Using methods of drainage-free urinary diversion in the surgical treatment for complications of neuromuscular bladder dysfunction in children 
 

Shevchuk D. V.

Zhitomyr Regional Clinical Children’s Hospital, Ukraine

Shupyk National Medical Academy of Postgraduate Education named, Kyiv, Ukraine

Zhitomyr State University named after I. Franko, Ukraine

Introduction. Prevalence of neuromuscular bladder dysfunction (NMBD) in the population of children is significant. The main manifestation of NMBD is urinary disorder, which consists is often/rare urination, incontinence. Consequently — the social maladjustment of the child and his parents. Typically, NMBD is the outcome of the innervation disorder of the bladder, but posterior urethral valves, which are the main cause infravesical obstruction in childhood, are of great importance (Atwell J.D., 1983). To preserve kidney function and to prevent urinary tract infections are main tasks in patients with NMBD, while urinary retention — a secondary one (Stein R. et al., 2012). In infants with posterior urethral valves and refluxing ureterohydronephrosism complicated by recurrent pyelonephritis and/or chronic renal failure, to ensure the efficient derivation of urine, vesicostomy or ureterocutaneostomycan be used. Efficacy of using the drainage-free methods of urinary diversion, according to various authors, reaches 88 and 79% (Kozyrev H.V., 2008; Nanda M. et al., 2012). Efficacy of vesicostomy in young children suffering from anorectal pathology and myelodysplasia has been noted by domestic authors too (Makedonskyi I.O., 2013). J.C. Hutcheson et al. (2001) noted the positive effect of prolonged vesicostomy use in patients with neuromuscular dysfunction of the bladder due to myelodysplasia.

Materials and methods. During the period of 2010–2015, in the Zhitomyr Regional Children’s Hospital, there were operated 10 patients with complications of neuromuscular dysfunction of the bladder (megaureter obstructive/refluxing, urinary tract infection, reduced renal function, etc.). The protocol included examinations: laboratory one (general clinical, biochemical, microbiological), instrumental (ultrasound of the kidneys (full and empty bladder) and bladder with obligatory determination of residual urine; X-ray contrast — excretory urography in the absence of renal insufficiency with a glomerular filtration rate < 50 ml/min and voiding cystography (in correction of urinary tract infection); dynamic renoscyntigraphy; urodynamic study). 3 patients before the surgery had partial renal dysfunction. 12 surgeries were carried out (in 1 child ureterocutaneostomy was made simultaneously on both sides, in 1 — ureterocutaneostomy shifting was made due to decompensated stenosis of bladder outlet). Of these, 3 vesicostomy were performed (by Blocksom method) (mean age of patients was 8 years old), 9 ureterocutaneostomy (by methods of Wilson — 6 cases and Sober — 3 cases) (mean age of patients — 7 months). By sex, there was marked the following distribution: 9 boys, 1 girl. All the patients before the surgery underwent diagnostic ureterocystoscopy to assess the condition of the bladder wall, function and anatomical location of the orifice of ureter, presence/absence of infravesical obstruction (posterior urethral valve and/or bladder neck stricture) etc. In 4 patients, imposition of vesicostomy/ureterocutaneostomy was preceded by endoscopic dissection of the posterior urethral valve due to diagnosed infravesical obstruction. In 1 patient, during control monitoring 1.5 years after the endoscopic dissection of the posterior urethral valve and at the imposition of ureterocutaneostomy in unilateral megaureter, we confirmed the reduction of dilatation of the upper urinary tract and restoration of the kidney and bladder function, that made it possible to close the ureterocutaneostomy without additional reconstructive surgeries. In one child, in which we carried out the imposition of cutaneostomy and its closure in 2 years (in the clinic outside the region area) without additional endoscopic diagnosis and endoscopic dissection of posterior urethral valve, obstructive megaureter recovery was noted with the sharp decrease in the excretory function of the kidney. A clinical case of the treatment for complications of neuromuscular dysfunction of the bladder using drainage-free methods (including vesicostomy) is presented.

Conclusions. 1. Neuromuscular dysfunction of bladder, caused by infravesical obstruction in particular, requires prompt surgical correction (in the neonatal period). 2. In case of endoscopic treatment failure, difficulties during permanent bladder catheterization, it is indicated to use drainage-free methods for urine diversion (vesicostomy/ureterocutaneostomy) as a temporary measure to restore urodynamics. 3. Application of vesicostomy enables to reduce the phenomenon of dilatation of the upper urinary tract, to improve renal perfusion and to reduce the effects of uremia.

Key words: neuromuscular dysfunction of bladder, posterior urethral valve, surgical treatment, children, vesicostomy, ureterocutaneostomy.

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