Biomedical subjects

P D Metcalfe

Publications and source records attributed to P D Metcalfe.

8 recordsLinked to original sources

PubMed2006

What is the need for additional bladder surgery after bladder augmentation in childhood?

PURPOSE: Bladder augmentation has revolutionized the care of children with a neuropathic bladder but it remains a major surgical procedure. However, the need for subsequent bladder surgery has not been well defined in a large series with long-term followup. MATERIALS AND METHODS: We retrospectively reviewed the records of the first 500 bladder augmentations performed from 1978 to 2003 at our institution. Charts were reviewed for complications requiring additional surgery, including malignancy, bladder perforation, repeat augmentation, bowel obstruction and bladder calculi. Mean and median followup was 13.3 years. RESULTS: Complications occurred in 169 patients (34%) resulting in a total of 254 surgeries. The cumulative risk of further surgery at the bladder level was 0.04 operations per patient per year of augmentation. Three patients (0.6%) had transitional cell carcinoma, of whom all presented with metastatic disease and died. Bladder perforation occurred in 43 patients (8.6%) with a total of 53 events. Of the patients 16 (3.2%) required laparotomy for bowel obstruction and 47 (9.4%) required repeat augmentation. Bladder stones were treated in 75 patients (15%), who required a total of 125 surgeries. CONCLUSIONS: Bladder augmentation provides immeasurable improvements in quality of life but it requires lifelong dedication from the patient, family and health care providers. While the requirements for additional surgery are not trivial, 66% of our patients have not required any further surgery in the augmented bladder.

Child↗

PubMed2006

Total continence reconstruction: a comparison to staged reconstruction of neuropathic bowel and bladder.

PURPOSE: Surgical treatment for neuropathic bowel and bladder has become an essential tool in maximizing the quality of life in patients with myelomeningocele. We present our results comparing results in patients who underwent total continence reconstruction of the urinary and gastrointestinal tracts to patients who underwent a separate or single operation. MATERIALS AND METHODS: We performed a retrospective chart review of all patients with myelomeningocele at our institution who underwent reconstruction with a cutaneous catheterizable urinary channel or Malone antegrade continence enema. We compared outcomes with regard to surgical revisions of the channel between patients who underwent the construction of each simultaneously, that is total continence reconstruction, to outcomes in those with a single channel or who underwent reconstruction at 2 or more operations. RESULTS: Most of our patients underwent genitourinary and gastrointestinal reconstruction, and few desired surgical intervention for only a single system. We were unable to find any differences in the continence rate or stomal complications. However, patients who underwent staged reconstruction usually had significant secondary reasons for repeat surgery. CONCLUSIONS: Surgical success for urinary and fecal continence can be safely and effectively achieved through single or multiple procedures. However, because of shared pathophysiology, we believe that most patients benefit from intervention in the gastrointestinal and the genitourinary tract. Therefore, a major advantage of total continence reconstruction is avoidance of the morbidity of a second major surgical procedure.

Child↗

PubMed2006

Treatment of the occult tethered spinal cord for neuropathic bladder: results of sectioning the filum terminale.

PURPOSE: Occult tethered cord syndrome applies to patients with signs and symptoms consistent with a caudal spinal cord malformation despite normal neuroimaging. Although several reports of successful surgical treatment exist, controversy remains with respect to patient selection and efficacy. We present a large series with excellent clinical followup, neuroimaging and urodynamic characterization. MATERIALS AND METHODS: We present our experience with 36 patients at a single institution with preoperative clinical findings, neuroimaging and urodynamics available. Postoperative outcomes were assessed clinically and with urodynamics. We determined predictive parameters to improve patient selection. RESULTS: Approximately 0.04% of pediatric urology clinic visits resulted in neurosurgical referral for the potential of an occult tethered cord. They occurred after failure of a mean of 2 years of aggressive medical management. Daytime urinary incontinence was present in 83% of patients and 47% had encopresis. Preoperative urodynamics were markedly abnormal in all patients with mean bladder capacity 55% of expected capacity. Clinical improvement in urinary symptoms was seen in 72% of patients with resolution of incontinence in 42%. Bowel symptoms improved in 88% of cases, including resolution of encopresis in 53% within 3 months of surgery. Urodynamic improvements were demonstrated in 57% of cases. We were unable to determine preoperative factors that were more likely associated with surgical success. CONCLUSIONS: In a highly select population with severe urinary and fecal dysfunction sectioning a normal-appearing filum terminale can result in significant improvement. We were unable to identify factors that may increase the chance of surgical success.

Adolescent↗

PubMed2006

Use of the mobilized sinus with total urogenital mobilization.

PURPOSE: The surgical treatment of urogenital sinus anomalies has undergone significant advances in recent years. Total urogenital mobilization, which mobilizes the urogenital sinus, vagina and urethra en bloc toward the perineum, represents one of these advances. MATERIALS AND METHODS: We have improved our results with total urogenital mobilization by incorporating the mobilized urogenital sinus tissue into the repair rather than discarding it, as described originally. We have found this a readily available, easily manipulated and well vascularized flap that is a significant aid to reconstruction. RESULTS: We present our 3 favored means of using the mobilized sinus tissue to create a mucosa lined vestibule, a posterior vaginal wall flap and an anterior vaginal wall flap. CONCLUSIONS: We believe that our techniques result in a further advancement in the cosmetic and surgical outcomes in these patients, and are beneficial in the reconstructive surgery armamentarium.

Adrenal Hyperplasia, Congenital↗

PubMed2006

Spontaneous bladder perforations: a report of 500 augmentations in children and analysis of risk.

PURPOSE: The spontaneous perforation of an augmented bladder is an uncommon but serious complication. To our knowledge our institution has the largest reported series of bladder augmentations. We examined our data to determine the incidence of spontaneous bladder perforation and to delineate associated risk factors. MATERIALS AND METHODS: We performed a retrospective chart review of 500 bladder augmentation procedures performed during the preceding 25 years with a minimum followup of 2 years. RESULTS: Spontaneous perforations occurred in 43 patients (8.6%), for a total of 54 events. The calculated risk was 0.0066 perforations per augmentation-year at risk. Approximately a third of the cases had perforated within 2 years of surgery, a third between 2 and 6 years postoperatively, and a third at more than 6 years after augmentation. Patients who underwent augmentation between 1997 and 2003 had a higher rate of perforation within 2 years of surgery than those operated on between 1978 and 1987. Increased risk of perforation was observed with the use of sigmoid colon and bladder neck surgery. A decreased risk was associated with the presence of a continent catheterizable channel. CONCLUSIONS: We believe that this large and comprehensive series gives valuable insight into this serious complication. The delineation of these potential risk factors serves as a guide for further discussion and investigation.

Child↗

PubMed2005

Mitrofanoff channel survival after pedicle ligation.

In patients who have undergone complex genitourinary reconstruction, additional abdominal surgery is often required. We report 2 cases in which the blood supply to an existing Mitrofanoff channel was divided. In both cases, the conduits appeared to remain well perfused, presumably based on collateral blood supply. Both conduits remained healthy and functioning at more than 1 year of follow-up.

Appendix↗

PubMed2004

Bladder perforation during laparoscopic donor nephrectomy.

We present two cases of bladder perforation during laparoscopic donor nephrectomy at our institution. Neither of the surgeries was otherwise complicated, and the diagnoses were made post-operatively. The kidneys were extracted through a Pfannenstiel incision and used blunt dissection to penetrate the peritoneum. Both patients had previous tubal ligations, adhesions from which may have increased the chance of injury. We believe that this is a previously unreported complication that merits attention. Care should be taken with the peritoneal incision and dissection as the bladder may be susceptible to injury.

Adult↗

PubMed2002

MCDK not excluded by virtue of function on renal scan.

INTRODUCTION: The conservative management of multicystic dysplastic kidneys (MCDK) has been very successful, largely due to advances in diagnostic imaging. Classically, MCDK is described as a non-functioning cystic renal mass. However, we noticed that the increasing sensitivity of renal scans is able to demonstrate function in MCDK that previously would not have been detected. METHODS: We describe eight cases of MCDK with elements of function on renal scan, and their follow up. RESULTS AND CONCLUSIONS: One half (4/8) of these children underwent nephrectomy, and histology was consistent with MCDK. The remaining 4/8 were successfully followed to radiographic involution, without any complications. Therefore, we believe that minimal function on nuclear scintigraphy does not preclude the diagnosis of MCDK, and is yet another adjustment in our understanding of this entity.

Female↗