Trauma/Reconstruction/Diversion Pregnancy and Delivery in Women with Lower Urinary Tract Reconstruction: A National Multicenter Retrospective Study from the French-Speaking Neuro-Urology Study Group (GENULF) and the Neuro-Urology Committee of the French Association of Urology E. Bey,* Q. Manach, B. Peyronnet, A. Even, E. Chartier Kastler, R. Walder, A. Ruffion, M. Baron, A. Charlanes, X. Biardeau, V. Quenneville, B. Boillot, C. Duport, T. Tricard, C. Saussine, X. Game, G. Capon, J. Kerdraon, J. N. Cornu, C. Garabedian, L. Le Normand, B. Perrouin-Verbe, V. Phe and M. A. Perrouin-Verbe From the Department of Urology (EB, LLN, MAP-V), Hoˆ tel-Dieu Hospital, University of Nantes, Nantes, France, Department of Urology (QM, ECK, VP), Pitie-Salpetri ere Academic Hospital, Paris 6 University, Paris, France, Department of Urology (BP), University of Rennes, Rennes, France, Department of Neuro-Urology and of Physical Medicine and Rehabilitation (AE), Raymond Poincare Hospital, Garches and Versailles Saint-Quentin en Yvelines University (AE), Versailles, France, Gynecology and Obstretrics Department (RW), Croix-Rousse Hospital, University of Lyon, Lyon, France, Department of Urology (AR), Lyon Sud Hospital-Pierre-Benite, University of Lyon, Lyon, France, Department of Urology (MB, JNC), University of Rouen, Rouen, France, Department of Physical Medicine and Rehabilitation (AC), Tenon Academic hospital, Paris 6 University, Paris, France, Department of Urology (XB), University of Lille, Lille, France, Department of Urology (VQ), Boulogne-Billancourt Hospital, Paris, France, Department of Urology University of Grenoble (BB), Grenoble, France, Department of Urology (CD), University of Dijon, Dijon, France, Department of Urology (TT, CS), University of Strasbourg, Strasbourg, France, Department of Urology (XG), Rangueil Hospital, University of Toulouse, Toulouse, France, Department of Urology (GC), University of Bordeaux, Bordeaux, France, Department of Physical Medicine and Rehabilitation of Kerpape (JK), Ploemeur, France, Department of gynecology and obstetrics (CG), University Hospital of Lille, Lille, France, and Department of Physical Medicine and Rehabilitation (BP-V), Saint-Jacques Hospital, University of Nantes, Nantes, France Purpose: Management of pregnancy and delivery in women with lower urinary Abbreviations tract reconstruction is challenging and the currently available literature is and Acronyms insufficient to guide clinical practice. We report pregnancy and delivery out- [ comes in this specific population. AE augmentation enterocystoplasty Materials and Methods: We conducted a national multicenter retrospective study AUS [ artificial urinary sphincter (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation CCC [ catheterizable channel enterocystoplasty, catheterizable channel creation and/or artificial urinary creation sphincter implantation. Maternal and fetal complications during pregnancy and LUTR [ lower urinary tract delivery were reported, as well as postpartum functional outcomes, according to reconstruction the delivery mode. The chi-square test and Student’s t-test were used to compare SCI [ spinal cord injury categorical and continuous variables, respectively. UTI [ urinary tract infection Results: Overall 32% of reported pregnancies were complicated by febrile urinary WA [ weeks of amenorrhea tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% Accepted for publication June 18, 2020. No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. * Correspondence: Department of Urology, CHU-Universite de Nantes, 1 place Alexis Ricordeau, 44000 Nantes, France (telephone: þ33673358799; FAX: þ33220083922; email: [email protected]). Editor’s Note: This article is the third of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1391 and 1392. 0022-5347/20/2046-1263/0 https://doi.org/10.1097/JU.0000000000001233 THE JOURNAL OF UROLOGY® Vol. 204, 1263-1269, December 2020 Ó 2020 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. www.auajournals.org/jurology j 1263 Copyright © 2020 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited. 1264 PREGNANCY AND DELIVERY AFTER LOWER URINARY TRACT RECONSTRUCTION of deliveries. Delivery mode (p[0.293) and multiparity (p[0.572) had no impact on urinary continence. Conclusions: In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women. Key Words: urinary sphincter, artificial; urinary diversion; delivery, obstetric THE management, treatment options and care given voiding mode, continence (urinary and fecal), parity, preg- to women with neurological disease or born with a nancy and delivery outcomes, and postpartum data complex urological malformation have dramatically (including continence). improved in recent decades. A growing number of Statistical Analysis these women now reach adulthood with good quality Data are expressed as mean and SD or frequency and of life and a desire for childbearing, although this percentage for continuous and categorical variables, has often been eluded in the past and was often respectively. Statistical significance was set at p <0.05. considered a complete fantasy in view of the wom- The chi-square test and Student’s t-test were used to an’s disability. Nevertheless, it is difficult to change compare categorical and continuous variables, respec- misconceptions about the incidence of fetal malfor- tively. When the application conditions were not met we mations and parental abilities.1,2 used Fisher’s exact test for categorical variables and Management of pregnancy and delivery in women Wilcoxon’s test for continuous variables. The normality of with a history of lower urinary tract reconstruction is the distribution was verified by the Shapiro-Wilk test. We challenging. Recent studies have allowed a more used analysis of variance (ANOVA) to compare means among 3 groups. Statistical analysis was performed using reassuring position in relation to maternal and fetal R Studio software V.1.0.143. issues of pregnancy in this situation while high- lighting the frequent complications that may occur, including febrile urinary tract infections, urinary RESULTS incontinence, self-catheterization and urinary diver- Population sion difficulties, therefore requiring special medical Overall 68 women with a total of 96 deliveries be- 1,3e11 attention. As no evidence-based recommenda- tween 1998 and January 2019 were included. Median tions can be drawn from the available literature, we age at delivery was 29 (18-39). Patient characteristics conducted this study in order to assess morbidity and are summarized in table 1. All women performed functional outcomes of pregnancy and delivery in a intermittent self-catheterization. Fifty percent of cohort of women with neurogenic bladder or bladder women had spinal dysraphism, 30% had SCI and 15% exstrophy, and a history of AE, CCC (Monti or had bladder exstrophy. One woman with bladder Mitrofanoff principle) and/or artificial urinary exstrophy had a bicornuate uterus and another sphincter. woman had undergone complex vaginoplasty. Most women had undergone AE (92.6%), 27 (39.7%) MATERIALS AND METHODS of whom had undergone concomitant CCC. At the Study Design and Population beginning of pregnancy 13 women (19%) were treated We conducted a national retrospective study in 16 tertiary with anticholinergic drugs and 14 (20%) received bot- referral centers after obtaining French data protection ulinum toxin injections for overactive bladder. agency approval to collect the available historical data The majority of these women were continent before (CNIL No. 2207432). We included all women older than 18 pregnancy, in terms of urine (91%) and feces (84%). years with a neurological disease (spinal dysraphism, SCI Urological followup was disrupted at adolescence for or multiple sclerosis) or bladder exstrophy, and a history of many of these women. Urodynamic data before AE, CCC and/or AUS implantation, who reported at least 1 pregnancy were often missing and/or too scarce to be successful pregnancy. These techniques imposed them- reported, with mostly a gap of almost 10 years be- selves as the international standard of care in the man- tween pregnancy and the last complete neuro- agement of many neuro-urological diseases for adults able urological assessment. to perform intermittent self-catheterization, justifying the special attention given to their consequences on pregnancy Pregnancy Outcomes and delivery. Women who underwent concomitant bladder A total of 45 women (55.5%) received antibiotic pro- neck closure, bladder neck reconstruction and/or fascial sling were also included in the