[REPAIR OF THE URINARY BLADDER AND URETHRA IN EXSTROPHY].
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Bladder Exstrophy↗
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Bladder reconstruction in children.
Bladder reconstruction in children attempts to provide for a low pressure reservoir of urine that is continent and may be emptied completely at appropriate intervals. The most common underlying causes of bladder dysfunction that may require reconstruction include neuropathic bladders associated with spina bifida, posterior urethral valves, and bladder exstrophy. Indications and patient selection for reconstruction have greatly improved and a variety of methods are available; each with its own advantages and drawbacks. The recent increased application of gastric segments in augmenting the bladder to increase size and compliance has been very successful, and particularly in patients with impaired renal function. The continent catheterizable stoma (Mitrofanoff principle), using appendix or ureter, has gained widespread acceptance in reconstructive procedures and provides a reliable, convenient, and well-accepted means of achieving continence. Although advances have been made in reconstructive techniques, new complications are being experienced, including stone formation and metabolic abnormalities. Gastrocystoplasty, although an excellent option in reconstruction, has produced a symptom complex of hematuria and dysuria in some patients, at times to a significant degree. With experience, these complications are becoming better understood and new strategies for management are being developed. On the horizon, new approaches to bladder replacement are being explored, and new investigation into the pathophysiology of pediatric bladder dysfunction is ongoing.
Child↗
Nonsecretory intestinocystoplasty: a 10-year experience.
PURPOSE: We present long-term results on the use of demucosalized intestine for reconstructive surgery of the bladder. MATERIALS AND METHODS: A total of 129 bladder augmentations with demucosalized intestine were performed in 123 patients (55% males and 45% females) 3 months to 53 years old during the last 10 years. Of the patients 82 presented with neurogenic bladder, 40 with bladder exstrophy, 3 each with tuberculosis and posterior urethral valves, and 1 with female hypospadias. Sigmoid was used in 104 cases and ileum in 25. In 105 cases a silicone balloon was left inside the augmented bladder for 2 weeks. In the remaining cases bladder mucosa was preserved and no mold was used. A silicone inflatable bladder neck cuff was implanted at the same time as augmentation in 32 patients. RESULTS: Followup ranged from 3 to 135 months (median 51.0). There was a 329% increase in bladder capacity and compliance increased 7-fold. There were 13 (10.1%) cases considered failures, which were treated with reaugmentation using demucosalized ileum (6), different forms of augmentation (5) and no reaugmentation (2). There was no mucus formation, bladder perforation or neoplasia. CONCLUSIONS: Based on our study we conclude that demucosalized intestine is a safe alternative for bladder augmentation and can be used for the same indications as total bowel segments.
Adolescent↗
[Gastrocytoplasty in pediatric patients--initial clinical experience with 5 cases].
Gastrocytoplasty was undertaken for 5 patients with bladder dysfunction and incontinence caused by neurogenic bladder in 3 cases, bladder exstrophy in 1 case and trauma in 1 case respectively. The age of the patients ranged from 5 years through 14 years at the operation. Decreased renal function was recognized in 3 cases with neurogenic bladder before reconstruction. The other 2 cases had normal renal function. Gastric segment was isolated with right gastroepiploic artery as a pedicle. Bladder was opened vertically and augmented with gastric segment. In 4 cases urethrogastrostomy with submucosal tunnel was performed in both sides. In neurogenic bladder cases, urethra was left without any surgical intervention, while other 2 cases underwent continent diversion using Mitrofanoff principle with urethra being closed. Postoperative follow up period was 18 to 22 months. All cases had increased bladder volume and the dilatation of upper urinary tract disappeared or decreased in size in those who had upper urinary tract dilatation before operation. Urinary incontinence completely disappeared in continent diversion cases. In neurogenic bladder cases urinary leakage through urethra was negligible with 4 hour interval clean intermittent catheterization. Laboratory examination showed no metabolic derangement in blood gas analysis and electrolytes even in those who had decreased renal function. Blood urea nitrogen (BUN) and serum creatinine showed a little improvement or the same level as before. We didn't encounter any troubles in CIC such as the obstruction caused by mucus produced by gastric segment. From our experience with those 5 pediatric cases underwent gastrocystoplasty, we thought gastric segment had some advantage as a tissue for augmentation cystoplasy compared with intestinal segment.
Adolescent↗
Modified ureterosigmoidostomy (Mainz II): a long-term follow-up.
OBJECTIVE: To assess the long-term results in patients treated using a modified ureterosigmoidostomy (Mainz II). PATIENTS AND METHODS: Between 1994 and 1999, 17 patients had their lower urinary tract reconstructed by a ureterosigmoidostomy, modified by reconfiguring the rectum to make a low-pressure reservoir (Mainz II). All patients were followed on a standard protocol. Data were extracted from the database and from a review of the case-notes. In 12 patients the procedure was with a radical cystectomy for carcinoma. Five had a failed conventional ureterosigmoidostomy for bladder exstrophy and therefore proceeded to a Mainz II. The data on continence and complications were retrieved for a retrospective analysis; the mean (range) follow-up was 6.4 (4-8.6) years. RESULTS: Ten of those with bladder cancer and one in the revision group were continent. Two patients in the revision group had sufficiently severe nocturnal incontinence to require conversion to a colonic conduit. Seven of the 17 patients had hyperchloraemic acidosis, one had pyelonephritis and one had renal stones. There were no anastomotic neoplasms. CONCLUSION: The Mainz II has a good outcome if used as the primary procedure. In patients with an existing ureterosigmoidostomy who are incontinent, detubularization of the rectosigmoid alone is unlikely to restore continence.
Adult↗
[Continent urinary diversion: the Mitrofanoff principle].
INTRODUCTION: Continent urinary diversion (based on Mitrofanoff's principle), despite its complexity, is the gold standard in the treatment of those vesicourethral disfunctions that need clean intermittent catheterization (CIC) to achieve complete vesical voiding, in patients with non easily catheterizable native urethra. AIM: To analize our experience in continent urinary diversion at our centre. PATIENTS AND METHODS: We have reviewed the records of the 14 cases of continent urinary diversion in the last 8 years. They were grouped in order to the underliying condition: 1-Bladder exstrophy group (n=5): Mean age at diversion time was 5.5 years (range 3-7). In all patients the original Mitrofanoff s technique was performed (continent cutaneous appendicovesicostomy). Associated procedures were: ureterovesical reimplantation in all 5 cases; bladder neck reconstruction also in all 5 (3 of them needed vesicourethral transection); and bladder augmentation in two cases, using ileum and sigmoid respectively. 2- Myelomeningocele group (n=9, 10 procedures): Mean age was 11.5 years (range 6-16). Appendicovesicostomy was performed in 7 cases and a reconfigured ileum with the Casale technique was used in 3 cases (primarily in 2 and as an alternative in one). Associated procedures were: ureterovesical reimplantetion in 5 cases and bladder augmentation in 7 (using sigmoid in 4, ileum in 2 and urether in one case). RESULTS: In all patients complete continence was achieved. Complications found were: one appendicostomy prolapse, one appendix necrosis (that was then diverted with Casale's technique), one appendicular conduit stenosis and one case with catheterization difficulties that needed a tappering of the ileum conduit. Nowadays, 13 out of 14 pacients follow the CIC program each 3-4 hours without complication. CONCLUSION: Continent urinary diversion improves autonomy and life quality in those patients that need a definitive urinary diversion and have a long life expectancy. We have used these procedure with good results in patients with severe vesicourethral disfunction (of an intrinsic or neuropathic origin) in which clean intermittent catheterization was not possible through native urethra, or in patients with refractary incontinence in which vesicourethral transection was the only effective treatment.
Adolescent↗
Urodynamic findings in children with isolated epispadias.
PURPOSE: The exstrophy-epispadias complex represents a spectrum of anomalies with variable implications for upper and lower urinary tract function. Successful treatment of incontinence in this population is challenging and often elusive. To date few studies have focused on urodynamic findings specific to primary epispadias. MATERIALS AND METHODS: We retrospectively reviewed the records of patients presenting with primary epispadias in the absence of bladder exstrophy. We identified 18 boys and 12 girls, of whom 16 underwent formal urodynamic evaluation before (5), after (6) or before and after (5) surgical narrowing of the bladder neck. Bladder capacity was recorded as percent of expected capacity for age. Bladders were considered hypertonic when end filling pressure was greater than 20 cm. water. End filling pressure was defined as the pressure at which urinary leakage was noted or the patient had discomfort. Uninhibited contractions were considered significant when the amplitude was greater than 15 cm water. The ability of the detrusor to generate a voiding contraction at the end of the filling phase was also recorded. Urodynamic studies were performed with a balloon catheter occluding the incompetent bladder neck or with a standard urodynamic catheter after formal bladder neck repair. RESULTS: Before bladder neck repair average bladder capacity was 157 ml (range 55 to 450), corresponding to 52% (range 22 to 100) of expected capacity. Significant uninhibited contractions were noted in 2 patients. In 7 of the 9 evaluable patients (78%) a voiding contraction was generated. In children in whom urodynamic studies were done after surgery mean bladder capacity was 260 ml (range 77 to 660), corresponding to 76% (range 36 to 147) of expected capacity. Hypertonicity and hyperreflexia were noted in 3 and 2 patients, respectively. In 5 of the 11 cases (46%) a voiding bladder contraction was generated. Of the 5 patients who underwent urodynamic evaluation before and after bladder neck repair the percent increase in bladder capacity was significantly greater in the 2 boys (67 and 110%, respectively) than in the 3 girls (-20, 10 and 20, respectively). CONCLUSIONS: The most frequently noted urodynamic pattern before surgical correction of the bladder neck in patients with isolated epispadias is a low capacity, highly compliant bladder with minimal detrusor dysfunction. Postoperatively capacity increases, albeit to a greater extent in boys than in girls, and the incidence of detrusor dysfunction increases as well. In some patients classic bladder neck repair may result in detrimental bladder dynamics due to as yet poorly elucidated mechanisms.
Adolescent↗
[Cancer of the colon following ureterosigmoidostomy or following bladder enlargement using a colonic graft].
The role of carcinogenic factors following urinary diversion are here studied on the basis of three very different cases. In the first, an adenocarcinoma developed at the site of a ureterocolic anastomosis thirty one years after Coffey's operation for bladder exstrophy. In the second, the tumor had developed, 31 years after uretero-sigmoidostomy, for ureteral trauma. The anastomosis had moreover ceased to function ten years previously. In the third case, the patient had undergone a right nephrectomy for urinary tuberculosis and a colocystoplasty to enlarge the bladder with re-implantation of the left ureter in the graft. Twenty one years later, an adenocarcinoma developed at the site of the anastomosis between the colonic graft and the bladder. This was an exceptional case (possibly the first) of a cryptal tumor developing out of contact with material. It thus runs counter to the alleged role of facies in the development of adenocarcinomas following urinary diversion.
Adenocarcinoma↗
Adenocarcinoma in the exstrophic bladder.
We report 2 cases of cancerous transformation in an exstrophic bladder. The histology of these tumors, methods of surveillance, and treatment are discussed in conjunction with a review of published reports. These rare tumors are almost entirely adenocarcinomas. Their treatment is surgical (radical cystectomy) with or without associated radiation therapy. Surveillance for patients with bladder exstrophy, whether surgically corrected or not, is indispensable and rests on cystoscopy and urine cytology.
Adenocarcinoma↗
Complete bladder duplication with exstrophy of 1 moiety in a male infant.
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Abnormalities, Multiple↗
Hydraulic valve for continence and antireflux. A 17-year experience of 210 cases.
The hydraulic ileal valve ensures urinary continence and can be employed in many different reservoirs. The valve is constructed by isolating a 14 cm long intestinal loop with its mesentery. The isolated ileal segment is then folded inward on itself throughout its length. This hydraulic valve was used in the construction of 210 continent urostomies--ileocaecal reservoir in 184 cases (including 8 detubularized), ileal reservoir in 15, sigmoid in three, rectum and transverse colon one each, and bladder (continent cystostomy) in six cases. The indications for continent urostomy included bladder tumour (45.5% of cases), complex vesicovaginal fistula (31%), neurogenic bladder (11%) and bladder exstrophy (7%). Continence was immediately achieved in 155 patients (75%), rising to 91.5% after valve repair. The mean postoperative follow-up was 56 (range 3-205) months.
Adult↗
Primary adenocarcinoma of the bladder: favorable prognostic significance of deoxyribonucleic acid diploidy measured by flow cytometry.
Flow cytometric nuclear deoxyribonucleic acid ploidy analysis was done successfully on 38 specimens of primary bladder adenocarcinoma treated between 1954 and 1985. Of the specimens 10 (26%) were deoxyribonucleic acid diploid, 8 (21%) were tetraploid and 20 (53%) were aneuploid. Distribution of ploidy patterns between the 14 histological low grade and 24 high grade tumors was similar. Of 38 tumors 35 (92%) showed muscle invasion. One tumor arose in a previously exstrophied bladder, 10 were of urachal origin and 27 arose in an anatomically normal bladder. Of the urachal origin tumors 80% were deoxyribonucleic acid aneuploid. At 5 and 10 years after diagnosis 80 and 70%, respectively, of the patients with diploid tumors were free of disease. By contrast, at 5 and 10 years after treatment only 20 and 12%, respectively, of the patients with nondiploid tumors have not had disease progression (p less than 0.001 log-rank test). None of the 6 patients with diploid, high grade, high stage, muscle invasive tumors had subsequent progression. In contrast, 16 of 17 patients (94%) with high grade, high stage, nondiploid tumors had either local or distant tumor recurrence (p less than 0.0005). Nuclear deoxyribonucleic acid ploidy pattern appears to be the most significant prognostic information currently available to stratify expected prognosis for patients with muscle invasive adenocarcinoma of the bladder. This test probably should be a standard tool in the clinical management of patients with this rare bladder malignancy.
Adenocarcinoma↗
Laparoscopic assisted reconstructive surgery: a 7-year experience.
PURPOSE: Laparoscopic assisted surgery results in an improved cosmetic appearance by allowing complex reconstruction without a midline upper abdominal incision. We report technique and outcomes in patients undergoing laparoscopic assisted reconstruction during a 7-year period. MATERIALS AND METHODS: A total of 31 consecutive patients with a mean age of 14 years (range 1 to 36) underwent laparoscopic assisted reconstructive surgery through a lower midline or Pfannenstiel incision by a single surgeon (SGD) between June 1995 and July 2002. Diagnoses included myelomeningocele (17), sacral agenesis (2), posterior urethral valves (2), classic bladder exstrophy (5), complicated ectopic ureter with ureterocele (1) and quadriplegia due to trauma (4). A total of 29 patients had 39 continent stomas (antegrade continence enema [ACE] or Mitrofanoff) created as part of the reconstruction. One case was converted to an open procedure due to dense adhesions and was excluded from the study. Continent stoma construction included Mitrofanoff stomas created from appendix (17), ileum (3), sigmoid (5) and bladder (1), and ACE stomas from appendix (12) and ileum (1). Ten patients underwent concurrent Mitrofanoff and ACE procedures. Laparoscopy was used for lysis of adhesions, mobilization of colon and/or harvesting the appendix, nephrectomy in preparation for ureteral augmentation, division of pedicle for gastrocystoplasty takedown and harvesting of omentum for interposition. Bladder augmentation (15), bladder neck reconstruction (7), fascial sling (3), ureteral reimplants (1), revision of epispadias (2) and/or redo orchiopexy (1) were concurrently performed in 19 patients. Data were obtained through chart review and personal communication. RESULTS: Median hospital stay was 6 days (range 2 to 20). Mean followup was 32 months (range 3 to 57). Revisions were required in 3 stomas (7.7%) at a mean of 19 months (range 8 to 36) postoperatively. Minor procedures were required in 10 stomas (25.6%) consisting of indwelling catheterization, dilation, collagen injection and cystoscopy. Of the 39 stomas 37 (94.9%) were continent of urine and/or stool, and easily catheterizable at last followup. Adequate capacity and compliance were maintained in all augmented bladders. No patient experienced delayed small bowel obstruction or other sequela of abdominal adhesions. CONCLUSIONS: At almost 3 years of mean followup laparoscopic assisted reconstructive surgery offers functional outcomes at least equivalent to conventional open surgery in complicated cases with excellent cosmesis. Laparoscopic assisted surgery remains our approach of choice for children and adults who require lower urinary tract reconstruction with a continent catheterizable stoma.
Adolescent↗
Bladder neck closure for treating pediatric incontinence.
AIMS OF STUDY: In order to evaluate the effects of bladder neck closure (BNC) for treatment of pediatric incontinence, on the quality of life of those children, we reviewed the files of 17 children who underwent this procedure during the last 5 years. Information on previous surgery before BNC, continence and complications after BNC and patient satisfaction are gathered. MATERIAL AND METHODS: During the study period, 17 children (9 male, 8 female) underwent BNC with continent diversion. Ten children (5 male, 5 female) suffered neurogenic incontinence in meningomyelocele, 5 children (4 male, 1 female) had bladder exstrophy, 1 girl suffered iatrogenic incontinence after treatment of an ectopic ureterocele and 1 girl suffered structural incontinence after pelvic fracture. Previous surgery for incontinence was done in 12 children with 36 procedures. Primary BNC was done in 5 children. For continent diversion the appendix was used in 13, the ureter in 2, a Monti procedure in 1, and an ileal valve in 1. In 9 children, ileal bladder augmentation was performed at the time of BNC. Four children were augmented before. Mean age at time of operation was 13.5 years. Mean follow-up is 35 months. RESULTS: After BNC, all patients were completely dry. One girl suffered some stomal incontinence during the night. This disappeared after recent bladder augmentation. Patient satisfaction is extremely high after surgery. All patients feel happy with their stoma and do not regret the choice they made. As for complications, urinary tract infections were seen in 9 patients. Stomal complications were seen in 8 patients. Three patients had some difficulty with catheterization, which could be solved with dilatation. Appendiceal polyps, which could be removed under local anesthesia, were seen in 3 and stomal stenosis which needed re-intervention in 2. In 1 patient, three revisions of the stoma were done, in the other patient, two surgical corrections. Out of 8 patients showing stomal complications, only 2 needed revision under anesthesia. All complications are seen in the first 6 months after the continent diversion. CONCLUSIONS: We present a series of patients who underwent BNC for treatment of incontinence. BNC is the ultimate bladder neck reconstruction. However, regarding the high success rate, the low complication rate and the high patient satisfaction, we must consider BNC as an important procedure for the reconstructive surgeon. If reconstruction fails, closure must be considered. Compared to most other procedures for bladder neck reconstruction, BNC gives the highest continence rate. Good patient compliance and strict medical follow-up of the upper tract is mandatory in these patients.
Adolescent↗
Urothelial carcinoma of the ureter, giant rectal stone and sigmoid carcinoma 55 years after ureterosigmoidostomy.
We present the case of a unique accumulation of complications 55 years after ureterosigmoidostomy for bladder exstrophy and discuss possible implications for follow-up strategies.
Adenocarcinoma↗
[Lower urinary tract reconstruction by augmentation cystoplasty and insertion of artificial urinary sphincter cuff only: long term follow-up].
OBJECTIVES: To review retrospectively our long-term experience with augmentation cystoplasty and simultaneously insertion of artificial urinary sphincter cuff only for lower urinary tract reconstruction in cases of mixed bladder and sphincteric dysfunction. We tried to assess the postoperative continence status, as well as the associated morbidity, focusing upon infections, urethral erosion and revision rates. PATIENTS AND METHODS: Eleven patients with urinary incontinence due to a small capacity and low compliant bladder, combined with incompetent outlet, underwent lower urinary tract reconstruction by augmentation cystoplasty and simultaneous insertion of a bladder neck sphincter cuff only (AMS, model AS-800). Mean age was 29 years (range 18-45). The etiology of voiding dysfunction was a seminal cord injury in 6 patients, myelomeningocele in 2 and spinal cord surgery in 1, bladder exstrophy (1) and pelvic trauma combined with spinal cord injury (1). RESULTS: With mean follow-up period of 115 months (range 45-141), 8 patients (73%) achieved continence on clean intermittent catheterization without any further interventions. Two patients required insertion of sphincter pump and reservoir at a second stage to achieve full continence and subsequently one was removed due to erosion (overall continence rate of 82%). In another patient, the cuff located at the level of the bladder neck has eroded and was removed. None of the patients has experienced an infection of the device in the immediate postoperative period, neither thereafter. CONCLUSIONS: Insertion of sphincter cuff only during augmentation cystoplasty may be sufficient to achieve continence in many incontinent patients who may not be cured by bladder augmentation alone. The procedure is technically easy and is not associated with increased risk of injury to the augmented bladder, neither with subsequent infectious complications.
Adolescent↗
Gastrocystoplasty: long-term complications in 22 patients.
PURPOSE: Gastrocystoplasty has been performed as an alternative to enterocystoplasty to increase bladder capacity and/or compliance while avoiding the complications associated with the use of bowel segments. Gastrocystoplasty is not without metabolic and physiological complications, such as the dysuria-hematuria syndrome and hypochloremic metabolic alkalosis. Currently to our knowledge there is limited long-term followup of gastrocystoplasty, which prompted us to review our experience with gastrocystoplasty and compare our findings with those of others. MATERIALS AND METHODS: We retrospectively reviewed for complications the records of 12 boys and 10 girls 8 to 24 years old who underwent gastrocystoplasty. Followup ranged from 48 to 96 months. The diagnosis included neurogenic bladder in 12 cases, posterior urethral valves in 6, bladder exstrophy in 3 and pelvic tumor in 1. All patients underwent preoperative evaluation of serum electrolytes, blood urea nitrogen and creatinine as well as a radionuclide renal scan. Urodynamics were done preoperatively in all patients and postoperatively for complications. A gastric wedge with the pedicle based on the right gastroepiploic artery was removed, leaving the lesser curvature and vagus nerve intact. This technique was used in 21 of the 22 cases, including 1 case after initial surgery elsewhere. Ureteroneocystotomy, Mitrofanoff appendicovesicostomy and bladder neck reconstruction were performed as indicated. RESULTS: There was 1 early complication (postoperative bleeding) and the remainder were late complications, including vesicoureteral reflux in 4 cases, Mitrofanoff valve stenosis in 3, the hematuria-dysuria syndrome, renal calculi, decreased bladder capacity with incontinence and metabolic alkalosis in 2 each, and ureterovesical stricture in 1. The late complication rate in our series was 36%. CONCLUSIONS: Our long-term results differ from those of others in the number of late complications (36 versus 21.8%). In addition, 50% of our patients with complications had multiple complications. These findings may be due to a longer followup. Nevertheless, our data cast serious doubt on the long-term advantages of using stomach for bladder augmentation.
Adolescent↗
Perimesenteric detubularization of ileum for ileocystoplasty improves compliance and increases capacity.
OBJECTIVE: To describe a modified form of detubularization using a perimesenteric incision of the ileal segment, which increases the capacity of the neobladder and reduces the length of the ileal segment required. PATIENTS AND METHODS: From February 1993 to November 1999, ileocystoplasty was undertaken in 20 patients (mean age 8.4 years, range 4-16). Six had myelodysplasia, four had primary epispadias, five had bladder exstrophy, three had post-traumatic lesions and two had cloacal exstrophy. The patients were divided into two groups; in the first (eight patients, mean age 9.6 years, range 5-15) the ileal segment was opened along the antemesenteric border and in the second (12 patients, mean age 7.7 years, range 4-16) the ileal segment was opened adjacent to the mesentery, perimesenterically. Each segment was then folded and the perimesenteric edges sutured to form the pouch. RESULTS: The patients were assessed at 1 year after surgery; the neobladder capacity was evaluated as ((neobladder capacity - bladder capacity)/body weight), which shows the relative increase of bladder capacity after enterocystoplasty per unit of weight. There was a statistically significant increase in neobladder capacity in group 2 (perimesenteric transection; Kruskal-Wallis chi-square, P = 0.005; Mann-Whitney U-test, P = 0.006). CONCLUSION: These results indicate that augmentation can be carried out by perimesenteric transection of the intestinal segment, which improves compliance and increases capacity of the neobladder.
Adolescent↗