Pregnancy and Delivery Following Lower Urinary Tract Reconstruction for Urinary Incontinence During Childhood
Ezekiel H. Landau, MD1, Guy Hidas, MD, MSc1, Ofer N. Gofrit, MD, PhD1, Yuval Bar Yoseph, MD2, ran Katz, MD3, Dov Pode, MD1, Mordechai Dundevani, MD1, Vladimir Yutkin, MD1, Joseph Binyamini, MD2, Jacob Ben Chaim, MD2.
1Hadassah Hebrew University Medical Center, Jerusalem, Israel, 2Dana Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 3Ziv Medical Center, Safed, Israel.
BACKGROUND: Advanced management, including lower urinary tract reconstruction (LUTR) for urinary incontinence during childhood, enables many of these patients to reach adulthood with preserve renal function and continence. Pregnancy and delivery following LUTR may challenge the pregnant women and the medical team. Catheterization of the Mitrofanoff conduit may be difficult due to shifting by the expanding uterus. New-onset hydronephrosis is another potential complication in these patients. Vaginal delivery can potentially damage the reconstructed bladder neck (BN), while Cesarean-section (CS) may damage the Mitrofanoff conduits, or the augmenting segment mesentery.
The aim of this study was to evaluate the management of patients who had LUTR during pregnancy and delivery.
METHODS: A multi-institutional retrospective review of all women, who underwent LUTR for urinary incontinence during childhood, became pregnant and delivered, was undertaken. Data regarding hydronephrosis, UTIs, continence, catheterization difficulties during pregnancy, recorded, as well as type of delivery (CS vs vaginal), and subsequent complications.
RESULTS: The study group comprised 13 patients aged 23-31 years (mean 23), who gave birth to 18 (mean 1.38) babies between 2011 and 2021. Etiology of incontinence included neurogenic-6 (myelodysplasia-4, sacral agenesis-1, spinal trauma-1), exstrophy-5, pelvic trauma-2, Hinman Syndrome-1. LUTR during Childhood included: bladder augmentation-11, BN reconstruction/closure-9, Mitrofanoff-9 (appendix-7, Monti-2). One patient had a concomitant Malone conduit. Stomas location was at the umbilicus-7, and in lower abdomen-3. Five patients had 17 previous miscarriages (mean-3.4). During pregnancy, 7 (54%)-patients had symptomatic UTI, 5 (54%)-patients experienced difficult conduit catheterization, necessitating urethral catheterization in 2, and 5 (19%) kidneys required diversion (3-stents, 2-nephrostomies) due to symptomatic hydronephrosis. One patient had a leaking Mitrofanoff stoma prior to pregnancy. Fifteen (83%) deliveries managed by CS, (elective-11, urgent-4), via Pfanensteil-13, and midline-2 incisions. All CS managed by transverse uterine incisions. A pediatric urologist assisted all CS. Two patients, with no BN reconstruction, arrived at the hospital with pending vaginal delivery, which was safely completed by the obstetric team. Surgical complications included small bowel perforation-2, and an inadvertent cystotomy (17%), all managed promptly. Difficult post-operative intermittent catheterization of the redundant Mitrofanoff conduit encountered in the first 2 patients, necessitating sedation for cystoscopy-guidance re-catheterization. Therefore, all subsequent patients managed by indwelling catheters for 3 post-CS weeks, with no further catheterization difficulties. Damaged Mitrofanoff or Malone conduits were not encountered. No patient suffered new onset post-CS urinary incontinence. No obstetric complications encountered.
CONCLUSIONS: Pregnancy in women who underwent LUTR for urinary incontinence during childhood, has high complication rate, including miscarriage. CS is safe in this unique patient group. Inclusion of a pediatric urologist in the surgical team during CS is advisable. Leaving an indwelling catheter in the redundant post-CS Mitrofanoff conduits for 3 weeks, is mandatory, if catheterization difficulties are to be avoided. Site of stoma (umbilicus vs lower abdomen) and type of conduit (appendix vs Monti) did not affect conduit integrity during CS.
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