Date post: | 17-Dec-2015 |
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Objectives
• Incidence/prevention• Decision making• Multidisciplinary team• Urologic management• Future prospects….
Early management
• Back closure: improved surgery reduced disability
• Multi disciplinary inputs….• Renal US: Kidneys, voiding function• Antibiotic prophylaxis
Goals:
Quality and Length of LifeRenal PreservationPrevent UTIContinence ( Bowels)Latex precautions
Decision making in Urologic therapy
• Timing and Type is controversial• Motivation and mobility• Support• IQ may be reduced• Hand function• Local expertise
Early vs Delayed
• Early• Ab Prophylaxis• Anti cholinergics• CIC• Renal US ( baseline)• MCU• UDS
• Manage to make bladderSafe (Pdet < 30 cm H20)Proactive treatment
–Late– Ab Prophylaxis– Renal US / MCU– Interval US
– CIC for emptying– Anticholinergics prn
– UDS prior to surgery
– Reactive treatment
WHAT I DO……….
Urologic management
Emptying: CIC ( Lapides 1970)Urethral / Mitrofanoff
Storage BladderAnticholinergicsBotoxAugmentation Outlet SlingInjectableAUSClosure BN
Note: Bowel management first
Bowel management
• In parallel with urinary tract• Regular complete emptying• Laxative• Enema
• ACE :
Issues:Fluid type and volumeCaecum vs Lt Colon
CIC : Outlet / Mitrofanoff
Lapides 1970’sSafe bladder emptyingUrethra is not sensateMitrofanoff in wheel chair patient
Complications rare… stricture, incontinence
Goal: Competent outlet that can be emptied
Bladder storage
• Goal: Low pressure high volume bladder• Voluntary voids: ( n=10/80)• Anticholinergics ( Oxybutinin ) ( n= 40/80 )• Botox ( n=1/80 )
• Ileal augmentation• Other bladder reconstruction
Bladder augmentation
34/802 died in F/U (UTI)
32 stable renal function1 re-augmentation
10 Mitrofanoff4 re-operation
Complications:
8 bladder calculi1 perforation1 laparotomy1 Latex allergy
Bladder Storage : Ileal augmentation
Ileal conduit : rare but still a place
Bladder storage: Outlet procedure
• Static resistance: Injectable, Sling ( skin ), reconstruction
Dynamic resistance: Artificial sphincter
N = 6 ( 1 bulbar )1 erosion : dry after removal1 malfunction4 success
Skin sling outcomes
• 19 patients, 11 boys. Age mean 10 yrs• Follow up: 8 years, Sx, Renal US and UDS• 14/19 dry on CIC
• Durable outcome• No long term complications
My Preference
• Goal: Independence, QoL, Renal preservation, prevent UTI and Continent
• Early renal dilatation: CIC, Anticholinergics +/- augmentation
• Bowels OK, supportive situation. RUS follow up
• Incontinence stable kidney growth: CIC, Anticholinergics. Review… Persistant wetting skin sling and Ileal augmentation. Mitrofanoff if in wheelchair
Adolescent Transition
• Transfer chronic paediatric condition to adult care
• Independence• Complex psychological / physical issues• Different personnel, decision making
• Traumatic• Formal handover beneficial with local practitioners
Expensive: Wellington study
• NZMJ 2012, Mar 125 : Bowkett et al• Reviewed 6 consecutive spina bifida patients,
10 – 21 yrs.• 124 operations ( Av 20 )• 8.5 Days Av LOS ( 1066 total )• 7.5 CT scans• $ 944,000/ patient
Future Issues
• Reduced incidence• Antenatal intervention study ( MOMS ) 2018• Tissue engineering, Xiao procedure• Increased patient expectation• Adolescent transition/ Pregnancy, / Adult life• Long term follow up unknown ( Malignancy risk )
• Remember: ….a simple intervention can make a substantial difference…