Long-term Assessment of Morbidity Associated with Lower Tract Reconstruction for Continence
Cyrus M. Adams, MD, MS, Chelsea J. Lauderdale, MPH, Annah Huang, BS, Deborah L. Jacobson, MD, Douglass B. Clayton, MD, John C. Pope, MD, Stacy T. Tanaka, MD, MS, Chevis N. Shannon, MBA, MPH, DrPH, John W. Brock, MD, John C. Thomas, MD, Mark C. Adams, MD.
Vanderbilt University, Nashville, TN, USA.
BACKGROUND: Lower urinary tract reconstruction including augmentation cystoplasty is reserved for patients failing conservative bladder management and may be performed in the setting of a hostile bladder or when needed to achieve urinary continence. We hypothesize that patients undergoing these procedures for urinary continence have less associated morbidity than those requiring them for bladder hostility, perhaps due to lesser outlet resistance or absence of secondary upper tract changes due to the bladder.
METHODS: Eighty-three patients undergoing lower tract reconstruction including augmentation cystoplasty between 2002 and 2014 are included in review. As expected, most patients (67/83 or 80.7%) had some manner of neurogenic dysfunction as an underlying diagnosis. In Group 1 (34 patients), surgery was patient/family driven in order to achieve urinary and fecal continence. Forty-nine patients (Group 2) were retrospectively categorized as having the reconstruction done for bladder hostility if pre-operative urodynamic studies had shown poor bladder compliance and high leak point pressure (>40cm H2O), with or without secondary upper tract changes. Patients were followed for a minimum of two years after surgery; median follow-up is 8.3 years and similar in both groups. All outcomes and adverse events resulting in any unexpected physician intervention were noted and categorized by Clavien-Dindo grade.
RESULTS: There was no difference in the rate of adverse events noted after surgery between the two groups divided by indication. Group 1 patients undergoing surgery to achieve continence experienced 0.47 adverse events/year after surgery compared to 0.36 in Group 2 (p=0.89). Likewise, there was no statistical difference in individual or combined Clavian grades between those two groups; the vast majority were grade I-III. On sub-group analysis if bladder neck repair was performed in Group 1 patients, the adverse event rate did increase from 0.27/year to 0.56, although the increase was not statistically significant (p=0.87). Interestingly, the pre-operative presence of secondary upper tract changes in Group 2 did not lead to an increased rate of adverse events compared to patients with urodynamic findings alone, 0.32/year versus 0.39 (p=0.95).
CONCLUSIONS: We accept the null hypothesis, and patients undergoing lower tract reconstruction can expect similar morbidity no matter what the indication for surgery. Patients with their families should be informed about the risks of surgery, particularly if it being considered to improve apparent quality of life. In our experience, these patients will suffer unexpected/adverse events requiring some intervention about once every three years after surgery.
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