Transitional Urology - Case Discussion

Everyone can see the slides. Yes, uh, yep. Right, so right now we're gonna be starting with some case discussion on transitional urology. Um, I appreciate the wonderful presentation, um, by Doctor Masseri. She's certainly a leader in this area and also has served an important role in my training as a resident. Um, also joining us on the panel will be Doctor Mahdi who spoke. Um, just a few moments ago. Um, he is the chief of Urology at our partnering adult institution, University of Cincinnati. Um, he also is, um, fellowship trained in pelvic reconstruction, female urology and also has been a great colleague and co-worker with us with transitioning a lot of our patients into adulthood. Um, in addition to those two, Doctor Vanderbrink, um, will be joining us as well as, uh, Doctor Dwry, um, two of my partners here in Cincinnati. Um, and anyone else on the call can also chime in with any comments, um, as we move through the presentations. Uh, I'm gonna start with one presentation and then Doctor Matty, um, requested to present an interesting presentation that he has taken care of. And then if we have additional time, we'll certainly have more to present after that. So, case number one is a 33 year old male uh with classic batter atrophy, um, has a normal right kidney, uh, chronically left atrophic kidney, um, previously had a small and hypoplastic phallus. Um, as a child, he underwent a modern stage repair, um, at another institution. Um, other pertinent history is that the patient ultimately underwent creation of a neopallus with a right forearm free flap, as well as a neourethral skin tube at 16 years of age. Uh, subsequent to that, the patient underwent a semi-rigid penile prosthesis with insertion of two cylinders. So with that pertinent history, I thought we would start with a question. Um, this can, um, also be answered by the audience, and once we get the poll results back, we'll, um, we can certainly discuss it further. So the question is, how would you manage the urinary tract with creation of a neopallus? A, neourethral skin tube, B, cutaneous uterostomy, C, neourethral skin tube and metrofanoff, D, bladder neck procedure and metrofenoff, or E, none of the above. So while we wait for some of the audience to answer that, um, I'll kind of pose this question to some of our panelists in terms of what their experience is and what they think would be the best option. So, um, Doctor Masseri, what are your thoughts about managing the urinary tract in this circumstance? So, I, I think the neopallus really, what you need is a conduit for For semen. Um, and, uh, the skin tube, and I, I don't know too much about phallic reconstruction. Um, I would probably defer that to somebody who does gender-affirming surgery, but, um, I would think that having a dry area, um, and you didn't really talk about how he voided prior to this neopallus, um, So, do you know how he voids? So, this patient, um, specifically went uh underwent a metrofenoff, but that was done later after the neurethral skin tube did not serve as an adequate reservoir for managing the urinary tract. So, um, so I would probably before embarking on the, uh, on the Neopallus really counsel the patient on this. Being an eventuality of metrofenoff. Um, I think a neourethral skin tube is, uh, probably will serve as a conduit for, for semen to roll out of. I don't think that there's gonna be forced ejaculation there. Um, so I probably would say the neourethral skin tube and a metrofenoff in this case, um, If they were continent prior. Um, so my assumption from your presentation is that they were continent, so. So, as I just alluded to, um, this patient, um, only had creation of a neourethral skin tube which did not work well. Um, patient ultimately required multiple urethral dilations for recurrent strictures of the neourethra and ultimately required a metroloffenoff appendicovassostomy several years later. Um, additional interesting history is that the patient had a prior injury while playing softball and actually had explantation of the right cylinder that was in the, um, neopallus. In addition to the history, the patient has also been treated for bladder stones and undergoing regular irrigations of the bladder, and also had episodes of recurrent epididymitis that required a vasectomy in the past. Um, now, as an adult, the patient has been sexually active and has conceived two biologic children through, um, IVF. So, not necessarily specific to this patient, but more in general, um, I want to have a discussion on follow-up regimens for adults that have had prior lower urinary tract reconstruction. So, um, Doctor Vander Brink, why don't you start by discussing what your typical follow-up regimen would be uh teenagers and patients as they transition to adulthood, uh, they've had prior surgery on their lower urinary tract. Well, I think a couple of minutes ago, we were kind of talking about, uh, depending upon the patient's developmental status is kind of start at square one. Why, why did anybody even do a reconstruction in the first place? Um, as I said, in, in the world of, say, neurogenic bladder reconstructions that the, you know, looking at their back, there's usually a scar, start at step 10, This is why I'm doing it, and we made these decisions. Uh, I think, uh, Doctor Mari, uh, hit the point home to say hopefully, when the reconstructive procedure is performed, the patient is motivated. And so if they're motivated, that would also sort of, one would hope, educated so that you're not, um, you know, starting from square one about uh follow-up. Um, I agree that, um, the spina bifida Association, longitudinal studies, uh, my colleagues at, uh, Luie with David Chu, uh, are really kind of emphasizing that maybe the assessment of GFR, uh, has not been traditionally very well done in a spina bifida population for a multitude of reasons. The Body habitus, the lack of maybe serum renal functions um being performed. So, for me, uh, I try to remember as a urologist that the kidneys are our prime directive. So, a renal ultrasound as well as a renal function test in the form of a blood test are the most important, along with counseling about why it was done. Uh, and then equally important is going over some of the techniques, uh, for intermittent catheterization to reduce infection, clean. Uh, adequate time emptying. And, uh, depending upon the components of the lower urinary tract reconstruction, such as augmentation, irrigation, surveillance, That's What I'm typically doing with my patients. Doctor Matti, do you, what type of imaging evaluation do you do routinely in some of our patients that have transitioned to, um, across the street with, um, your care? Uh, I mean, I echo what Brian said. I do ultrasound. Uh, I do rely much on renal function tests, obviously because unilateral kidney, even 80% unilaterally functioning kidney would be enough to maintain the proper like good renal function. Uh, so I do ultrasound and a screening test, and then if the ultrasound shows something, uh, that I feel there's anatomical finding would explain it like hydronephrosis, um, while making sure the bladder compliance is normal, then I proceed with a CAT scan for further imaging. For patients who have definitive history of, uh, ureotiasis or recurrent, uh, stones, I, um, I do a CT scan as a baseline assessment, but my routine annual follow-up would be ultrasound. Um, now, this case that we're discussing, I, I look at it in two different aspects. One is the voiding part and one is the, uh, sexual function part. Um, from the voiding standpoint, I also want to make sure with the pigeon of bladder atrophy that the bladder pressures and volumes are, um, Um, uh, you know, safe. Um, so that probably he, he had uh multiple kidney stones probably because the bladders, his contracted bladder and, and probably bladder out obstruction as well. All right, thank you. So, in terms of follow-up with this patient, um, we did do additional, uh, evaluation which we'll go through in a moment. Um, his primary complaint that he had when he presented, um, was he's having constant dribbling of urine from his neopallus. This was still after, um, catheterizing themerofenov and being reliable with doing that. Um, it was requiring at least one pad per day and was bothersome enough for him to discuss it as an issue, um, that he wanted to address. Um, so we obviously did a further evaluation as you had suggested, we typically would begin with an ultrasound as well. Um, the ultrasound demonstrated, uh, um, some debris in the bladder, um, showed a fairly normal, healthy right kidney with maybe a mild hydronephrosis, and then that chronically smaller scarred left kidney which had been stable from previously. Um, a VCUG was also obtained, um, which demonstrated a fairly smooth, round, regular shape to the bladder. Um, we'll go over the capacity in a minute, and then there's a little bit of dilation of the first part of the prostatic urethra, and then you can see, as indicated by the arrow, there's a very narrow, almost pan stricture along the length of that, um, neourethral skin tube that was created at the time of the neopallus creation. Um, also, I'll draw your attention to the fact that there's only 1 cylinder in place, um, with previously 2 being in place after having that prior injury. Um, a urodynamics evaluation, um, was subsequently performed, um, and demonstrated, uh, fairly good, um, CMG with low pressures during filling, um, at maximum bladder capacity of 565. No uninhibited detrusive contractions, um, and as, um, was consistent with the history, had small leak from the urethra with stress at, um, several, um, volumes and then had a fairly low, um, leak point pressure. Uh, the patient ultimately underwent a cysto, uh, endoscopic evaluation as well. Um, and findings included cystitis glandularis in the bladder. There is mucus but no recurrent stones at the time. Um, the bladder neck actually appeared to be fairly co-acting in the image there in the lower right. And then they were able to scope the, um, neourethra, but it was essentially narrowed along its entire length and it was only able to accommodate a 4.5 French, uh, scope. So, patient um was actually lost to follow-up for several years after having this evaluation and didn't pursue any further treatment options and then returned later as will obviously happen with patients when they have acute issues. Um, this patient actually had a recent admission for an abscess of his neopallus at another institution and he was ultimately diagnosed with a urethrocutaneous fistula, um, at the, um, at that site. And in addition to that, he was having worsening and now very bothersome urinary incontinence. Um, they'd previously tried multiple interventions including increasing frequency of catheterization, anticholinergic therapy, despite their fairly reassuring urodynamics, and nothing really improved it. Um, patient underwent, uh, video urodynamics. Um, the CMG portion was essentially stable from previously, and these are some images of the, uh, video component. Um, and as you can see, um, with the arrows there, they delineated a, um, fistula from the more dilated proximal urethra out at the base of the neopallus, um. Which was um explaining some of the symptoms that the patient was having. So, at this point, um, we have a 33-year-old patient with a fairly good bladder in terms of the capacity, no overactivity, pressure seemed to be good. He's catheterizing routinely through his metrofenoff and doing well with that, um, but obviously having an issue with the neopallus abscess as well as this kind of worsening, um, urinary leakage from his neopallus as well as a resulting fistula. So, um, I wanna kinda discuss some options for management moving forward. Um, so, Doctor Masseri, what are your thoughts about doing, um, additional surgery, whether a bladder, neck closure, urethral ligation, or something else to address it? You'd already kinda commented on the concern about, um, egress of prostatic and seminal secretions. How would you address that? And what do you think the risk of prostatitis would be in this patient? So, um, a couple of questions. One is, um, what bladder neck procedure did he have done previously? So he never had a, he had a modern-stage repair of his bladder atrophy, so there was likely some tail tailoring, funneling of the bladder neck but didn't have a formal bladder neck reconstruction. The other thing is in scoping him, where, um, where are his ejaculatory ducts? Are they, you know, in, in bladder atrophy patients, oftentimes they're very, very close, if not in their bladder necks, um, as we've seen. The other thing is this, um, Is the, the, uh, issue he's had with the abscess of his neopallus related to Where this ejaculate is egressing, did that add to the, the issue that he had? Um, so I think, I, I think the location of his, um, ejaculatory ducts is probably, uh, is probably important to me, um, and knowing whether you're gonna do a urethral ligation or bladder neck closure. Um, I think if he, um, If his seminal vesicle and prostatic secretions go into his, his bladder neck which is appears to be slightly open and refluxes into there, that might not be an issue. Otherwise, um, you can actually make a little pouch so that it can dribble out the base of his, of his penis, um, like a little man-made fistula for that. I think that's an important point, like you said, in terms of the location of the ejaculatory ducts. And um I would encourage people to not only consider that in the circumstances like this, but also in patients with anal rectum malformations cause they can often have abnormal positions of their ejaculatory ducts and can lead to issues related to that. Um, with regard to this patient, um, the ejaculator ducts were not in the bladder, so they were distal to the bladder neck. Um, and they're in the expected location. It was proximal to where that urethral stricture was from the, uh, neopallus skin tube. Um, I, I probably would, would, uh, create something for that ejaculate to come out of and it might not be the tip of his penis, uh, but what's gonna be safer for him not to have a recurrent, um, Neophilic abscess because that could be catastrophic, right? He's already had a forearm flap that um that's, that's been there. Um, I do think these patients are at increased risk of prostatitis if the, if the ejaculate doesn't make it out. So, um, so I do think it's important to either create a pouch for that ejaculate to collect in and then drain into his bladder or uh make something. Uh, preferably that drains. Thank you, Doctor Matty. Any thoughts on this? Uh, I just wanted to make sure about the, the prostate. Is, is it still there with this kind of active infection? Whether the prostate is still there, you said, yeah, um, the full embodiment of infection, I would probably initially I would just remove that first, um. So, um, I believe the prostate is still there. Um, how would you, would you assess that based on endoscopic evaluation? Would you get some type of cross-sectional imaging? How would you make that determination? Yeah, clinically, of course, number one, I see where the, um, what is the infection in relation to the prosthesis, and then imaging, go to CT scan probably also would help. Um, but we tend to not to leave foreign bodies in the infected tissue. Um, and as far as the, uh, management of his urethra, is there any reason why wouldn't he have a tissue transfer, uh, urethroplasty, that vocal graft? For that, would you do that for managing the uh urethral stricture from the prior skin tube? Yeah, he has a, he has a, he has a tissue arm phalloplasty. So whether that's an ideal bed for the, you know, stricture that is causing the fistula, I don't know. Actually, I was gonna ask you, Doctor Monty, any, if this is a man who's using IVF for fertility, he's got a, uh, penile prosthesis for sexual function. His prostatic egress may be what is causing this. Uh, it's hard from the cystographic appearance. It looks like there possibly could also be some urine pooling in this proximal urethra, so that's not. Um, the, I, I think Doctor Maceri's first line of trying to formalize this fistula may be the least morbid, but what are your thoughts as an adult neurologist, Doctor Matty, of, is this a, a man who might have a, a prostatectomy and the bladder neck closure, given he's got a reliable channel, good dynamics to It's it quite an aggressive one. I'm just throwing it out there to see what your opinion is, if, if, uh, more milder forms didn't cure this issue. Yeah, I mean, in adult population, when, when we close, when we need to close the bladder neck, uh, back to your point in the cystogram study, it seems like it's more of urine related, urine leak related more than prostate excion, and the fact that he's looking to be fertile, I would not remove the prostate. I would consider just closing the bladder neck proximal to the prostate. To get that urine diverted. And what would you do for the prostatic seminal secretions if you close the bladder neck? Uh, I don't know if that would be by itself a source of infection. Um, we've seen patients that had also benefit from perineal arthrostomy, but, uh, that may also hamper his, um, you know, desire to be fertile. Quick question for uh Doctor Marie and uh Rosalie is, um, you know, so the group from uh Hopkins has shown that the prostate gland in patients with bladder atrophy does not have the normal anatomy, uh, and the shape configuration that, uh, uh, men without bladder atrophy have. And so how would you tackle a prostatectomy in these individuals cause it's so dispersed, the tissue is not confined by an ice capsule. Secondly, um, do you feel like, uh, cause I, there's some Um, varying reports that talk about increased risk of prostate cancer in patients with bladder atrophy happening at a younger age. Uh, I've not seen any real proof other than, uh, a few papers coming from Hopkins on that, but, um, uh, is there any other documentation to your knowledge about that being a real risk factor, and should we be counseling families about that? Uh, so I personally have no business touching anybody's prostate. Um, uh, uh, I do have one patient that I follow who did have very similar situation with the neopallus, uh, actually a, um, cloacal atrophy who, um, Mike Cook did a prostatectomy on and that seemed to make everything, uh, Much better, um, for him, um, but in fact, knowing that these are very difficult prostatectomies to perform, so I, I'm not sure that there's any other data out there that I know of about, uh, about their increased risk of prostate cancer, so, uh, At present, probably just routine um PSA screening for them. Yeah, uh, so there is no, uh, in the AUA guidelines for screening for prostate cancer, there is no specific guidelines for the extra patients, but this is gonna be a good point. Um, obviously, radical prostatectomy is the job of our oncologist also, as I shared with Doctor Masseri, the same, um, that we, I don't have experience with radical prostatectomy per se, but as far as screening, Um, the guidelines still did not change based on the, uh, Mayo Clinic data, so, uh. And then for the uh neopallus as a substrate for like a buccal mucosal urethroplasty, we did a lot of the revisions of the neopallus strictures in residency with our reconstructive urologist. Um, and for these, it would, he would, depending on what the goals of what the patient would have or if their goal is to have the neopallus for sexual function versus normal urination with standing, depending on how you would manage them moving forward. But those that wanted to have uh the ability to avoid standing up and just normal voiding patterns, we would basically rebuild the urethra, even by putting the stage procedure of the buccal mucosa on this, and they would heal fairly well from it. So it is feasible, even with it not being the ideal substrate for it. So the first stage would be a neoalsceration, then second stage would be um buckle grafts, and then third stage tubularization. Most times the original neopallus was done elsewhere with the plan of a, they created a urethra in some way, and then those that had urethrals, urethras that strictured after, it would be that you then stage it within you basically open everything up, you inlay the buckle to it, and then you do at least one more stage after that to close it, if not a third, depending on how they, would they not routinely recommend uh metrofanil for bladder management with neophiles creation. I don't, none of them ended up having uh a metrofena for it depend on what their goals for. If it was they wanted it from the sexual function versus voiding, it would just depend on what they wanted, but I did not see any of them that had a Metrofanov made for it. OK, perfect. Um, so in this patient's case, um, we elected to do a staged approach. So someone had mentioned urethrostomy and that was actually our initial procedure of choice in managing this patient. And the real goal with that was to allow for neopallus and neourethral rest and resolution of the infection um that had previously occurred. And then plan after that was to, um, perform, um, a procedure whether a bladder neck closure or urethral ligation, um, to address the urinary incontinence, um, that occurred previously as well as the fistula. Um, at the time of the operating room, the patient had almost complete obliteration of the neourethra that was created from the skin tube and underwent a, um, cutaneous ureterostomy and excision of part of the penile, um, urethra at the same time. Uh, post-operatively, patient did well, had no recurrent infections, either urinary tract or the neopallus, and was able to occasionally void through the cutaneous uterostomy, although the patient was continuing to perform intermittent catheterization through their metrofanoff. Um, now that the patient's underhead a, um, cutaneous ureostomy, what would be your next step? Would you just observe them at that point? Would you move forward with the bladder neck closure or urethral ligation? And then in addition to that, how would you manage the penile prosthesis at surgery? Would you maintain it in sightitu with antibiotic irrigation? Would you consider explantation or any other, um, options for management of the prosthesis at that time? Um, Doctor Vanderbrink, what are your thoughts on this? So, from your presentation, it sounded like this was a really good idea to do the urethrostomy and the patient's all better. So the first bullet point. Um, I'd probably say observation. I don't know whether or not the leakage that you discussed prior to the urethrostomy, you said he, he has the ability to void and catheterize. So I guess I would say the goals if he still has urinary incontinence would be to adjust that, more surgery. And at that point, so the patient does, the patient can void, but the patient is still having leakage, um, that still bothersome to him. So that was my next question. Is the leakage bothersome enough that he would like to have a bladder neck procedure? So, yes, the patient still has bothersome leakage. Would you have a preference towards bladder neck closure, trying a urethral ligation in that scenario? Uh, well, with the urethra now being at the perineum. Um, I worry given the cystographic appearance in that bladder neck that um, I'm not, I personally don't have experience with closure of a perineal urethrostomy and an extra fee to find out if that's gonna stay closed. So I Don't think that's an unreasonable. It's a much easier operation than going back down to the bladder neck, but I'm worrying whether that's gonna maybe give you the same outcome as say Uh, urethral closure in a female urethra through a perineal approach. Um, so, I'd probably counsel bladder neck closure without any simultaneous bladder procedure if the urodynamics are showing the same good capacity, low compliance. And I would, uh, If I'm running into that penile prosthesis, uh, hopefully I'm not gonna see it, cause if it's in the corporate cavernosa, that's usually not something I Go into, um, So I would not explant it. So, um, what's your guys' experience with, uh, balkan agent, the injection to the bladder neck, since it's already, um, it seems from the scope, it's a healthy mucosa. Uh, that's a good, that's a good question, um, whether you could do a bulking agent at the bladder neck to help address the leakage. So, um, we do have some experience with atrophy patients with that and actually through our PUMA collaborative with, um, the other hospitals in, uh, at Riley, Mayo Clinic, um, Columbus, um, Nationwide Children's, as well as Chicago, we looked. That are long-term outcomes with doing deflux injections for patients with bladder atrophy and from our experience, it did not work well as a long-term solution for urinary incontinence. And most of those patients, if not all of them, ultimately required a bladder neck procedure rather, whether a reconstruction or a bladder neck closure to help manage that issue. Yeah, because in the adult population, obviously, the most common reason for stress incontinence is prosthetic procedures, uh, especially radical prostatectomy, but in those patients, the sphincter itself is dilated. Um, so they, they tend to improve, but it's a short term, and you have to use a large amount of bulky agent, but I was just wondering when the bladder neck is actually otherwise healthy, uh, if it would give a different outcome. I agree with you. The bladder neck looks fairly good for an extra few patients, so that certainly would be an option. So, Andrew, the one thing about bladder neck closure that worries me. In this patient Is his inability to show up for 4 years until half of his penis was, uh, was falling off for lack of a better term. Um, so, uh, So, while I'm not, I don't think that bulking agents are great long-term solutions. Sometimes you have to make people prove that they really want something and, and that's a difficult decision to make because what people tell you and what they do are often two different things. So I hate to sound cynical, but Um, so I, uh, you have to take that into consideration cause next thing you know he's gonna come and have a, a blown out upper tract, so, um, So keeping that into consideration. I would probably um argue for a bladder neck closure in a patient who's gonna be compliant and who had uh an excellent method of emptying his bladder like that metrofenac, which I assume is working perfectly well. And uh this patient was interesting in that he was seeking care of a number, at a number of institutions. Um, so he likely had some follow-up during that period of time. It was just intermittent depending on the location. He's actually a fairly reliable patient that communicates regularly with one of our faculty and actually he's also the um local lead for the American Bladder Atrophy Consortium, um, in this area. So, um, with, um, having had the perineal urethrostomy, uh, the decision was made to try to do a perineal approach to this to help reduce the morbidity of having additional abdominal surgery, a larger operation in terms of a bladder neck closure. Um, so this patient ultimately underwent a takedown of the cutaneous ureterostomy, had urethral ligation distal to the vera montanum, and then placement of a suprapubic catheter, uh, for management. Um, unfortunately, um, things did not go as planned. So about 1 to 2 weeks after surgery, the patient developed a small opening near the base of the neopallus with drainage and elevated creatinine consistent with a recurrent fistula. Um, didn't have any signs of a, uh, surgical site infection, um, or infection in the neopallus at that time. Um, in follow-up, a cystogram was obtained after exchanging out the suprapubic tube and keeping it in for a prolonged period of drainage. Um, and again, it demonstrated, uh, persistent recurrent communication, um, between the, um, bladder neck area, um, into the proximal urethra, and then, um, cutaneously at the base of the neopallus. So, at this point, Failed bladder neck or failed urethral ligation, has a recurrent fistula. What would be your long-term management? Would you try an extended period of continuous bladder drainage, um, with the suprapubic catheter? Would you embark on repair of that urethra cutaneous fistula? Would you move forward with a bladder neck closure or none of the above? I mean that's a question for the audience as well as our, um, panelists. So, um, Are you, are we sure this leak is through the closure site, the ligation site, or just proximal to the litigation site? Is it just we left the stump that kind of pulling urine, or is it actually a failure of the ligation? So it looks like it's at the ligation site where the fistula is. So it's a failed ligation. Correct. Yeah, I mean, At this, I mean, have this, so let's kind of go over the, the, the choices again, um, Andrea, if you don't mind. Yeah. So if you leave an SP tube, that's not a long-term solution for obvious reasons. A young patient that want to be independent, uh, a lot of issues with crustation, infection, bladder irritation, and even cancer down the road with a long-term SP tube, that's not gonna be a good choice. Um, repair, we've done this several times, apparently, so that's kind of more kind of reinventing the wheel. I, I, I don't favor that option just because it's already failed twice. Uh, bladder neck closure, I would agree with the commissary with the, um, concern about the compliance of the patient with, you know, failing to self-catheterize. His bladder so far is stable. Um, So blood under the closure is an OK option with just making sure this patient is followed up and monitored. And I, I should add the option of incontinent diversion also. Um, I don't see why not. If we don't, if the patient is not reliable to catheterize himself. Um, then probably a diversion would be a choice as well. Anyone have any um additional thoughts on that or difference of opinion? No, I, you know, I think you're dealing with at least at the level beyond the bladder neck, you're dealing with some Bad tissue because it's recurred. Um, not that his bladder neck is gonna be the best tissue since he had a bladder atrophy, but, but certainly probably more robust than that. But making sure that you really get something down there to, to keep it from fistulizing cause uh I'd, I'd be pretty concerned about him developing a fistula there. And also, um, to Doctor Matty's point, and this is something that we're, um, We're very reluctant to do as pediatric urologist, but sometimes the answer is incontinent diversion. I'm not sure on this guy based on how you've discussed, you know, who he is and, and what he does, um, but I think, um, I think in some, in some patients, that's, that's the only answer. Um, And I hate, I hate saying that out loud because it makes me feel like, you know, um, as pediatric neurologists, we think that's failure. Um, but I have, at least in the adults, I've seen such relief when they get a bag. It's, it's like the weight of the world is taken off their shoulders cause it's not Is the channel gonna fail? Am I gonna leak? Am I gonna do this or that? They, they have an incontinent diversion and they're quite happy with it. So, um, uh, Rosalie, I would just try to echo, uh, we as pediatric urologists probably don't blink an eye on the use of a vesicostomy to allow a safe bladder at an early age, but yet we are In the same sentence, selling the temporary nature of it, and the The um The opportunity to convert it to a continent safe urinary reservoir. Um, but, uh, you and I have, and many of the audience members have also seen that same set of relief when the family no longer have to do every 3 hours continuous overnight drainage. And some of our pediatric patients never have their vesicostomy taken down. It is a very small minority. But I've even seen parents fearful. But a vasicostomy was made by somebody else, was told it was going to be reversed at school age, and they are not so excited to talk about closing a vasicostomy around school age cause they've enjoyed it so much. So, I think, uh, once again, we're all urologists and the kidneys are important to take care of. So, whether that's an incontinent or continent diversion, that's a surgical decision that has to be individualized, but Uh, Doctor Mondi brings up that point that maybe choice E. I should say, or D is none of the above is an incontinent diversion, but it's something to counsel families always as an option. Thank you. Um, so this patient ultimately elected to undergo a bladder neck closure. Um, as Doctor Masseri alluded to, it's important to be able to interpose healthy tissue to prevent another fistula, which was done with the rectus flap. Um, the fistula that had previously developed was actually maintained to allow for egress of prostatic and seminal secretions. Um, fistula resolved postoperatively. Um, the patient was dry, um, with intermittent catheterization, not having any issues. That being said, the patient now did not have any egressive prostatic or seminal secretions from that fistula and was actually particularly worried about that being an ongoing problem moving forward. Um, so in this scenario, would you now create a new path for egress of prosthetic or seminal secretions or kind of leave things as is, um, with the bladder neck closed? Well, do I have evidence of any collective secretions? I mean, perineal ultrasound or even a CT scan? I mean, if there's nothing in there, um, Um, no radiographic evidence of anything like that. Don't go looking for trouble. Yeah, I agree. I agree too. So, um, in this case, they, what they essentially did was just open the fistula and mature it to the skin, um, the epithelialized portion, and that seemed to work well for the patient. Um, so in follow-up, patient did not have any urinary incontinence, had good egress after that fistula rematured, and then he was also remaining sexually active with no, uh, specific complaints. So that's the end of our first case. Andrew, do you know how much time there was with no observed, cause like you said, once the fistula was matured, we, the secretions were observed. But I'm just curious, after the fistula was closed from the bladder neck there, with the bladder neck procedure, shall I say, how much time elapsed before the fistula maturation procedure was performed? Um, I would probably rely on his primary neurologist who's on the call to maybe fill in that information. OK. It was a couple of months. It was, it was a couple of months. He, he had a, he got another infection. Uh, OK. So something clinically led to the, uh, fistulization. OK, got it. Yeah. And, and, and when you say perineal, it was really sort of penis scrotal, um, because as you know, his urethra doesn't drop that deep down into the perineum. All right. So that's the end of our first case. Um, Doctor Matti had a couple of quick interesting cases that he wanted to present with the panel as well as the audience here. So I'm gonna stop sharing my screen and allow him to take over. Uh, how much time we actually have? I mean, we're approaching 12:30 just to sort of keep us stay on time. If you wanna take 10 minutes, so we'll, you know, we'll, we'll take 5 minutes away from lunch to make sure you can have time to discuss your cases. Um, you already see my slides? Yes, we can see him. Yep. Great. I mean, the two cases actually present a similar concept. Uh, of the multiple anomalies that we can face while we're treating a patient with congenitalism, um, with meningocele. I have a couple of disclosures. Uh, so, MJ is a 39 year old female who came with uh recurrent urinary tract infections and history of neurogenic bladder after meningiolocele. She reports 5 urinary tract infections over the last year, symptomatic with dysuria and smelly urine. And she failed a prior uh attempt for uh Bactrim prophylaxis. The question to Doctor Masseri, how do you approach recurrent TTIs in the setting of symptomatic recurrent TTIs in the setting of meningiolosele patients? With great disdain. Yeah, um, I, I, I have, uh, uh, I, I think I may have tried everything, uh. At least one time. So, um, uh, I do do gentamicin bladder irrigations. I do think that they work in some patients. Um, I have used phosphamycin in, in some patients for therapy. Um, when you talk to our infectious disease colleagues, they're quite, uh, resistant to the use of prophylactic antibiotic in this patient population. I, uh, the one thing that I think is very helpful is copious bladder irrigations even in patients who don't have, uh, a bladder augmentation with the hopes that, um, That it will help dilute some of the bacteria before it becomes uh pathologic. Um, it's really, like I said in my talk, the, the worst part of the job, um, I, the resistance patterns are, are just insane. Um, so I wish I had some magic for that. I've used antibiotic-coated catheters, um, You know, as long as their urodynamics don't don't show anything um that could be potentially um causing it or and that they don't have any stones on imaging, uh, it's really trial and error. I, I'm a big fan of irrigation, um, to help prevent them from happening, um, but it's um It, it's a big challenge and I think whoever figures that sorts out that is, is gonna make a big uh impact on the care of these patients. I, I agree. Um, so she also has history of neurogenic bladder after meningiomatocele and um she reports there is history of urine retention with self catheterization 7 times a day. Uh, she reported pain with urethral catheterization and she came with the mindset being ready for diversion. Uh, she also leaks between the self-catheterization even though the frequency is 7 times a day, and, um, um, she also reports some stress urinary incontinence, and she does have a terminal colostomy. Doctor van der Berk, uh, what are your indications for, um, urodynamics in those patients? Do you, do you do it annually, routinely, or you do it only if the symptom change or what's your protocol for that? Um, I think that, uh, you know, if I was seeing this patient for the first time, um, I would have um Gotten a baseline urodynamics and, you know, what I'm expecting to find from your history is that there's gonna be, you know, uh, I hope, a low leak point pressure given the stress urinary incontinence, but a catheter diary would help to also formulate if invasive urodynamics are done. Um, I think it's very important. I like when I can have an old Eurodynamics to compare to the one, because one would have imagined after 39 years on the planet, if she lived in the greater Cincinnati area, somebody had performed Eurodynamics previously, but, um, So my indications are she definitely has a Medical diagnosis that puts her at risk for lower urinary tract dysfunction and upper urinary tract. So, I would wanna get one if we made sure that there was no, say, bladder stone or some baseline imaging to make sure you're not doing urodynamics with a foreign body in there. That's great. The patient is an active smoker. She has a history of kidney stones, um, and has done urethroscopies and laser in the past. She does have past medical history of, um, asthma, sleep apnea, and hydrocephalus. Uh, on examination, she's a wheelchair-bound, uh, full range of motion of the upper extremities. She is not able to bear weight and a height of 4 ft 5 inches, BMI of 28, and she has a, a left side colostomy. Doctor Stein, what's your next step? Uh, you, you're mute. Um, like Doctor Vander Brink said, I think the next step is to get an understanding of the, um, bladder in terms of, um, uh, urodynamics and likely would get a video urodynamics. Um, so, our initial plan was to culture her urine, uh, perform video dynamics. We started, uh, anti-assarinic, and because of the history of stones, uh, and the possibility of urinary diversion, we obtained a CT scan as well. So this is our video study. Uh, luckily, there is no, no issue with the bladder compliance. She does have low maximum systematicc capacity, a trayarduser, and stress urinary incontinence. Uh, the cystogram on, on, uh, on the screen here shows the leaky urethra during, um, Valsalva test. And the tracing here shows the voiding phase or the attempt to void with Valsalva. Um, And the, we did a CT scan which showed a single ectopic pelvic kidney with the left ureter and uh if you look to the very right, the small bowel on the, on one side, the large bowel on the other side which diagnoses um malrotated bowel. Doctor Mairi, what are the most common neurological anomalies that you've seen with uh meningioocele and have you seen a lot of patients with marrotated bowel, and did that affect your decision if you're considering diversion? Mm. I have seen some fortunate, I, I think I saw more during fellowships than I have in practice, fortunately, um, and, uh, the The pediatric surgeons who would come in and, and consult at that time would just uh say, you know, continue, and we're talking about bladder augmentations not um And not, uh, ileal conduits or the like, but um, So I think I would probably just look for some good bowel to use um in that case. Uh, I mean, this is, this is a really tough Tough case because you have a patient who has stones. The next thing is you have a patient who has an incompetent bladder neck. And so You know, are you gonna do a cystectomy or are you gonna do an, an incontinent ileosicostomy with bladder neck closure which, um, in a patient who's prone to making stones, it might not be the best choice. Um, This is a, a pretty difficult, um, situation you have here, but I think this is one of the cases where having this information ahead of time, I would get the, the general surgeons on board or the colorectal guys on board before I went ahead and did a Did a diversion. But you said you had a terminal colostomy, right? Yes. So, I mean, I guess depending on how we're positioning in a wheelchair too, I mean, you could also consider if you're going to do a diversion, a left-sided, your like uh the deffunctionalized colon as your uh conduit for it. So you don't avoid, you avoid the small bowel and you just don't interfere with that too because it's already not functionalized. Yeah, that's what we did for this patient actually. Uh, we've discussed the three options. Um, I think we're running out of time. We'll discuss the three options, either to put a sling and perform Botox injection, but her, one of her problems is difficult catheterization through the urethra. So now that brought the second option of sling to kind of for the stress incontinence and bladder augment and catheterize the stoma, uh, which she declined. She is more leaning towards having some sort of incontinent diversion. She doesn't want to catheterize, period. And that's why we performed a colon conduit that's using the colostomy on the left as our conduit and then rerouting the proximal part of the colon to the right side to use that as a colostomy and this way we avoid bowel anastomosis. There were a couple of times. We found ample, uh, sigmoid colon that we're able to use like they call the, uh the Hartmann pouch. So we use that pouch for the colostomy, uh, sorry, for the colon conduit, leaving the colostomy alone, but with that, you have to have the two stomas on the same left side, which has been acceptable to patients given the advantage and benefit of avoiding massive bowel dissection, uh, because some of those patients who have VP shunt. We've said, we've seen a lot of adhesions at the shunt site and also the concern about contaminate contaminating that shunt tube. So we leave it alone where it is, uh, covered by scar tissue and adhesions. We don't tend to dissect over the tube and just work in an area that's kind of fresh and, uh, less adhesive. Uh, that's when we use the con sigmoid, uh, as an option. Um, I mean, I don't know, I don't think we have time for the next case. It's really a similar concept that the only difference is, um, that we, she didn't have a colostomy, so we ended up doing it in a condom for that patient. Um, and she does have, um, Sorry. I think it was a great way to use the existing stoma uh for just saying that's, you know, the patient, you, you probably already had a nice history of how the appliance fit on it and everything and what it healed. Um, because as you could say, it's sometimes a lot easier to mo, mobilize, you know, the, the fecal outlet than it is the urinary outlet, like the ureter and everything from that, so. Glad that your surgical colleagues could help donate the initial terminal colostomy to become the urostomy and just make another one. Doctor Matty, um, I had a question for you. So, um, in terms of incontinent diversions, um, when we're considering them, sometimes we consider doing an ileosicostomy. So we use a small segment of ileum and attach it to the dome of the bladder and bring it as a lower stoma versus a more traditional ileal or colon conduit. Um, I know we've had our issues in some patients that have had, um, a, had an ileo chimney or a colonic chimney, and the primary impetus for doing that is avoiding having to do any type of ureteral anastomosis. And for it to be a more simple, quicker procedure. Um, what's your experience with those two different types of, um, diversions, whether a chimney or a formal conduit? Very good question, very good point. So we avoid that procedure. Obviously it depends primarily on the gravity, drainage, and secondly on the prostasis of the piece of bowel. So if we're able to get that short, the shortest possible piece of bowel to utilize. In a good location on the patient's skin that allows for appliance without any issues with leakage, and therefore, we avoid that in obese patients or patients who have body deformity like this lady. In addition, uh, I agree with your point, avoiding ureterral anastomosis. She has a single ureter, not to, that's one thing, but also you're gonna have to address the outlet at the same time. Uh, so now you're gonna put a sling, you're gonna do a vasocostomy in a deformed patient, uh, or belly deformity like this that may come with an issue with the, uh, stoma appliance, and in the meantime, you still may not resolve the issue of recurrent UTIs because her bladder is flabby and acontractile that may not empty properly. If you do the ileal conduit or colon conduit, do you always leave the native bladder in place? So in men, I always remove it for the risk of piocytes. In women, I tend to leave it if there is uh ISD that will reassure or ensure bladder drainage without the concern about polycystis. I also leave it in patients who have radiation history, especially kind of increased body mass index. On those patients, the cystectomy can add to the morbidity of the procedure. Especially if they're not sexually active, they can always go and create a fistula between the bladder, ureter, and vagina to allow for those kind of creatures to come out, which is not an option in men, obviously. Overall, when we remove the bladder for benign reasons and given the luxury of the mice, new instruments that we can cauterize and cut at the same time, the cystectomy otherwise has not been a, a, a major uh morbid, morbidity in addition to the morbidity surgeries. So we use a quick procedure, uh, less blood loss than it used to be because we're removing it for a benign reason like simple cystectomy. But if there is radiation, increased body mass index, especially in women, I tend to leave the bladder. In men, I always remove it. OK. For her smoking history, is that another indication to try and take the bladder out so it's less to surveil. That's a good point. And also meningocelin, you know, has also increased risk for bladder cancer too, so she has multiple reasons, uh, why I removed the, the bladder in her case and with the history of recurrent infections and colonization, the risk of pious cyst is also kind of high. Well, thank you very much for uh listening to my case and uh I don't know if you have uh any questions. I'm Doctor Matty, this is, uh, Bob Deford. There was one question on the chat, uh, about the indications for a CT urogram in this patient. Um, and then just wanted a little more clarification on if, on if you felt it was very helpful in preoperative planning in this obviously complex patient with a Pelvic, kidney, and previous abdominal surgery. Certainly, so whenever I consider urinary diversion that involves urethral anastomosis, I always do a CT scan for two reasons. One is to rule out kidney stones or urethral stones that need to be addressed prior. Uh, just because of the axis, after the surgery will have to be an antegrade axis, otherwise. And secondly, because there's 1% chance for uh, a double ureter, I wanted to make sure I'm anastomosing a single ureter, um, not missing another ureter. Uh, so even though it's rare in the regular population, it could be even higher risk in patients who already have some congenitalism history. So whenever I'm considering diversion, I do CT scans. And to give me an idea about the bowel anatomy, especially the previous surgery, I mean, in these two patients, we've kinda diagnosed marrotated bowel, which kind of helped me, um, map my surgery and just uh see what we're getting at. Well, that was a great, uh, session, everyone. Thank you so much, Rosalia and, uh, Doctor Mahdi. Thank you for joining us and, uh, imparting us with your knowledge and experience. I'm sure the audience around the world found it very helpful too. And, uh, as I mentioned at the beginning, this is a, you know, this is an ongoing part of pediatric urology that we have to continue to develop and Really, it is our moral, ethical, and medical duty to ensure that these patients that we've cared for from birth until age 18 or 21, whatever the cutoff is in your institution, continue to get the level of care and access to care that they rightfully deserve. So it's something that we should all be on board with. Thank you. Thank you very much. I really appreciate it. Have a good day, everyone. Thank you.