JU INSIGHT Dextranomer Endoscopic Injections for Urinary Incontinence in Bladder Exstrophy-epispadias Complex

By: Venusia Fiorenza, MD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France; Maria Hukkinen, MD, PhD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France, Children’s Hospital, Helsinki University Hospital and University of Helsinki, Finland; Ilona Alova, MD, PhD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France; Pauline Clermidi, MD, Armand Trousseau Children’s University Hospital, Paris, France; Aline Broch, MD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France; Nathalie Botto, MD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France; Thomas Blanc, MD, PhD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France, AP-HP Centre, Université de Paris, France; Henri B. Lottmann, MD, PhD, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France | Posted on: 17 Mar 2023

Fiorenza V, Hukkinen M, Alova I, et al. Dextranomer endoscopic injections for the treatment of urinary incontinence in bladder exstrophy-epispadias complex. J Urol. 2023;209(3):591-599.

Study Need and Importance

To treat urinary incontinence related with bladder exstrophy-epispadias complex (BEEC), passive peripheral resistance can be increased surgically by bladder neck reconstruction (BNR). However, none of the described techniques guarantees success and BNR may result to loss of volitional voiding. Since bladder neck dextranomer/hyaluronic acid copolymer (Dx/Ha, Deflux) injections can improve urinary incontinence of various etiologies, we hypothesized that incontinent children with BEEC would benefit from Dx/Ha. We analyzed Dx/Ha efficacy and predictors of treatment success in BEEC.

What We Found

Incontinent BEEC children aged >4 years undergoing Dx/Ha injections in our hospital between October 1997 and January 2021 were included (n=58; 27 male epispadias, 9 female epispadias, 22 bladder exstrophy). After single (n=25) or multiple (n=33) injections, patients were categorized as “dry,” “significantly improved,” or “failure” (see Figure). Median age at injection was 8.5 years (interquartile range 5.8–12). Previous BNR had been performed in 38 (66%) and complications occurred in 9. In Kaplan-Meier analyses, 5-year failure-free survival was 70% (standard error [SE] 9.1) and dry survival 44% (SE 9.7) in male epispadias compared to 45% (9.0) and 23% (SE 7.5) in females and exstrophy patients (P = .04 and .02, respectively). Previous BNR associated with improved 5-year failure-free survival in females and exstrophy patients (58%, SE 11) but not in male epispadias (75%, SE 11). In Cox regression, older age predicted improved failure-free survival (P = .006) while higher pre-injection bladder capacity improved dry survival (P = .02).

Figure. Flow diagram of dextranomer/hyaluronic acid injections. Reinjections were proposed to patients who showed some improvement in continence after the first treatment session but could not be classified as success. Continence status after the latest injection was registered for the study analyses.

Limitations

This study is limited by the heterogeneity of patients as well as some missing bladder capacity results.

Interpretation for Patient Care

Dx/Ha injections provided satisfactory and lasting continence in over half of BEEC patients. While injections were successful in male epispadias regardless of BNR timing, results were better in bladder exstrophy and female epispadias after previous BNR.