Biomedical subjects
Publications and source records attributed to M E Mitchell.
A modification of the Gilchrist procedure is used to create a continent urinary reservoir that provides reliable continence and antireflux mechanisms. The tubular form of the cecum is altered by a patch or reconfiguration to prevent bolus contractions of the reservoir. The procedure offers a choice of locations of the reservoir and stoma in most patients. Each step of the procedure uses techniques already familiar to urologists.
Intestinocystoplasty in combination with clean intermittent catheterization has been used in the management of 60 young patients with bladder dysfunction. Of the patients 39 (65 per cent) had the primary diagnosis of myelomeningocele, 8 had sacral agenesis, 3 had spinal cord tumors and 1 had spinal cord trauma. The remaining 9 patients had either congenital, surgical or traumatic loss of all or a large portion of the bladder. Of the 60 patients 30 had undergone prior urinary diversion, while the remaining 30 were considered failures with management by clean intermittent catheterization and medication. A total of 16 patients underwent ileocecocystoplasty, while 44 had augmentation with either cecum (8), sigmoid (18) or ileum (18). Mean followup was 4 years (range 16 months to 7 years). Fifty-nine patients have stable or improved renal function and the excretory urogram is stable or improved in all 60. Of the patients 38 (63 per cent) were considered dry after the initial bladder augmentation, while an additional 14 were rendered dry by a second procedure consisting of bladder neck reconstruction or placement of the artificial urinary sphincter, for a total of 52 (87 per cent) currently considered to be dry. Eleven patients have had at least 1 symptomatic urinary tract infection (18 per cent) and 21 had a positive urine culture but remained asymptomatic. In contrast to earlier beliefs, intestinocystoplasty can be applied effectively and appropriately to patients with bladder and urethral dysfunction. Intestinocystoplasty combined with clean intermittent catheterization offers a significant alternative to diversion in such patients.
Epidermolysis bullosa is a rare skin disorder that may at times involve the respiratory, gastrointestinal and genitourinary systems. We report 3 cases of epidermolysis bullosa involving the urinary tract. The radiographic evaluation of this entity and its relationship to other forms of obstructive uropathy are discussed along with a management plan for patients with genitourinary involvement owing to epidermolysis bullosa.
We report on 44 consecutive patients who underwent 1-stage hypospadias repair based on a urethral splent (silicone pleated stent). The severity of hypospadias ranged from subcoronal in 12 cases and distal in 23 to midshaft in 4 and penoscrotal in 5. In the first 15 patients of this series the splent was used with a suprapubic tube. All patients were able to void within the first 36 hours postoperatively. The next 29 patients underwent repairs without the use of a bladder catheter, including 15 who had outpatient procedures. None of the 44 patients has required subsequent catheterization or hospitalization. There have been 2 fistulas in this series. The urethral splent permits normal voiding through and drainage of the neourethra in a variety of hypospadias repairs. The splent expands and contracts with the degree of edema and permits catheterization should this be necessary. The advantages of hypospadias repair without bladder drainage, such as short hospital stay, total ambulation, and decreased potential for infection and bladder spasm, can be realized with the use of a urethral splent.
Urinary undiversion is becoming an uncommon procedure because fewer patients are being diverted. The lessons learned from undiversion, however, have made possible early primary reconstructions in patients who would previously have been candidates for diversion. Intermittent clean catheterization and the use of bowel to augment or form a compliant storage vessel for urine have permitted reconstruction in patients with abnormal bladder and urethral function. Thus patients with neurogenic bladder or with severe lower urinary tract abnormalities can look forward to healthy kidneys and urinary continence without the use of appliances. Certainly there are yet many lessons to be learned, but the potential is just starting to be appreciated.
We have developed a model for cloacal exstrophy in the chick embryo using the Cavitron AO 300 CO2 laser. Embryos between 68 and 76 hours of development have been injured caudal to the omphalomesenteric vessels in the region of the tail bud in ovo. This has resulted in the induction of cloacal exstrophy in 5 of 59 chicks that survived ten days after injury. Evidence from this model suggests that cloacal exstrophy is caused by early disruption of the cloacal membrane or that group of cells responsible for its subsequent development.
Urinary diversion as a permanent mode of therapy in childhood is becoming uncommon. Indications for temporary diversion are also few, particularly since the advent of percutaneous placement of tubes for temporary diversion. In the same sense, techniques and principles applied to urinary undiversion that are outlined in this article are now used for primary reconstruction in patients who previously would have been diverted.
Attitudinal and demographic correlates to food supplement use were ascertained for 689 adults residing in seven Western states. Of the 689, 372 (54%) were food supplement users and 317 (46%) were non-users. The only attitudinal variable significantly (p less than .001) related to the practice of food supplementation was the belief that vitamin C could cure and prevent a cold. More users than non-users agreed with the statement that "vitamin C can both prevent and cure a cold." Demographic variables found to be significantly (p less than .05) related to food supplement use included education, marital status, home type, employment status, and population of town/city in which the respondent resided. Food supplement users tended to be living together without marriage, never married, or divorced and living in town houses or "other" types of dwellings. More users than non-users resided in communities with populations of 2,500 or in communities with populations of 10,000 to 49,999.
Over the last 6 years, 114 patients have undergone surgery for urinary incontinence. The majority (79%) had neurologic dysfunction of the bladder because of spinal malformation (myelodysplasia, sacral agenesis, or trauma) and the remaining were a mixed group including exstrophy/epispadias, urethral valves, pelvic fractures, etc. The patients were grouped in six categories. Those with lower urethral resistance underwent bladder neck reconstruction with Young-Dees-Leadbetter procedure (five patients) or had placement of an artificial urinary sphincter (27 patients). Those with poor bladder compliance underwent primary bladder augmentation (21 patients). Those with combined urethral problems and poor compliance had combined procedures (14 patients). Thirty-seven patients previously diverted for incontinence and undergoing undiversion were considered separately, as were ten patients without any bladder precluding preoperative assessment. Of the entire group, continence was achieved in 83 patients with the initial procedure (73%). Secondary procedures have resulted in continence in 101 patients (89%). Three patients were improved but unsatisfactory, and nine remain wet; one is unknown.
The preputial island flap technique introduced by Duckett for repair of severe hypospadias has met with much clinical popularity. We report the use of a modification of this technique for repair of epispadias in 3 boys with exstrophy of the bladder and in 1 with penile epispadias. The results have been excellent in 3 cases and good in 1. Minimum followup has been 18 months.
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The artificial urinary sphincter (model AS 791-792), American Medical Systems, Minnetonka, Minn.) has been implanted in 41 patients (mean age 13.9 years) who were incontinent in spite of intensive efforts with other modes of management. Neurogenic bladder dysfunction is present in 34 patients. Seven patients have non-neuropathic dysfunction of the bladder neck and urethra (3 with exstrophy/epispadias, 3 incontinent after multiple bladder and urethral procedures, and 1 incontinent after a pelvic fracture). Twenty-two patients have had intestinocystoplasty performed and 11 patients had previous urinary diversion. Mean follow-up for a given device is 23 months (range 6 to 47 months). Of these patients, 80.5% are totally or acceptably dry. Five patients (12.2%) were rated as fair, and three were failures (7.3%). Complications have been significant in that reoperation has been necessary in 16 patients. Indications for patient selection is emphasized.
Neurofibromatosis in children occurs uncommonly and involvement of the bladder is exceedingly rare. The syndrome is transmitted as an autosomal dominant trait and is characterized by cutaneous pigmentation and tumors of neural crest origin. Hypertension has been documented in association with neurofibromatosis in the form of renovascular disease in children and with pheochromocytomas in adults. We report on 2 children with extensive neurofibromas of the bladder, upper tract damage and genital enlargement. One case was misdiagnosed as posterior urethral valves and the other case as clitoral hypertrophy. The literature of urogenital neurofibromatosis is reviewed with particular attention to bladder lesions, hypertension, malignant potential and treatment options.
Five young female patients with a functionally short or absent urethra are described. Two patients had an abnormal urethra related to a congenital malformation (1 female hypospadias, 1 urogenital sinus) and three patients had an absent urethra related to previous surgery. Four of the five patients were totally incontinent of urine. Urethral reconstruction was achieved by tubularizing the mucosa of the vaginal vault and swinging a full thickness pedicle skin flap from the posterior perineum and buttock to cover the urethral repair. In two patients previously diverted, undiversion was made possible. Urinary continence has been achieved in all five patients.
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Twenty-nine pediatric patients underwent bladder augmentation as part of their urinary undiversion. Indications included spina bifida deformity, contracted small bladder, and extrophy. Cecal and sigmoid segments were used. Prior diversion included ureterointestinal conduits, vesicostomies, ureterostomies, and suprapubic catheter drainage. In most cases the renal function was normal. Intermittent catheterization is used in almost every cases. Several illustrative cases are shown.
Undiversion is an interesting phenomenon but may in part be self-limiting. As the experience with techniques in reconstruction increases, the need for diversion may give way to that of earlier correction of the original pathology, Thus, reversal of diversion by offering a wealth of experience in reconstruction may well lead to its own demise. Nevertheless, even with newer reconstructive techniques, there is, to date, a definite place for diversion of the urinary tract in the pediatric age group and there are now many pediatric patients still to be considered candidates for undiversion