This Month in Pediatric Urology

Article Outline

• The Malone Antegrade Continence Enema
• Transurethral Autologous Myoblast Injection for Urinary Incontinence in Children With Bladder Exstrophy
• Clinical Inconsistency Between Nocturia Questionnaire and Bladder Diary
• Intravesical Oxybutynin for Poorly Compliant Neurogenic Bladder
• Copyright

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The Malone Antegrade Continence Enema 

The Malone antegrade continence enema (MACE) represents one of the most significant advances in the treatment and quality of life for children with neuropathic bowel associated with fecal incontinence and refractory constipation. Bani-Hani et al (page 1106) from Indianapolis, Indiana retrospectively reviewed their experience with 236 patients, including 172 with in situ appendicocecostomy, 23 with split appendix channels, 9 with appendicocecostomy and cecal extension, 22 with Yang-Monti ileocecostomy and 10 with colon flap channels. Median patient age at surgery was 9 years (range 2 to 36) and median followup was 50 months (6 to 115). A total of 5 surgical revisions were required in 39 patients (16.5%), most of which were due to stomal stenosis (13.65), with a median time to first revision of 9.5 months (range 1 to 105). There was no significant difference between umbilical versus lower quadrant locations of the stoma in this group. The appendicocecostomy group had the lowest rate of stomal stenosis (stomal leakage 3%, complete channel obliteration 3%), although this difference was not statistically significant. Overall 221 of the 236 patients (93.6%) achieved fecal continence with irrigations. The authors conclude that the long-term outcomes of the Malone antegrade continence enema in properly selected and counseled patients are encouraging, and that in situ appendicocecostomy has the lowest surgical revision rate.

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Transurethral Autologous Myoblast Injection for Urinary Incontinence in Children With Bladder Exstrophy 

Achieving urinary continence in patients with the bladder exstrophy-epispadias complex remains one of the greatest challenges in pediatric urology. In a novel and preliminary report Kajbafzadeh et al (page 1098) from Tehran, Iran evaluated the use of autologous myoblast injection into the external sphincter in 7 boys and periurethrally in 1 girl. Injections were followed by pelvic floor electrical stimulation using transcutaneous low frequency electrical stimulation. All bladders had initially been closed at ages 3 to 12 months. Previous surgery included a staged urethroplasty followed by bladder neck reconstruction in 4 cases, and single stage bladder neck reconstruction and epispadias repair in 3. Five patients had also received endourethral bulking agents before autologous myoblast injection. All 8 patients were still incontinent at the time of myoblast injection. Urodynamic evaluation was performed preoperatively, and 6 months and 1 year after injection.

Continence improved during the first 2 weeks after injection but then deteriorated by 1 month. Subsequently gradual improvement was noted during the next few months, beginning with nocturnal dryness followed by daytime continence. At 6 months after injection all 7 boys were socially continent and voiding per urethra without intermittent catheterization, while the girl remained incontinent. At final followup 4 boys were socially continent and 3 were completely dry. Postoperative urodynamic evaluation revealed a significant increase in bladder capacity by 6 and 12 months after injection, and all except 1 patient demonstrated good bladder compliance. The authors conclude that based on these results injection of autologous myoblasts should be considered a valid option for the treatment of bladder extrophy-epispadias complex. However, further scientific validation study of a larger number of patients and longer followup are needed.

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Clinical Inconsistency Between Nocturia Questionnaire and Bladder Diary 

Voiding (bladder) diaries and voiding questionnaires are commonly used in clinical practice and research of children with nocturnal enuresis and other voiding disorders. These tools are used to categorize nocturnal enuresis as monosymptomatic or nonmonosymptomatic when other lower urinary tract symptoms are present. Such categorization is helpful in directing further evaluation and therapy. In a prospective study Kwak et al (page 1085) from Seoul, Korea analyzed the consistency between the diary and questionnaire in 108 physically and neurologically normal patients with enuresis, of whom 93 also underwent uroflowmetry and residual urine measurements.

The percentage of patients with nonmonosymptomatic versus monosymptomatic nocturnal enuresis was 89.8% based on the questionnaire vs 68.5% based on the voiding diary. When the symptoms of urinary frequency, daytime incontinence and voiding postponement were analyzed, no consistency was found between the questionnaire and voiding diary. Based on the voiding diary, the maximum voided volume, average voided volume and percentage of maximum voided volume to expected bladder capacity in patients with monosymptomatic nocturnal enuresis were significantly higher than in those with nonmonosymptomatic nocturnal enuresis. However, no significant differences in these 3 parameters were found when the 2 groups of patients were classified based on the questionnaire. Meanwhile, maximum flow rate and volume of residual urine were not significantly different between children with monosymptomatic and nonmonosymptomatic nocturnal enuresis on either the questionnaire or the voiding diary. The authors conclude that classification based on a voiding diary may be more reliable than currently used questionnaires, and suggest the need to develop a new validated scoring system for a lower urinary tract symptom questionnaire.

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Intravesical Oxybutynin for Poorly Compliant Neurogenic Bladder 

Anticholinergic medication, usually coupled with clean intermittent catheterization, remains a mainstay in the treatment of the majority of children with neuropathic bladder. Side effects and/or increasing tolerance to the medication can limit its use. In an effort to control these problems, intravesical administration of anticholinergics has been proposed as an alternative to oral therapy. In a systematic meta-analysis of the English literature Guerra et al (page 1091) from Ottawa, Canada evaluated the effectiveness and tolerability of intravesical oxybutynin in children with a poorly compliant neuropathic bladder. Of 38 studies identified for closer examination 8 ultimately met their inclusion criteria for detailed review.

A total of 297 children were treated with 10 mg oxybutynin instilled into the bladder through a urethral catheter daily for 3 to 36 months. Of the children 66 (22%) discontinued treatment, including 28 (42%) because of side effects and 38 (58%) for “other causes,” the most frequent being inconvenience of the procedure. Mean change in bladder compliance was reported in only 2 studies which showed improvement of +7.4 and +7.5 ml/cm H₂O. The pooled mean change in pressure at maximum bladder capacity was −16.4 cm H₂O (95% CI −22.8 to −10.0). Incontinence improved in most studies with 61% to 83% being “dry and improved.” Although mean maximum bladder capacity increased and intravesical pressure decreased, the studies identified provided a low level of evidence. Also, although the incidence of side effects was lower with intravesical administration compared with oral therapy, side effects still occurred. The authors conclude that the evidence available is currently insufficient to recommend this therapy, and that a randomized controlled trial should be conducted to properly assess efficacy and side effects of intravesical oxybutynin in children with neuropathic poorly compliant bladder.