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At least 1,711 records · Page 95Linked to original sources
PubMed2003

Outcome of continence procedures in the pediatric patient: a single institutional experience.

PURPOSE: Achieving continence remains a major goal in the treatment of children with neurogenic and/or anatomical voiding dysfunction. We reviewed our experience with continence procedures in pediatric lower urinary tract reconstruction. MATERIALS AND METHODS: We reviewed the records of all pediatric patients who underwent continence procedures at our institution since July 1993. We reviewed the diagnosis, type of primary reconstructive procedure, concomitant procedure(s) and initial success rate. In cases of primary failure we noted the type of secondary continence procedure performed and the ultimate success rate. Success was defined as dry intervals of at least 4 hours when the patient was compliant with a catheterization or voiding regimen. RESULTS: Primary continence procedures were performed in 43 cases and secondary procedures were performed in 6 for a total of 49 continence procedures. The diagnoses included myelomeningocele in 22 patients, exstrophy in 12, epispadias in 3, bilateral single system ureteral ectopia in 3 and spinal cord injury in 3. A total of 32 primary procedures were performed concomitantly with or were preceded by bladder augmentation with creation of a catheterizable stoma. The remaining 11 patients underwent a continence procedure only. The diagnosis in these 11 patients was exstrophy in 5, epispadias in 3, with spinal cord injury in 2 and myelomingocele in 1. Mean followup was 35 months (range 1 to 95). Initial continence procedures included Young-Dees-Leadbetter bladder neck repair in 14 cases, of which 11 (79%) were initially successful, a urethral sling in 9 with 7 initial successes (78%), bladder neck division and closure in 7 with all successful (100%), collagen in 5 with 1 success (20%), other urethral lengthening procedure (eg Pippi Salle or Kropp) in 4 with 3 successes, (75%), combined urethral sling and Young-Dees-Leadbetter in 2 with 1 success (50%), and an artificial sphincter and fascial wrap in 1 each, which were successful. Of the 6 secondary procedures performed for primary failure collagen was injected in 4 and the bladder neck was divided and closed in 2. All were successful. CONCLUSIONS: Various lower urinary tract procedures can be performed to achieve successful continence in the pediatric population. At our institution all procedures had a reasonable success rate except primary collagen injection. Collagen injection and bladder neck division/closure proved to be reliable secondary procedures in cases of primary failure.

Adolescent↗
PubMed2005

Automated bladder scan urine volumes are not reliable in complex neonatal cases.

PURPOSE: We investigate the accuracy of urine volumes obtained by an automated bladder scan in complex neonatal cases. MATERIALS AND METHODS: Automated bladder scan determinations of urine volumes were obtained by neonatal intensive care unit nursing staff in 10 patients with myelodysplasia and cloacal exstrophy. Urine volumes were then immediately obtained by straight catheterization. Correlation between the scan and catheter volumes was then evaluated across and within cases. RESULTS: There was low correlation between automated bladder scan volume and catheter volume across and within cases (0.037 +/- 0.37) and (0.188 +/- 0.12), respectively. Using a cutoff of 20 cc 25% of significant volumes were missed. The 95% confidence interval from these data indicates that a significant volume is missed 7% to 25% of the time. CONCLUSIONS: We urge clinicians to exercise caution in the use of automated bladder scanners for determination of urine volumes in complex neonatal intensive care unit cases.

Automation↗
PubMed1999

Bladder augmentation with urothelial preservation.

PURPOSE: Bladder reconstruction is performed because the characteristic properties of a healthy bladder are no longer present. The bladder manifests poor capacity, poor compliance and potential or actual changes in the upper tracts that may lead to damage. Augmentation procedures provide a means to improve capacity and compliance, and they may be performed with catheterizable channels to facilitate bladder emptying. Natural tissues or synthetic materials may be used but urothelial preservation is desirable. Demucosalized augmentation with a gastric flap and auto-augmentation with peritoneum are techniques that have been used in the last 5 years. MATERIALS AND METHODS: We retrospectively evaluated the records of 13 patients who underwent demucosalized augmentation with a gastric flap and 8 who underwent augmentation with peritoneum from 1992 to 1995. Average age of the 11 girls and 10 boys was 8 years (range 6 to 12). The diagnosis was myelomeningocele in 15 patients, exstrophy in 2, and the VATER association, posterior urethral valves, spinal cord injury and nonneurogenic neurogenic bladder in 1 each. Concurrent procedures included appendicovesicostomy creation, a fascial sling or wrap and ureteroneocystostomy. RESULTS: Mean followup is 50 months for patients who underwent demucosalized augmentation with a gastric flap and 47 for those who underwent augmentation with peritoneum. Outcome was defined as good-dry for 4 hours, catheterization without difficulty and a stable upper tract; poor-a secondary procedure (augmentation) required because the initial procedure did not improve bladder capacity, compliance, continence or the degree ofhydronephrosis, and fair-dry for less than 4 hours, some problems with incontinence, or compliance 10 ml/cm water or less. Of the patients who underwent demucosalized augmentation with a gastric flap the outcome was good in 5, fair in 4 and poor in 4 who required repeat augmentation. Of the 8 patients who underwent auto-augmentation with peritoneum the outcome was good in 5 and poor in 2, and 1 was lost to followup. CONCLUSIONS: Augmentation with urothelial preservation may result in a good capacity, compliant bladder in certain patients but a poorly compliant, small capacity bladder in others. Our overall results underscore the lack of understanding of the properties and characteristics of these bladders and of stromal-epithelial interaction that occurs after augmentation. Such an understanding is critical before this procedure can be recommended routinely.

Child↗
PubMed1989

Reconstruction of the epispadiac penis in adolescents.

Now that reconstructive surgery has taken the exstrophy and epispadias patient beyond the stage of merely saving life and even preserving bladder function, it is essential that proper attention is paid to the penis. Careful surgery in early life may well give a good cosmetic appearance during the important years of schooling. It may also produce a penis with a satisfactory angle of erection for sexual intercourse. In those patients who are not so fortunate in infancy or who were born before the era of modern reconstructive surgery, careful assessment must be made at an appropriate time as the patient goes through puberty. The commonest erectile deformity found in epispadias in adult life is tight dorsal chordee. Surgical correction is required. In some patients, adequate correction will be achieved by clearance of superficial pericorporeal scar tissue, possibly aided by Nesbit's procedure. For the remainder, formal correction of the chordee is required. This is best done by the insertion of a gusset of dura or other material to lengthen the concave side of the curve.

Adolescent↗
PubMed1985

A neo-urethral enteroplication for urinary continence in a case of cloacal exstrophy.

A four-year-old female, born with cloacal exstrophy, returned for evaluation of her urinary incontinence two years after her initial repair. Her bladder had been turned in at her first operation and had a capacity of approximately 15 cc. Her ureters exited close to the reconstructed introitus. At reoperation, her bladder measured 3.5 cm in length and appeared to be well healed and of normal consistency. An anterior wall bladder flap was created which was based at the dome and was reflected 180 degrees cephalad. The bladder was then tubularized over a #10 french catheter to create a "neo-urethra" of 6 cm in length. Both ureters were reimplanted into an intestinal conduit, constructed 18 cm long, in a nonrefluxing fashion. The distal, oversewn, end of the conduit was sewn down into the pelvis, at the level of the bladder neck and posterior to the "neo-urethra." The end of the neo-urethra was anastomosed to the anterior wall of the intestinal reservoir, which was then plicated circumferentially around the neo-urethra in a manner very similar to the construction of a Nissen fundoplication for gastro-esophageal reflux. Pressure in the reservoir serves to keep the neo-urethra closed so that urine cannot escape until the neo-urethra is intubated. She is currently continent of urine with a successful program of clean intermittent catheterization. Her upper tracts remain undilated and are free of intestinal-ureteral reflux. Her urine is sterile.

Child, Preschool↗
PubMed1996

A new approach to the closure of cloacal exstrophy.

Cloacal exstrophy patients are often difficult to reconstruct. Urinary continence is usually achievable only with a catheterizable stoma of some type. Since cloacal exstrophy is usually associated with omphalocele or gastroschisis, one-stage closure of the abdominal wall defect is frequently impossible. We prefer to incorporate the exstrophic large bowel, which separates the hemibladders, into the closed bladder as a sort of "natural" augmentation to maximize its volume for use as a continent reservoir. If a silastic "silo" or synthetic mesh is required to close the abdominal wall, excessive scarring occurs and later creation of a continent stoma is usually difficult and time-consuming. In all but those with the smallest abdominal wall defects we recommend that the omphalocele and upper abdominal wall be repaired first, replacing the evicted gut into the peritoneal cavity. During nutritional stabilization a tissue expander is placed under the superficial musculature of the chest wall. The flap is enlarged by gradual inflation of the tissue expander until it fills the abdominal wall defect left by subsequent closure of the cloacal exstrophy. The flap is then rotated inferiorly with blood supply intact at the time of bladder closure to make good the remaining abdominal wall defect. This flap improves the appearance of the abdominal wall and reduces scarring. Thus, this approach has the possibility of making subsequent operations to provide continence shorter, simpler, and more successful in most infants with cloacal exstrophy.

Abdomen↗
PubMed2004

An adult female epispadias without exstrophy was presented with urinary incontinence: a case report.

A 39-year-old woman with three children presented with primary severe urinary incontinence. Epispadias without exstrophy was determined in physical examination. The single-stage procedure including vulvoplasty and modified Young-Dees-Leadbetter bladder neck repair was performed to obtain sufficient cosmetic outcome and continence. Excellent functional and cosmetic results were obtained.

Adult↗
PubMed2003

Continent colonic urinary reservoir (Florida pouch): long-term surgical complications (greater than 11 years).

PURPOSE: We analyzed the long-term results (greater than 10 years) of a continent cutaneous colonic urinary reservoir (Florida pouch), focusing primarily on the incidence of significant complications. MATERIALS AND METHODS: Between January 1986 and October 1991, 179 patients underwent continent cutaneous colonic urinary reservoir construction. Of these patients 105 died of primary disease or were lost to followup, leaving 38 males and 36 females with a mean followup of 133 months with adequate data for analysis who are the subject of this report. The surgical technique has been previously reported. Briefly, a detubularized right colonic segment forms the reservoir, a tapered external limb reinforced at the ileocecal valve level allows continent catheterization and the ureters are directly anastomosed to the pouch. The diseases that prompted urinary diversion included bladder cancer in 28 cases, conversion from another diversion in 12, neurogenic bladder in 11, interstitial cystitis in 10, crippling incontinence in 4, radiation cystitis in 6, hemorrhagic cystitis in 1, exstrophy in 1 and colon cancer in 1. A total of 146 direct ureterocolonic reimplantations were performed. RESULTS: Complications were grouped by etiology and the number of patients, including abdominal wall (peristomal hernia in 3 patients or 4%), external limb (incontinence in 5 or 6.7%, stomal stenosis in 3 or 4% and difficult catheterization in 1 or 1.4%), reservoir stones (4 or 5.4%), ureteral obstruction (primary reimplantation in 7 of 108 or 6.3%, repeat reimplantation in 4 of 24 or 16.4% and radiated ureters in 4 of 14 or 28.4%) and metabolic (persistent diarrhea in 2 or 2.7%, renal failure in 2 or 2.7% and low vitamin B12 in 3 or 4%). Severe acidosis developed in 4 individuals (5.5%). Of the 12 patients who underwent conversion from another type of diversion 7 (58%) experienced metabolic alterations. CONCLUSIONS: In the long term continent colonic reservoirs have an acceptable complication rate. The most common problem is ureteral obstruction, especially in patients who have previously undergone irradiation (28.4% versus 6.3%, Fisher's test p = 0.02). Patients in whom longer bowel segments were resected, such as those with conversion from another type of diversions, experienced a greater number of complications, especially ureteral obstruction associated with repeat reimplantation (16.4% versus 6.3%, Fisher's test p = 0.23) and metabolic derangements (58% versus 6.4%, Fisher's test p = 0.0001).

Acidosis↗
PubMed1995

Applications of osteotomy in the cloacal exstrophy patient.

During the last 18 years we treated 22 patients with cloacal exstrophy of whom 13 were referred for further treatment after initial treatment elsewhere. One patient underwent cystectomy with ileal conduit urinary diversion soon after birth and 9 of the remaining 21 underwent initial closure without osteotomy. Of these 9 patients significant complications developed in 8 (89%) after bladder closure, including dehiscence in 6 (1 underwent 2 unsuccessful closures), a vesicocutaneous fistula and postoperative ventral hernia in 1, and bladder prolapse in 1. In contrast, complications developed in only 2 of the 12 patients (17%) who underwent osteotomy at the time of initial closure, including bladder dehiscence in 1 and significant prolapse in 1. Patients who underwent osteotomy and those who did not were similar in terms of the size of omphalocele, presence of myelomeningocele and time of primary closure. We also found that osteotomy or failed closure has no effect on the eventual continence of cloacal exstrophy patients. While osteotomy is not the only variable involved in successful cloacal exstrophy closure, our results indicate the need for osteotomy in these patients to increase the success rate at the time of initial bladder closure.

Child↗
PubMed1979

Duplications of the lower urinary tract in children.

Seven cases of bladder duplication are described, and compared with 27 cases of urethral duplication. Bladder duplication was collateral while urethral duplication was usually in the sagittal plane. The conditions may coexist when the duplication of the bladder extends caudally to produce a collateral urethral duplication, but in one boy bladder duplication was associated with 4 urethrae in the sagittal plane. In 5 cases the bladders were united; in 2 cases, one bladder was excised. The results were satisfactory in 6 and in one the bladder failed to empty. The basic defects that lead to duplication are unknown. Several features of the conditons suggest that there are different aetiologies in each type. There are similarities with the exstrophy epispadias complex. Even when there are major abnormalities in other systems the general and urological prognosis is good.

Abnormalities, Multiple↗
PubMed1993

Cloacal exstrophy: experience with 20 cases.

Exstrophy of the cloaca, a rare anomaly, is among the most complex malformations of infancy. Features include omphalocele, imperforate anus, and exstrophy of two hemibladders, between which lies the everted cecum. A small colon ends blindly in the pelvis, and the terminal ileum often prolapses out of the exposed cecum. Formerly, most of these infants died. From 1974 to 1992, 20 of these patients were treated, the majority in the past decade. Six were managed primarily; 14 were referred after prior surgery elsewhere. Current treatment of a newborn with cloacal exstrophy includes closure of the omphalocele, separation of the gastro-intestinal tract from the hemibladders, and closure of the two hemibladders as a single viscus. The colon can be pulled through in some cases, either immediately or later (6 cases). The bladder must be augmented in all cases to provide adequate volume and compliance; stomach is ideal for this (10 cases). A bladder continence mechanism must be constructed by narrowing the outlet (9 cases), or inserting a reversed small bowel nipple (7 cases). Intermittent catheterization is needed for the patient to empty the reconstructed bladder. Although two thirds of these patients are genetic males, they should be raised as females because they lack adequate tissue to construct a phallus. Magnetic resonance imaging of the spine has shown tethering of the cord in all patients; most were released neurosurgically. Lessons provided by these cases demonstrate that a satisfactory surgical and social outcome can be achieved today in most children with cloacal exstrophy.

Abnormalities, Multiple↗
PubMed1989

Compatibility of enterocystoplasty and the artificial urinary sphincter.

Placement of the artificial urinary sphincter during augmentation enterocystoplasty may lead to infection, erosion and eventual removal of the device. To assess compatibility of artificial urinary sphincter implantation and enterocystoplasty we reviewed the records of 30 patients who had undergone enterocystoplasty and artificial urinary sphincter placement simultaneously (11), enterocystoplasty before artificial urinary sphincter placement (12) and artificial urinary sphincter placement before enterocystoplasty (7). The 19 male and 11 female patients were between 4 and 42 years old (median age 13.5 years). Followup in 28 patients ranged from 6 months to 8 years (average 17 months). Incontinence resulted from myelodysplasia in 16 patients, sacral agenesis in 3, spinal cord injury in 6, posterior urethral valves in 1, bilateral ectopic ureters in 1 and epispadias-exstrophy in 3. Erosion occurred in 2 patients (7 per cent): 1 female patient who underwent simultaneous sphincter implantation and enterocystoplasty and who had undergone previously many bladder neck reconstructive procedures, including polytetrafluoroethylene (Teflon) injection, and 1 female patient in whom the augmented bladder was entered at artificial urinary sphincter implantation. Mechanical failure occurred 4 times in 3 patients and the artificial urinary sphincter was improperly placed in 1. Over-all continence rate was 87 per cent (26 of 30 patients). Simultaneous placement of the artificial urinary sphincter and enterocystoplasty did not seem to affect the outcome of sphincter implantation if good bowel preparation, intravenous antibiotics and sterility of urine were accomplished preoperatively. Entering the augmented bladder during sphincter implantation may predispose to infection and erosion.

Adolescent↗