Continent Stoma Research Articles

Using Mitrofanoff's principle and Monti's technique as a surgical option for bladder augmentation with a continent stoma: a case report

IntroductionHydronephrosis, reflux and renal failure are serious complications that occur in patients with neurogenic bladder associated with myelomeningocele. When the bladder compliance is lost, it is imperative to carry out surgery aimed at reducing bladder storage pressure. An ileocystoplasty, and for patients not suitable for intermittent catheterization, using the Mitrofanoff principle to form a continent stoma and the subsequent closure of the bladder neck, can be used. We report here, for the first time to the best of our knowledge, an association between two previously described techniques (the Mitrofanoff principle and the technique of Monti), that can solve the problem of a short appendix in obese patients.Case presentationA 33-year-old male Caucasian patient with myelomeningocele and neurogenic bladder developed low bladder compliance (4.0 mL/cm H2O) while still maintaining normal renal function. A bladder augmentation (ileocystoplasty) with continent derivation principle (Mitrofanoff) was performed. During surgery, we found that the patient's appendix was too short and was insufficient to reach the skin. We decided to make an association between the Mitrofanoff conduit and the ileal technique of Monti, through which we performed an anastomosis of the distal stump of the appendix to the bladder (with an antireflux valve). Later, the proximal stump of the appendix was anastomosed to an ileal segment of 2.0 cm that was open longitudinally and reconfigured transversally (Monti technique), modeled by a 12-Fr urethral catheter, and finally, the distal stump was sutured at the patient's navel.After the procedure, a suprapubic cystostomy (22 Fr) and a Foley catheter (10 Fr) through the continent conduit were left in place. The patient had recovered well and was discharged on the tenth day after surgery. He remained with the Foley catheter (through the conduit) for 21 days and cystostomy for 30 days. Six months after surgery he was continent with good bladder compliance without reflux and fully adapted to catheterization through the navel.ConclusionThe unpublished association between the Mitrofanoff and Monti techniques is feasible and a very useful alternative in urologic cases of derivation continent in which the ileocecal appendix is too short to reach the skin (i.e., in obese patients).

Monti as continent catheterized stoma using serosal-lined trough "Ghoneim Abolenin" technique in ileocystoplasty

It is a great challenge to select and perform continent mechanism in a stoma for urinary reservoir. A new technique by combining MONTI ileal conduit with the serosal lined trough in order to achieve continent catheterizable stoma to the umbilicus as a part of augmentation ileocystoplasty. We applied serosal-lined trough as a continent mechanism with MONTI ileal tube in 12 years smart girl underwent ileocystoplasty for neuropathic bladder due to meylomeningocele in whom continence failed to be achieved by using Mitrofanoff with submucosal tunnel of the bladder as continent mechanism before, also the previous operation included left to right transuretero-ureterostomy, ureterocystoplasty and reimplantation of the right ureter. The patient became completely continent; she was able to do self-catheterization easily through the umbilical stoma using 16-French catheter and was able to wash the mucous easily. The capacity of the augmented bladder was 300ccs. She became independent from her mother and stopped using diapers, anticholinergic and antibiotics. Combining MONTI conduit with serosal-lined extramural valve trough (The Ghoneim technique) is an effective continent technique and gives wider channel for catheterization and washing out the mucous.

Bladder exstrophy: An overview of the surgical management

Background:The surgical management of urinary bladder exstrophy is challenging. This paper describes the personal experience in a tertiary care hospital over a period exceeding a quarter of a century.Methods:During the period 1984-2010, 248 patients of the epispadias-exstrophy complex have been treated. The cases of classical bladder exstrophy (n = 210) form the basis of this paper. The stages/procedures used in the surgical reconstruction of bladder exstrophy included bladder closure with anterior abdominal wall reconstruction, bladder neck repair, ureteric reimplantation, epispadias repair and augmentation colocystoplasty in various combinations. Some of these patients had their initial operations done prior to 1984 or in other hospitals. Evaluation methods included, amongst others, clinical evaluation and urodynamic assessment. Eight patients opted out of treatment; 15 patients underwent permanent urinary diversion by either ureterosigmoidostomy or colon conduit. The remaining 187 patients were treated with bladder reconstruction, and of these, 132 patients have had at least one attempt at bladder neck reconstruction with 56 of these patients having undergone an augmentation colocystoplasty.Results:A total of 105 patients had socially acceptable continence: 57 from the bladder neck reconstruction group and 48 from the bladder augmentation group. Further attempts at continence surgery have been offered to the inadequately continent patients.Conclusions:Surgical management of bladder exstrophy demands patience and perseverance. It is possible to provide all patients with socially acceptable continence with bladder neck division and catheterizable continent stoma as the last resort. Urodynamic assessment has emerged as an essential tool in the follow-up evaluation of these patients. Anticholinergic medication with imipramine or oxybutinin is a useful adjunct in the overall management.

Perineale, endoskopische Desobliteration einer kompletten Anastomosenstriktur nach radikaler Salvageprostatektomie

Anastomotic strictures are a known complication following a radical prostatectomy for prostate cancer. In rare cases there can be a complete displacement of the urethral anastomosis region. Treating this obstruction poses a technical challenge. Therapy includes open reconstruction of the bladder neck, continent stoma but also often only a suprapubic urinary diversion. A problem occurs when precisely this diversion has to be removed. We report on a 68-year-old patient who, due to recurrent post operative and post radiogenic anastomotic strictures, has been fitted with a suprapubic urinary drainage device. Following an infection that spread locally, the patient developed symphysitis that had to be treated surgically. As a result, it became necessary to switch the urine drainage system. As a result of a perineal puncture of the urethra and scarring obliteration into the bladder it was possible to establish a transurethral catheter. The needle was guided by means of endoscopic view and transrectal ultrasound. This case demonstrates a method to re-establish a transurethral urinary diversion in cases of complete anastomotic strictures.

Hydrophilic-coated catheter appreciation study

The objective of the paper was to compare the satisfaction of hydrophilic-coated catheters (HC) (SpeediCath, Coloplast Canada, Mississauga, ON) versus uncoated catheters in a pediatric neurogenic bladder population, in order to identify a target group for HC. The main hypothesis was that our patients, with regard to their limitations, might have difficulties using the HC.A comparative prospective study was initiated in one pediatric rehabilitation centre. Out of the 39 patients who tried the HC during a routine clinic visit, 31 patients/parents accepted to participate in a 1-week trial and to answer a satisfaction questionnaire. Their medical records were reviewed for age, neurological disease, intellectual deficit, impaired dexterity and method of catheterization (Mitrofanoff/urethra).Thirty of the 31 patients answered the satisfaction questionnaire. The median age for the 30 patients was 13.5 years (range 6-20 years). Of these patients, 19 were females (63%), 26 performed self-catheterization (87%), and 6 had Mitrofanoff (20%). Ten children (33%) would be ready to proceed with HC and all 10 children would receive catheterization by the urethra. Of these, 9 were females (90%), 8 used compact-HC (80%) and all were self-sufficient. Patients using compact-HC would continue with this catheter. In the patient comments, males catheterizing per-urethra and patients using a continent stoma requiring long catheters had problems with the excess of lubricant.Most children preferred their usual uncoated catheter and would not change for HC. Female patients catheterizing per-urethra with a compact-HC seem to benefit most from this catheter.

Use of Cutaneous Flap for Continent Cystostomy (Daoud Technique)

We present the results of a new technique using a pedicled cutaneous flap for continent cystostomy. A total of 15 boys and 8 girls (mean +/- SD age 13.4 +/- 6.4 years) underwent continent cystostomy for neurogenic bladder (20), bladder exstrophy (2) and sequelae of hypospadias (1) between 1999 and 2008. In this procedure a rectangular pedicled flap is surgically elevated from a hairless area on the abdomen. The flap is tubularized and passed through the anterior abdominal wall directly into the bladder. A submucosal detrusor incision is made to expose the bladder mucosa, and the distal part of the flap is anastomosed to the bladder mucosa in a circular manner. The tube is positioned along the incised detrusor, which is closed over. Viability of the flap, self-catheterization management and continence status are then evaluated. Mean +/- SD followup was 4.5 +/- 3.1 years. There was 1 case of distal necrosis of the flap, which required a secondary surgery using the Mitrofanoff technique. The 22 remaining flaps were initially viable, although 2 patients were eventually lost to followup and 3 subsequently presented with false-passage incidents requiring a few days of calibration using a balloon catheter. Dryness was achieved immediately in 73% of the cases. After adding a complementary bulking agent the dryness rate reached 77%. We present a novel approach to continent cystostomy that is safe and easy to perform. This technique is a less invasive and more efficient alternative to other commonly used approaches.

The Boari bladder flap: an effective continent stoma for the high‐compliance neurogenic bladder

To determine if a continent urinary stoma can be created effectively using a Boari bladder flap (BBF) technique. Selected patients (15, eight women and seven men) with a neurogenic bladder and a bladder compliance of >20 mL/cmH(2)O had a procedure to create a BBF continent urinary stoma. The technique consisted of tubularising a trapezoidal, full-thickness detrusor flap 10 cm long, 5-6 cm wide at the base and 2 cm at the tip, over a 12 F catheter, and plication of detrusor muscle around the stomal base. Outcomes after surgery were assessed by reviewing stomal continence, stomal patency, and stability of the upper urinary tract. Ten BBF procedures were performed using native detrusor muscle, four with enterocystoplasty tissue and one in a defunctionalized bladder. Over a mean follow-up of 13 months, 11 patients had functioning stomas and 10 of these reported complete stomal continence. The mean change in serum creatinine level from the preoperative baseline for all patients was 0.1 mg/dL. The odds ratio for procedural failure, defined as a stoma unusable for self-catheterization, was 7.5 (P = 0.04) when the BBF was created from augmented or defunctionalized bladder tissue, compared to native high-compliance detrusor. A BBF can be used to create a viable, functional stoma in the high-compliance neurogenic bladder, although the rate of stomal complications is high when the BBF is created from enterocystoplasty tissue.

Continent urinary diversion. Variations on the Ureteric Mitrofanoff Conduit

Purpose Mitrofanoff described the use of a nonrefluxing ureter to construct a continent stoma(CS), which sometimes involves risking the good kidney with a complicated transuretero-ureterostomy. Material and Methods During the period from 1993-2008 we performed and evaluated 74 children with CS, age from 2-7 years. Apendicovesicostomy was most frequent method, involving 31(41.9%) patients, followed by CS with distal ureter in 27(36.5%) patients. Latter method was applied in patients with neurogenic bladder, posterior urethral valve, bladder extrophy or intraspinal neuroblastoma. Follow-up period ranged from 8 months to15 years. We formed a CS by using the distal part of the refluxing or obstructive ureter/megaureter on the functioning or nonfunctioning kidney. In patients with reflux the continent mechanism was formed by using the Lich-Gregoire technique or Barry's tunneling method, with or without tapering of the distal ureter. Previous reimplantation is not a contraindication to the usage of the distal ureter for CS. Results Patients had no stenosis of the ureterocutaneous junction. For 24 patients we found no leakage, while for 3 patients the leakage was solved with sting procedure. Catheterization was easy and painless, and the aesthetic results were excellent in 73 (98.6%) patients. Conclusions Compared with other techniques for continent stomas this method is quicker, requires less skill and causes few complications, which is the reason why this vesicostomy is frequently used in our hospital. Our experience with extravesical ureterocystoneostomies suggests that there is always enough ureter for continent stoma and ureterocystoneostomy. Avoidance of intraperitoneal dissection is one of its main advantage, especially for patients with ventriculo-peritoneal shunt.

US Experience With Bladder Management Following Spinal Cord Injury

This review of management of the neurogenic bladder due to spinal cord injury focuses specifically on the most current literature (2007–2009) regarding therapies offered in the United States. Urodynamic surveillance, indwelling and intermittent catheterization, sphincterotomy, urinary diversion, continent catheterizable stomas, and botulinum toxin usage are all reviewed.

Teapot Ureterocystoplasty and Ureteral Mitrofanoff Channel for Bilateral Megaureters: Technical Points and Surgical Results of Neurogenic Bladder

We present the long-term results of simultaneous "teapot" ureterocystoplasty and ureteral Mitrofanoff in patients with bilateral megaureters due to neurogenic bladder, and compare urodynamic results before and after the procedure. We treated 13 children (mean age 7.3 years) with end stage neurogenic bladder and refluxing megaureters (mean diameter 5.5 cm) with simultaneous teapot ureterocystoplasty and Mitrofanoff appendicovesicostomy between April 1995 and May 2001. The larger ureter was used for teapot bladder augmentation while keeping its distal 2 cm tubularized. The Mitrofanoff channel was then created using the opposite ureter. Followup ranged from 109 to 169 months (median 121). At the end of the followup period all patients were dry with clean intermittent catheterization and/or voiding. No repeat augmentation was needed and there were no bladder calculi during followup. Median postoperative bladder capacity was 430 ml (IQR 380 to 477), which was increased significantly compared to preoperative evaluations (210 ml, IQR 181 to 230, p = 0.001). During followup bladder compliance also improved significantly (p = 0.001) and serum creatinine level decreased (p = 0.021). Although neurogenic bladder and high grade reflux are poor prognostic factors for ureterocystoplasty, the present modification resulted in enduring bladder augmentation with no calculus formation. Bladders remained compliant with good capacity, presumably because sufficient tissue and blood supply were provided for the augmented flap.

Complications of Benchekroun vesicostomy in a spina bifida patient: severe stenosis requiring permanent suprapubic cystostomy, recurrent vesical calculi and abdominal hernia containing ileocystoplasty - a case report

IntroductionIn female patients with neuropathic bladder, the urethra is closed permanently in order to avoid urine leak. Then Benchekroun hydraulic ileal valve is attached to urinary bladder, thus providing a continent stoma for performing intermittent catheterisations.Case presentationWe present a female patient with spina bifida who underwent Benchekroun continent vesicostomy in 1993. This patient developed severe stenosis of Benchekroun stoma and stones in urinary bladder. Dilatation of stoma and vesicolithotomy were carried out in 1995. Vesical calculi recurred; suprapubic cystolithotomy was performed in 1999. In March 2000, catheterisation of stoma was not possible and emergency suprapubic cystostomy was done. In April 2000, endoscopy was attempted through Benchekroun stoma. It was not possible to insert ureterorenoscope beyond two inches. The track was completely blocked. In November 2001, X-ray of abdomen showed several vesical calculi; suprapubic cystolithotomy was performed.In March 2005, this patient developed pain in abdomen. X-ray of abdomen showed a large vesical calculus. In June 2005, suprapubic catheter was removed and a cystoscope was introduced in to the bladder. Then electrohydraulic lithotripsy was performed. In 2007, this patient was concerned about the increasing swelling in lower abdomen. Computed tomography of abdomen revealed midline, lower abdominal wall hernia, which contained several loops of small bowel and ileal cystoplasty. The large hernia was uncomfortable and tender on coughing, but did not cause obstructive bowel symptoms. Surgical repair of hernia was considered. But this patient would require alternative way of urinary diversion because the current location of suprapubic catheter would almost lead to infection of prosthetic material used in reconstruction of the anterior abdominal wall. After discussing risks of operative procedures with patient and her husband, it was decided not to proceed with surgery.ConclusionThis case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously, and patients should be informed of potential complications of surgical procedures some of which could be irreversible.

Health Related Quality of Life in Patients With Spina Bifida: A Prospective Assessment Before and After Lower Urinary Tract Reconstruction

In a previous retrospective cohort study we challenged the assumption that lower urinary tract reconstruction improves health related quality of life in spina bifida cases. We readdressed this issue prospectively in a new series of patients. A total of 31 consecutive incontinent patients with spina bifida undergoing reconstruction with a continent stoma with or without augmentation, with or without bladder neck reconstruction and with or without cecostomy were assessed preoperatively and 6 months postoperatively with the Parkin disease specific health related quality of life score. The instrument stratifies patients by ages 12 years or younger and 13 years or older. An additional 4-item questionnaire was used to score bladder and bowel continence. There was no significant change in health related quality of life following surgery in either age group. The median score changed from 167 to 174 in patients 12 years old or younger (p = 0.74) and from 199 to 193 in patients 13 years old or older (p = 0.42) despite a significant improvement in scores on all continence questions (p <0.05). In patients 12 years old or younger there was significant improvement in 3 items in the domains of independence and emotional expression (p <0.05). In adolescents 4 items changed significantly, and all were related to the independence and emotional domains (p <0.05). Despite improvement in some question items we did not note an improvement in overall quality of life following reconstruction. Correcting only 1 system in a profound multisystem disability may be insufficient to improve health related quality of life or perhaps only caregiver quality of life is improved. The impact of lower urinary tract reconstruction on quality of life in patients with spina bifida requires further assessment before improvements are assumed.

Bladder augmentation in a young adult female exstrophy patient with associated omphalocele: An extremely unusual case

We present the case of a 20-year-old woman with uncorrected bladder exstrophy and omphalocele treated with ileocystoplasty and continent urinary stoma. To our knowledge this is the first reported case of a young adult patient presenting with both congenital anomalies. The treatment result suggests that bladder preservation is a safe and feasible therapeutic option in bladder exstrophy.

The Neuro-Orthopedic Manifestations of the Omphalocele Exstrophy Imperforate Anus Spinal Defects (OEIS) Complex

Purpose OEIS complex is a severe multi-system congenital defect. As the pediatric urologist assumes a primary role in the comprehensive management of these patients, it is important to appreciate the impact of neurologic and orthopedic manifestations on the overall health of the child. Material and Methods We retrospectively reviewed the medical records of 75 children with OEIS treated at our institution. We identified neurologic and orthopedic anomalies and correlated them with the ambulatory ability and urologic status of the child. Results No neurologic data was available in 5 patients. Of the remaining 70 patients, 8 had no spinal anomalies, 61 had spina bifida (SB), and one had coccygeal hypoplasia. Thirty-eight of the SB patients were additionally classified: 5 as SB occulta, 13 as meningocele/lipomeningocele, 16 as myelomeningocele/lipomyelomeningocele, and 4 as sacral agenesis. Half of the patients with SB (30) had a tethered cord. The most common identified orthopedic anomalies requiring follow-up or surgery included vertebral malformation (62), scoliosis (25), club foot (6), and limb length discrepancy (8). The ambulatory status for 56 patients over the age of two revealed 40 to be fully ambulatory, 7 to ambulate with assistive devices, 2 to ambulate minimally with assistive devices, and 7 to be wheel-chair bound. Continence data was available in 63 closed cases. Twenty-three were incontinent, including 3 with conduit diversions. Forty patients were socially continent, with 35 catheterizing via continent abdominal stomas and 5 voiding/cathing through the urethra. Conclusions Early evaluation of neurosurgical and orthopedic anomalies is vital in caring for children with OEIS. Despite a high incidence of spinal pathology, most patients are able to ambulate without assistance. Very few children with OEIS achieve continence per urethra with volitional voiding. Vigilant follow up of spinal pathology in these children will help promptly identify correctable problems such as cord tethering which can significantly impact quality of life.

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.

Complications of Complex Lower Urinary Tract Reconstruction in Patients With Neurogenic Versus Nonneurogenic Bladder—Is There a Difference?

The complications of lower urinary tract reconstruction have been well documented in children with neurogenic bladders. While most series include small numbers of nonneurogenic diagnoses, this group is typically underrepresented. Despite a number of fundamental anatomical and functional differences, a direct comparison of surgical complications of lower urinary tract reconstruction in patients with neurogenic vs nonneurogenic bladders has not been performed. We identified patients undergoing lower urinary tract reconstruction incorporating enterocystoplasty from 1996 to 2006. We performed a retrospective review of operative notes and medical records of patients who met inclusion criteria. Patients were divided into a neurogenic group and a nonneurogenic group based on the underlying diagnosis. The 2 groups were compared with respect to demographics, historical data, operative techniques, perioperative morbidity, long-term complications and need for surgical revision. Of the 127 patients who met inclusion criteria 72 were assigned to the nonneurogenic group and 55 to the neurogenic group. Overall the rates of significant perioperative morbidity (39%), long-term complications (54%) and need for surgical revision (39%) were substantial. The rates of catheter related complications, rehospitalization for dehydration and spontaneous bladder rupture were higher in the neurogenic group (p <0.05). Reconstruction of the lower urinary tract in children is associated with a considerable rate of complications and need for surgical revision regardless of whether the bladder is neurogenic or nonneurogenic. Children with neurogenic bladders are more prone to spontaneous rupture, catheter mishaps and early rehospitalization for dehydration.

Rectus sheath tunnels for continent stomas

Continent stoma rectus sheath tunnel (CSRST) has been used in antegrade colonic enema (ACE) and urinary continent cutaneous diversion (UCCD) stomas to reduce leakage and to support a straight track for the continent conduit. All patients that underwent CSRST between 1995 and 2005 were identified and their case notes retrospectively reviewed. Patients were divided into two groups: the ACE group and the UCCD group. Demographic data, age at surgery and complications including stenosis and leakage were recorded. Forty patients underwent CSRST between 1995 and 2005. The mean age and standard deviation (SD) at surgery was 6.8 (2.1) years. Eighteen patients underwent ACE with a mean (SD) follow-up of 7.6 (3.1) years. No patient has faecal leakage. No patient had stomal revision, but one patient (5.5%) required an indwelling gastrostomy button to maintain patency. Twenty-two patients underwent UCCD with a mean (SD) follow-up of 8.1 (2.8) years. No patient developed urinary leakage. Two patients (9%) required revision of the stoma and one (4.5%) required an indwelling catheter because of recurring stomal stenosis. CSRST prevents stoma leakage. Revision surgery rate after CSRST is low, particularly after ACE reconstruction.

Salvage reconstructive surgery in an adult patient with failed previous repair of an extrophy-epispadias complex: an operation with a functional and aesthetic purpose

Salvage surgical procedures after failed reconstruction for an extrophy-epispadias complex are extremely challenging. The goals are to restore continence and improve aesthetic appearance in order to provide quality of life and an improved body image to the patient. We describe the surgical steps in an adult patient who presented anal urinary incontinence and a poor body image due to the absence of an umbilicus and the presence of hypertrophic scars. He underwent a modified Mainz II reconstruction of the lower urinary tract at childhood for an extrophy-epispadias complex. Restoration of continence was achieved by the construction of a modified Mainz I pouch with a continent stoma in a neo-umbilicus. Body image improved dramatically by the construction of a neo-umbilicus, a surgical revision of the hypertrophic abdominal scars and an abdominoplasty. It is mandatory that such demanding surgery should only be attempted as a combined multidisciplinary effort with urologists and plastic/reconstructive surgeons.

Salvage Procedures to Achieve Continence After Failed Bladder Exstrophy Repair

We assessed the results from a single exstrophy center of salvage continence surgery after failed staged reconstruction for bladder exstrophy. A total of 32 patients with bladder exstrophy had undergone salvage continence procedures. Indications for surgery included incontinence due to poor bladder capacity or failed bladder neck repair, and upper tract deterioration. Continence was defined according to the International Children's Continence Society as continent, intermittently incontinent and continuously incontinent. A total of 29 patients (91%) are continent, 3 (9%) are intermittently incontinent and none is continuously incontinent. One patient is continent after bladder augmentation and urethral clean intermittent catheterization. Two patients are continent and 1 is intermittently incontinent after bladder augmentation and modified Young-Dees bladder neck repair using urethral clean intermittent catheterization. One patient is continent using clean intermittent catheterization through a continent cutaneous diversion into a bladder substitution. A total of 19 patients are continent after bladder neck closure, bladder augmentation and continent cutaneous diversion using clean intermittent catheterization. Four patients are continent after cutaneous urinary diversion. Two are continent and 2 are intermittently incontinent after a Mainz II pouch. The majority of patients can still achieve continence following failed staged repair. Patients who have a low bladder leak pressure and who tolerate urethral catheterization can be consistently dry with bladder augmentation and bladder neck repair, which is a viable alternative to bladder neck closure, bladder augmentation and continent cutaneous diversion. Cutaneous urinary diversion has a role in selected patients. Mainz II pouch has not yielded consistent results. With better patient selection and increasing experience within specialist exstrophy centers fewer patients should require salvage continent surgery in the future.

Results of Bladder Neck Reconstruction After Newborn Complete Primary Repair of Exstrophy

We describe the results of modified Young-Dees-Leadbetter bladder neck reconstruction to achieve continence in patients who underwent complete primary repair of bladder exstrophy as newborns. Using the Johns Hopkins Exstrophy Database we identified patients who underwent bladder neck reconstruction after having undergone complete primary repair of bladder exstrophy as newborns. We determined patient characteristics and surgical outcomes. A total of 30 males and 3 females were referred after complete primary repair of bladder exstrophy, of whom 26 underwent bladder neck reconstruction. Results of complete primary repair of bladder exstrophy were strongly associated with osteotomy use. Of the patients 19 (58%), including 16 males and 3 females, who underwent complete primary repair of bladder exstrophy without osteotomy had complications (dehiscence and bladder prolapse), while none of 14 male patients who underwent complete primary repair of bladder exstrophy with osteotomy had complications, although none were subsequently continent. Of the 19 patients who had complications after complete primary repair of bladder exstrophy 12 underwent bladder neck reconstruction and total continence was achieved in only 3 (25%). Of the 14 patients with successful complete primary repair of bladder exstrophy 8 (57%) are dry day and night, 4 (28%) are dry during the day and wet at night, and 2 (14%) are completely incontinent. Continent children underwent successful complete primary repair of bladder exstrophy with pelvic osteotomy, all underwent hypospadias repair before age 1 year and none required ureteral reimplantation before bladder neck reconstruction. Many patients who undergo newborn complete primary repair of bladder exstrophy will require bladder neck reconstruction. Bladder neck reconstruction is more successful in those in whom complete primary repair of bladder exstrophy was successful. As in all types of repair, failed initial closure usually results in a bladder that is unsuitable for bladder neck reconstruction. These patients often require bladder augmentation and a continent stoma to be dry.