Permanent cutaneous vesicostomy: a pragmatic approach to safely manage lower urinary tract dysfunction in pediatric patients with chronic and life-limiting conditions and neuropathic bladders

Permanent cutaneous vesicostomy: a pragmatic approach to safely manage lower urinary tract dysfunction in pediatric patients with chronic and life-limiting conditions and neuropathic bladders

Vallasciani S; Al Saeedi A; Khalil IA; Mohamed RB; Muneer E; Abdelmaguid N; Pippi Salle JL

Frontiers in Pediatrics

2024

spinal muscular atrophy; adolescent; quadriplegia; Article; cerebral palsy; major clinical study; retrospective study; follow up; hypoxic ischemic encephalopathy; school child; preschool child; polypharmacy; long term care; clinical effectiveness; antibiotic agent; patient safety; human; child; female; male; controlled study; palliative therapy; stenosis; hydrocephalus; conservative treatment; neuromuscular disease; urinary tract infection; neurogenic bladder; nephrolithiasis; pragmatic trial; postoperative period; postoperative complication; Gross Motor Function Classification System; meningomyelocele; antibiotic prophylaxis; bladder catheterization; bladder irrigation; bladder stone; chronic life-limiting disease; cutaneous vesicostomy; cystostomy; encephalomyelitis; hydronephrosis; hydroureter; lower urinary tract dysfunction (LUTD); lower urinary tract symptom; neurogenic bladder dysfunction; neuropathic bladder; occult spinal dysraphism; recurrent infection; stoma; vesicostomy

Introduction: Lower urinary tract dysfunction (LUTD) in cerebral palsy (CP) and other neuromuscular diseases can present with chronic retention that leads to hydronephrosis, recurrent urinary tract infections (UTI), and stone formation. Whenever the conservative treatment of LUTD fails for any reason, it is considered to be complicated LUTD, in which a surgical approach is warranted. Cutaneous vesicostomy (CV) is a simple, well-tolerated, and potentially reversible procedure that protects the upper tracts. We describe our experience using CV for this complex population. Materials and methods: Children with CP and other neuromuscular diseases admitted to pediatric long-term care units for palliative care between 2015 and 2019 were included in the study. They present multi-system involvement, polypharmacy, and Gross Motor Function Classification System levels of 4 or 5. We retrospectively studied this population's indications and results of CV. Results: Of the 52 admitted patients, 18 presented LUTD with UTI (n:18; 100%), stones (n:5; 28%), progressive hydroureteronephrosis (n:3; 17%), or stones (n:2; 11%). Conservative initial management (catheterizations, prophylaxis antibiotics) was effective in half the cases. The remaining nine were defined as complicated LUTD and underwent CV. After a mean follow-up of 11.3 months, the follow-up showed improved hydronephrosis in all nine (100%) patients. Recurrent UTIs were no longer seen in eight of nine patients, although three patients required bladder irrigations; bladder stones did not recur after CV; the kidney stones needed further intervention. Revision of the CV was required in two (11%) cases at 12 and 24 months postoperatively due to stoma stenosis. Conclusion: CV is a relatively simple and effective procedure representing a pragmatic solution for managing complicated LUTD in complex long-term institutionalized pediatric palliative care patients with neuropathic bladders.

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