Additional surgeries after bladder augmentation in patients with spina bifida in the 21st century
Konrad M. Szymanski, MD MPH, Rosalia Misseri, MD, Benjamin Whittam, MD MS, Nathan Hollowell, BSc, Rachel Hardacker, BSc, Carly Swenson, BA, Martin Kaefer, MD, Richard C. Rink, MD, Mark P. Cain, MD.
Riley Hospital for Children, Indianapolis, IN, USA.
BACKGROUND: Rarely have long-term outcomes after genitourinary reconstruction been reported that account for patients being followed for different lengths of time. Our goal was to determine long-term risks of surgery after augmentation in a modern spina bifida (SB) cohort accounting for differential follow-up.
METHODS: We retrospectively reviewed records of patients with SB followed at our institution after augmentation (born ≥1972, surgery 1979-2017). Outcomes included: diversion, bowel obstruction, reaugmentation, perforation, bladder stones and cancer. Survival analysis was used to analyze the entire cohort and the modern cohort (ileocystoplasty since 2000).
RESULTS: At median 11.2 years of follow-up of 413 patients (80.9% ileocystoplasty), 177 (42.9%) underwent 359 surgeries. Ten-year risk of any reoperation was 43.1% (16.2% underwent ≥2 additional surgeries, 10.9% ≥3, 4.5% ≥4). This included conversion to incontinent diversion (2.7% at 10yr), exploration for bowel obstruction (4.5%), perforation (9.9% if segment initially detubularized and reconfigured [DR] vs. 23.7% if not, p=0.01) and reaugmentation (DR: 5.3% vs. 15.2% if not, p=0.0004). Ten-year re-perforation risk was 23.8% for DR vs. 69.0% for non-DR (p=0.01). Bladder stone risk was 28.4% (38.3% 10yr recurrence), regardless if segment was reconfigured (p=0.64). Twenty-year risk of cancer was 0.0%. For 222 patients in the modern cohort (median follow-up 9.1 years), 10-year risk of any reoperation was 44.0%: diversion (4.0%), obstruction (4.9%), perforation (9.2%, recurrence: 27.0%), reaugmentation (4.3%), stones (33.2%, recurrence: 32.3%) and cancer (0.0%).
CONCLUSIONS: Bladder augmentation in patients with SB is durable, but carries significant long-term risks, especially of bladder stones, necessitating close follow-up. Since survival analysis-based risks and benefits of alternative bladder management options, like incontinent diversion, are not available, reliable comparisons with augmentation are not feasible.
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