Surgical Management Of Incontinence Research Articles

The Modified Invance Perineal Sling in the Treatment of Incontinence in Boys with the Exstrophy-Epispadias Complex

Purpose The surgical management of incontinence in boys with the exstrophy-epispadias complex has challenged surgeons for many decades. We present a modification of our previously described sling for the treatment of neurogenic incontinence to permit the treatment of these patients. Material and Methods Two boys aged 11 and 18 with the exstrophy-epispadias complex were treated for severe urinary incontinence. The 11 year old was status post a Mitchell single stage repair with an anterior iliac osteotomy. The 18 year old had undergone a staged Cantwell –Ransley repair with a posterior iliac osteotomy. Both patients underwent the placement of an AMS InVance sling modified with the creation of a midline polypropylene bolster to permit adequate urethral compression while obviating corporal compression. Both procedures were discharged home the day of surgery. Results Both patients immediately had an improvement in continence and were able to volitionally void without CIC. With a follow-up ranging to 26 months, both patients maintain a significant clinical improvement. The 18 year old has minor spotting with valsalva but is otherwise dry both day and night. The younger boy required the placement of a larger bolster 7 months following his initial repair but remains largely dry with occasional daytime pad use for mild stress incontinence. Both patients are on oxybutynin and have not undergone bladder augmentation. Conclusions The modified bone-anchored perineal sling is a simple out-patient option in the treatment of this difficult problem. Long-term studies with larger number of patients will be required to determine the ultimate role of this new procedure.

COMPARATIVE STUDY OF THE YANG-MONTI CHANNEL AND APPENDIX FOR CONTINENT DIVERSION IN THE MITROFANOFF AND MALONE PRINCIPLES

Continent conduits for Mitrofanoff and Malone procedures are widely used for incontinence management. Because the appendix is not always suitable or available, Monti proposed a transversely retubularized short segment of ileum. We present our experience and compare outcomes according to the type of conduit. In a retrospective study from 1988 to 2003 case notes were reviewed specifying conduit characteristics, underlying disease, overall surgical management of incontinence and subsequent complications. Comparison was based on followup, details of complications and treatments. In 32 men and 14 women with a total of 65 conduits (Mitrofanoff in 41 and Malone procedure in 24) the condition was spina bifida in 29, bladder exstrophy in 5 and sacral agenesia in 3. Other cases included various origins. Mean age at operation was 14.2 years (range 1 to 31). Mean followup was 5.3 years (range 1 to 14.7). Appendix was used in 23 cases and a Yang-Monti channel was performed in 18 (ileum in 7 and sigmoid in 11) for urinary diversion. The Malone procedure was performed using appendix in 11 cases and a Yang-Monti tube in 13. At followup 61 conduits (93.8%) were in use and 4 (6.2%) were abandoned. Complications were cutaneous stenosis, kink blockage and stomal leakage. No significant differences were observed between the types and purposes of the conduit. With constant availability and various possibilities of construction the Yang-Monti channel is recommended for continent diversion creation when appendix does not look suitable or is already in use or absent.

Questionnaire-based survey on obstetricians and gynaecologists’ attitudes towards the surgical management of urinary incontinence in women during their childbearing years

Objective: To determine the appropriate surgical management of incontinence in women who desire to maintain their childbearing capacity. Design: Questionnaire-based survey. Method: A postal questionnaire was sent to 251 (every fourth) consultant obstetricians and gynaecologists in the UK practising in both district general hospitals ( n=156) and teaching hospitals ( n=95). Main outcome measures: Clinical consensus in the management of incontinence in women who are interested in childbearing. Results: One hundred and thirty two (53%) consultants responded of which 22 (17%) were not involved in managing this group of women and were therefore excluded from analysis. Thirty-nine (36%) of the replies were from teaching hospital, 71 (65%) were from district general hospitals. Eighty-six (78%) consultants are prepared to perform a continence procedure on women who had not completed their families. One hundred (91%) would offer caesarean section to those continent pregnant women following their continence surgery. (Fisher’s exact test’ P=0.038). Interestingly, 67 (60.9%) of respondents still perform caesarean section to the pregnant women even if they are incontinent. Conclusions: The majority of UK consultants would perform a continence procedure in women who wish to maintain their childbearing capacity. Colposuspension is the favoured surgical procedure. If women are continent following surgery, most prefer them to be delivered by caesarean section.

Abstracts from the 21st Annual Meeting of the Society for Urodynamics & Female Urology: ?Surgical Management of Incontinence and Pelvic Prolapse? Atlanta, Georgia, April 29, 2000

Abstracts from the 21st Annual Meeting of the Society for Urodynamics & Female Urology: ?Surgical Management of Incontinence and Pelvic Prolapse? Atlanta, Georgia, April 29, 2000

Surgical Management of Incontinence in Bladder Exstrophy*

Between 1978 and 1990, 86 patients with previously closed classical bladder exstrophy and 10 patients seeking undiversion have presented for continence management and have undergone selective reconstruction designed for voiding and/or intermittent urethral catheterisation. The reconstruction in these 96 patients has been reviewed. Eight of the 10 patients undergoing undiversion achieved a satisfactory state of continence but 4 required Mitrofanoff procedures to enable catheterisation. Of the other 86 patients, 2 reached a satisfactory state of continence without further surgery; 79 underwent bladder neck surgery for continence either without augmentation (n = 32) or with augmentation (n = 47). Twenty of the 32 patients who were treated by bladder neck reconstruction alone were later found to require augmentation. Five patients had very early augmentation either to facilitate neonatal closure or on account of severe upper tract dilatation. Of these, 1 became continent without further surgery and 4 demonstrated the need for bladder neck reconstruction. Thus 12 children achieved successful continence (n = 6) or are evolving satisfactorily with potential success (n = 6) as a result of bladder neck reconstruction. Of the 71 patients requiring bladder neck reconstruction and augmentation, 68 have completed their surgery. The current status of these patients is: satisfactory in 57 (80%) (42 void/urethral clean intermittent catheterisation (CIC), 7 waiting to learn CIC, 5 Mitrofanoff, 3 artificial urinary sphincter (AUS]. Of the remaining 11 patients (20%), 8 are unsatisfactory to varying degrees and the status of the other 3 is unknown.