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The Mitrofanoff continent catheterizable channel is a surgical option that gives rehabilitation patients who have difficulty gaining access to their urethras for clean intermittent catheterization more independence in selfcare. This article presents a historical review, pre- and postoperative nursing assessment, nursing care, and a case study.
BACKGROUND AND OBJECTIVE: The purpose of this study was to determine the geometrical development of a coagulated zone in the canine prostate during free beam side fire Nd:YAG laser coagulation. STUDY DESIGN/MATERIALS AND METHODS: A series of 10 male dogs underwent endoscopic prostatic Nd:YAG fixed position laser coagulation through a suprapubic cystotomy using a right-angle deflecting delivery catheter (Microvasive, Boston, MA) at times varying from 10 to 120 seconds at 30 watts. In addition, two dogs underwent lasing by pulling the catheter at 1 mm/s in four quadrants. Acute gross and microscopic pathology specimens were prepared and the lesion shape and volume determined. RESULTS: Analysis of the coagulated volume showed that during the initial 15 seconds of lasing, the zone of coagulation approximates a sphere centered on the urothelium opposite the laser fiber. However, as lasing progressed, the lesion changed from a sphere to an expanding ellipse. This changing geometry can be explained by the absorption and scatter characteristics of the laser and the temperature equilibrium that is established within the prostate. CONCLUSION: An understanding of this time-dependent geometrical shift from a sphere to an ellipse allows the surgeon to supplement the fixed protocols for lasing at certain positions for given amounts of time. Specific plans can then be established for tissue at the bladder neck, apex, anterior stroma, floor, and irregular prostatic regrowth.
AIMS: To report outcome and urodynamic follow-up of incontinent ileovesicostomy in quadriplegic patients with neurogenic bladder. METHODS: Seven patients (five male, two female; mean age, 33.7 yr) with neurogenic bladder underwent ileovesicostomy for management of leakage or complications of chronic catheter drainage. Five had chronic indwelling catheters: three suprapubic and two urethral. Preoperatively, all had upper tract evaluation and videourodynamics. All seven patients had detrusor hyperreflexia. Preoperative detrusor leak point pressures averaged 42.7 cm H(2)O. Two females had intrinsic sphincteric deficiency from prolonged Foley catheter drainage. Ileovesicostomy involves isolation of a 15-20-cm segment of terminal ileum. The proximal 6-8 cm of this segment is opened on the antimesenteric border. The dome of the bladder is opened widely in a transverse manner and the proximal portion of the bowel is sutured onto the bladder. The distal portion of the ileum remains tubularized and becomes the stoma. RESULTS: There were no intraoperative complications. Operative time averaged 159 minutes. Associated procedures included removal of bladder calculus (n = 1), pubovaginal sling (n = 2), and Marshall Marchetti Krantz suspension (n = 1). Mean blood loss was <200 cc in six patients. Mean hospital stay was 8 days. Complications in two patients included: fascial stenosis requiring stoma revision (n = 1), wound infection (n = 1), and postoperative ileus (n = 1). Mean follow-up was 37.4 months. Postoperatively, mean detrusor leak point pressures were 16.7 cm H(2)O (P = 0.0061). Patient satisfaction is high with only one complaint of occasional difficulty fitting the appliance. CONCLUSIONS: Ileovesicostomy is an effective method of urinary drainage in quadriplegic patients. Detrusor leak point pressures were lowered, and upper tracts were preserved. No long-term complications were encountered.
Transrectal hyperthermia, transurethral thermotherapy, prostatic stent, and prostatic spiral were used to treat 120 poor operative risk patients with symptomatic benign prostatic hyperplasia. The preoperative subjective and objective conditions of the four groups (each of 30 patients) were comparable. None of the patients had an indwelling catheter, but according to flow nomograms, all were obstructed. The greatest increase in peak flow rate was observed after stent placement, while the greatest decrease of residual urine volume was seen after the insertion of the stent and transrectal hyperthermia. According to maximum flow nomograms, only the placement of the stent resolved bladder outlet obstruction. The greatest improvement in subjective symptoms was the result of stent insertion, but the heating procedures also caused a significant reduction of symptom scores. The spiral produced satisfactory results only in the short term.
From October 1988 to December 1993, 148 kidney transplants were carried out at our institution. An extravesical ureteral reimplantation technique resulting in a submucosal tunnel in the bladder wall was performed on 101 of the patients. For this technique, two small incisions are made at the outer part of the bladder wall until the mucosa is seen, then a submucosal tunnel is dissected between them and the graft's ureter is introduced and advanced in it (Alférez-Barry). Afterward the bladder mucosa is opened at the distal incision and the ureter is introduced into the bladder and fixed by a single direct anchorage stich (Taguchi). The minimal patients' follow-up is 18 months. Complications deriving from ureter reimplantation with this technique were present in 12.8% of the patients and included 4 cases of stenosis (3.9%), 4 cases of urinary fistula (3.9%), and 5 cases of hematuria (4.9%). We conclude that submucosal tunnelled ureteroneocystostomy with direct anchorage is a technique that simplifies kidney transplant surgery with good results. Ureteral direct anchorage can be used in any kind of ureteral anastomosis.
This study evaluated the role of activated urinary trypsin in mediating the increased incidence of infectious and hemorrhagic lower urinary tract complications in pancreas transplant patients with pancreatico-duodenocystostomies (PDC). The effect of trypsin concentrations corresponding to those observed in the urine of PDC patients were studied using an in vitro assay of clot lysis and an in vivo assay of bacterial-urinary tract adherence. Results were compared with those of parallel assays performed using urine from a pancreas transplant patient with a duodenocystostomy and control human urine. All trypsin concentrations studied demonstrated fibrinolytic activity. Fibrinolysis increased as a direct function of both trypsin concentration and duration of substrate exposure (P < 0.0001). Fibrin lysis resulting from the urine of the transplant patient was 4.6 times greater than that predicted based upon assays of total trypsin content in the sample. Fibrinolytic activity in control urine specimens was 0.16% of that observed in transplant urine specimens. Exposure of the rat urinary bladder to 200 micrograms/ml trypsin concentrations, or transplant urine, resulted in a significant increase in bacterial adherence over that seen in control urine from treated animals (P < 0.05). These findings demonstrate a significant effect of urinary trypsin on physiologic processes involved in hemostasis and the prevention of urinary tract infection. Active urinary trypsin may play an etiologic role in hemorrhagic and infectious lower urinary tract complications observed in patients with a PDC.
Eighty Wistar rats were randomized into two groups. In group 1 vesicosigmoidostomy with proximal colostomy was performed, in group 2, vesicosigmoidostomy. The total tumor incidence did not significantly (group 1 10/40, 25%; group 2 13/40, 32.5%). The tumor spectrum differed, with more adenocarcinomas in group 2 (11/40, 27.5% vs 4/40, 10%; P = 0.047) and urothelial carcinomas only in group 1 (5/40, 2.5%). One hundred and ten other Wistar rats were randomized into three groups. Animals in group A received vesicoileosigmoidostomy, group B, two-step vesicosigmoidostomy with initial separation of urine and the urocolonic anastomosis, group C, vesicosigmoidostomy. Significantly fewer adenocarcinomas were observed in group A (2/40, 5%) than in group B (16/40, 40%; P < 0.002) and group C (9/30, 30%; P < 0.007). These results indicate a similar cancer risk in all continent forms of urinary diversion, at least via colon. Ileal interposition seems to be an effective carcinoma prophylaxis following ureterosigmoidostomy. The proliferative instability at the urointestinal anastomosis is crucial for the pathogenesis and prophylaxis of this form of carcinogenesis, whereas urine seems to play only a minor role.
The content of these papers has been heavily weighted towards reconstructions performed utilizing segments of stomach. This was not done to place a value judgment on this type of reconstruction, rather it helps establish an awareness of: (1) potentially serious metabolic and gastrointestinal complications not previously reported in children and (2) particularly frequent symptomatic disturbances collectively included in the hematuria-dysuria syndrome. Recognition of problems specifically associated with a certain type of intestinal segment, as well as complications generally accompanying any form of intestinal reconstruction, will hopefully provide pediatric urologists and nephrologists with a better understanding of the issues that must be addressed in using these newer surgical techniques and focus attention on the specific indications and contraindications for incorporating intestinal segments into the urinary tract. Although long-term follow-up information still remains sparse, it appears that regular surveillance programs are required and both pediatric nephrologists and urologists need to be part of these programs.
Detrusor dysfunction does not recover in some patients with benign prostatic hyperplasia (BPH) even after prostate resection. 'We studied the functional restoration of the rat bladder after release of short- or long-term outflow obstruction. Bladder function was assessed by in vivo infusion cystometry and an in vitro organ bath technique. There were no significant differences in bladder weight and contractile strength induced by stimuli in detrusor muscle strips from obstructed rats and age-matched control rats. After short-term obstruction the whole bladder pressure generated in vitro by field stimulation, bethanechol, ATP, and KCl completely recovered to control levels. In contrast, after long-term obstruction, the whole bladder pressure in response to field stimulation remained significantly lower than in controls. Infusion cystometry variables, including the pressure at which micturition was induced, maximal voiding pressure, capacity, and residual urine volume, were similar between controls and rats subjected to short-term obstruction. However, the maximal voiding pressure after long-term obstruction was significantly less than that of controls.
The most common method of exocrine drainage in pancreatic transplantation is urinary drainage. With the shift from enteric drainage and duct occlusion techniques, there has been a concomitant shift from intraabdominal to urological complications. We present a case in which a simultaneous pancreas-kidney (SPK) transplant recipient developed urethral disruption and associated bladder outlet obstruction 11 months following surgery.
Vesicoureteral reflux (VUR) was recognized neonatally by voiding cystography in 25 of 117 infants with a dilated fetal urinary tract. There was a male preponderance (76%) and a high percentage (40%) of associated urinary malformations. Thirty-nine refluxing units were studied. All grades of VUR were detected but gross dilating VUR dominated (59%). Spontaneous resolution was excellent in lower grades of VUR but was poor in gross VUR. Surgery was successfully performed in 13 renal units of nine patients with gross reflux, additional ipsilateral malformations, or pyelonephritis during antibiotic prophylaxis. Segmental renal scars developed in four kidneys after urinary infections, and a diffuse parenchymal lesion was noted in nine kidneys even at birth. One boy with duplication had a non-functioning refluxing system. Our results in a small number of infants show differences to children with VUR detected after urinary infections and seem to support the existence of a congenital reflux nephropathy.
Suprapubic catheterization is a common procedure in continence surgery and hematuria is a common complication after suprapubic catheterization. The authors report an unusual case of acute clot retention after the removal of a Cystofix suprapubic catheter in a patient who had had a Burch colposuspension. Suprapubic cystotomy as an alternate suprapubic method is also discussed.
A new technique for transvaginal closure of the urethra and placement of a suprapubic catheter in 4 patients with total urinary incontinence gave excellent results with all patients remaining dry and accepting the suprapubic catheter. Suspension of the invaginated, closed urethra by sutures, passed through the bladder, is believed to reduce the risk of inadequate healing of the urethra. However, extreme obesity and extensive fibrosis of the periurethral tissue especially with adhesions to the pubic bone are contraindications to the transvaginal approach.
We describe our experience in treating 16 established cases of vesicovaginal fistulae in non-irradiated bladders which followed obstetric and gynecological procedures. The fistulae, most of which were large and complex, were successfully repaired surgically after two to three months intervals, using the O'Connor transvesical technique. The advantages of late correction using the transvesical approach in such cases are discussed. Thirteen additional cases of accidental bladder injuries during obstetric and gynecological procedures are presented. These injuries were successfully treated by immediate primary sutures. Our experience shows that bladder injuries mainly occur in women who had previously had a Cesarean section.
Anomalies of the fetal urachus are rare. Normally, the postnatal urachus presents as a fibrous band extending from the bladder to the umbilicus. Urachal cysts may occur in postnatal life. Spontaneous perforation of urachal cysts is a very rare condition, which clinically may not be distinguishable from other acute abdominal conditions. We report a case of a 63-year-old male with a history of recurrent urinary tract infections and a bladder rupture caused by a spontaneous perforation of an infected urachal cyst. The symptomatology showed abdominal rigidity and pain, a palpable mass in the lower abdomen, and hematuria. Laboratory findings showed leukocytosis and an increased CRP level. The bladder rupture was confirmed by cystography. Bacteriologic examination identified Proteus vulgaris, Corynebacterium species, and Klebsiella pneumoniae. Most of the published cases in the literature report about intraperitoneal perforation of infected urachal cysts. In the present case, we found a spontaneous perforation of an infected urachal cyst leading to an extraperitoneal bladder rupture with an extraperitoneal limitation of the infection. The definitive therapy was complete surgical excision including a cuff of the bladder, drainage, and systemic broad-spectrum and local application of antibiotics. The further course was uneventful.
Anaplastic seminomas account for 5-10% of all seminomas. Their metastatic pattern is similar to the classic form of seminoma. We report on an oligophrenic patient with seminoma pT1 who developed a metastasis to the corpus spongiosum and penile urethra, which was successfully treated by local external radiotherapy resulting in long-term tumor remission over a 4-year follow-up period.
For more than 10 years VUR has been treated by endoscopic injections with biocompatible substances. This study presents the results of this procedure with bovine collagen (Zyplast) in 42 children with 66 refluxing ureters. The follow-up period comprises an average time of 6.5 years (2-10 years). In 16 ureters a second and in 4 a third injection was given. In 5 kidneys scarring occurred during the years of follow up. Growth, kidney function and blood pressure remained normal in all children. 6 ureters were reimplanted because of recurrences, in 13 ureters (23%) the reflux improved and since no infection recurred no further management became necessary. In 36 (65.4%) ureters reflux was cured and in further 11 this was supposedly the case. However this was not proven by MCU, because parents refused this investigation. Earlier MCU have shown no reflux. We think that the endoscopic injection with collagen is a excellent option in management of VUR grade I-IV.
In the past, extravesical ureteroneocystostomy has been technically modified several times, with varying results. In this study, we evaluate our experience with modified extravesical re-implantation and routine stenting. From January 1988 to September 2001, 411 consecutive renal transplantations (220 LRD/LUD, 191 CAD) were performed at our institutions. Of 220 kidneys utilized for living related transplantation, 39 were retrieved laparoscopically and 181 were retrieved by open nephrectomy. The ureteroneocystostomy performed was a modified Lich-Gregoir re-implantation with routine stenting, using the upper transplant ureter. A double ureter was encountered in 11 patients and was managed with a conjoint ureteral ostium-to-mucosa anastomosis, using two stents. In two patients with graft ureteropelvic junction (UPJ) stenosis, a double ipsilateral drainage was performed, applying modified extravesical reimplantation with concomitant ureteroneocystostomy. There were no ureteral leaks. Five (1.22%) patients developed temporary ureterovesical junction (UVJ) obstruction/edema following stent removal, which necessitated re-stenting for 4-6 weeks. Two patients (0.49%) developed delayed stenosis and were successfully treated with retrograde balloon dilatation.(One at the UPJ of a pediatric kidney, and one at UVJ). All patients with functioning grafts in this series are currently stent-free. We conclude that the modified extravesical reimplantation with routine stenting is an effective and safe technique in renal transplantation, associated with almost no complications.