Continent Catheterizable Channel Research Articles

Extravesical Implantation of a Continent Catheterizable Channel

Extravesical ureteral reimplantation provides results equivalent to those of the open technique with the advantage of less postoperative morbidity from a large cystotomy. Surgical series describing the technique and efficacy of extravesical implantation of continent catheterizable channel are lacking. We reviewed our results to determine the efficacy of this technique with an emphasis on continence and the need for revision. We reviewed the records of 394 patients who underwent a bladder continent catheterizable channel procedure from 1999 to 2009. Operative records describing an extravesical technique were noted. Briefly, a 3 to 6 cm incision is made in the detrusor and seromuscular flaps are created. The continent catheterizable channel is laid in the tunnel and the flaps are brought anterior to the channel and sutured to each other. Fixation of the bladder wall to the abdominal wall preserves tunnel length and minimizes the risk of angulation. The type of continent catheterizable channel, stomal continence and the need for revision were recorded. The extravesical implantation technique of a continent catheterizable channel was done in 84 of 394 patients (21%). The channel was an appendix in 47 cases and Monti ileovesicostomy in 37. Stomal continence was achieved in 79 of 84 cases (94%). At a mean followup of 45 months 22 patients (26%) required a total of 30 surgical revisions, of which most were skin level or endoscopic procedures at a mean of 26 months after channel creation. The extravesical technique for continent catheterizable channel implantation is effective. If intravesical surgery is not necessary, avoidance of a large cystotomy and longer operative time may expedite postoperative recovery when using an extravesical implantation technique to create a continent catheterizable channel.

Long-Term Followup and Time to Event Outcome Analysis of Continent Catheterizable Channels

Creation of a continent catheterizable channel has facilitated the treatment of patients undergoing lower urinary tract reconstruction. We present outcomes and complications of a single center series of continent catheterizable channels followed out to 15 years. We retrospectively reviewed medical records of all children who underwent continent catheterizable channel (Mitrofanoff and Monti) between 1992 and 2007. Collected data included age, underlying diagnosis, associated procedures, stoma site, conduit type (appendix or reconfigured bowel), time to complications and need for subsequent surgical revisions. We identified 71 girls and 98 boys who underwent surgery at a mean age of 7.5 years (range 6 months to 22 years) and were subsequently followed for a mean of 5.8 years (8 months to 15 years). Underlying diagnoses included neurogenic bladder (36% of patients), bladder exstrophy (25%), epispadias (6%) and posterior urethral valves (6%). Concurrent procedures were conducted in 71% of cases, including augmentation (35%) and bladder neck plasty (22%) or closure (8%). Surgical revision was performed in 39% of patients, including stomal revision (18%), redo operation (8%), bulking agent injection (8%) and prolapse correction (4%). Although an initial peak was followed by a relatively stable complication-free period, delayed problems were detected on long-term followup. No statistically significant differences in complication rates were noted when comparing use of appendix and reconfigured bowel or different stoma locations. Despite an initial decrease in complications soon after continent catheterizable channel creation, late problems appeared on long-term evaluation. In our experience no specific factor predicted the likelihood of complications. Nevertheless, despite the need for surgical revision, good functional outcomes were evidenced in this series.

1191 RESULTS OF A SPLIT APPENDIX TECHNIQUE FOR CONCOMITANT CREATION OF MITROFANOFF AND MALONE CONTINENT CATHETERIZABLE CHANNELS

You have accessJournal of UrologyPediatrics: Reconstructive Surgery1 Apr 20111191 RESULTS OF A SPLIT APPENDIX TECHNIQUE FOR CONCOMITANT CREATION OF MITROFANOFF AND MALONE CONTINENT CATHETERIZABLE CHANNELS Alice Payton, Shumyle Alam, William Defoor, Eugene Minevich, Pramod Reddy, Paul Noh, and Curtis Sheldon Alice PaytonAlice Payton Cincinnati, OH More articles by this author , Shumyle AlamShumyle Alam Cincinnati, OH More articles by this author , William DefoorWilliam Defoor Cincinnati, OH More articles by this author , Eugene MinevichEugene Minevich Cincinnati, OH More articles by this author , Pramod ReddyPramod Reddy Cincinnati, OH More articles by this author , Paul NohPaul Noh Cincinnati, OH More articles by this author , and Curtis SheldonCurtis Sheldon Cincinnati, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.824AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary tract reconstruction in children with complex urologic abnormalities can be challenging. We have previously reported the technique of splitting the appendix to create both a Mitrofanoff neo-urethra as well as a Malone anterograde continence enema. The purpose of this study is to report our experience and longterm outcomes with this technique. METHODS A retrospective cohort study was performed of all children and young adults who underwent continent urinary reconstruction who had their Mitrofanoff and Malone created using a split appendix technique at a single pediatric institution from 1990 to 2010. Patient demographics, surgical technique, complications, and clinical outcomes were abstracted from the medical record. The distal end of the appendix was used for the Mitrofanoff and was implanted into the bladder using an extravesical technique and the stoma matured in the right lower quadrant in all cases. The proximal end of the appendix was used for the Malone and the stoma was brought to either the umbilicus or right lower quadrant. RESULTS A total of 40 patients (22 male and 18 female) were identified. Mean age at the time of reconstruction was 7.0 years and mean follow-up was 4.0 years (range 1–13 years). Diagnoses included myelomeningocele (21), anorectal malformation and cloacal anomalies (13), tethered cord and spinal cord abnormalities (6). There were no intra-operative complications or loss of the appendix due to vascular accident. Mitrofanoff outcomes included stomal stenosis in 5 patients, false passage in 2, and mild incontinence in 2. Mitrofanoff stomal revision for stenosis was required in 4 patients. Malone outcomes included stomal stenosis in 8 patients, fecal leakage in 3 patients, traumatic false passage in 2 patients, and prolapse in one patient. Revision of the Malone stoma was required in 3 patients. In addition, stenosis of the Malone was treated with topical steroids in 2 patients, dilation in 2 patients, and temporary Mic-key button placement in 1 patient. CONCLUSIONS Creation of continent catheterizable channels for both Mitrofanoff neo-urethra and Malone can be safely and effectively performed using a split appendix technique with an extravesical reimplantation into the bladder. This avoids harvesting additional enteric tissue for purposes of a Monti-mitrofanoff or a neo-appendicostomy. A bowel anastomosis is also avoided when an augmentation is not indicated. Stomal complications are not insignificant however, and comprise the majority of complications for this procedure. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e478 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alice Payton Cincinnati, OH More articles by this author Shumyle Alam Cincinnati, OH More articles by this author William Defoor Cincinnati, OH More articles by this author Eugene Minevich Cincinnati, OH More articles by this author Pramod Reddy Cincinnati, OH More articles by this author Paul Noh Cincinnati, OH More articles by this author Curtis Sheldon Cincinnati, OH More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Continence Outcomes in Patients Undergoing Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy

Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence.

Clean Intermittent Catheterization (CIC) in Children Through Continent Catheterizable Channel: A Developing Country Experience

Purpose To evaluate the role of CISC through continent cathetrizable channel (mitrofanoff) in an augmented bladder in children with bladder dysfunction/outlet obstruction managed in a public sector hospital of a developing country. Material and Methods This is a retrospective analysis of 126 patients managed between 2001 and 2008. Patients belong to urban, periurban and rural areas of various part of whole country with diverse ethnic, cultural, linguistic, poor socioeconomic and low educational backgrounds. Results We present our data of 126 patients, age ranged between 21/2 to 15 years, male female ratio of 1.5:1.0, with various congenital and acquired causes of bladder dysfunction/ outlet obstruction including Neurogenic bladder, Non Neurogenic Neurogenic bladder, Posterior Urethral Valve, Exstrophy Epispadias complex, traumatic stricture urethra and Genitourinary Tuberculosis. These patients had augmentation cystoplasty using different bowel segments. The continent catheterizable channel “mitrofanoff channel” was made using appendix in 108 cases while in 18 “spiral Montii” method was used. A stoma was created by VQZ technique in 116 patients while concealed umbilical stoma was made in 10. Complications included superficial wound infection in 9 patients, subacute intestinal obstruction in 6 patients which was resolved by conservative treatment, acute intestinal obstruction, bladder calculus and stomal stenosis in 6, 10 and 3 patients respectively. More than 90% patients showed good compliance and are under regular follow up as per advice of treating team. Conclusions In a developing country setting with low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of paediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance. To evaluate the role of CISC through continent cathetrizable channel (mitrofanoff) in an augmented bladder in children with bladder dysfunction/outlet obstruction managed in a public sector hospital of a developing country. This is a retrospective analysis of 126 patients managed between 2001 and 2008. Patients belong to urban, periurban and rural areas of various part of whole country with diverse ethnic, cultural, linguistic, poor socioeconomic and low educational backgrounds. We present our data of 126 patients, age ranged between 21/2 to 15 years, male female ratio of 1.5:1.0, with various congenital and acquired causes of bladder dysfunction/ outlet obstruction including Neurogenic bladder, Non Neurogenic Neurogenic bladder, Posterior Urethral Valve, Exstrophy Epispadias complex, traumatic stricture urethra and Genitourinary Tuberculosis. These patients had augmentation cystoplasty using different bowel segments. The continent catheterizable channel “mitrofanoff channel” was made using appendix in 108 cases while in 18 “spiral Montii” method was used. A stoma was created by VQZ technique in 116 patients while concealed umbilical stoma was made in 10. Complications included superficial wound infection in 9 patients, subacute intestinal obstruction in 6 patients which was resolved by conservative treatment, acute intestinal obstruction, bladder calculus and stomal stenosis in 6, 10 and 3 patients respectively. More than 90% patients showed good compliance and are under regular follow up as per advice of treating team. In a developing country setting with low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of paediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance.

Renal Transplant in Children with Lower Urinary Tract Dysfunction: A Developing Country Experience

Purpose Paediatric transplantation is challenging in many ways, especially so when it is performed in patients with history of lower urinary tract dysfunction. We report our experience of Paediatric renal transplants with and without lower urinary tract dysfunction. Material and Methods 300 Paediatric (2-18 years) living related renal transplants (LRRTX) were performed between 1986 and 2008. Among them twenty had (significant) lower urinary tract dysfunction, majority including posterior urethral valves and non neurogenic neuropathic bladders. Of the twenty, 16 had undergone augmentation cystoplasty using various bowel segments and mitrofanoff continent catheterizable channel and were trained for CISC prior to LRRTX. Pre transplant native kidney nephrectomies were performed in four patients for optimization. Results Average age of the patient was 14 years. One year and five year graft survival in both groups were similar, 92% and 80% respectively. Acute rejection episodes were 23%. Chronic rejection (63%) and infections were the main causes of graft losses. Recurrent urinary tract infection was the major complication encountered in patient with augmented bladders performing CISC. One patient needed redo ureteroneocystostomy. All graft ureters were reimplanted in native bladder. Post transplant, native kidney nephrectomy was needed in one patient because of pyonephrosis. Conclusions Renal transplantation provides equally good graft and patient survival even in patients with history of lower urinary tract abnormalities, at least in short term. However, frequent urinary tract infection carries a high risk for the graft.

Determinants of Success and Failure of Seromuscular Colocystoplasty Lined With Urothelium

Seromuscular colocystoplasty lined with urothelium is a method of bladder augmentation that avoids incorporating intestinal mucosa into the urinary tract. Others have reported a repeat augmentation rate of 23%. We analyzed the results in 20 patients who underwent the procedure, as performed by one of us (RG), at 3 institutions. After receiving institutional review board approval we retrospectively reviewed the charts of all patients operated on since 1998. Preoperative and postoperative bladder capacity at 30 cm H(2)O, expressed as the percent of expected capacity for age using the equation, bladder capacity in ml = (age +1) x 30, as well as prior, concomitant and subsequent bladder or bladder neck procedures, continence and the need for repeat augmentation were recorded. There were 20 patients, including 7 females, with a mean age at surgery of 9 years and a mean followup of 53 months. All patients had neurogenic bladder dysfunction. An artificial urinary sphincter was implanted at the time of seromuscular colocystoplasty in 10 patients, preoperatively in 6 and postoperatively in 1. A sling was used in 3 females. Patients were divided into 2 groups. The 15 group 1 patients underwent no concomitant procedure in the bladder and the 5 in group 2 underwent creation of a continent channel at seromuscular colocystoplasty. There were no failures of augmentation in group 1, in which bladder capacity increased from 60% of that expected for age to 100%. All patients were continent. Three of the 5 patients in group 2 required repeat augmentation. Seromuscular colocystoplasty lined with urothelium has proved to be an effective method to augment the bladder in patients who have an artificial urinary sphincter or who undergo simultaneous artificial urinary sphincter implantation. We do not recommend constructing a continent catheterizable channel at the time of seromuscular colocystoplasty lined with urothelium.

Bulbar urethral ligation for managing persistent urinary incontinence in young men with myelomeningocele

To report our experience with ligation of the bulbar urethra for treating refractory stress incontinence in a selected group of young men with neuropathic bladders secondary to myelomeningocele (MM), in whom primary anti-incontinence procedures had failed. Persistent urethral incontinence leading to chronic perineal skin ulceration can occur in these patients, despite aggressive medical and surgical efforts to decrease wetting by increasing bladder capacity, compliance and outlet resistance. Four young men with MM had bulbar urethral ligation; all had undergone a previous ileocystoplasty and functioning continent catheterizable channels (CCC, three appendicovesicostomies, one Monti procedure). Three patients had primary bladder neck procedures using rectus fascia slings, and secondary attempts were made at urethral bulking in two patients. All patients had persistent incontinence through their native urethra, with dry intervals of <2 h. The bulbar urethra was ligated through a small midline perineal incision at 1 year after augmentation, and successfully resolved incontinence in all four patients. All reported satisfaction with their bladder regimen at a mean (range) follow-up of 49 (20-93) months. There were no perineal wound infections. While one patient developed bladder calculi, no patient developed urethral stones, febrile urinary tract infections, fistulae or bladder perforations. We report the results of bulbar urethral ligation for resolution of incontinence in patients with MM in whom anti-incontinence bladder neck procedures had failed. Ligation of the urethra is effective, and can be considered an alternative treatment for refractory urinary incontinence in patients with a functional CCC in whom previous bladder neck-supporting procedures have failed.

The Use of an Antegrade Continence Enema Stopper in Catheterizable Channels Virtually Eliminates the Incidence of Stomal Stenosis: Preliminary Experience

We report the effectiveness of an antegrade continence enema stopper device in preventing stomal stenosis in catheterizable channels. All cases in which a channel was created for clean intermittent catheterization during a 5-year period beginning in May 2002 were included in the analysis. For the first 31 months the catheterizable channels were used for clean intermittent catheterization but were not kept patent between catheterizations (group 1, 19 patients). For the next 29 months we began to use an antegrade continence enema stopper in the stoma between catheterizations for a period of 3 to 6 months postoperatively (group 2, 14 patients). A total of 33 catheterizable channels were studied. Six catheterizable channels in group 1 (32%) had to be revised within 6 months of reconstruction. No catheterizable channel in group 2 had to be revised. This difference is statistically significant (p = 0.02). An antegrade continence enema stopper inserted into the catheterizable channel for 3 to 6 months postoperatively effectively eliminates the incidence of stomal stenosis.

Clean Intermittent Catheterization in Children Through a Continent Catheterizable Channel: A Developing Country Experience

We evaluated the role of clean intermittent self-catheterization through a continent catheterizable Mitrofanoff channel in an augmented bladder in children with bladder dysfunction and outlet obstruction. We retrospectively analyzed the records of 82 patients treated at a public sector hospital with pediatric urology services in a developing country. Patients came from all provinces of the country with diverse ethnic, cultural, linguistic, socioeconomic and educational backgrounds. Mean +/- SD patient age was 9.07 +/- 3.38 years (range 2.5 to 15) with a male-to-female ratio 2.5:1.0. The main congenital and acquired abnormalities were posterior urethral valves in 29% of patients, neuropathic bladder in 22%, nonneurogenic neurogenic bladder in 17%, exstrophy plus epispadias in 10% and urethral stricture in 7%. Augmentation cystoplasty was performed using various bowel segments. The Mitrofanoff channel was made using appendix in 70 cases and by the spiral Monti method in 12. A stoma was created in the right iliac fossa using VQZ plasty in 72 patients and an umbilical stoma was created in 10. Complications included bladder calculus in 3 patients, stomal stenosis in 2, subacute intestinal obstruction in 4 and acute intestinal obstruction in 1. Compliance was observed in greater than 90% of the patients at a mean followup of 860 days. In a developing country setting with a low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self-catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of pediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance.

Complications of the Catheterizable Channel Following Continent Urinary Diversion: Their Nature and Timing

We reviewed the incidence, nature and timing of complications related to the catheterizable channel following continent urinary diversion. We retrospectively reviewed the records of 67 patients who underwent continent urinary diversion at British Columbia Children's Hospital from 2000 to 2006. Catheterizable channels included 54 Mitrofanoff appendicovesicostomies and 13 ileovesicostomies. Medical records were reviewed for predetermined complications and their timing, that is early -12 months or less, or late - more than 12 months. At a median followup of 28 months (range 3 to 62) a total of 17 complications were identified in 14 patients (21%). Superficial cutaneous stenosis developed in 4 of 67 cases (6%) as an early and as a late complication. These cases were initially treated with operative dilation and surgical revision as necessary. Channel stricture, which developed in 4 of 67 patients (6%) as an early and as a late complication, was treated with operative revision in 2 and endoscopic resection in 2. Three patients (5%) had stomal prolapse, which was generally a late occurrence and required operative revision in all. Channel leakage developed in 6 of 67 patients, presenting as an early complication in 50%. Endoscopic injection of bulking agents was attempted in 4 of these patients and it was successful in 2. Overall 82% of complications were successfully managed by endoscopic or superficial procedures. Complications of the catheterizable channel are a frequent and challenging problem. They appear to occur throughout the life of the channel with most developing within the first 2 years. Further followup is required to assess the performance and durability of continent catheterizable channels in children as patients progress to adulthood.

Endoscopic management of polyps in a urinary continent catheterizable channel

We report a case of polyps in a urinary continent catheterizable channel that were endoscopically resected with the holmium laser. An 11-year-old boy underwent lower urinary tract reconstruction, along with a continent catheterizable channel. Due to persistent problems catheterizing, he underwent an endoscopy which revealed multiple broad-based polyps in his channel. These polyps were resected completely with the holmium laser without complication. The polyps were benign on final pathological examination. Follow-up endoscopy 4 weeks later revealed a healthy channel with no residual polyps. The patient has had no difficulties catheterizing in the interim. To our knowledge, this is the only report published of using the holmium laser to resect polyps in a urinary catheterizable channel.

Laparoscopic Robot-Assisted Appendicovesicostomy: An Initial Experience

To describe our initial experience with laparoscopic robot-assisted appendicovesicostomy (LRAA). We have performed the LRAA in three patients, aged 9, 17, and 45 years. The underlying medical conditions were myelomeningocele, prune-belly syndrome, and multiple sclerosis. Adjuvant procedures consisted of extensive lysis of adhesions and a bladder-neck fascial sling. All procedures were completed intracorporeally. The mean blood loss was 50 mL. The mean operative time was 301 minutes (range 203-362 minutes). The mean hospital stay was 3 days (range 2-4 days). Follow-up ranges from 1 to 8 months. All patients currently catheterize without difficulty and are continent. In our initial experience, LRAA is a safe and effective option for creating a continent catheterizable channel into the urinary bladder.

Cirugía robótica en urología pediátrica

To review the use of robotic surgery in pediatric urology and provide a platform from which discussions regarding this technology can arise. The available literature and the experience at the author's institution were reviewed to examine the applications of robotic surgery in pediatric urology. MEDLINE was queried using the following key words: robot, robotic, laparoscopy, surgery, child, and pediatrics. The available literature is comprised mainly of case reports and case series. Two groups have published small analyses comparing robotic assisted laparoscopic pyeloplasty and open pyeloplasty. At our institution, we have utilized the daVinci robotic surgical system to perform the following surgical procedures: orchidopexy of the intraabdominal testis, total and partial nephrectomy, dismembered pyeloplasty, pyelolithotomy, excision of calyceal diverticula, ureteroureterostomy, ureteropyelostomy, intra- and extravesical ureteral reimplantation, megaureter' tapering and reimplantation, adrenelectomy, creation of a Mitrofanoff continent catheterizable channel, and resection of pelvic Mullerian remnants. Robotic surgery in pediatric urology is an evolving technology that holds promise for application to most urological surgeries. Refinements in equipment will improve the efficiency of these systems. Ultimately, the efficacy and role of robotic surgical systems need to be defined with rigorous prospective studies that provide comparisons to gold standard techniques, be they open surgery or conventional laparoscopy.

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

Objective Continent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang–Monti) and site of implantation (augmentation vs. native bladder) on outcome. Patients and methods A retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon). Results There were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang–Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang–Monti CCC ( P = 0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder ( P = 0.3). The majority of revisions were at skin level. Conclusions Although there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.

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.

Simplified Technique to Create a Concealed Catheterizable Stoma: The VR Flap

We describe a surgical modification of VQZ plasty, the VR flap. In addition to avoiding skin surface mucosal prolapse and preventing stenosis, this procedure is easier to describe and perform. A total of 12 patients (4 males and 8 females) 6 to 14 years old (mean age 11.6) underwent simultaneous creation of a continent catheterizable channel using the Mitrofanoff principle and MACE procedure. VQZ plasty was modified by using a quadrilateral flap positioned at a 90-degree angle from the V flap instead of immediately next to it. The quadrilateral flap is used to create a skin channel allowing the use of a shorter conduit and avoiding exposed mucosa. The modification creates a linear closure. A total of 24 CCCs (Mitrofanoff 12, MACE 12) were done simultaneously in 12 patients. Of the channels 12 were implanted in the umbilicus (CCC 6, MACE 6) and 12 in a stoma created by the VR flap. There were no significant complications. One patient required surgical revision and 1 required stomal dilation for stomal stenosis. All patients were continent through all channels. Mean followup was 18 months. This modification offers good cosmetic and functional results, and the outcome compares favorably with other series. The procedure is easy to understand and perform, and its application is not limited by the thickness of the abdominal wall. Moreover, it allows for an easier closure and limits the Z-shaped appearance of the closure.

Antegrade enemas for the treatment of severe idiopathic constipation.

The technique of appendicocaecostomy produces a continent catheterizable channel through which colonic washouts are given. This procedure was performed on six women of mean age 33.5 years with severe idiopathic constipation (mean stool frequency less than 1 per week) resistant to medical therapy. All patients had prolonged colonic transit times, three had evidence of obstructed defaecation and all had reduced or absent voluntary anal squeeze pressure. Patients found the appendicocaecostomy and catheterization acceptable, and symptoms of abdominal distension and pain resolved. All patients were able to initiate defaecation and evacuate the colon within 1 h of irrigation, and no patient had appreciable incontinence. Irrigation was necessary every 48-72 h. Adults with intractable constipation and pelvic floor weakness would be at risk of faecal incontinence after ileorectal anastomosis; it is in these patients that appendicocaecostomy has potential for the greatest benefit.

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.

SEROSAL LINED EXTRAMURAL TUNNEL (GHONEIM) PRINCIPLE IN THE CREATION OF A CATHETERIZABLE CHANNEL IN BLADDER AUGMENTATION

The flap valve mechanism is often the preferred technique for creating a continent catheterizable channel in bladder reconstruction. The umbilicus is usually the preferred site for stomal placement. However, it is not always possible to bring the conduit to the umbilicus when creating the flap valve mechanism at the bladder level. To prevent this problem, we applied the Ghoneim technique to construct the flap valve mechanism during ileal bladder augmentation. A total of 10 patients (7 boys and 3 girls) 5 to 17 years old underwent ileocystoplasty in combination with an appendiceal Mitrofanoff procedure as a catheterizable channel. The U-shaped ileal segment was anastomosed to the bivalve native bladder, leaving redundant bowel on the right side. The musculomucosal edges of the redundant bowel were sutured together, forming the posterior wall of the tunnel. The appendix was positioned onto the musculomucosal suture line, and the proximal end was anastomosed to the reservoir with an advancement suture. The ileal segment was then imbricated over the appendix by interrupted silk sutures, forming a serosal lined extramural tunnel. The stoma was placed at the depth of the umbilicus. The underlying diagnoses included mylomeningocele (8) and posterior urethral valve (2). Mean followup time was 12.5 months (range 7 to 21). All patients were continent, and there were no stoma related complications such as stenosis or difficult catheterization. The Ghoneim technique creates an effective continence mechanism and allows the conduit to reach the umbilicus easily.