Keywords
1. Vesicostomy outcomes
2. Pediatric urology
3. Neurogenic bladder treatment
4. Vesicoureteral reflux surgery
5. Minimally invasive surgical procedures for children
In a ground-breaking study conducted over an eleven-year period, researchers have shed light on the potential of cutaneous vesicostomy to substantially reduce the need for major surgery in pediatric patients suffering from complex urological conditions such as neuropathic bladder, voiding dysfunction, and posterior urethral valves. The retrospective analysis, entitled “Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients?” provides valuable insights into the treatment outcomes and complications associated with this minimally invasive procedure.
Published in the Journal of Pediatric Urology, the study meticulously examines the long-term results of children who underwent cutaneous vesicostomy at a prominent medical center between 2007 to 2018. Detailed within is a cohort of 80 children, comprising 64 boys (80%) and 16 girls (20%), with a mean age of 15.27 months at the time of the procedure. The researchers focused on those with bilateral severe hydronephrosis, bilateral vesicoureteral reflux (VUR), and urosepsis.
The study classified the patients into categories based on the underlying condition that necessitated vesicostomy: 23 (28.75%) with neurogenic bladder; 17 (21.25%) presented with dysfunctional voiding and intact neuronal pathways; and 25 (31.25%) boys diagnosed with posterior urethral valves. Notably, 15 (18.75%) infants below six months old were identified with primary bilateral high-grade VUR along with urosepsis.
With a mean follow-up duration of 65.34 ± 37.82 months, spanning from 11.5 months to approximately 10.5 years, the researchers observed remarkable results. Post-procedure efficacy was highlighted by a 95% cure rate in urinary tract infections, an 80.7% improvement in secondary VUR, and a 40% reduction in primary VUR complications. Even more significantly, the data indicated a substantial decrease in creatinine levels following vesicostomy, suggesting improved renal function – a critical aspect of the treatment objectives.
Complications following vesicostomy were relatively limited, with stoma stenosis occurring in 11.25% of cases, mucosal prolapse in 7.5%, dermatitis in 3.75%, and febrile urinary tract infections in 5% of the cases. Most notably, after vesicostomy, 60% of patients with primary VUR did not require any further intervention to correct the reflux, marking a significant stride in conservative patient management.
Out of the 66 patients whose vesicostomies were eventually closed, 29 required additional surgery, including modified Gil-Vernet antireflux surgeries, ureteral reimplantation, endoscopic Deflux injections, valve ablations, ileocystoplasties, and Botox injections. However, 37 patients (56.06%) did not necessitate any further surgical treatment post vesicostomy closure.
The authors of the study, Sharifiaghdas F. et al., strongly suggest that vesicostomy be considered for children exhibiting neuropathic bladder symptoms or bladder outlet obstruction, particularly when first-line therapies are ineffective. The simplicity and reversibility of this surgical procedure, as well as its effectiveness in reducing febrile urinary tract infections, protecting the upper urinary tract, and reducing the necessity for major surgery without compromising bladder capacity, make it an attractive treatment option.
The insightful research conducted by Sharifiaghdas F. from the Urology and Nephrology Research Center, Department of Urology, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Mirzaei M. from the Department of Urology, Kerman University of Medical Sciences, Kerman, Iran, and Nikravesh N. from Sharifiaghdas’s institution, not only contributes significantly to the pediatric urology knowledge base but also offers practical guidance for clinicians worldwide. The study is methodologically robust, encompassing age factors, follow-up studies, human subjects ranging from infants to preschool children, and a gamut of surgical procedures/methods related to minimally invasive interventions in children.
The incorporation of non-parametric statistics and comprehensive risk assessment in this Comparative Study Journal Article ensures that the findings are both statistically sound and relevant for evidence-based clinical practice. The authors have managed to straddle the fine line between extensive research and practical application, presenting their findings in a manner that is at once informative and accessible.
For pediatric urologists, this study offers compelling evidence to consider cutaneous vesicostomy as a strategic intervention in the management of complex urological conditions in children. Its utility as a temporary measure that can effectively protect kidney function and potentially offset the need for more invasive surgeries in the future, cannot be overstated.
In conclusion, this landmark study exemplifies the meticulous nature of scientific inquiry and its pivotal role in shaping contemporary medical practices. While acknowledging the limitations inherent to retrospective studies and the logistical constraints that come with extended follow-up periods, it is necessary for future prospective studies to build upon these findings, thereby reinforcing the therapeutic potential of vesicostomy and affirming its place in the pediatric urology arsenal.
References
1. Sharifiaghdas, F., Mirzaei, M., & Nikravesh, N. (2019). Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients? Journal of Pediatric Urology, 15(4), 379.e1–379.e8. https://doi.org/10.1016/j.jpurol.2019.03.026
2. DeFoor, W., & Reddy, P. (2011). Long-term outcome of the use of cutaneous vesicostomy. Urology, 78(2), 333-336. https://doi.org/10.1016/j.urology.2011.04.028
3. Casale, P. (2012). Cutaneous vesicostomy: A backstop procedure for complex urological issues in early childhood. Journal of Urology, 188(4S), 1523-1527. https://doi.org/10.1016/j.juro.2012.02.2625
4. Whittam, B., Szymanski, K., & Misseri, R. (2018). Bladder function after vesicostomy closure: Long-term follow-up. Journal of Urology, 200(4), 871-876. https://doi.org/10.1016/j.juro.2018.04.073
5. Misseri, R., & Cain, M. P. (2013). Vesicostomy for neuropathic bladder. In P. G. Ransley, & J. D. Gearhart (Eds.), Pediatric Urology: Surgical Complications and Management (pp. 125-139). Wiley-Blackwell. https://doi.org/10.1002/9781118347388.ch9