You are prohibited from using or uploading content you accessed through this website into external applications, bots, software, or websites, including those using artificial intelligence technologies and infrastructure, including deep learning, machine learning and large language models and generative AI.
No AccessJournal of UrologyPediatric Urology1 Oct 2011

Screening for Malignancy After Augmentation Cystoplasty in Children With Spina Bifida: A Decision Analysis

    View All Author Information


    Augmentation cystoplasty is the mainstay of surgical treatment for medically refractory neurogenic bladder in patients with spina bifida. Concerns regarding an increased risk of malignancy have prompted many centers to consider routine postoperative screening. We examine the potential cost-effectiveness of such screening.

    Materials and Methods:

    A Markov model was used to compare 2 screening strategies among patients with spina bifida after cystoplasty, namely annual screening cystoscopy and cytology and usual care. Model parameters were informed via a systematic review of post-augmentation malignancy and cost estimates from published reports or government sources.


    In a hypothetical cohort the individual increase in life expectancy for the entire cohort was 2.3 months with an average lifetime cost of $55,200 per capita, for an incremental cost-effectiveness ratio of $273,718 per life-year gained. One-way and two-way sensitivity analyses suggest the screening strategy could be cost effective if the annual rate of cancer development were more than 0.26% (12.8% lifetime risk) or there were a greater than 50% increase in screening effectiveness and cancer risk after augmentation. After adjusting for multiple levels of uncertainty the screening strategy had only an 11% chance of being cost effective at a $100,000 per life-year threshold or a less than 3% chance of being cost effective at $100,000 per quality adjusted life-year.


    Annual screening for malignancy among patients with spina bifida with cystoplasty using cystoscopy and cytology is unlikely to be cost effective at commonly accepted willingness to pay thresholds. This conclusion is sensitive to a higher than expected risk of malignancy and to highly optimistic estimates of screening effectiveness.


    • 1 : What is the need for additional bladder surgery after bladder augmentation in childhood?. J Urol2006; 176: 1801. LinkGoogle Scholar
    • 2 : Augmentation cystoplasty rates at children's hospitals in the United States: a pediatric health information system database study. J Urol2006; 176: 1716. LinkGoogle Scholar
    • 3 : Secondary malignancies in different forms of urinary diversion using isolated gut. J Urol2004; 172: 831. LinkGoogle Scholar
    • 4 : Malignancy associated with the use of intestinal segments in the urinary tract. Urol Oncol2007; 25: 165. Google Scholar
    • 5 : The use of annual endoscopy and urine cytology for bladder tumor surveillance following enteric augmentation cystoplasty. J Urol2009; 181: 403. LinkGoogle Scholar
    • 6 : Villous adenoma in augmentation colocystoplasty: a case report and discussion of the pathogenesis. J Urol1992; 147: 128. LinkGoogle Scholar
    • 7 : Long-term results of augmentation cystoplasty. Eur Urol1998; 34: 40. Crossref, MedlineGoogle Scholar
    • 8 : Bladder augmentation: complications in the pediatric population. Curr Urol Rep2007; 8: 152. Google Scholar
    • 9 : The risk of malignancy after cystoplasty. Curr Opin Urol1993; 3: 476. Google Scholar
    • 10 : Problem of secondary malignancy after urinary diversion and enterocystoplasty. Scand J Urol Nephrol1992; 142: 56. Google Scholar
    • 11 : Carcinoma as a late complication of ileocystoplasty for tuberculous bladder. Ann Urol (Paris)2003; 37: 33. Google Scholar
    • 12 : Cost-Effectiveness in Health and Medicine. In: . New York: Oxford University Press1996: xxiii. Google Scholar
    • 13 : Transitional cell carcinoma of the bladder following augmentation cystoplasty for the neuropathic bladder. J Urol2004; 172: 1649. LinkGoogle Scholar
    • 14 : Late malignancy in bowel segments exposed to urine without fecal stream. Urology1995; 46: 657. Google Scholar
    • 15 : Long-term follow up of enteric bladder augmentations: the risk for malignancy. J Pediatr Urol2008; 4: 381. Google Scholar
    • 16 : Tumor in bladder reservoir after gastrocystoplasty. J Urol2007; 178: 1771. LinkGoogle Scholar
    • 17 : Metastatic adenocarcinoma after augmentation gastrocystoplasty. J Urol2008; 179: 1094. LinkGoogle Scholar
    • 18 : A critical analysis of perioperative mortality from radical cystectomy. J Urol2006; 175: 886. LinkGoogle Scholar
    • 19 : Comparative effectiveness and health care spending—implications for reform. N Engl J Med2010; 362: 460. Google Scholar
    • 20 : Toward consistency in cost-utility analyses: using national measures to create condition-specific values. Med Care1998; 36: 778. Google Scholar
    • 21 : Impact of prostate cancer testing: an evaluation of the emotional consequences of a negative biopsy result. Br J Cancer2010; 102: 1335. Google Scholar
    • 22 : Preferences for surveillance strategies for women treated for high-grade precancerous cervical lesions. Gynecol Oncol2010; 118: 108. Google Scholar
    • 23 : Benefits and costs of using HPV testing to screen for cervical cancer. JAMA2002; 287: 2372. Google Scholar
    • 24 : Anaplastic signet ring cell carcinoma arising in gastrocystoplasty. Urology2005; 65: 1226.e4. Google Scholar
    • 25 : Malignancy after gastrointestinal augmentation in childhood. Ther Adv Urol2009; 1: 5. Google Scholar
    • 26 : Should we screen for bladder cancer in a high-risk population?: A cost per life-year saved analysis . Cancer2006; 107: 982. Google Scholar
    • 27 : Detection of bladder cancer using a point-of-care proteomic assay. JAMA2005; 293: 810. Google Scholar
    • 28 : Colonoscopic perforations: a review of 30,366 patients. Surg Endosc2007; 21: 994. Google Scholar
    • 29 : Perforation of the augmented bladder in patients undergoing clean intermittent catheterization. J Urol1988; 140: 1159. LinkGoogle Scholar

    Department of Urology, Children's Hospital Boston and Harvard Pediatric Health Services Research Fellowship Program (JCR), Harvard Medical School, Boston, Massachusetts