Columbus, OH - November 2016
Pediatric bladder neck closures are commonly performed with a transabdominal approach, since they are often paired with Mitrofanoff and other abdominal procedures. The location of the bladder deep within the pelvis can make for a challenging dissection, however.
Two cases at Nationwide Children’s Hospital – in which children were to undergo a number of procedures, including anorectoplasty and bladder neck closure – have allowed urologists to use a posterior sagittal approach for the closures. They appear to be the first procedures performed this way in children with anorectal malformations.
“We are used to working on patients from ‘above’, and visualization of the bladder neck is often difficult,” says Venkata (Rama) Jayanthi, MD, chief of Urology at Nationwide Children’s and senior author of a publication describing the cases in the journal Urology. “These patients were undergoing other procedures that allowed for an approach from ‘below.’ We found it much easier than performing the bladder neck closure through the abdomen.”
This was only possible because of the Section of Urology’s close collaboration with colorectal surgeons in the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s, says Dr. Jayanthi. Every patient evaluation through the center includes a urologic evaluation.
“If not for the center, there could have been two separate surgeries on each patient,” explains Dr. Jayanthi, who is also a clinical professor of Surgery in the Department of Urology at The Ohio State University College of Medicine. “One would have been colorectal, and one urological.”
The patients were girls, 7 and 10 years old, with histories of urinary incontinence and numerous other complex medical conditions. Each had each undergone multiple interventions to treat those conditions before referral to the Center for Colorectal and Pelvic Reconstruction.
One year after the bladder neck procedures, the 10-year old remained dry with clean intermittent catheterization every four hours. Mild urine leakage occurred when there were prolonged times between catheterizations or in times of excessive activity. The 7-year old has achieved complete urinary continence with catheterization.
Dr. Jayanthi makes clear that these are rare cases. Bladder neck closures are only contemplated after multiple failed attempts at traditional management, and a primary posterior sagittal approach in patients who have normal colorectal function would be inadvisable. This approach may also be more challenging in boys because of the proximity of the ejaculatory ducts and the potential risks to fertility. In boys, it may be prudent to approach bladder neck closure from “above.”
These cases would not have been successful at all, though, unless urologists and colorectal colleagues were communicating from the beginning.
“If you are a urologist, and you have a child with complex urinary incontinence, you should speak to a colorectal surgeon before you do anything,” Dr. Jayanthi says. “I think the same is true for colorectal surgeons, who should reach out to urologists. These children are better served in a collaborative system where all involved discuss and plan together. We feel this approach may lead to better outcomes.”
Preece J, Wood RJ, Lane VA, Levitt MA, Jayanthi VR. The posterior sagittal approach to bladder neck closure in patients with anorectal malformation: a novel collaborative technique. Urology. 2016 Sep; 95:184-6.