrent UTI can therefore occur due to urinary stasis and colonization with urease-splitting bacteria in the ileocystoplasty. Inadequate bladder emptying by catheterising abdominal wall stoma can further increase the risk of stone formation [9, 13, 22]. Hensle et al. [23] concluded that patients with an abdominal stoma had a greater risk of reservoir calculi than those using the native urethra. Possible risk factors related to increased stone formation described in literature were cloacal malformations, vaginal reconstructions, anal atresia, difculties with clean intermittent catheterisation, bladder neck reconstruction and ureter reimplantation [6, 9, 24]. Bladder neck repair will improve continence in patients with a neuropathic bladder, but increases residuals, which lead to less than adequate bladder emptying by intermittent catheterisation through a Mitrofanoff channel than through the native urethra [23]. In our series, 68% (19 of 28 patients) of the patients underwent ileocystoplasty, abdominal wall stoma and BNR. None of them developed bladder calculi. Unlike previous studies, we did not nd an

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BLADDER WASHOUT QUESTIONNAIRE

increased stone rate in children with a concomitant bladder neck repair. Prevention of bladder calculi attributes to the successful long-term management in this patient group. Lifelong daily irrigation to clear mucous and crystals to facilitate complete emptying of the augmented bladder has an important role in preventing stone formation [8, 23]. Bladder irrigation protocols have been associated in preventing reservoir calculi after augmentation cystoplasty and continent urinary diversion [19, 21, 23, 2527]. Acetylcysteine was used in seven patients with severe mucous production. Acetylcysteine has also been given orally or by enema to loosen impacted bowel mucous in case of meconium ileus in neonates with cystic brosis [28]. It has been described that it facilitates muco-ciliary clearance by reducing the viscosity of ileal neobladder mucous. Therefore, acetylcholine may have the capacity to facilitate the evacuation of mucous by decreasing viscosity [19, 22]. Mundy et al. [20] reported the successful use of acetylcysteine as a bladder instillation in patients using intermittent self-catheterisation after enterocystoplasty. NDow et al. questioned the effectiveness of acetylcysteine bladder instillation in a small prospective randomised trial [20, 21]. Only a randomised controlled trial will truly assess the role of acetylcysteine in bladder irrigation regime. Although we recognise that we have no control group in this study, in our cohort study only two children developed bladder calculi and no recurrent UTI were reported. One child was lost to follow up for 2 years regarding bladder irrigation. All the other patients, who adhered to the bladder irrigation regime carried out regular bladder irrigations and remained stone-free except one.

1. HAVE YOU HAD AN OPERATION TO MAKE YOUR BLADDER BIGGER? IF YES WHEN WAS THE OPERATION PERFORMED 2. DO YOU HAVE A MITROFANOFF TO ASSIST BLADDER DRAINAGE? 3. DO YOU HAVE A LOT OF MUCOUS IN YOUR BLADDER? 4. DO YOU PERFORM BLADDER WASHOUTS? IF YES IS THIS URETHRALY OR BY WAY OF A MITROFANOFF? 5. DO YOU USE AN INTERMITTENT CATHETER EG LOFRIC/SPEEDICATH OR AN INDWELLING CATHETER EG NIGHTIME FOLEY TO PERFORM BLADDER WASHOUTS? 6. WHAT SOLUTION DO YOU USE FOR BLADDER WASHOUTS? EG NORMAL SALINE 7. HOW OFTEN DO YOU PERFORM BLADDER WASHOUTS? 8. HAVE YOU ALWAYS PERFORMED BLADDER WASHOUTS THIS MANY TIMES OR PREVIOUSLY DID YOU PERFORM MORE/LESS FREQUENTLY? IF SO PLEASE STATE HOW OFTEN 9. HOW LONG DO YOU LEAVE THE WASHOUT SOLUTION IN THE BLADDER BEFORE DRAINING OUT? 10. DID YOU AT ANY TIME NEED PARVOLEX TO BE USED AS BLADDER IRRIGATION? 11. HOW FREQUENTLY DO YOU HAVE URINE INFECTIONS REQUIRING MEDICATION?. 12. DO YOU TAKE A PROPHYLACTIC ANTIBIOTIC? 13. HAVE EVER HAD STONES IN THE BLADDER? IF SO WHEN? EG BEFORE OR AFTER BLADDER SURGERY 14. DO YOU USE AN ACE STOPPER IN YOUR MITROFFANOF? IF SO WHAT SIZE IS IT?................................................................................................................................................................. 15. HAS YOUR MITROFFANOF EVER BEEN REVISED? IF SO HOW MANY TIMES?

Fig. 1 Bladder washout questionnaire

Conclusions We conclude that daily bladder irrigation with saline in the postoperative period plays a role in prevention of recurrent UTI and bladder calculi in patients with ileocystoplasty with or without BNR. Moreover, children with an excessive mucous production after ileocystoplasty may benet from acetylcysteine instillations. We also acknowledge the important role of a CNS in the postoperative surveillance in achieving excellent standards of care and outcomes after ileocystoplasty.
Acknowledgments None.

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