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A case of proximal female hypospadias with urethral atresia is reported, and a nosological definition of this rare congenital anomaly is proposed. An attempt to clarify the difference between a urogenital sinus and a proximal or distal female hypospadias is made by examining the embryology of the urogenital tract.
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A case of signet ring cell adenocarcinoma of the bladder occurring in association with long-term suprapubic catheterization is presented, the tumor appearing to have arisen in dysplastic glands of metaplastic urothelium. The possible implications of this findings are presented.
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With newer methods of managing lower urinary tract pathology in the young child, the role of cutaneous vesicostomy may be changing. This prompted a review of 50 consecutive patients treated with initial vesicostomy at our center over ten-year period. These children underwent vesicostomy diversion at a median age of 5.8 months and, of the 34 vesicostomies which have been subsequently closed, for a median duration of twenty-five months. Our indications agree with series reported previously and include patients with meningomyelocele, posterior urethral valves, or other forms of congenital or acquired lower urinary tract anomaly or dysfunction, along with complicating factors such as vesicoureteral reflux, recurrent infections, and/or renal deterioration. However, we also have identified a major group--those with primary gross vesicoureteral reflux--not previously included in detail. Follow-up averaged thirty-eight months. Improvement or stabilization of upper urinary tracts was achieved in over 90 percent of cases, and this trend continued after vesicostomy closure. As well, cutaneous vesicostomy allowed ureteral dilation to normalize, decreasing the degree of reflux and need for subsequent ureteral tapering and reimplantation at closure. Finally, though our stomal revision rate of 20 percent is high, modified techniques are being pursued.
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In the past two decades, the widespread use of cross-trigonal ureteral reimplants for the treatment of children with vesicoureteral reflux has resulted in a large population of patients with transversely lying ureters. As this population gets older they will consequently be entering an age group at higher risk for stone and urothelial cancer formation, with the potential for diagnostic and/or therapeutic ureteroscopy. The anatomic orientation of the ureters resulting from a cross-trigonal reimplantation may create difficulty or even inability to perform transurethral ureteroscopy. This case presents the technique of percutaneous transvesical ureteroscopy for stone extraction in a seventeen-year-old male with a lower ureteral stone following cross-trigonal ureteral reimplantation. The described technique may serve as an addition to the current endoscopic methods.
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OBJECTIVES: To present the preliminary results of a novel technique of ureteroneocystostomy with a new principle (extravesical seromuscular tunnel). METHODS: The new technique was applied in the left ureter of 12 mongrel dogs. The dogs were stratified into three groups (4 dogs each) according to the length of the extravesical seromuscular tunnel. Tunnel lengths of 3, 2, and 1 cm were used for groups I, II, and III, respectively. All the dogs were evaluated by excretory urography, radioisotope renography, and ascending cystography before and at 2 weeks and 3 months after ureteroneocystostomy. Urodynamic evaluation by the Whitaker test and ureteral pressure profile were carried out at 3 months. RESULTS: None of the 12 dogs showed vesicoureteral reflux. All but 1 dog of group I and 2 dogs of group II showed evidence of ureteric obstruction. All 4 dogs of group III showed perfect configuration and function of the corresponding renal units at 2 weeks and 3 months after ureteroneocystostomy. Moreover, the intrapelvic pressure and the superimposed ureteral pressure of this group were approximately similar to pressures of the normal contralateral side. CONCLUSIONS: Preliminary results of this new technique of ureteroneocystostomy revealed that an extravesical seromuscular tunnel of 1 cm provides reflux prevention without obstruction.
OBJECTIVE: Using a previously described animal model, we sought to compare 3 methods of double-layer cystotomy repair to each other and to single-layer repair in the prevention of vesicovaginal fistula formation. STUDY DESIGN: Twenty-four female mongrels, which were divided into 3 groups, underwent laparoscopic hysterectomy followed by monopolar electrosurgical cystotomy. Group 1 had simple 2-layer cystotomy repair with interrupted 2-0 polyglactin sutures; group 2 had resection of tissue 5 mm beyond the visible electrosurgical burn margin followed by 2-layer closure, and group 3 had interposition of an omental flap after 2-layer closure. Animals were killed at least 27 days after the operation, and a careful evaluation for vesicovaginal fistulas was undertaken by retrograde bladder filling. Group results were compared with one another and to a historic control group of 8 dogs that had undergone cystotomy repair with single-layer closure. RESULTS: All groups were similar in preoperative and necropsy weight. Bladder perforation occurred in 1 dog in group 1 on postoperative day 3; necropsy revealed perforation in the area of electrosurgical thermal spread with intact sutures. No vesicovaginal fistulas were noted in any of the study dogs (0/23 dogs; 95% CI, 0-12.7%) compared with 2 of 8 dogs (25%) that underwent single-layer closure (95% CI, 0-55%; P=.06). CONCLUSION: Double-layer repair appears to be superior to single-layer repair for the prevention of vesicovaginal fistulas after monopolar cystotomy. The benefit of electrosurgical burn margin excision or omental flap interposition remains unclear, but both are accomplished easily with little risk and may play a role in fistula prevention.
OBJECTIVE: The purpose of this study is to describe the incidence and types of ureteral surgical procedures that are necessitated during the course of surgical treatment of a population of patients who are cared for by a gynecologic oncology training program. STUDY DESIGN: From 1997 through 2004, the University of South Florida Division of Gynecologic Oncology database was accessed to extract the specifics of ureteral surgery that had been done during the course of the fellowship training program. RESULTS: Forty-six of 4844 major operations included ureteral surgery. Thirty of 46 procedures were repair of injury; all were recognized intraoperatively. The method of repair was simple closure (1 procedure), ureteroureterostomy (7 procedures), or direct ureteroneocystostomy (22 procedures). Two of the 7 ureteroureterostomies strictured. Ureteral resection was done for gynecologic malignancy in 15 of 16 patients. All 16 patients underwent reconstruction with direct ureteroneocystostomy. Seven of 16 patients underwent concomitant rectosigmoid colectomy. One of 16 patients who underwent en-bloc partial cystectomy had a postoperative vesicovaginal fistula. All 36 ureteroneocystostomies with short-term follow-up had radiologically normal upper urinary tracts. Eighteen patients had subsequent follow-up evaluations; all of them had radiologically normal upper urinary tracts at 5 to 42 months (mean, 19 months). CONCLUSION: When significant injury to the pelvic ureter occurs during radical pelvic surgery, ureteroneocystostomy may be the repair of choice. After resection of a portion of the pelvic ureter for gynecologic malignancy, the urinary tract was reconstructed successfully with direct ureteroneocystostomy. In those patients who underwent ureteral resection for malignancy, the extent of the disease process necessitated concomitant rectosigmoid colectomy 47% of the time.
During the last decade continent urinary diversion, especially orthotopic bladder substitution has become increasingly popular following radical cystectomy for bladder cancer. In general, if sphincter sparing surgery is possible, orthotopic bladder substitution is performed, if not then continent catheterisable reservoirs are a viable option. Strict patient selection criteria and improved surgical technique have had a positive influence on outcome, not only on survival but also on quality of life issues. It is becoming increasingly obvious, that a nerve sparing surgical technique not only improves sexual function but also continence. In addition, the length of the intestinal segment has an influence on continence and the degree of metabolic consequences, which are discussed in detail. Postoperative surveillance and instruction of patients is of utmost value for good functional results. Overall patient satisfaction and quality of life seem comparable in the various types of continent urinary diversions, and improved when compared to a urinary stoma. Continent urinary diversion offers a good quality of life with few long-term complications and should be considered the treatment of choice in the majority of patients, independent of sex.
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Chronic indwelling catheters are used to manage urinary retention, especially in the presence of urethral obstruction, and to facilitate healing of incontinence-related skin breakdown. These indwelling foreign bodies become coated and sometimes obstructed by biofilm laden with bacteria and struvite crystals. Bacteria invariably colonize the system and may invade the blood stream following trauma or obstruction. Staff should maintain a closed, dependent system to avoid introducing new organisms and be vigilant for the development of obstruction, avoid trauma, and consider chronic catheters and drainage bags to be potential sources of antibiotic-resistant bacteria for secretion containment and when antibiotics are selected for empiric therapy. Suprapubic catheters should be considered when urethral catheters are associated with discomfort or periurethral suppurative complications, especially in males.
BACKGROUND AND PURPOSE: Laparoscopic extravesical ureteroneocystostomy is an infrequently described technique. Our aim is to describe five cases where we used the intracorporeal freehand suturing technique successfully for performing laparoscopic extravesical transperitoneal ureteral reimplantation with psoas hitch. We describe the preliminary results of these cases. PATIENTS AND METHODS: We performed this surgery in five female patients. Two patients had a low ureterovaginal fistula after total laparoscopic hysterectomy. The other three patients had undergone laparoscopic radical hysterectomy. RESULTS: The average surgical time was 220 minutes. The average blood loss was 150 mL. The average stay was 3 days, and the average time to starting oral intake was 12 hours. No intraoperative or postoperative complications occurred. The urinary catheter was removed after 3 weeks and the double j stent after 6 weeks. Follow-up urography showed good clearance of the kidney and ureter. There was no reflux on the postoperative cystogram. CONCLUSION: Laparoscopic extravesical ureteroneocystostomy with intracorporeal freehand suturing technique and psoas hitch is a feasible procedure in females for managing ureterovaginal fistulas after laparoscopic gynecologic surgeries. The patients need not be subjected to open surgery because this complication can be repaired laparoscopically, thus minimizing the morbidity.
The Mitrofanoff urinary diversion is fraught with the complication of cutaneous stomal stenosis, which prevents catheterization. The authors report another sequel of stomal stenosis-acute appendicitis, a complication not reported hitherto.
PURPOSE: Creation of a vesico-amniotic shunt for obstructive uropathy removes the normal fetal urination cycle. It is unclear how this affects bladder function at term. The authors measured the bladder volume and reviewed the bladder histology after fetal vesicostomy. METHODS: The authors created an obstructive uropathy in fetal lambs at 60 days' gestation by ligating the urethra and urachus. Vesicostomy (female) or urethrostomy (male) were performed 21 days after obstruction to release the obstruction. The fetuses were killed at term (145 days). RESULTS: Thirteen fetuses were shunted. Seven fetuses miscarried after shunting. Six survived, and 3 had a successful shunt with a very small bladder (5 to 7 mL). Two had incomplete shunts that failed some time after shunting. These both had huge bladders (399 mL). In one, the obstruction was unsuccessful. Histologic examination showed that the obstruction caused bladder muscle hypertrophy. Shunted lambs had severe fibrosis of the bladder wall and very poor bladder compliance. CONCLUSIONS: Shunt operations after obstructive uropathy may salvage the kidney but fail to preserve bladder function. The fetus needs a normal urination cycle for normal bladder development. This requirement exists even when the obstruction is successfully bypassed.