Continent Bladder Research Articles

Simultaneous Robotic-Assisted Laparoscopy for Bladder and Bowel Reconstruction

Patients with neurogenic bladder frequently also have bowel dysfunction and a simultaneous urologic and colorectal reconstruction is possible. We present our experience with combined reconstructive procedures using robot-assisted laparoscopy, and demonstrate the utility of a minimally invasive approach that considers both the bowel and bladder management of these patients. We retrospectively reviewed all patients who underwent combined bowel and urologic reconstruction at our institution since the start of our multidisciplinary robotic program. Seven patients were identified in our cohort with a mean age of 6.4 years (3.8-10.1 years). Six patients had myelomeningocele and 1 had caudal regression. Malone appendicostomies were placed in all 7 patients. A split appendix technique was used as a conduit in 5 patients, in situ appendix in 1, and neoappendicostomy with cecal flap in 1. Six patients had a Mitrofanoff appendiceal conduit created, while 1 patient had a sigmoid colovesicostomy for urinary diversion. Five patients required bladder neck repair. One patient had stenosis of the Mitrofanoff and one patient had an anastomotic leak of the sigmoid anastomosis. The average operating time was 526 minutes (313-724 minutes). The median length of stay (LOS) was 5 days (4-7 days), excluding one outlier who suffered an anastomotic leak and had an extended LOS (50 days). All patients who underwent continent bladder reconstruction are dry on their current catheterizing regimen, 6/7 are clean with antegrade flushes. Patients with neurogenic bladder often have coexisting bowel dysfunction, which provides an opportunity to reconstruct both organ systems simultaneously and achieve social urinary and bowel continence. Before committing to any intervention, the surgeon should consider both the urologic and gastrointestinal needs of the patient, and perform the needed procedures simultaneously. We describe a number of combined operations aimed at bowel and bladder management that can be performed safely using robot-assisted laparoscopy.

Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction

To determine if intradetrusor injection of onabotulinumtoxin-A (BTX-A) would reduce postoperative narcotic and anticholinergic requirements in children undergoing open continent bladder reconstruction. After institutional review board approval, we retrospectively reviewed all bladder reconstructions performed. Bladder reconstruction was defined as the following procedures in any combination: bladder neck reconstruction and sling, bladder neck closure, Mitrofanoff, Monti, or bladder augmentation. We identified 15 children who underwent reconstruction with BTX-A injection and compared these with 15 children who did not receive BTX-A. Postoperative narcotic and anticholinergic requirements were recorded as well as length of stay, time to diet, time to return of bowel function, and complications. All medications were converted to morphine mEq/kg per day or mg/kg per day to standardize for patient size and length of stay. Thirty patients who underwent open bladder reconstruction were included. Fifteen received BTX-A injection and 15 did not. The BTX-A group required significantly less narcotic medication postoperatively compared with the no-BTX-A group (0.32 vs 0.85 morphine mEq/kg per day; P = .0002). The BTX-A group also required significantly less anticholinergic medication compared with the no-BTX-A group (0.22 vs 0.88 mg/kg per day; P = .024). There was no significant difference between the groups with respect to length of stay (98.27 vs 9.287 days; P = .34) or return of bowel function (5.53 vs 4.93 days; P = .994). Complication rate between the groups was similar (P >.99). Intraoperative injection of BTX-A significantly reduced postoperative narcotic and anticholinergic requirements in patients who underwent open continent bladder reconstruction. This is an encouraging alternative treatment to manage postoperative pain with no associated risk of significant complications.

Achieving urinary continence in cloacal exstrophy: The surgical cost

IntroductionCloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence. Materials and methodsA retrospective review of a prospectively maintained database of 1311 exstrophy epispadias complex patients was performed. Patients with CE who have had at least one continence procedure were included. A continence procedure was defined as bladder neck reconstruction with or without augmentation, bladder neck transection with continent urinary diversion, augmentation cystoplasty, or use of injectable bulking agents. Continence was defined as a dry interval greater than 3 hours without leakage at night. ResultsIn total, 140 CE and CE variant patients have been managed at the authors’ institution. Of the 116 CE patients, 59 received at least one continence procedure, 14 were excluded for incontinent diversion or cystectomy, and the remaining 43 patients are awaiting a continence procedure. At the time of analysis, 42 (71%) patients who underwent a continence procedure were dry. The median number of total urologic procedures to reach urinary continence was 4 (range 2–10). This included 1 bladder closure (range 1–3), 2 urinary continence procedures (range 1–4), and 1 (range 0–4) “other” genitourinary procedures. The median time to urinary continence was 11.0 years (95% CI [9.2–14.2]). ConclusionsA majority of CE patients who undergo a diversion procedure can achieve urinary continence. However multiple continence procedures are likely necessary. Of patients who are candidates for a continence procedure, half will be continent by the age of 11. Level of EvidenceLevel IV, Case series with no comparison group.

25-Year Experience with Replacement of the Human Bladder (Camey Procedure).

The Carney enterocystoplasty is a technique for constructing a functional, continent bladder in male patients following cystoprostatectomy for carcinoma. The technique is described and 84 patients treated during a 25-year interval are reviewed.

Pediatric Bladder Reconstruction

When medications and neuromodulation have failed to adequately treat pediatric bladders that are abnormal functionally or structurally, bladder reconstruction offers renal protection and the opportunity to achieve continence in carefully selected patients. Several surgical options, including incontinent and continent urinary diversion, bladder augmentation, and orthotopic neobladder, are available, using various bowel segments. Each has its own advantages, disadvantages, and complications based on the bowel segment’s physiologic properties. While there is no consensus regarding the optimal age for bladder augmentation, the key to ensuring better outcomes and patient compliance is extensive preoperative counseling and close monitoring for compliance with catheterization and bladder irrigation. Additionally, long-term follow up is necessary to monitor for metabolic and nutritional issues and, rarely, malignancy. New techniques, including bladder tissue engineering and robot-assisted laparoscopic ileocystoplasty, are being explored.

Reconstructive option after radical mutilating surgery in children with genitourinary rhabdomyosarcoma: When sparing the bladder is not an option.

To present versatile surgical reconstructive techniques and their outcomes in pediatric patients with genitourinary rhabdomyosarcoma. We retrospectively analyzed the oncological and urological outcomes of seven patients treated between 1992 and 2014 according to the Cooperative Weichteilsarkom Studiengruppe protocols. Intergroup Rhabdomyosarcoma Study staging: local, six patients; and IV, one patient. embryonal, five patients; unclassified, one patient; triton tumor one patient. Surgical treatment included: cystectomy, uterectomy and partial vaginectomy, one patient; radical cystectomy, two patients; cystectomy, one patient; cystectomy with partial prostatectomy, one patient; partial cystectomy, one patient; and partial prostatectomy, one patient. All patients were alive in complete remission at last follow up. In four cases, ileal conduit with ureteral reimplantation with serous-lined extramural tunnel (Abol-Enein technique) was carried out, which was followed by conversion into ileal continent bladder with continent appendiceal stoma for clean intermittent catheterization in three patients. In one boy, partial cystectomy and continent reconstruction was carried out during a single surgical procedure. One child with incontinent urinary diversion is still awaiting a continence solution. One child after partial prostatectomy is continent without any voiding disturbances. The timing and extent of radical surgery for treatment of genitourinary rhabdomyosarcoma depend on the local anatomical conditions, and the response to previous chemo- and radiotherapy. Cystectomy followed by various reconstructive techniques still remains an important option in the local treatment.

V7-04 MULTI-INSTITUTIONAL BLADDER EXSTROPHY CONSORTIUM: TECHNICAL STANDARDIZATION OF DISTAL EPISPADIAS REPAIR IN A BOY

You have accessJournal of UrologyPediatrics1 Apr 2016V7-04 MULTI-INSTITUTIONAL BLADDER EXSTROPHY CONSORTIUM: TECHNICAL STANDARDIZATION OF DISTAL EPISPADIAS REPAIR IN A BOY John Ward, David Chu, Jason Van Batavia, Aseem Shukla, Dana Weiss, Joseph Borer, Evalynn Vasquez, John Kryger, Travis Groth, Michael Mitchell, and Douglas Canning John WardJohn Ward More articles by this author , David ChuDavid Chu More articles by this author , Jason Van BataviaJason Van Batavia More articles by this author , Aseem ShuklaAseem Shukla More articles by this author , Dana WeissDana Weiss More articles by this author , Joseph BorerJoseph Borer More articles by this author , Evalynn VasquezEvalynn Vasquez More articles by this author , John KrygerJohn Kryger More articles by this author , Travis GrothTravis Groth More articles by this author , Michael MitchellMichael Mitchell More articles by this author , and Douglas CanningDouglas Canning More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.561AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Distal male epispadias is a relatively rare entity in the spectrum of exstrophy-epispadias complex. We present a video of a recent distal male epispadias repair that includes skin closure with a rotational skin flap as described by Salle. Preoperative videourodynamics had demonstrated a marginally continent bladder neck, but otherwise normal bladder function. METHODS Technique was male epispadias repair without osteotomy performed at 9 months of life. No pelvic diastasis was present. High-definition video recording was used for real-time local and remote observation and future teaching, analysis, and review as part of the Multi-Institutional Bladder Exstrophy Consortium (MIBEC). RESULTS Our video demonstrates the repair of a mid-shaft distal male epispadias. The penis was initially degloved with a dorsal incision that circumscribes the urethral plate. The corpus spongiosum was then carefully separated off the corpora cavernosal bodies ventrally before moving dorsally. The proximal extent of dissection was the penopubic junction. The corpus spongiosum with dorsal urethral plate was isolated on a vessel loop. Distally, glans wings were made. The glans was never completely disassembled from the corpora cavernosal bodies. A urethroplasty was performed over an 8F urethral stent, and then replaced with a 6F stent that was sutured in place. Next, the neo-urethra and neo-meatus were advanced distally and the urethral plate situated more ventrally. Glansplasty was performed followed by reapproximation of corpora cavernosal bodies dorsally over the urethra without significant medial rotation. Finally, a ventral transverse island penile shaft skin flap was rotated 270 degrees counterclockwise around the penis using the technique of Salle to form a lateral-lying suture line. Three months later the meatus appeared orthotopic and the repair had healed well, with the exception of a small noticeable scar at the location of the suture line of the Salle skin flap (Figure 1). CONCLUSIONS Distal male epispadias repair can be performed effectively in the setting of MIBEC. High-quality video recording of such rare repairs can aid in future teaching and review. The Salle skin closure offers promise to avoid a dorsal penile shaft scar but requires long-term outcomes. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e723 Advertisement Copyright & Permissions© 2016MetricsAuthor Information John Ward More articles by this author David Chu More articles by this author Jason Van Batavia More articles by this author Aseem Shukla More articles by this author Dana Weiss More articles by this author Joseph Borer More articles by this author Evalynn Vasquez More articles by this author John Kryger More articles by this author Travis Groth More articles by this author Michael Mitchell More articles by this author Douglas Canning More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Reconstructive techniques for creation of catheterizable channels: tunneled and nipple valve channels.

Cutaneous catheterizable channels allow for continent bladder emptying when an alternate route is desired. The goals of channel creation in the neurogenic bladder population are successful urine elimination, renal preservation, continence and lastly cosmesis. In addition to a particular surgeon’s comfort and experience with a given procedure, individual patient factors such as medical comorbidities, anatomic factors, and occupational function should be central to the selection of a surgical approach. An ideal channel is one that is short, straight, and well supported by associated blood supply and surrounding adventitia, so as to minimize difficulty with catheterization. Two types of channel continence mechanisms are discussed at length in this review—the tunneled channel, and the nipple valve. The appendicovesicostomy (Mitrofanoff), and reconfigured ileum (Yang-Monti) are both tunneled channels. The ileocecal valve is a commonly used nipple valve and provides continence when reinforced. The continent catheterizable ileal cecocystoplasty (CCIC) is an example of this channel technique. This method couples a tapered ileal limb as a catheterizable channel, the ileocecal valve as the continence mechanism, and the cecum and ascending colon as a bladder augmentation. While this procedure has higher perioperative complications relative to a simple tunneled channel, it has increased channel length flexibility and is also coupled with a bladder augment, which is completely performed using one bowel segment. Continent channel creation in adults can improve quality of life and minimize morbidity associated with neurogenic bladder. However, the decision to proceed with creation of a catheterizable channel should be made only after careful consideration of the patient’s medical comorbidities, physical abilities social support, and surgeon experience.

Blasenaugmentation und -ersatz bei Kindern und Jugendlichen

In children and adolescents, the indication for continent urinary diversion or bladder augmentation is rare. Today, for most patients with a neurogenic bladder, conservative treatment (clean intermittent catheterization [CIC] and pharmacotherapy) is the method of choice, while for patients with bladder exstrophy-epispadias complex (BEEC), primary reconstruction is recommended. Only after failure of conservative treatment or primary reconstruction should bladder augmentation or urinary diversion be considered. Other rare indications include patients with malignant tumor involving the lower urinary tract (e. g., rhabdomyosarcoma). In patients with a hyperreflexive, small capacity, and/or low compliance bladder with a normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. For those unable to perform CIC via the urethra, a continent cutaneous stoma should be offered. In patients with irreparable sphincter defects and normal renal function, a continent cutaneous diversion is an option and in those with a competent anal sphincter the rectosigmoid pouch can be offered. In this review, surgical options with their advantages and disadvantages are discussed.

Modified Cantwell-Ransley repair in penopubic epispadias with continent bladder

Modified Cantwell-Ransley repair in penopubic epispadias with continent bladder

Urinary diversion metabolic complications - underestimated problem.

Bladder cancer is one of the most frequent human cancers. In 2011 more than six thousand people in Poland developed BC and more than three thousand died because of it. Treatment of bladder cancer depends on its stage. In less advanced tumours (Ta, Tcis, T1) transurethral resection of bladder tumor with adjuvant immunotherapy is often therapeutic. In more advanced cases (≥ T2) radical cystectomy is needed. There are several surgical types of post-cystectomy urinary diversion divided into two fundamental types - enabling and not enabling urine continence. The most common procedures include ureterocutaneostomy, ileal or colon conduit, orthopic ileal bladder, heterotopic continent bladder replacement (pouch) and urinary diversion via the rectum. Depending on type of cystectomy, various metabolic complications occur, because the absorptive-secretory function of used bowel segment is intact. Complications include bowel dysfunction, malabsorption of various vitamins, acid-base imbalance, electrolyte imbalance, abnormalities in bone metabolism, formation of renal calculi, secondary malignancies and disturbances in function of kidneys or liver. Early diagnosed complications can be treated easier, recognised in advanced stages are often irreversible. In our paper we present review of different approaches to bladder cancer treatment and metabolic complications occurring after these procedures.

A real-life snapshot of the current trends of urinary diversion

Continent bladder substitution has substantially developed since its introduction nearly three decades ago. Although the ideal bladder substitute is yet to be developed, it has been well established that all patients undergoing radical cystectomy should be considered at least potential candidates for orthotopic urinary diversion 1. Notably, in many bladder cancer referral centres, including ours, orthotopic substitution has replaced ileal conduit as the primary form of reconstruction 2-4. However, this dissemination has not been noticed at the community level. The authors 5 provide a real-life snapshot of the current trends of urinary diversion on the nationwide level. Using the nationwide inpatient sample, they report significant underutilisation of continent urinary diversion after radical cystectomy; 92% of patients undergoing radical cystectomy received incontinent reconstruction. Nonetheless, they noticed a modest trend towards increased continent diversion in the later years of the study; however, the percentage is still far from expected. Moreover, the study reinforces previous findings of significant demographic disparities in receiving continent diversion. These disparities have become a persistent theme and have also been demonstrated in resource utilisation, oncological outcomes and access to minimally invasive surgery 6. Is it surgeons' bias or patients' choice? This issue is far from resolved. Undoubtedly, these disparities are to be addressed in healthcare policy planning, more research is also needed to investigate factors influencing the surgeon's decision-making process.

A Tribute to Nils G. Kock, 1924–2011

Nils Kock was born in Jakobstad, Finland. He graduated in 1951 from the University of Helsinki Medical School and began his surgical residency in Finland, but then spent 5 years in surgical training at the University of Gothenburg in Sweden, the institution with which he remained affiliated for his entire professional career. In 1959, he obtained his PhD from that university and assumed the position of Assistant Professor of Surgery. There followed a series of promotions, culminating in his appointment as Professor of Surgery in Gothenburg and Chairman of the Department of Surgery at Sahlgrenska University Hospital. In the 1960s, Dr. Kock became interested in developing a continent bladder using a reservoir made of the small intestine. There followed many experiments in canine and feline models, but in 1969, his highly elegant clinical investigations led to the development and the seminal manuscript on the intra-abdominal reservoir as an alternative to conventional ileostomy.

Differenzialindikationen für verschiedene Harnableitungsformen

When urinary diversion is indicated, patient information concerning the advantages and disadvantages of different types of urinary diversion and their choices is of utmost importance for the functional outcome and patient satisfaction. There is a variety of choices for incontinent urinary diversion (ureterocutaneostomy, ileal conduit, colonic conduit) and continent urinary diversion (continent anal urinary diversion, continent cutaneous urinary diversion and urethral bladder substitution). In the individual case, the choices may be limited by patient criteria and/or medical criteria. Important patient criteria are preference, age and comorbidity, BMI, motivation, underlying disease and indication for cystectomy. Medical criteria which possibly limit choices of type of urinary diversion are kidney function/upper urinary tract status and limitations concerning the gastrointestinal tract, concerning urethra/sphincter as well as the ability and motivation to perform intermittent self-catheterization. Preoperative information may use simulation of certain postoperative scenarios (urethral self-catheterization, fixation of water-filled conduit bags, holding test for anal liquids) to allow the individual patient to choose the optimal type of urinary diversion for his/her given situation from the mosaic of choices and possible individual limitations.

Osteotomia pélvica anterior bilateral para o fechamento de extrofia de bexiga: descrição de técnica

Bladder and cloacal exstrophy are rare malformations associated with abnormalities in the pelvis. The objectives in reconstruction are to obtain a closed and continent bladder, with an acceptable cosmetic appearance. Treatment for the abnormalities of pelvic anatomy is an important part of achieving successful treatment for these urological conditions. This article aims to describe the technique of bilateral anterior pelvic osteotomy for treating bladder and cloacal exstrophy, and presents two cases to demonstrate the difficulties and applications of the technique.

BILATERAL ANTERIOR PELVIC OSTEOTOMY FOR OLOSURE OF BLADDER EXSTROPHY: DESCRIPTION OF TECHNIQUE

Bladder and cloacal exstrophy are rare malformations associated with abnormalities in the pelvis. The objectives in reconstruction are to obtain a closed and continent bladder, with an acceptable cosmetic appearance. Treatment for the abnormalities of pelvic anatomy is an important part of achieving successful treatment for these urological conditions. This article aims to describe the technique of bilateral anterior pelvic osteotomy for treating bladder and cloacal exstrophy, and presents two cases to demonstrate the difficulties and applications of the technique.

A Comparative Study Between Continent Derivation and Bladder Neck Closure and Continent Derivation and Bladder Neck Reconstruction in Children

Purpose To assess the long-term outcome of continent diversion in children with structural or neurogenic cause for incontinence with special interest in differences between closed or open bladder neck. Material and Methods A cohort of 63 children with intractable incontinence treated with continent diversion between january 1998 and january 2008 was reviewed for underlying disease, type of surgery, complications and outcome. Results 40 patients have had a continent diversion with bladder neck reconstruction (group 1), 23 patients have had their bladder neck closed (group 2: 11 primarily closed=2A, 12 secondarily closed =Group 2B). There was no difference in patient's characteristics, in surgical complications or reinterventions or in stone formation ( table 1 ). The continence rate however was significantly better in group 2 (95.7% vs 78.5%). Table 1 . Surgical interventions following continent diversion with and without BN closure. Closed BN (n=23) #procedures (#patients) Open BN (n=40) #procedures (#patients) p-value Cystotomy for stones 2 (2) 3 (3) Ns Endoscopic stone treatment 4 (3) 6 (4) Ns Bladder neck revision 4 (4) 3 (3) Ns Open revision for stomal stenosis 6 (4) 13 (8) Ns Endoscopic revision for stomal stenosis 1 (1) 7 (5) Ns External stomal orifice revision 6 (5) 11 (8) Ns Revision for stomal leakage 2 (1) 7 (6) Ns Other related surgery (augmentation, ureter reimplantation, bladder perforation, …) 7 (2) 11 (10) Ns Total 31 (14) 61 (16) P=0,04 Conclusions In children treated with a continent diversion for intractable incontinence, bladder neck closure as primary or as salvage procedure does not result in extra morbidity and has high success ratio. Good urodynamic evaluation of bladder function is an important key to success in therapy planning for these children and thus minimizing the need for reintervention.

Updated Experience With the Monti Catheterizable Channel

The Monti catheterizable channel is used as an integral part of continent bladder reconstruction in children. We have updated our ongoing experience at Riley Children's Hospital with 199 patients. We identified 199 patients for retrospective review, including all patients for whom a Monti ileovesicostomy was created from January 1997 to August 2004. We assessed the complications, surgical procedures, and stomal continence. At mean follow-up of 28 months, we found that 194 of 199 patients (97.5%) continued to use their Monti catheterizable channel for bladder drainage. Early surgical complications occurred in 7 patients (3.5%), usually in those who had undergone simultaneous bladder augmentation (5 of 7). Revision was required in 16 patients (8%) for stomal stenosis (n = 11), prolapse (n = 2), or superficial stomal problems (n = 3). Of the 199 patients, 17 (8.5%) required 19 bladder or channel revisions. The primary indications were related to elongation and angulation of the channel in 7 and deficient tunnel length in 8. Minor difficulty with catheterization was noted in 16 patients (8%), and endoscopy with minor procedures was required in 4 patients (2%). Leakage from the channel was uncommon, occurring in only 4 of 115 patients (3.5%). With increasing demand for simultaneous appendicocecostomy for stool continence at bladder reconstruction, we continue to use the Monti ileovesicostomy for bladder drainage. Our experience with nearly 200 patients has demonstrated the durability and success of this technique.

Continent Catheterizable Channels and the Timing of Their Complications

We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications. A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%. Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis. Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

Factors that influence outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive procedures in children.

Surgical techniques that provide adequate urinary and fecal continence in children with neurogenic bladder and bowel dysfunction are becoming increasingly used. We reviewed our experience and discuss factors that influence outcome. Between 1994 and 2000, 65 stomal procedures were performed in 47 patients. For the urinary continent catheterizable channel we used appendix in 60% of cases, a continent bladder tube in 20%, a Yang-Monti tube in 16% and ureter in 4%. For the antegrade continence enema continent catheterizable channel we used appendix in 85% of cases, a Yang-Monti tube in 5% and a cecal tube in 10%. In the 19 patients who underwent simultaneous Mitrofanoff and antegrade continence enema procedures the urinary continent catheterizable channel was appendix in 21%, a Yang-Monti tube in 32% and continent vesicostomy in 47%. Patients were divided into 2 groups based on compliance status. In addition, percentile body weight for age was evaluated. Stomal continence was achieved in 63 of the 65 cases (97%). Of the patients who underwent the antegrade continence enema procedure 95% achieved continence via the rectum. Except for ureter stenosis rates according to continent catheterizable channel type did not differ greatly, namely 19% for appendix, 11% for the Yang-Monti tube, 22% for the bladder tube, 50% for ureter and 0% for the cecal tube. Infectious complications developed in 16 patients and 4 had stones. The rates of infection (p = 0.004), stomal stenosis (p = 0.001) and revision (p = 0.004) were statistically lower in the compliant group and the stone formation rate showed a trend favoring the compliant group (p = 0.11). No significant difference was noted for incontinence. Percentile weight predicted a higher rate of stomal stenosis with the highest rate of stomal stenosis overall in the greater than 100th percentile group. The Mitrofanoff and antegrade continence enema procedures are reliable and effective. Proper patient selection and surgical technique with a tension-free anastomosis are essential. The choice of tissue for constructing the continent catheterizable channel is not as important as patient compliance, age and possibly body habitus. This report reinforces the importance of careful screening, and rigorous preoperative and postoperative teaching to achieve overall patient success.