Continent Channel Research Articles

The exstrophy experience: A national survey assessing urinary continence, bladder management, and oncologic outcomes in adults

The bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of congenital genitourinary malformations with an incidence of 1:10,000 to 1:50,000. Advances in reconstructive surgical techniques have improved clinical outcomes, but there is a paucity in data about disease sequela in adulthood. This is the largest survey to date in the United States exploring the urinary continence, bladder management, and oncologic outcomes in adults with BEEC. Respondents were over the age of 18 with a diagnosis of bladder exstrophy, cloacal exstrophy, or epispadias. They were treated at the authors' institution, included in the Association for the Bladder Exstrophy Community (A-BE-C) mailing list, and/or engaged in A-BE-C social media. A survey was created using uniquely designed questions and questionnaires. Survey responses between May 2020 and July 2020 were processed using Research Electronic Data Capture (REDCap). Quantitative and qualitative statistics were used to analyze the data with significance at p<0.05. A total of 165 patients completed the survey. The median age was 31.5 years (IQR 25.9-45.9). Many patients considered themselves continent of urine, with a median satisfaction score of 74 (IQR 50-97) on a scale from 0 (consider themselves to be completely incontinent) to 100 (consider themselves to be completely continent). There was less leakage among those with a continent urinary diversion compared to those who void or catheterize per urethra (p=0.003). Patients with intestinal-urinary tract reconstruction, such as augmentation cystoplasty or neobladder creation, were more likely to perform bladder irrigations (p=0.03). Patients with continent channels were more likely to report UTI than all other forms of bladder management (89.0% vs. 66.2%, p=0.003). Three (1.9%) patients were diagnosed with bladder cancer. A small portion of patients (27.2%) were given bladder cancer surveillance recommendations by a physician. Most patients achieved a satisfactory level of urinary continence, with the highest continence rates in those with a continent urinary diversion. Those with intestinal-urinary tract reconstruction were more likely to perform bladder irrigations, perhaps to avoid complications from intestinal mucous production. The rates of self-reported UTI and were higher in patients with continent channels, but recurrent UTIs were not affected by the type of genitourinary reconstruction. Bladder cancer exists in this population, highlighting the need for long-term follow-up. Most BEEC patients achieve a satisfactory level of urinary continence, with the best outcomes in those with a continent urinary diversion. This population requires long-term follow-up with a transitional urologist to ensure adequate oncologic care.

Simultaneous placement of fecal and urinary continent channel stomas in the umbilicus: Single-center experience

In patients with urinary continent channel (UCC) and Malone Antegrade Continent Enema (MACE) procedures, two separate abdominal stomas are needed. The umbilicus is a preferred site for single channel stomas given the ability to conceal the stoma. However, there are no studies describing outcomes of both stomas being created in the umbilicus. We aimed to describe our experience in patients who underwent UCC and MACE stomas both placed in the umbilicus. A retrospective review from 2009 to 2020 was performed in our institution for patients who underwent the creation of UCC and MACE stomas simultaneously in the umbilicus. The variation in the technique involves two V-skin shaped flaps in the umbilicus; the MACE and UCC stomas are delivered from both flaps and placed at the right and left side respectively. Patients with greater than 3 months of follow-up were included in the study. There were 17 patients identified with the median age of 13.5 years and a median follow-up of 32.8 months. The mean BMI percentile was 89.5%. Monti technique and split appendix with cecal extension were utilized in 8 (47.1%) and 7 (41.2%) patients respectively and 13 (76.5%) patients required concurrent urological procedures. All channel-related complications occurred within a mean time of 15.7 months. Skin-level stenosis in the MACE occurred in 5 (29.4%) events, and all were successfully managed by placing an indwelling catheter for up to two weeks. There were 2 (11.8%) complications related to UCC, which required subfascial minor surgical revision. The rate of patients with symptomatic UTI decreased 35.3% postoperatively, and no new onset of UTI occurred in patients without a prior history of UTI. During follow-up, all patients remained dry between CIC, however one had occasional leakage related to delay in catheterization. Total fecal continence was achieved in 14 (82.3%) patients. Additionally, 3 (16.6%) patients experienced improvement in fecal continence with sporadic soiling episodes. Placement of UCC and MACE stomas in the umbilicus demonstrate a percentage of complication of 7/34 (20.6%) with only 2 patients requiring surgical intervention, comparable to the standard. UTI rate decreased in patients with a prior history of UTI. We believe the patients' perspective and degree of satisfaction will fully determine the benefits of this technique. Simultaneous UCC and MACE stomas placed at the umbilicus showed good functional outcomes and similar complication rates to traditional approach where stomas were placed separately in the abdominal wall.

Évaluation à long terme des cystostomies continentes de type Mitrofanoff chez l’adulte : résultats à 5 ans

This study analyzed long-term functional outcome of continent catheterizable channels with the Mitrofanoff procedure, their continence, complications and the satisfaction of the patients. Data from patients who underwent a Mitrofanoff procedure at our institution from June 1997to March 2015were retrospectively collected. All patients were contacted at the end of the study, a survey was submitted to them. Sixty-seven patients underwent a continent cystostomy with the Mirtrofanoff procedure. Forty-five patients had the inclusion criteria: 18years old or older, no previous urinary diversion with a minimum of 6months of follow-up. The cohort comprised mainly neurologic bladder (84%) with spinal cord injuries (54%) or spina-bifida patients (15%). Median age was 35years old [22-49]. Median follow-up was 64months [39-90]. The surgical procedure used an appendicular channel: 30patients (67%) or a continent ileal plasty: 15patients (33%). At the end of follow-up: 88% patients have a full cystostomy continence, 89% full uretral continence. Twenty-nine patients had one (41%) or more reinterventions. Reasons for the 58reinterventions were: stomal stenosis (31%), uretral incontinence (29%), cystostomy incontinence (15%), lithiasis (9%). Those reinterventions were done with a local surgery (31%) or an endoscopic surgery (35%). Overall early adverse events (<30days) or delayed (>30days) adverse events were similar (P=0.93) in appendicovesicostomy group or continent ileal plasty group. Ninety-four percent patients described a satisfactory urinary comfort. The cystostomy was considered esthetic by 71%, its realization allowed an improvement of the quality of life for 89% of them. Continent channels in adults demonstrate favorable long-term outcomes even if reinterventions could be necessary to maintain a continent and catheterizable channel. Despite reinterventions, patients remain satisfied by the Mitrofanoff procedure which facilitate the process of clean intermittent catheterization. 4.

Dérivations urinaires continentes trans-conduit selon Mitrofanoff chez l’enfant : suivi à long terme et complications spécifiques

In children, intermittent catheterization by appendicovesicostomy according to Mitrofanoff is an interesting alternative to the urethral approach. Objective of the study was to evaluate the rate of appendicovesicostomy's specific complications. From 1997 to 2017, data on children treated and followed for an appendicovesicostomy in an academic institution were collected retrospectively. Rates of surgical complications specifically encountered on appendicovesicostomy, time of onset, frequency, and necessity of surgical reinterventions have been reported. Thirty-four patients were operated on and followed for a median of 6.2 years [0.3-24]. Fifty percent had a complication, occurring after a median of 8 months [2-90], and 38% required at least one surgical revision. If complication occurred, adjustment of medical treatment and intermittent catheterization was effective in 12% of patients, endoscopic or over-fascial surgery was necessary in 17% of cases, and under-fascial revision in 21% of cases. Median time to complication was 4 months [1-90] after creation or revision of appendicovesicostomy. Thirty-height percent of difficult channel catheterization were reported, of which 46% were over or under-fascial stenosis. Inaugural urinary incontinence was 18%, and only 9% if using the appendix. At the end, 97% of appendicovesicostomy were continent. Appendicovesicostomy is a high risk of complications and postoperative revisions surgery, in order to have a functional continent channel. 4.

Outcomes of revision surgery for difficult to catheterize continent channels in a multi-institutional cohort of adults.

The study aimed to describe the strategies of surgical revision for catheterizable channel obstruction and their outcomes, including restenosis and new channel incontinence. We retrospectively queried the charts of adults who underwent catheterizable channel revision or replacement from 2000-2014 for stomal stenosis, channel obstruction, or difficulty with catheterization at the Universities of Minnesota, Michigan, and Utah. The primary endpoint was channel patency as measured by freedom from repeat surgical intervention. Secondary endpoints included post-revision incontinence and complication rates. Revision surgeries were classified by strategy into "above fascia," "below fascia," and "channel replacement" groupings. A total of 51 patients who underwent 68 repairs (age 18-82 years old; mean 45) were identified who met our inclusion criteria. Channel patency was achieved in 66% at a median 19 months post-revision for all repair types. There was no difference in patency by the type of channel being revised, but there was based on revision technique, with channel replacement and above the fascia repairs being more successful (p=0.046). Channel incontinence occurred in 40% and was moderate to severe in 12%. The type of channel being revised was strongly associated (p=0.003) with any postoperative channel incontinence. Surgical complications occurred in 29% of all revision procedures, although most were low-grade. Surgical revision of continent catheterizable channels for channel obstruction can be performed with acceptable rates of durable patency and incontinence; however, the surgeon needs to have experience in complex urinary diversion and familiarity with a variety of surgical revision strategies.

Laparoscopic Appendicostomy Low-Profile Balloon Button for Antegrade Enemas in Children.

The Malone appendicostomy is a continent channel used for antegrade enemas. It requires daily cannulation and is susceptible to stenosis. We use an indwelling low-profile balloon button tube inserted through the appendix into the cecum for antegrade enemas. We hypothesized that this method is effective at managing constipation or fecal incontinence and is associated with a low rate of stenosis. Children who underwent laparoscopic appendicostomy balloon button placement at our institution from January 2011 to April 2017 were identified. The primary outcome was success in managing constipation or fecal continence as measured by the Malone continence scale. Postoperative complications were analyzed. Thirty-six children underwent the procedure, 35 of which met the inclusion criteria. Thirty-one patients (88.5%) underwent the operation for idiopathic constipation, 3 patients (8.6%) for anorectal malformation, and 1 patient (2.9%) for hypermobility. Rate of open conversion was 3%. A full response was obtained in 24 patients (68.6%), partial response in 9 patients (25.7%), and 2 patients failed (5.7%). One patient developed an internal hernia requiring laparotomy and later developed mucosal prolapse. One patient developed a stricture noted at button change. Seven patients (20%) underwent reversal of their appendicostomy tube: 5 due to return of normal bowel function and 2 due to discomfort with flushes. A laparoscopic appendicostomy with a balloon button tube is an effective means of addressing chronic constipation or fecal incontinence. The stenosis rate associated with tube appendicostomy may be lower than those reported for Malone antegrade continence enema procedures.

Flow characteristics of urethral catheters of the same caliber vary between manufacturers

Clean intermittent catheterization (CIC) is frequently prescribed for bladder dysfunction, either per urethra or via a continent catheterizable channel. Small catheters may be required for infants or continent channels. Success with CIC is highly dependent upon patient and family compliance. The urinary flow rate through the catheter is an important factor, which can decrease CIC time and improve quality of life. There is little objective information regarding flow rate through urinary catheters to guide catheter recommendation or prescription. Clinically, we noted that there was a difference in flow among catheter brands, and we questioned if catheters of the same-labeled diameter exhibit the same flow characteristics, which could have implications for catheter selection. Twenty-one commercially available male pediatric urinary catheters from nine brands were tested (11 straight tip, 10 coude tip). Nine of the 21 tested catheters had a hydrophilic coating. All tested catheters shared a 10F outer diameter. For each, microscopic imaging and a precision caliper were used to measure the inner diameter and tip inlet area. A hydraulic system modified from ASTM standard testing specifications was used to simulate bladder catheterization. Measurement of each catheter was repeated five times using three different static hydraulic pressures (20, 40 and 50cmH2O). Catheter flow rate and structural measurements were identified and the fastest and slowest of the catheters are presented in the table. The variable flow rates between brands were due to the differences in catheter structural characteristics such as the inner diameter (ID) and the tip inlet area to inner lumen area ratio (AR). The maximum variation of flow rate of all tested 10F catheters was 48%, ID varied up to 22%, from 1.71 to 2.11mm or 5.13-6.33F. AR varied up to 166%. The table delineates the fastest and slowest rates at three measured pressures. The outer diameter labeled 10F on packaging was true to size. Based on packaging information, providers, and patients are unable to predict urinary flow through a catheter and thus use information regarding flow rate to guide catheter selection. This information cannot be calculated based on ideal flow calculations and could be listed on packaging to assist physicians and families in selecting the optimal urinary catheter for CIC.

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.

PD11-06 DURABILITY OF REVISION SURGERY FOR STENOSIS OF CATHETERIZABLE CHANNELS IN ADULTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion II1 Apr 2015PD11-06 DURABILITY OF REVISION SURGERY FOR STENOSIS OF CATHETERIZABLE CHANNELS IN ADULTS Travis Pagliara, Daniel Liberman, Jeremy Myers, John Stoffel, and Sean Elliott Travis PagliaraTravis Pagliara More articles by this author , Daniel LibermanDaniel Liberman More articles by this author , Jeremy MyersJeremy Myers More articles by this author , John StoffelJohn Stoffel More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1095AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The incidence of stenosis of continent catheterizable channels varies by channel type (e.g. Mitrofanoff vs. Monti vs. tapered ileal limb) and patient factors. Up to 55% of channels will require intervention for stenosis; intervention is usually a dilation but for recurrent stenosis revision surgery may be required. We sought to describe the strategies of surgical revision for catheterizable channel stenosis and their outcomes. METHODS We retrospectively reviewed the charts of 74 adult patients who underwent catheterizable channel revision or replacement from 2000 to 2014 for stomal stenosis or difficult catheterization. The primary outcome was continued ability to catheterize the channel post-operatively without surgical dilation or revision. Secondary outcomes included channel continence and post-operative complications. Revisions were classified into the following strategies: revision above the rectus fascia, below the fascia, or channel replacement. RESULTS Revision approaches included 42% above the fascia, 30% below the fascia, and 28% channel replacement. Patients with congenital etiology of neurogenic bladder were more likely than other patients to undergo more complicated revisions (p=0.012). Channel patency was achieved in 65% at a median 34 months post-revision procedure; there was no difference by revision strategy (p=0.104). Severe stomal incontinence occurred in 3.2% after above the fascia repairs, 22.7% after below the fascia repairs and 14.3% after channel replacement (p=0.111). Surgical complications occurred in 28.4%; almost all were Clavien 1-2 and there was no difference by revision strategy (p=0.293). CONCLUSIONS Surgical revision for continent channel stenosis can be performed with good rates of durable patency. Patency rates are similar across surgical strategies of revision. Those with congenital neuropathic bladder require more complex revisions. Severe post-operative channel incontinence is not uncommon. We present our management algorithm based on length of stenosis, the amount of redundant channel available for reconstruction, and the presence or lack of a continence mechanism prior to intervention (Figure 1). © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e253 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Travis Pagliara More articles by this author Daniel Liberman More articles by this author Jeremy Myers More articles by this author John Stoffel More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urologic complications of major genitourinary reconstruction in the exstrophy–epispadias complex

ObjectiveTo present the authors' experiences with urologic complications associated with various techniques used to create a continent stoma (CS), augmentation cystoplasty (AC), and neobladder in the exstrophy–epispadias complex (EEC) population. MethodsRetrospective review of medical records of patients who underwent CS with or without bladder augmentation were identified from an institutional review board-approved database of 1208 EEC patients. Surgical indications, tissue type, length of hospital stay, age, preoperative bladder capacity, prior genitourinary surgeries, postoperative urological complications, and continence status were reviewed. ResultsAmong the EEC patients reviewed, 133 underwent CS (80 male, 53 female). Mean follow-up time after initial continent stoma was 5.31 years (range: 6 months to 20 years). Appendix and tapered ileum were the primary bowel segments used for the continent channel and stoma in the EEC population. The most common stomal complications in this population were stenosis, incontinence, and prolapse. Seventy-nine percent of EEC CS patients underwent AC primarily done with sigmoid colon or ileum. Eleven patients (8%) underwent neobladder creation with either colon or a combination of colon and ileum. Bladder calculi, vesicocutaneous fistula, and pyelonephritis were the most common non-stomal complications. Stomal ischemia was significantly increased in Monti ileovesicostomy compared to Mitrofanoff appendicovesicostomy in classic bladder exstrophy patients (p = 0.036). Furthermore, pyelonephritis was more than twice as likely in colonic neobladder than all other reservoir tissue types in the same cohort (OR = 2.53, 95% CI: 1.762–3.301, p < 0.001). ConclusionsTo the best of the authors' knowledge, this is the largest study examining catheterizable stomas in the exstrophy population. While Mitrofanoff appendicovesicostomy is preferred to Monti ileovesicostomy because it is technically less challenging, it may also confer a lower rate of stomal ischemia. Furthermore, even though ileum or colon can be used in AC with equally low complication rates, practitioners must be wary of potential urologic complications that should be primarily managed by an experienced reconstructive surgeon.

The Contemporary Indications for Augmentation Cystoplasty

Augmentation cystoplasty (AC) is a well-established technique for improving bladder compliance and capacity, preserving renal function, and minimizing incontinence due to severe detrusor overactivity. The popularity of AC has declined over the past decade due to the improved efficacy of other conservative therapies such as botulinum toxin. However, AC plays an important role in the management of refractory patients. Many patients requiring AC will also benefit from the creation of a continent catheterizable channel and bladder outlet surgery. Various augmentation and continent channel techniques are described, along with associated complications. In the appropriate patient, AC is an excellent treatment option that can improve bladder function and improve patients’ quality of life.

Vesicoscopic Bladder Neck Procedure in Children: What We Have Learned from the First Series

To assess the results of endoscopic bladder neck procedure on the anterior bladder wall in children. Surgery is done in the lithotomy position using three 5-mm ports. The bladder is insufflated with CO2. A U-shaped incision is made around the bladder neck. A mucosal strip is tabularized around a 12 French catheter and covered with the second layer of mucosa. Twenty procedures were performed on 18 patients (mean age, 9.8 years), and the follow-up period was >1 year (mean, 34 months). Mean operation time was 149 minutes. Twelve patients had neurogenic lower urinary tract dysfunction. Fifteen patients failed earlier bladder neck surgery, predominantly fascia sling suspension. Preoperatively, all patients had low detrusor leak point pressure. Clean intermittent catheterization (CIC) was resumed through the urethra in 11 patients and through a stoma in 6 patients. Two patients needed conversion because of CO2 leakage. Six patients were dry, and 4 improved in the short term (3-6 months). After 1 year of follow-up, 2 patients were dry, and 6 improved. In the long term, 1 (9%) out of 11 patients who were catheterized through the urethra was dry, and 3 of the 11 patients (27%) improved. Of the 6 patients with a CIC stoma, 1 (17%) was dry, and 3 (50%) improved. Endoscopic bladder neck surgery is, for most patients, a minor operation, but the long-term results are disappointing. The construction of a continent channel for CIC can improve the outcome when anterior bladder neck plasty is performed.

Nephrogenic Adenoma in the Augmented Bladder

Nephrogenic adenoma is an uncommon, benign urothelial lesion. Risk factors for nephrogenic adenoma include trauma, chronic inflammation, immunosuppression and radiation. We characterized nephrogenic adenoma in the pediatric augmented bladder. We reviewed the records of patients diagnosed with nephrogenic adenoma from January 2000 to March 2010. Those with prior bladder augmentation were studied further. Data were retrospectively obtained on pathological characteristics, cystoscopic findings, recurrence patterns and presentation. Ten patients with ileal bladder augmentation and nephrogenic adenoma were identified. The underlying pathological condition was myelodysplasia in 7 patients, sacral agenesis in 2 and bladder exstrophy in 1. Concomitant procedures were a continent channel in 9 patients, ureteroneocystostomy in 5 and bladder neck reconstruction in 7. Mean time to the discovery of nephrogenic adenoma was 9.2 years. During that time a total of 221 surveillance cystoscopies were performed in patients with bladder augmentation. The diagnosis was made by surveillance cystoscopy in 7 cases, at surgery for bladder stone in 2 and by cystoscopy for urinary incontinence in 1. Nephrogenic adenoma was identified along the floor in 5 cases, near the channel entrance in 3 and adjacent to the enteric anastomosis in 2. Six patients returned for surveillance with recurrence identified in 2. The longest recurrence free interval was 27 months. Nephrogenic adenoma is not uncommon in the augmented bladder and it is often asymptomatic. The lesions tend to develop at sites that may be prone to chronic catheterization injury. Recurrent lesions are not unusual.

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.

Medium Term Results of Seromuscular Colocystoplasty Lined with Urothelium

Purpose SCLU is an alternative to conventional augmentation to avoid incorporating intestinal mucosa into the urinary tract. Here we analyse the determinants of success and failure in 20 patients operated at 3 institutions. Material and Methods Institutional approved retrospective chart review of all patients who underwent SCLU in Wilmington, Salzburg and Zurich since 1998. Pre-and postoperative bladder capacity (BC) at 30 cm of water expressed in percentage of expected capacity for age (BC in ml = age + 1x30), prior, concomitant and subsequent bladder or bladder neck procedures, continence and need for re-augmentation was recorded. Results Twenty patients with neuropathic bladder, mean age 9 years, mean follow-up 53 months. An artificial urinary sphincter (AUS) was implanted at the time of SCLU in 10 patients, prior in 6, and after in 1. A sling was used in 3. G1 (n = 15) had no concomitant procedure in the bladder; G2 (n = 5) had simultaneous creation of a continent channel (CC). G1 BC increased from 60 % of expected for age to 100%. All patients are continent, none reaugmented. Of the 5 patients in G2, 3 required re-augmentation, 1 has stenosis of the CC and one is continent and using the CC without problems. Conclusions SCLU and AUS or sling is effective to augment the bladder. An intact bladder mucosa and early postoperative distention appear important for success. We have not been consistently successful in creating a CC at the time of SCLU and for patients who need it we recommend doing it at a later stage.

Endoscopic injection of submucosal bulking agents for the management of incontinent catheterizable channels

Urinary and fecal continence can be achieved by constructing catheterizable continent channels that provide access to the bladder and bowel. Some patients develop persistent stomal leakage. A minimally invasive method of injection with a bulking agent for treatment of stomal incontinence was evaluated. A retrospective review identified patients with incontinence of their catheterizable continent urinary channel (CUC) and/or antegrade continence enema (ACE). All patients underwent circumferential endoscopic sub-mucosal injection of the channel with a bulking agent, performed at the level of the continence mechanism. The type of injected material, number of procedures required, and success rates were evaluated. Out of 157 patients with a CUC and/or ACE (total of 164 stomas), eight patients underwent the minimally invasive therapy (total of nine stomas). The initial reconstructive procedure was appendicovesicostomy in one patient, ileovesicostomy (Monti) in seven patients, and ACE in two patients. Amount of bulking agent injected varied from 1.4 to 7 cc (mean 3.72 cc). Follow up ranged from 1 to 39 months (median 15 months). Two patients received multiple injections. One patient had injection of both a CUC and ACE. At the time of final follow up, 6/7 (86%) patients with a CUC and 1/2 (50%) with an ACE were continent per catheterizable channel. Injection of a bulking agent provides an excellent minimally invasive treatment alternative for incontinence of a catheterizable channel.

The Mitrofanoff procedure in paediatric urinary tract reconstruction.

Urinary tract reconstruction is required in many congenital and some acquired urological conditions in childhood. The majority are managed by clean intermittent catheterization (CIC), for which purpose the appendix or other tubular structure may be used to provide a continent catheterizable abdominal stoma. Between 1991 and 1996, 23 children underwent urinary tract reconstruction of varying complexity together with a continent diversion according to the Mitrofanoff principle. The appendix was used in 14 patients and the ureter in seven. Two patients had previously had an appendicectomy and the ureters were not suitable. One had a catheterizable channel made from an isolated segment of colon and the other had a detrusor tube constructed. Twelve patients with an appendix conduit, six with a ureteric conduit, and one with a colonic tube are continent, although the latter has had some problems with stomal stenosis. All manage CIC with comfort, the older children doing the procedure themselves. One appendix conduit has stomal incontinence and another was inadvertently divided during renal transplantation. The detrusor tube strictured and was removed. A continent abdominal stoma using the Mitrofanoff principle gives reliable results in children and is well tolerated. It should be considered in the management of children undergoing urinary tract reconstruction when CIC is necessary. The appendix is eminently suitable for this purpose but the ureter provides a satisfactory alternative in selected cases. When neither is available, alternative techniques for constructing a catheterizable continent channel may be considered.