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PubMed2003

Continent bladder stoma.

The formation of an aesthetically desirable urinary diversion through a continent bladder stoma requires a long-term commitment by both patient and urologist to monitoring patient progress and addressing problems, both urological and otherwise, which arise over time. In this manuscript, issues relating to physical aspects of surgical management are discussed. These include the nature of and site of the stoma and its catheterizing track, the continence mechanism, provision of a low-pressure storage system of adequate capacity and management of the bladder neck/urethra when incompetent. It is imperative that careful patient selection is practised at the outset when such surgery is contemplated, otherwise a satisfactory outcome is unlikely to ensue irrespective of the procedural skills employed operatively.

Cystostomy↗
PubMed2003

A simple and reliable continent bladder stoma constructed from bladder wall.

Patients presenting with recurrent bladder neck strictures or severe incontinence refractory to all forms of infravesical treatment usually require chronic catheterization or supravesical urinary diversion. As an alternative, we use a simple continent bladder stoma made from the bladder wall. After extraperitoneal bladder mobilization, a Lapides-like 4 x 8 cm U-shaped bladder flap is excised and sutured to a tube. Depending on the location of the stoma, the base of the flap can be chosen and/or the length of the flap can be adapted. After bladder neck closure the tube is reflected and, after incision and dissection of the detrusor in the middle of the base of the flap, embedded in Lich-Gregoir's technique. The distal end of the tube is then sutured to the stoma site. Five of our patients now have a minimum follow-up of 11 months (mean 17 months). All are continent with a bladder capacity between 250 and 560 ml. In two, stomal stenosis at the skin level required epifascial stomal revision.

Adolescent↗
PubMed2002

Initial surgical treatment as a determinant of bladder dysfunction in posterior urethral valves.

Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy; vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder; (2) vesicostomy group: small-capacity, hyperreflexic bladder; and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function.

Child↗
PubMed2005

Fetal hydrops in experimental obstructive uropathy resolves after vesicostomy formation: is this cause and effect?

The association of obstructive uropathy and hydrops is rare but often fatal. Hydrops has been observed in our fetal lamb model with obstructive uropathy. We created a vesicoamniotic shunt 21 days after creating the obstruction to explore the effect of relieving the obstruction on the hydrops. Fetal lambs underwent urethral and urachal ligation at 60 days gestation. We created a vesicostomy (female) or urethrostomy (male) in 12 lambs to release the pressure 21 days after creating the obstruction. The fetuses were delivered at term (145 days), and the urinary tract was removed for histological examination. Six fetuses had severe hydrops at the time of the vesicostomy (group A), and six had no hydrops (group B). Only two lambs from group A survived (33%), and four lambs survived from group B (66%). Three lambs miscarried, and one was stillborn from group A. Two lambs from group B miscarried. In our fetal lamb model, hydrops appears to be associated with massive urinary ascites. We hypothesize that a connection exists between urinary ascites and hydrops. Vesicostomy, by bypassing the obstruction, may allow the lambs to recover from their hydrops. However, it is possible that by 21 days after creation of the obstruction, the damage created by the hydrops is irreversible.

Animals↗
PubMed2006

Evaluation of bone mineral density after ileocystoplasty in children with and without myelomeningocele.

We evaluated the bone mineral density (BMD) after ileal augmentation cystoplasty in a group of children with and without myelomeningocele. Between 1996 and 2003, eight patients with neurogenic bladder and seven patients with non-neurogenic bladder underwent augmentation ileocystoplasty. Preoperative and postoperative serum creatinine and electrolytes were measured. All patients underwent clinical evaluation, supine height measurement, blood gas analysis, and BMD measurement using a dual energy X-ray absorptiometry (DEXA) postoperatively. BMD was measured at L1-L4 and femoral neck, and compared to age- and sex-matched population. Follow-up time was calculated from the day of surgery to the day of DEXA performance. A total of eight boys and seven girls with the mean age of 10.2 +/- 4.1 years were evaluated with respect to BMD measurement. Mean age was 9.8 years in neurogenic group and 10.5 in non-neurogenic group. Mean follow-up was 728 and 616 days in neurogenic and non-neurogenic groups, respectively. There were no significant differences between ages, follow-up times, preoperative and postoperative creatinine levels, pH and bicarbonate values, and supine heights. Mean BMD at L1-L4 was 55.7% in neurogenic group and 83.8% in non-neurogenic group. There was a statistically significant difference between the two groups (P = 0.02). Mean BMD at femoral neck was 72% in neurogenic group and 86.2% in non-neurogenic group. The difference was also statistically significant (P = 0.028). After augmentation ileocystoplasty, the BMD in early postoperative period of patients with myelomeningocele is lower than the patients with non-neurogenic neurogenic bladder, which have the same clinical characteristics except the neurologic pathology. In the light of our findings and the reported literature data as well, we may claim that BMD decrease after augmentation ileocystoplasty depends more on the underlying neurologic pathology and its locomotor consequences rather than the enterocystoplasty itself.

Absorptiometry, Photon↗
PubMed2001

Posterior urethral valves: the scenario in a developing center.

We have reviewed 233 patients with posterior urethral valves treated in a single center in Calcutta, India, over the last 20 years: 37 were neonates, 75 were between 1 and 12 months, 88 were between 1 and 5 years, and 33 were more than 5 years old when first seen. The clinical presentation and methods employed in diagnosis and assessment are described. Primary endoscopic valve ablation was performed in 140 patients (60%). One or other form of diversion was done in 100 (43%), 93 before and 7 either during or after valve ablation. The short- and long-term results have been studied. Eleven patients died during the initial hospitalization, 3 died subsequently, 15 are in end-stage renal disease, 17 are in poor health, and 18 have been totally lost to follow-up. The remaining 169 have been in good health for periods between 1 and 20 years. While our results of primary valve ablation in low-risk patients with responsible parents are as good as anywhere else in the world, we are concerned at our relatively high diversion rate and relatively poor long-term follow up; the methods being adopted to reduce these problems are discussed.

Child, Preschool↗
PubMed1999

Congenital pouch colon in females.

From January 1995 to March 1998, congenital pouch colon (CPC) with anorectal agenesis was diagnosed in ten girls who were classified into four groups based on the length of normal colon proximal to the colonic pouch. Of six girls with little or no normal colon, one had a cloacal anomaly while five had a colovesical or colovestibular fistula along with a completely bifid uterus and cervix and a septate vagina. Initial surgery consisted of ligation of the fistula and subtotal pouch excision with tubularization of the remaining colon in four girls, ileostomy after excision of a gangrenous pouch in one, and window colostomy in another. None of the patients had a sacral abnormality or associated major malformation. Definitive surgery using the posterior sagittal approach consisted of a pull-through of the tubularized colon in three girls (including one in whom one-stage cloacal reconstruction was performed), the ileum in one, and the proximal colon in another. The four girls with a longer length of normal colon had an associated vestibular fistula. In these, a colostomy was constructed just proximal to the pouch with definitive surgery in two patients consisting of excision of the pouch and pull-through of the proximal colon. Definitive surgery was well tolerated in all seven patients. The embryogenesis of this condition and the related genitourinary tract abnormalities are discussed.

Abnormalities, Multiple↗
PubMed1999

Urodynamic evaluation in boys treated for posterior urethral valves.

This study describes the urodynamic findings in 22 patients with posterior urethral valves and discusses their association with urinary incontinence, age, mode of primary treatment, renal function, and changes in the upper tracts. The patients' ages ranged from 3 to 26 years and 27% were either adolescents or older. The urodynamic findings were categorized into 5 main patterns, although mixed patterns were also observed; (1) normal capacity and compliance with normal detrusor contractility (2/22 patients, 9.1%); (2) small-capacity, hypocompliant bladder (8/22 patients, 36.4%); (3) unstable bladder (2/22 patients, 9.1%); (4) large-capacity, hypotonic bladder with decreased detrusor contractility (2/22 patients, 9.1%); and (5) normal capacity and compliance but with decreased detrusor contractility (8/22 patients, 36.4%). More than one-half of the patients (57.1%) evacuated their bladders incompletely, and this seemed to be associated with post-treatment episodes of urinary-tract infection. The commonest symptom was daytime frequency, urgency, and leak with nocturnal enuresis, which urodynamically correlated with a small-capacity, hypocompliant or unstable bladder or to incomplete evacuation of the bladder, leading to significant post-void residue. Significant detrusor dysfunction was identified in 2 asymptomatic patients as well, emphasizing the need to perform a routine urodynamic work-up on all valve patients. Urodynamic properties seemed to be associated with age. Small, hypocompliant, and unstable bladders were almost always seen in prepubertal boys and in the first 5 years following undiversion, whereas large, hypotonic bladders with impaired contractility were seen in post-pubertal boys. While the current policy is to avoid high diversion, data in this study suggest that disorders of detrusor capacity, compliance, and contractility exist in children treated by primary valve ablation and vesicostomy and that abnormal detrusor dynamics seem to be a reflection of inherent developmental detrusor dysfunction consequent to congenital infravesical obstruction.

Adolescent↗
PubMed2002

Placenta previa percreta with urinary bladder and ureter invasion.

A 26-year-old woman, with one previous cesarean delivery and two uterine curettage due to incomplete abortion, was admitted to the labor ward with the diagnosis of partial placenta previa at 35 weeks of gestation. Repeat cesarean section was performed due to profuse vaginal bleeding. Placenta previa percreta invading the bladder trigone was confirmed with cystotomy. As bilateral hypogastric artery ligation and supracervical hysterectomy performed were not successful in stopping the profuse bleeding, the abdomen was packed with laparotomy pads. Dilatation of the left ureter was noticed on the second postoperative day. Relaparotomy was performed to remove the pads, and placental invasion of the distal left ureter was noticed. Ureteroneocystostomy was performed. The postoperative course was uneventful, and the double-J-catheter was removed two months later.

Adult↗
PubMed2006

Utility of an atraumatic self-retaining ring retractor in pediatric surgery.

The Protractor is a self-retaining ring retractor used mainly for minilaparotomies in adults. We report our positive results of using this retractor in pediatric surgery. We performed surgery with the aid of the Protractor in 57 pediatric patients aged from 1 day old to 16 years old. The Protractor allowed a wide operative view and did not cause any major complications. It was especially useful for Kasai's portoenterostomies and ureteroneocystostomy (Cohen's repair). In neonatal surgery, the Protractor not only provided a wide operative view, but also prevented the washing fluid from overflowing onto the covering sheet. In appendectomy, the Protractor protected the surgical wound from contaminated ascites and the appendix. The Protractor is a very useful tool for assisting with various abdominal operations in infants and children.

Adolescent↗
PubMed1993

Anuric acute renal failure due to bilateral accidental ureteric ligation during abdominal hysterectomy.

OBJECTIVE: To determine the incidence of accidental ureteric ligation causing acute anuric renal failure (AARF) at the KorleBu Teaching Hospital, Accra, Between August 1984 and December 1991. METHOD: The records and operative data of all cases managed with acute anuric renal failure at the hospital during the period were reviewed. RESULT: The 7 patients with AARF presented with mean pre-referral anuria of 3.2 days. Total abdominal hysterectomy (4 for fibroids, 2 for carcinoma of uterus and 1 for post partum hemorrhage) was the cause of ureteric ligation. The 7 patients mean age 38.5 years were anemic (mean HB 4.1 g/dl) and uremic (mean blood urea 40.51 mmol/l) on admission. Abdominal ultrasonography was useful for diagnosis of obstructive uropathy. Hemodialysis was required in all cases prior to laparotomy and ureteroneocystostomy. The ureters were usually ligated at the distal 3 cm. Five survived ureteroneocystostomy and 2 died before laparatomy from septicemia and/or pulmonary edema. CONCLUSION: Abdominal hysterectomy is a major cause of anuric acute renal failure and early recognition and treatment prevents death.

Acute Kidney Injury↗
PubMed1991

The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children.

The Mitrofanoff principle has been used to achieve clean intermittent catheterisation (CIC) and urinary continence in 28 children. The mean age at operation was 10.1 years (range, 1 to 19 years). A catheterisable conduit was created using the appendix (19), ureter (8), or vas deferens (1). CIC was commenced 10 to 28 days postoperatively (median, 15 days). After a mean follow-up of 13 months (range, 2 to 45 months), 24 children (86%) have achieved successful CIC and urinary continence. Use of the Mitrofanoff principle is a valuable adjunct to the treatment of urinary incontinence in children and may allow successful CIC in patients who are unable to catheterise urethrally.

Adolescent↗
PubMed1994

Cloacal anomalies: role of vesicostomy.

The purpose of this report is to discuss the use of vesicostomy in the treatment of cloacal anomalies. In 4 years, the authors have performed primary reconstruction in four children who had cloacal anomalies. Three children had hydrocolpos, which in two cases failed to decompress with tube vaginostomy or clean intermittent catheterization. In both cases, cutaneous vesicostomy effectively prevented urinary sepsis, which allowed the children to thrive before definitive reconstruction was performed. Vesicostomy is technically simple to perform and is easily reversed without loss of bladder volume. Further, it lends itself well to definitive reconstruction of cloacal anomalies.

Cloaca↗
PubMed1994

Type III posterior urethral valves: presentation and management.

The clinical and radiographic presentation of infants with type III posterior urethral valves help to distinguish them from patients with the more common type I valves. The diaphragmatic valvular obstruction may make catheterization impossible. Percutaneous cystography can confirm the diagnosis and allow for short-term decompression. The presence of smooth-walled bladders with narrow posterior urethras is unique to type III valves but is not always present. Type III valves present within a spectrum of clinical severity; however, the majority involve significant renal impairment. The prognosis for survival and renal function appears poorer for patients with type III valves than for those with type I valves.

Child, Preschool↗
PubMed1995

Detrusorrhaphy for the repair of vesicoureteral reflux: comparison with the Leadbetter-Politano ureteroneocystostomy.

The authors report their surgical experience for 56 patients (81 ureters) with vesicoureteral reflux using either the extravesical (detrusorrhaphy) approach or the Leadbetter-Politano (intravesical) procedure. The success rate was the same in both. Patients undergoing the extravesical approach required less pain medication and less anticholinergic therapy to control bladder spasms in the postoperative period as compared with the patients undergoing the repair through an intravesical approach. Because the bilateral extravesical approach may be associated with transient urinary retention, the authors recommend that bilateral procedures be performed with minimal dissection of the trigone or that this approach be limited to unilateral repair.

Case-Control Studies↗
PubMed1995

Bilateral ureteral obstruction after appendectomy in children.

Five cases of bilateral ureteral obstruction after appendicectomy are presented. All five patients were boys (age range, 9 to 15 years). All of them had had severe appendicitis. Based on the urethrocystoscopy findings, edema of the posterior bladder wall appeared to be the cause of obstruction of both distal ureters. This is confirmed by the immediate recovery of renal function after installation of bilateral uretercatheters. It is known that contamination of the peritoneal cavity can occur by organisms leaking from a gangrenous or perforated appendix. This can cause localized inflammatory edema of the posterior bladder wall. It is remarkable that through ultrasound investigation, only mild to moderate dilatation of the urinary tract was observed. An explanation can be obtained from animal models, wherein acute obstruction of the ureter leads only to a transient increase in ureteral pressure, followed by a decline toward the preobstruction level. It is important to be aware that this complication can occur after appendectomy; bilateral uretercatheters can be installed, and irreversible renal damage can be avoided.

Adolescent↗