Tunnel In Patients Research Articles

Coexistence of a Bifid Median Nerve and Persistent Median Artery in a Pediatric Trauma Case

Knowledge of the variations of the branching of the median nerve is important particularly in surgical decompression and trauma cases. Bifid median nerve together with palmar type median artery is a rare anatomic variation. The importance of the persistent median artery lies in the fact that the one with a large calibre may lead to an early compression of the median nerve in the carpal tunnel in patients. Surgeons, in the presence of persistent median artery, must be aware of possibility of additional median nerve anomalies.

Avaliação radiológica do posicionamento do túnel femoral na reconstrução do ligamento cruzado anterior

ObjectiveTo evaluate the inclination and the length of the femoral tunnel in patients submitted to anterior cruciate ligament reconstruction (ACL) surgery by transtibial and anatomical techniques. MethodsThis is an analytical observational study in patients with ACL injury that underwent arthroscopic reconstruction through transtibial and anatomical surgical techniques. In the immediate postoperative period, computed tomography (CT) and anteroposterior (AP) view digital radiographs (X‐rays) were performed to evaluate the inclination and length of the femoral tunnel. ResultsForty‐two patients were analyzed: 27 underwent anatomical reconstruction and 15, transtibial reconstruction. The inclination angle and tunnel length by the transtibial technique are always greater than by the anatomical technique. The mean inclination angles were 59.75° (53.9 to 66.1°) in the X‐rays and 54.17° (43.5 to 62.3°) in CT for the transtibial technique, and 42.91° (29.3 to 57.4°) in the X‐rays and 39.10° (23.8 to 50.6°) in CT for the anatomical technique. Regarding the length of the femoral tunnel, the transtibial technique promotes longer tunnels: mean 55.7mm (40.0‐70.2mm) in the transtibial and 35.5mm (24.5–47mm) in the anatomical technique. No statistically significant correlation was observed between the length and the inclination of the tunnel, regardless of the technique used. Thus, these variables can be considered as independent. ConclusionThe anatomical reconstruction technique presented shorter femoral tunnels and lower angle of inclination than the transtibial technique. The CT showed smaller inclination angle than the X‐rays, regardless of the surgical technique.

Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Using a Gracilis Autograft without Bone Tunnel.

BackgroundSeveral tendon graft and fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation. The purpose of this study was to evaluate the results of MPFL reconstruction using a gracilis autograft fixation without bone tunnel in patients with recurrent patellar instability.MethodsNine patients (four males and five females) diagnosed with recurrent patellar instability from July 2009 to January 2013 and had MPFL reconstruction using a gracilis autograft were included. The average age of the patients was 24.6 years (range, 13 to 48 years), and the average follow-up period was 19.3 months (range, 12 to 30 months). For every patient, femoral attachment was fixed using suture anchors securing the patella by suturing the periosteum and surrounding soft tissue. Clinical evaluation included the Kujala, Lysholm, and Tegner scores; in addition, patients were examined for any complication including recurrent dislocation. The congruence angle and patella alta were assessed radiologically before and after surgery.ResultsThe Kujala score improved from an average of 42.7 ± 8.4 before surgery to 79.6 ± 13.6 (p = 0.008) at final follow-up; the Lysholm score improved from 45.8 ± 5.7 to 82.0 ± 10.5 (p = 0.008); and the Tegner score improved from 2.8 ± 0.8 to 5.6 ± 1.5 (p = 0.007). The Insall-Salvati ratio changed from 1.16 ± 0.1 (range, 0.94 to 1.35) before surgery to 1.14 ± 0.1 (range, 0.96 to 1.29; p = 0.233) at the final follow-up without significance. The congruence angle significantly improved from 26.5° ± 10.6° (range, 12° to 43°) before surgery to -4.0° ± 4.3° (range, -12° to 5°; p = 0.008) at final follow-up. Subluxation was observed in one patient and hemarthrosis occurred in another patient 2 years after surgery, but these patients were asymptomatic.ConclusionsWe achieved good results with a patellar fixation technique in MPFL reconstruction using a gracilis autograft employing soft tissue suturing in patients with recurrent patellar dislocation.

Stereological and comparative evaluation of the carpal tunnel in patients with carpal tunnel syndrome using magnetic resonance images

Stereological and comparative evaluation of the carpal tunnel in patients with carpal tunnel syndrome using magnetic resonance images

Altered tibial nerve biomechanics in patients with diabetes mellitus

Hyperglycemia associated with diabetes mellitus (DM) has adverse impacts on peripheral nerve connective tissue structure, and there is preliminary evidence that nerve biomechanics may be altered. Ultrasound imaging was utilized to quantify the magnitude and timing of tibial nerve excursion during ankle dorsiflexion in patients with DM and matched healthy controls. Tibial nerve longitudinal excursion at the ankle and knee was reduced, and timing was delayed at the ankle in the DM group. Severity of neuropathy was correlated with larger reductions in longitudinal excursion. Nerve cross-sectional area was increased at the ankle in the DM group. Larger tibial nerve size within the tarsal tunnel in patients with DM may restrict longitudinal excursion, which was most evident with more severe neuropathy. It is hypothesized that these alterations may be related to painful symptoms during functional activities that utilize similar physiological motions through various biomechanical and physiological mechanisms.

AB0871 Ultrasound Evaluation of Carpal Tunnel Syndrom in Primary Hypothyroidism

BackgroundA bilateral carpal tunnel syndrome (CTS) is relatively commonly connected to hypothyroidism and presents in 5 to 10% of hypothyroid patients. Ultrasound imaging is a method of choice in early...

Ultrasound Findings After Surgical Decompression of the Tarsal Tunnel in Patients With Painful Diabetic Polyneuropathy: A Prospective Randomized Study

It has been hypothesized that the development of diabetic polyneuropathy (DPN) is due to swelling of the nerve, as well as thickening and stiffening of the surrounding ligaments, causing chronic compression of nerves. We aimed to examine the effect of surgical decompression of the tibial nerve on the mean cross-sectional area (CSA). We performed a randomized controlled trial of 42 subjects with painful DPN diagnosed using the Diabetic Neuropathy Score. A computer randomized for the surgery arm of the study. A control group consisting of 38 healthy subjects was included. An experienced sonographer measured the CSA and thickness-to-width (T/W) ratio of the tibial nerve, as well as the thickness of the flexor retinaculum. CSA is significantly larger in patients with painful DPN (8.4 ± 3.9 mm(2)) than in control subjects (6.4 ± 1.3 mm(2)), P = 0.007. The T/W ratio in patients with painful DPN is 0.64 and in control subjects 0.59, P = 0.03. Patients with DPN have a significantly thicker retinaculum (1.07 mm) than control subjects (0.84 mm), P < 0.001. Mean follow-up was 28.2 weeks (range 23-45). Difference between baseline and follow-up in the operated leg was 1.49 mm(2) and in the control leg 1.81 mm(2), P = 0.674. Decompression of the tibial nerve does not result in a significant difference between baseline and follow-up in CSA using ultrasound between the operated and control leg. Ultrasound measurements show a significantly increased CSA, a significantly thicker retinaculum, and a significantly increased T/W ratio in patients with painful DPN compared with healthy control subjects. Clinical trial reg. no. NTR2344, www.trialregister.nl.

PS8 - 5. Ultrasound findings after surgical decompression of the tarsal tunnel in patients with painful diabetic polyneuropathy. A prospective, randomized, study

It has been hypothesized that the development of diabetic polyneuropathy (DPN) is due to swelling of the nerve, as well as thickening and stiffening of the surrounding ligaments, causing chronic compression of nerves. The authors aimed to examine the effect of surgical decompression of the tibial nerve on the mean cross sectional area (CSA).

BIOLOGIC REACTIONS AT ACL GRAFT INSERTION SITES MEASURED BY 99MTC-HDP-SPECT/CT TRACER UPTAKE

IntroductionNot much is known about biologic reactions at ACL graft insertion sites. SPECT/CT is a hybrid imaging modality, which combines a 3D single photon emission computed tomography and a conventional...

SPECT/CT tracer uptake is influenced by tunnel orientation and position of the femoral and tibial ACL graft insertion site

SPECT/CT is a hybrid imaging modality, which combines a 3D scintigraphy (SPECT) and a conventional computerised tomography (CT). SPECT/CT allows accurate anatomical localisation of metabolic tracer activity. It allows the correlation of surgical factors such as tunnel position and orientation with mechanical alignment, clinical outcome and biological factors. The purpose of this study was to investigate whether the SPECT/CT tracer uptake (intensity and distribution) correlates with the stability and laxity of the knee joint and the position and orientation of the tibial and femoral tunnels in patients after anterior cruciate ligament (ACL) reconstruction. A consecutive series of knees (n=66), with symptoms of pain and/or instability after ACL reconstruction were prospectively evaluated using clinical examination and 99mTc-HDP-SPECT/CT. Clinical laxity testing was performed using the Rolimeter (Ormed, Freiburg, Germany) including Lachman testing (0-2 mm, 3-5 mm, 6-10 mm, >10 mm), anterior drawer test (0-2 mm, 3-5 mm, 6-10 mm, >10 mm), pivot shift test (positive versus negative) and patient-based subjective instability (yes versus no). For analysis of SPECT/CT tracer uptake a previously validated SPECT/CT localisation scheme consisting of 17 tibial, nine femoral and four patellar regions on standardised axial, coronal, and sagittal slices was used. The tracer activity on SPECT/CT was localised and recorded using a 3D volumetric and quantitative analysis software. Mean, standard deviation, minimum and maximum of grading for each area of the localisation scheme were recorded. The position and orientation of the tibial and femoral tunnel was assessed using a previously published method on 3D-CT. Correlation of instability, pivot shift as well as clinical laxity testing with 99mTc-HDP-SPECT/CT tracer uptake intensity and distribution showed no significant correlation. 99mTc-HDP-SPECT/CT tracer uptake correlated significantly with the position and orientation of the ACL graft. A more horizontal femoral graft position showed significantly increased tracer uptake within the superior and posterior femoral regions. A more posteriorly-placed femoral insertion site showed significantly more tracer uptake within the femoral and tibial tunnel regions. A more vertical or a less medial tibial tunnel orientation showed significant increased uptake within the tibial and femoral tunnel regions. A more anterior tibial tunnel position showed significantly more tracer uptake in the femoral and tibial tunnel regions as well as the entire tibiofemoral joint. SPECT/CT tracer uptake intensity and distribution showed a significant correlation with the femoral and tibial tunnel position and orientation in patients with symptomatic knees after ACL reconstruction. No correlation was found with stability or clinical laxity. SPECT/CT tracer uptake distribution has the potential to give us important information on joint homeostasis and remodelling after ACL reconstruction. It might help to predict ACL graft failure and improve our surgical ACL reconstruction technique in finding the optimal tunnel and graft position and orientation.

Transtibial ACL reconstruction technique fails to position drill tunnels anatomically in vivo 3D CT study

PurposeThe purpose of this study was to visualize and quantify the positions of femoral and tibial tunnels in patients who underwent traditional transtibial single-bundle ACL reconstruction, as performed by multiple surgeons, utilizing 3D CT models, and to compare these positions to our previously reported anatomical tunnel positions.MethodsFifty-eight knee computed tomography (CT) scans were performed on patients who underwent primary or revision transtibial single-bundle ACL reconstruction, and three-dimensional reconstructions of the CT scans were aligned within an anatomical coordinate system. The position of femoral tunnel aperture centers was measured with (1) the quadrant method and (2) in the anatomic posterior-to-anterior and proximal-to-distal directions. The position of tibia tunnel aperture centers were measured similarly, in the anterior-to-posterior and medial-to-lateral dimensions on the tibial plateau. Comparisons were made to previously established anatomical tunnel positions, and data were presented as “mean value ± standard deviation (range).”ResultsThe location of tibial tunnels was at 48.0 ± 5.4% (35.6–59.5%) of the anterior-to-posterior plateau depth and at 47.9 ± 2.9% (42.2–57.4%) of the medial-to-lateral plateau width. The location of femoral tunnels was at 55.8 ± 8.0% (41.5–79.5%) in the anatomic posterior-to-anterior direction and at 41.2 ± 10.4% (15.1–67.4%) in the proximal-to-distal directions. Utilizing a quadrant method, femoral tunnels were positioned at 37.4 ± 5.1% (24.9–50.6%) from the proximal condylar surface, parallel to Blumensaat line, and at 11.0 ± 7.3% (−6.0–28.7%) from the notch roof, perpendicular to Blumensaat line. In summary, tibial tunnels were positioned medial to the anatomic PL position (p < 0.001), and femoral tunnels were positioned anterior to both AM and PL anatomic tunnel locations (p < 0.001 and p < 0.001).ConclusionACL reconstruction via traditional transtibial technique fails to accurately position femoral and tibial tunnels within the native ACL insertion site. To achieve anatomical graft placement, other surgical techniques should be considered.Level of evidenceIV.Electronic supplementary materialThe online version of this article (doi:10.1007/s00167-011-1851-z) contains supplementary material, which is available to authorized users.

Efficacy and Safety of Right Hemihepatectomy Through the Right Retrohepatic Tunnel

We wished to study the efficacy and safety of the retrograde ligation of short hepatic veins (SHVs) and the right hepatic vein (HV) through the retrohepatic tunnel in patients who underwent hemihepatectomy due to large hepatic carcinoma in the right lobe of the liver. Right hemihepatectomy was performed in 23 patients with tumors larger than 8 cm in diameter. The liver was separated at the secondary porta, and the interspace between right HVs and middle HVs was expanded. The right hepatic portal vein and hepatic artery were freed and ligated, followed by the retrograde dissection of SHVs and the right HV along the right retrohepatic space anterior to the inferior vena cava. A blocking belt was set at the left side of the midline, after which the right liver was cut off. The procedure was successfully completed in all patients. The average amount of intraoperative blood loss was 640 ml. The change in hepatic function was observed on the third postoperative day. Twenty-two patients exhibited satisfactory results; one patient died from postoperative hepatic failure. In conclusion, this procedure can be safely performed in most hemihepatectomy patients with liver tumors.

Median nerve deformation in differential finger motions: Ultrasonographic comparison of carpal tunnel syndrome patients and healthy controls

AbstractWe investigated the median nerve deformation in the carpal tunnel in patients with carpal tunnel syndrome and controls during thumb, index finger, middle finger, and a four finger motion, using ultrasound. Both wrists of 29 asymptomatic volunteers and 29 patients with idiopathic carpal tunnel syndrome were evaluated by ultrasound. Cross‐sectional images during motion from full extension to flexion were recorded. Median nerve cross‐sectional area, perimeter, aspect ratio of the minimal enclosing rectangle, and circularity in extension and flexion positions were calculated. Additionally, a deformation index was calculated. We also calculated the intra‐rater reliability. In both controls and patients, the median nerve cross‐sectional area became significantly smaller from extension to flexion in all finger motions (p &lt; 0.05). In flexion and extension, regardless of the specific finger motion, the median nerve deformation, circularity and the change in perimeter were all significantly greater in CTS patients than in controls (p &lt; 0.05). We found excellent intra‐rater reliability for all measurements (ICC &gt; 0.84). With this study we have shown that it is possible to assess the deformation of the median nerve in carpal tunnel syndrome with ultrasonography and that there is more deformation of the median nerve in carpal tunnel syndrome patients during active finger motion. These parameters might be useful in the evaluation of kinematics within the carpal tunnel, and in furthering our understanding of the biomechanics of carpal tunnel syndrome in the future. © 2011 Orthopaedic Research Society. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 30:643–648, 2012

Poster 128 Comparison of Cross-sectional Area of the Median Nerve and Carpal Tunnel in Patients With Carpal Tunnel Syndrome

Poster 128 Comparison of Cross-sectional Area of the Median Nerve and Carpal Tunnel in Patients With Carpal Tunnel Syndrome

Nonanatomic Tunnel Position in Traditional Transtibial Single-Bundle Anterior Cruciate Ligament Reconstruction Evaluated by Three-Dimensional Computed Tomography

Transtibial drilling techniques are widely used for arthroscopic reconstruction of the anterior cruciate ligament, most likely because they simplify femoral tunnel placement and reduce surgical time. Recently, however, there has been concern that this technique results in nonanatomically positioned bone tunnels, which may cause abnormal knee function. The purpose of this study was to use three-dimensional computed tomography models to visualize and quantify the positions of femoral and tibial tunnels in patients who underwent traditional transtibial single-bundle reconstruction of the anterior cruciate ligament and to compare these positions with reference data on anatomical tunnel positions. Computed tomography scans were performed on thirty-two knees that had undergone transtibial single-bundle reconstruction of the anterior cruciate ligament. Three-dimensional computed tomography models were aligned into an anatomical coordinate system. Tibial tunnel aperture centers were measured in the anterior-to-posterior and medial-to-lateral directions on the tibial plateau. Femoral tunnel aperture centers were measured in anatomic posterior-to-anterior and proximal-to-distal directions and with the quadrant method. These measurements were compared with reference data on anatomical tunnel positions. Tibial tunnels were located at a mean (and standard deviation) of 48.0% +/- 5.5% of the anterior-to-posterior plateau depth and a mean of 47.8% +/- 2.4% of the medial-to-lateral plateau width. Femoral tunnels were measured at a mean of 54.3% +/- 8.3% in the anatomic posterior-to-anterior direction and at a mean of 41.1% +/- 10.3% in the proximal-to-distal direction. With the quadrant method, femoral tunnels were measured at a mean of 37.2% +/- 5.5% from the proximal condylar surface (parallel to the Blumensaat line) and at a mean of 11.3% +/- 6.6% from the notch roof (perpendicular to the Blumensaat line). Tibial tunnels were positioned medial to the anatomic posterolateral position (p < 0.001). Femoral tunnels were positioned anterior to both anteromedial and posterolateral anatomic tunnel locations (p < 0.001 for both). Transtibial anterior cruciate ligament reconstruction failed to accurately place femoral and tibial tunnels within the native anterior cruciate ligament insertion site. If anatomical graft placement is desired, transtibial techniques should be performed only after careful identification of the native insertions. If anatomical positioning of the femoral tunnel cannot be achieved, then an alternative approach may be indicated.

Changes in Electrophysiological Parameters After Surgery for the Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common condition, affecting mostly females. Nerve conduction studies are performed routinely for the diagnosis of carpal tunnel syndrome. Surgical intervention for release of the median nerve at the carpal tunnel is the treatment of choice. Few studies have looked at the improvement in the electrophysiological parameters after carpal tunnel release. This study compared the distal motor and sensory latencies, motor and sensory amplitudes, and sensory conduction velocities of the median nerves across the carpal tunnel in patients with the carpal tunnel syndrome preoperatively and postoperatively at 18 and 42 weeks, respectively. The results showed improvement in all the studied variables, except the distal sensory latency, 18 weeks after the surgery, whereas the distal sensory latency improved only at 42 weeks postoperatively. These findings denote the differential affection of the sensory and motor fibers in the carpal tunnel syndrome and confirm the value of nerve conduction studies in the evaluation of patients who do not improve or who have recurrence of their symptoms after carpal tunnel release.

Local steroid injection for moderately severe idiopathic carpal tunnel syndrome: Protocol of a randomized double-blind placebo-controlled trial (NCT 00806871)

BackgroundPatients with idiopathic carpal tunnel syndrome (CTS) are commonly treated with steroid injection into or proximal to the carpal tunnel. However, evidence for its efficacy beyond one month has not been established in randomized placebo-controlled trials. The primary aim of this randomized trial is to assess the efficacy of steroid injection into the carpal tunnel in relieving symptoms of CTS in patients with symptoms of such severity to warrant surgical treatment but have not been treated with steroid injection.Methods/DesignThe study is a randomized double-blind placebo-controlled trial. Patients referred to one orthopedic department because of CTS are screened. Eligibility criteria are age 18 to 70 years, clinical diagnosis of primary idiopathic CTS and abnormal nerve conduction tests or clinical diagnosis made independently by two orthopedic surgeons, failed treatment with wrist splinting, symptom severity of such magnitude that the patient is willing to undergo surgery, no severe sensory loss or thenar muscle atrophy, and no previous steroid injection for CTS. A total of 120 patients will be randomized to injection of 80 mg Methylprednisolone, 40 mg Methylprednisolone, or normal saline, each also containing 10 mg Lidocaine. Evaluation at baseline and at 5, 10, 24 and 52 weeks after injection includes validated questionnaires (CTS symptom severity scale, QuickDASH and SF-6D), adverse events, physical examination by a blinded assessor, and nerve conduction tests. The primary outcome measures are change in the CTS symptom severity score at 10 weeks and the rate of surgery at 52 weeks. The secondary outcome measures are the score change in the CTS symptom severity scale at 52 weeks, time to surgery, and change in QuickDASH and SF-6D scores and patient satisfaction at 10 and 52 weeks. The primary analysis will be carried out using mixed model analysis of repeated measures.DiscussionThis paper describes the rationale and design of a double-blind, randomized placebo-controlled trial that aims to determine the efficacy of two different doses of steroid injected into the carpal tunnel in patients with moderately severe idiopathic CTS.Trial registrationClinicaltrials.gov identifier NCT00806871

Growth of the lateral tunnel in patients who underwent a total cavopulmonary connection at less than 5 years of age☆

A lateral tunnel-total cavopulmonary connection (LT-TCPC) using a right atrial (RA) free wall is the first choice of treatment for patients with a small body weight in this institute. Whether the growth of the LT is appropriate or not according to the growth of the body remains controversial. In addition, the optimal initial diameter of an LT is unknown. The purpose of this study was to verify the growth of the LT. Ninety-one patients of a total of 267 TCPC cases underwent an LT-TCPC at less than 5 years of age in this institute between March 1991 and June 2008. The data on 47 of the 91 patients, which were available to investigate the LT growth, were retrospectively reviewed. The mean age at LT-TCPC was 37+/-11 months (16-57 months). The mean body weight at TCPC was 12.4+/-2.4 kg (7.6-20.0 kg). The initial LT diameter was determined with Hegar's sizer of the estimated half-pulmonary arterial (PA) diameter, which is a diameter that results in half of the dimension of the normal pulmonary valve. The measured maximum LT diameter (mm) divided by the estimated half-PA diameter (mm) was considered as the LT index. The size of the LT was evaluated using either echocardiography or angiography. The mean follow-up period was 7.4+/-3.5 years (1.6-13.5 years). The LT index was initially 2.0+/-0.7 (1.3-4.5), 2.0+/-0.4 (1.3-3.2) at 1 year after operation, 2.1+/-0.5 (1.5-3.2) at 5 years after operation, 1.9+/-0.4 (1.5-2.8) at 10 years after operation and 2.1+/-0.5 (1.6-2.5) at 13 years after operation, respectively. LT growth suitable for the body growth can be expected. Although there was some variation in the initial LT diameter, the LT index tended to converge at 2.0 with growth.

Cubital tunnel syndrome in patients with haemophilia

Elbow is the second most common joint involved in patients with haemophilia; however, there is little data about the involvement of ulnar nerve at elbow in patients with haemophilic arthropathy. The purpose of this study was to address this problem in the elbow and evaluate the results of anterior subcutaneous transposition of the ulnar nerve in a small group of patients with haemophilia who had been managed in two institutions. Information on six patients who were diagnosed with tardy ulnar nerve palsy in two institutions was retrospectively collected. All patients suffered form severe haemophilia A. Anterior subcutaneous transposition of the ulnar nerve had been performed in all except one. The mean age of the patients at the time of procedure was 45.8 years and the mean duration of follow-up was 60.2 months. No postoperative complication or recurrence was observed. No additional surgery was required in operated patients. Evaluation was performed using subjective and objective measures, and a modified Bishop score. After operation, subjective sensory and motor disturbances were improved or resolved in all of the operated patients, while objective measures improved less well. Ulnar nerve can be involved in cubital tunnel in patients with haemophilia. Anterior subcutaneous transposition of the ulnar nerve is an effective procedure for improving patients' symptoms, with low risk of complications.

In-situ Catheterizable Bladder Tube with Submucosal Tunneling CATHERIZABLE CHANNEL as Continent Mechanism for Urinary Diversion: A Technique

Introduction: Patients who are unable to perform intermittent self-catheterization may undergo continent catheterizable stomas using the appendix (Mitrofanoff Appendico-vesicostomy). If the appendix is not available, the bowel is used to create a catherizable channel (Monti-Yang-Casale technique). Patients may develop shortening of the submucosal bladder tunnel with secondary leakage after being dry from the initial procedure. We have devised a novel technique for elongation of the submucosal intravesical tunnel in patients with secondary stomal leakage due to acquired shortening of the submucosal bladder tunnel. Methods: An in-situ bladder tube was created from the dome of the bladder with one end attached to bladder. A submucosal tunnel of adequate length (6: 1 ratio over 10F red rubber catheter) was created. The in situ bladder tube was rotated and brought through the tunnel to create flap valve mechanism. The intravesical end of the tube is anastomosed and the other end is attached to Monti-Yang-Casale tube, which is brought out as a catherizable stoma through the umbilicus. In the second patient, modification was used to create an in-situ tube from the posterolateral portion of the bladder, with urethral side attached to the bladder to prevent any rotation of the tube while placing it in the tunnel. Results:. We have used this technique in two patients. The first patient, who had Monti-Yang-Casale procedures, was fully continent after initial surgery and subsequently developed urinary leakage at the stoma. The second patient had a bladder tube combined with the Monti-Yang-Casale as the primary procedure. Both patients are totally continent following the new in-situ continent bladder tube procedure. Conclusions: Revision for incontinence may be surgically challenging and can lead to vascular compromise. The advantages of this technique are: (1) An in-situ continent bladder tube with can be added to the Monti-Yang-Casale procedure to correct recurrent urinary stomal leak. This technique preserves the stoma loop without handling of the bowel mesentery. (2) This method can also be used as a primary method when the Monti-Yang-Casale tunnel is not sufficiently long enough to cause continence, or compromised blood supply to the Monti-Yang-Casale catheterizable tube.