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Renal function may continue to deteriorate with long-term follow-up after gastrocystoplasty
Katherine Hubert, MD, MPH, Tim Large, MD, Allison Keenan, MD, Konrad Szymanski, MD, MPH, Benjamin Whittam, MD, Misseri Rosalia, MD, Martin Kaefer, MD, Benjamin Judge, BS, Richard Rink, MD, Mark Cain, MD.
Riley Children's Hospital, Indianapolis, IN, USA.

BACKGROUND: Gastrocystoplasty was historically performed in patients with short gut or renal insufficiency requiring bladder augmentation. Prior studies have reported postoperative morbidities including bladder malignancy, hematuria-dysuria syndrome (HDS) and electrolyte abnormalities. The purpose of this study was to analyze the long-term mortality and morbidities associated with primary gastrocystoplasty.
METHODS: We performed a retrospective chart review of all patients who underwent primary gastrocystoplasty between 1984 and 2004. Patients who were older than 21 years at the time of surgery, underwent secondary gastrocystoplasty or primary composite augmentation or had cloacal exstrophy were excluded. Outcomes of interest were deaths obtained using the Social Security Administration Death Index, bladder malignancy, HDS, electrolyte abnormalities and morbidities related to the gastric segment that resulted in secondary surgery. Additionally, end stage renal disease (ESRD) was a measured outcome, with baseline Glomerular filtration rate (GFR) calculated using the Schwartz formula and at the date of last clinical follow-up using the Modification of Diet in Renal Disease formula.
RESULTS: Of 50 gastrocystoplasty patients, 38 (55.2% male, median age 9 years) met inclusion criteria. Median follow up was 19 years (interquartile range (IQR) 10.3-25). Seven (18.9%) deaths occurred in our cohort at a median of 16 years (IQR 12.5-18.5) postoperatively. Causes of death included septic shock due to a urinary tract infection(2), a ventriculoperitoneal shunt infection(1), pneumonia(1), ESRD(1), complications of pregnancy(1), and unknown(1). At baseline, of 38 patients, 14 (36.8%) had normal kidney function, 8 (21%) had chronic kidney disease (CKD) stage 2, 11 (28.9%) had stage 3 and 5(13.2%) stage 4. Of the 16 with preoperative CKD 3 or 4, six improved to CKD 1 or 2 and one remained at stage 4 with median follow up of 22 years (IQR 14-24). The remaining nine progressed to stage 5 requiring dialysis and/or renal transplant. All patients with CKD 1 or 2 at time of gastrocystoplasty maintained their renal function except one who developed ESRD requiring dialysis after 18 years of normal kidney function following an episode of septic shock from decubitus ulcers and osteomyelitis. The ten who developed ESRD requiring chronic dialysis did so at a median of 9.5 years (IQR 3-11.5) postoperatively and 7 of 10 had subsequent renal transplantation. No patient had a bladder malignancy; nine (23.7%) developed HDS. Nine (23.7%) patients required revisions of their augmented bladders. Six patients underwent secondary composite augmentation with ileum for electrolyte abnormalities (1), small bladder capacity (1), persistent urinary incontinence, pain and difficulty catheterizing with HDS (3) and pain and difficulty catheterizing with a symptomatic parastomal hernia of a colostomy (1). Three patients had a cystectomy with non-continent urinary diversion because of pain with difficulty catheterizing and either electrolyte abnormalities (2) or HDS (1)
CONCLUSIONS: There were no deaths directly attributable to gastric augmentation and no cases of bladder malignancy. Approximately one fourth of patients required revision surgery of their augmented bladder because of morbidities associated with the gastric patch. Approximately half of all patients with preoperative CKD stages 3 or 4 progressed to ESRD in the postoperative period.

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