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At least 127 records · Page 7Linked to original sources

PubMed2005

Use of Malone antegrade continence enema in patients with perineal colostomy after rectal resection.

PURPOSE: Abdominoperineal resection, with iliac colostomy, remains the gold standard treatment for very low-lying rectal cancer, but it alters patients' quality of life. Alternatives to iliac colostomy need to be experimented. Antegrade enemas via a cecal access (Malone operation) obtains a colonic emptying and improves continence for incontinent patients. Continence and quality of life after abdominoperineal resection and perineal colostomy associated to a Malone antegrade continence enema were studied. METHODS: After abdominoperineal resection for cancer, 18 patients had a digestive reconstruction by perineal colostomy and Malone antegrade continence enema. Patients performed antegrade enemas every 24 to 48 hours with tap water. After six months, continence (Cleveland Clinic score) and quality of life (Fecal Incontinence Quality of Life scale) were recorded. RESULTS: Morbidity was 5 percent (1 appendix necrosis). All patients could perform antegrade enemas by themselves. Mean continence score was 6.41/20 (standard error, 2.31). Fecal Incontinence Quality of Life scores were: lifestyle 3.18/4 (standard error, 0.83); coping/ behavior 2.99/4 (standard error, 0.83); depression/self-perception 3.11/4 (standard error, 0.83); embarrassment 2.84/4 (standard error, 0.63). CONCLUSIONS: After abdominoperineal resection, Malone antegrade continence enema associated to perineal colostomy provided an acceptable continence. It preserved patients' body image and resulted in a satisfying quality of life. It could become an alternative to iliac colostomy in selected patients.

Adult↗

PubMed2006

Long-term outcome and quality of life after continent ileostomy.

INTRODUCTION: This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy, identify factors associated with adverse outcomes, and compare changes in quality of life after removal of the reservoir. METHODS: The records of all patients (n = 330) undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed. Patient-related, intraoperative, and postoperative factors were evaluated as predictor variables of long-term pouch survival. Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale (n = 216). These were compared between patients with continent ileostomy (n = 181) and patients who underwent removal of the continent ileostomy and conversion to an end stoma (n = 35). RESULTS: The median patient follow-up was 11 (range, 1-27) years. The median revision-free pouch interval was 14 (95 percent confidence interval, 11-17) months. The 10-year and 20-year pouch survival was 87 and 77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up. On multivariate analysis, Crohn's disease (hazard ratio = 4.5), female gender (hazard ratio = 2.4), fistula development (hazard ratio = 3), and body mass index (hazard ratio = 2.4 per 5 unit increase) were independent predictors of pouch failure. Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy. CONCLUSIONS: Despite the associated morbidity with continent ileostomy surgery, long-term results and quality of life were encouraging. Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy.

Adolescent↗

PubMed2007

Malone antegrade continent enema: an alternative to resection in severe defecation disorders.

PURPOSE: This study was designed to evaluate patient self-reported outcome of the Malone antegrade continent enema at a single institution in patients suffering from severe defecatory disorders. METHODS: A total of 18 patients (15 females; median age, 31 (range, 12-63) years) underwent a Malone antegrade continent enema (August 1999 to September 2004). The Malone antegrade continent enema technique has been previously described; however, in this series emphasis was placed on method appendix tunneling. Patients' charts were reviewed and follow-up telephone interviews were conducted. Indications for Malone antegrade continent enema were chronic constipation (n = 12), intractable fecal incontinence (n = 5), or both (n = 1). The underlying pathology included neurogenic (n = 2), congenital (n = 4), postsurgery-related (n = 4), irritable bowel syndrome (n = 6), and megarectum (n = 2). The appendix (n = 17) or cecum (n = 1) was used as a conduit. RESULTS: The mean follow-up was 18.5 (range, 3-67) months. Fourteen patients (78 percent) still use the Malone antegrade continent enema routinely and report good functional outcome. Three patients (20 percent) required stoma creation as subsequent alternate treatment. A total of 10 patients experienced 12 complications: 3 perioperative (infections) and 9 postoperative Malone antegrade continent enema use/nonuse complications (4 stomal orifice strictures, 2 fecal impactions, 2 appendiceal perforations, and 1 irrigation catheter knot). No patient experienced leakage from the appendiceal stoma. During the follow-up interval, one patient underwent proctectomy for megarectum. No failures occurred in patients with congenital or neurogenic disorders. CONCLUSIONS: Malone antegrade continent enema is a reasonable option for the treatment of select patients with severe defecation disorders. Good functional patient self-reported outcome was achieved by 78 percent of patients. The social inconvenience of stoma leakage is avoided with appropriate surgical technique. Malone antegrade continent enema is one option that provides a less invasive surgical alternative than colectomy or ileostomy for severe defecation disorders.

Adolescent↗

PubMed2006

Assessment of the continence status and patients' satisfaction after retropubic radical prostatectomy: a questionnaire based study.

OBJECTIVE: The aim of this study was to assess the continence status and patients' satisfaction after retropubic radical prostatectomy by a self-administered questionnaire composed of 12 questions. MATERIALS AND METHODS: In total, 143 patients who underwent RRP operation at our department from 1992 to 2000 with a minimum 6 months of follow-up were assessed. Seventy two patients participated in the study. The continence status was classified as follows; patients who did not leak were considered as "continent", those who had leakage that occurred less frequent than or equal to once a day were regarded as "socially continent", and those who had more than once a day leakage were regarded as "incontinent". The correlation between urinary leakage, patients' satisfaction and pre-operative, peri-operative and post-operative factors were investigated. Univariate and multivariate analyses were done using Fisher's exact, chi-square, Student's-t and logistic regression tests. RESULTS: The mean age of patients at surgery was 63.9 years (49-76) with a follow-up period of 37.1 months (6-97). Of these patients, 44% were continent, 48% were socially continent, 8% were incontinent. A total of 64 of 72 patients (89%) were satisfied with their final continence status, and 63 (87%) patients accepted to undergo the same surgery again if it is indicated. Pre-, peri- and post-operative factors did not influence the urinary leakage rates. Patients with nocturnal leakage, urgency, decreased urinary flow and patients who use pad (-s) were significantly less satisfied on univariate analysis, while only nocturnal leakage had a significant impact on patients' satisfaction on multivariate analysis. CONCLUSION: Urinary leakage and patients' satisfaction rates after RRP were 56% and 89%, respectively. None of the factors could predict the post-operative continence status. When evaluating the patients' satisfaction, only nocturnal leakage was found to have an adverse affect on multivariate analyses.

Aged↗

PubMed2003

Association of anorectal dose-volume histograms and impaired fecal continence after 3D conformal radiotherapy for carcinoma of the prostate.

PURPOSE: The late toxicity of fecal incontinence after pelvic radiotherapy is now frequently recognized but the etiology poorly understood. We therefore investigated associations between dose-volume histogram (DVH) parameters of the rectum and the anal canal with fecal continence as measured by an established 10-item questionnaire. METHODS AND MATERIALS: Forty-four patients treated for carcinoma of the prostate with 58-72 Gy of 3D conformal radiotherapy between 1995 and 1999 who completed the questionnaire formed the study population. Total continence scores of treated patients obtained 1.5 years (median) after radiotherapy were compared to a control group of 30 patients before radiotherapy. Median, mean, minimum and maximum doses as well as the volume (% and ml) treated to 40, 50, 60 and 70 Gy were determined separately for anal canal and rectum. DVH parameters were correlated with total continence score (Spearman rank test) and patients grouped according to observed continence were compared regarding DVH values (Mann-Whitney U-test). RESULTS: Median fecal continence scores were significantly worse in the irradiated than in the control group (31 vs. 35 of a maximum 36 points). In treated patients, 59%/27%/14% were classified as fully continent, slightly incontinent and severely incontinent. Continence was similar in the 58-to-62-Gy, 66-Gy and 68-to-72-Gy dose groups. No DVH parameter was significantly correlated with total continence score, but severely incontinent patients had a significantly higher minimum dose to the anal canal than fully continent/slightly incontinent, accompanied by portals extending significantly further inferiorly with respect to the ischial tuberosities. CONCLUSIONS: Excluding the inferior part of the anal canal from the treated volume in 3D conformal therapy for carcinoma of the prostate appears to be a promising strategy to prevent radiation-induced fecal incontinence.

Aged↗

PubMed2002

Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging.

PURPOSE: We determined whether membranous urethral length on preoperative magnetic resonance imaging (MRI) is predictive of urinary continence after radical retropubic prostatectomy. MATERIALS AND METHODS: Membranous urethral length was measured on preoperative endorectal MRI in 211 consecutive patients with newly diagnosed prostate cancer before radical retropubic prostatectomy performed by a single surgeon. Neurovascular bundle resection was done in 60 cases. After surgery the time to stable postoperative continence was recorded in 180 cases and the level of stable continence was graded on a 5-point scale of 1-complete continence to 5-complete incontinence. RESULTS: After controlling for age and surgical technique multivariate analysis showed that membranous urethral length was related to time to stable postoperative continence (p = 0.02), such that a longer membranous urethra was associated with a shorter time to stable continence. For example, 1 year after surgery 120 of the 134 patients (89%) with a preoperative membranous urethral length of greater than 12 mm. were completely continent compared with 35 of the 46 (77%) with a preoperative length of 12 mm. or less. CONCLUSIONS: On endorectal MRI before radical prostatectomy a longer membranous urethra is associated with significantly more rapid return of urinary continence after surgery.

Adult↗

PubMed1992

Early continence after radical prostatectomy.

A prospective evaluation of urinary continence in 60 consecutive patients undergoing radical prostatectomy with incorporation of the fascia posterior to the urethra into the vesicourethral anastomosis is described. With this technique complete continence without the need for pads has been achieved in 88% of the patients, with stress incontinence in 10% and total incontinence in 2%. Continence was achieved within 1 to 16 weeks, with 13% of the patients dry during week 1, 55% dry at 6 weeks and 83% dry at 3 months. The median interval to achieve continence was 5 weeks. Median age of the continent patients was significantly lower than that of incontinent patients (65 versus 69 years). Neither the number of neurovascular bundles resected nor the need to reconstruct the vesical neck affected the rate of continence. While the exact mechanism of continence after radical prostatectomy remains unknown, incorporation of the fascia posterior to the urethra into the vesicourethral anastomosis results in earlier continence and thereby lessens the morbidity of this procedure.

Anastomosis, Surgical↗

PubMed1986

Achieving enteric continence: principles and applications.

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Adult↗

PubMed1998

Puboprostatic ligament sparing improves urinary continence after radical retropubic prostatectomy.

OBJECTIVES: To determine whether a puboprostatic ligament-sparing technique of prostatic apical dissection provided improved urinary continence after radical retropubic prostatectomy. METHODS: A total of 43 men with clinically localized prostate cancer underwent radical retropubic prostatectomy (standard apical dissection in 25, puboprostatic ligament-sparing technique in 18). Patients were evaluated by independent observer questionnaire to determine their continence status. The questionnaire was tested in a control group of 25 men who had not undergone prostate surgery. The overall continence rate and time to achieve continence was compared between the two surgical groups. In addition, the clinical and pathologic stages and both the rate and location of positive margins were assessed. RESULTS: Mean patient age and serum prostate-specific antigen values were not significantly different between the two groups. Clinical and pathologic stages were also similar. The mean follow-up period for the puboprostatic ligament-sparing group was 35 weeks compared with 57 weeks for the standard group (P < 0.05). The median time until continence was achieved after surgery was significantly shorter (P = 0.01) for the puboprostatic ligament-sparing group than for the standard method (6.5 and 12 weeks, respectively). However, the overall continence rate at 1-year follow-up for the two groups was similar (100% and 94%, respectively). The positive margin rate and location of positive margins were not different with the puboprostatic ligament-sparing technique. CONCLUSIONS: The puboprostatic ligament-sparing technique improves the rapidity of return of urinary continence after radical prostatectomy without significantly enhancing overall continence or interfering with the therapeutic efficacy of the procedure.

Adenocarcinoma↗

PubMed2001

[Urinary continence after radial prostatectomy. Prognostic factors and recovery time].

OBJECTIVES: To assess the urinary continence after radical prostatectomy and its evolution over time. To analyse possible prognosis factors. MATERIAL AND METHODS: We have reviewed 101 patients that have undergone radical prostatectomy. We define "continent patient" as that one who doesn't require any type of urinary protection. By means of Kaplan-Meier method, we evaluate the recovery of continence along time. We analyze potential conditional factors (age, stage, surgery technique, surgery experience,...). The statistical tools used are: chi-square, Fisher, Cox regression, T-test and Kaplan-Meier. RESULTS: Median monitoring time: 27.33 months. 80% are continent patients, 48.7% of which reach maximum continence before the 3rd, month is due and 17.5% after the 6 months (2.5% between 9-12 months). Their probability of becoming "continents" during the first 4 months es 0.4692. patients under 70 years old recover continence before those who are over 70 years old (medians: 3.51 months and 5.67 months respectively, p = 0.0211). CONCLUSIONS: The recovery of continence takes place progressively and a 17.5% of patients reach plain recovery in the 6-12 months period after surgery. The evaluation of the surgery treatment to correct incontinence should consider the possibility of "spontaneous" recovery in a 2.5% of patients in the 9-12 months period after surgery. Age affects negatively the recovery time; it is significantly less for patients under 70.

Aged↗

PubMed1997

Combined Mitrofanoff and antegrade continence enema procedures for urinary and fecal incontinence.

PURPOSE: Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children undergoing major reconstructive urological operations. To treat double incontinence or the combination of wetting and severe constipation, we constructed a Mitrofanoff conduit and a channel for antegrade continence enemas in 18 patients between 1989 and 1995. We review the underlying pathological conditions, various surgical techniques and outcomes of these operations. MATERIALS AND METHODS: Underlying abnormalities mainly included spinal lesions, bladder exstrophy, imperforate anus and various cloacal anomalies. Patient age ranged from 2 to 18 years (average 8.4). In 13 patients both procedures were done simultaneously. The appendix was used to construct the antegrade continence enema channel in 8 cases and the Mitrofanoff channel in 5. It was long enough to be divided and used for both procedures in 2 cases but it was missing or unsuitable in 3. Alternative antegrade continence enema conduits were cecal flap in 7 patients and ileum in 1, while the ureter, ileum and detrusor tube were used to establish Mitrofanoff channels in 5, 5 and 1, respectively. Stomas were constructed according to the V-flap or V. Z. Q. technique and situated in close proximity in the right lower abdominal quadrant in 13 cases. RESULTS: Convalescence was uneventful except for 1 abscess near an antegrade continence enema stoma. Ten patients needed dilation or minor revisions due to difficulty in catheterizing the antegrade continence enema (5), Mitrofanoff (3) or both conduits (2). Subsequently 3 patients underwent repeat operations for reconstruction of 2 antegrade continence enema channels (cecal flap and ileum) and 1 detrusor tube Mitrofanoff channel. Currently 15 patients are dry on regular clean intermittent catheterization using 10 to 12F catheters. Outcomes of the antegrade continence enema channels are satisfactory in 15 patients who are clean or rarely soil. Failure occurred in 1 patients with severe constipation necessitating colostomy and 2 (1 noncompliant who stopped catheterizing regularly) in whom the channels subsequently closed. CONCLUSIONS: Synchronous construction of antegrade continence enema and Mitrofanoff channels is successful in the majority of doubly incontinent patients. Selection of patients with high motivation is important to obtain satisfactory results.

Adolescent↗

PubMed2002

Urinary continence outcome after augmentation ileocystoplasty as a single surgical procedure in patients with myelodysplasia.

PURPOSE: Preoperative prediction of urinary continence in patients with myelodysplasia requiring augmentation cystoplasty is uncertain. To determine reliable factors to predict postoperative urinary continence, we retrospectively analyzed preoperative videourodynamic parameters and urinary continence outcome in a group of patients with myelodysplasia who underwent augmentation ileocystoplasty. MATERIALS AND METHODS: Of 75 patients with myelodysplasia with neurogenic bladder dysfunction refractory to conservative management (anticholinergic drugs and clean intermittent catheterization) who underwent augmentation cystoplasty as a single procedure we selected 14 girls and 12 boys without previous vesicostomy drainage and with preoperative and postoperative videourodynamic studies in whom detubularized ileocystoplasty was performed. Preoperative and postoperative evaluation included physical examination, assessment of renal function, urine culture, renal and bladder ultrasound and videourodynamic studies. We analyzed on preoperative videourodynamic studies bladder outlet morphology at 20 cm. water of filling detrusor pressure, leak point pressure, cystometric bladder capacity and end filling detrusor pressure. Videourodynamic bladder outlet morphology was classified as closed bladder outlet, insinuated bladder neck, bladder neck and urethra open up to the sphincter, and bladder outlet widely open. Patients were considered continent if they were able to remain dry between catheterization without pads. For analysis patients were divided into group 1-19 with preoperative incontinence and group 2-7 without urinary incontinence. RESULTS: After surgery 4 group 1 patients had urinary incontinence whereas all group 2 patients remained continent. Only 1 group 1 patients with leak point pressure less than 50 cm. H2O and 3 with leak point pressure greater than 50 cm. H2O were incontinent after surgery. Seven group 1 patients with cystometric bladder capacity greater than 75% and 8 with cystometric bladder capacity less than 75% of the age expected bladder capacity achieved continence. Two group 1 patients with filling detrusor pressure less than 40 cm. H2O and 2 with filling detrusor pressure greater than 40 cm. H2O continued with urinary incontinence after ileocystoplasty. Preoperative videourodynamic images of the 4 group 1 patients who remained incontinent after surgery demonstrated irrespective of the aforementioned urodynamic parameter widely open bladder outlet. Moreover, none of the postoperative continent patients had an open bladder neck and urethra on preoperative evaluation. CONCLUSIONS: According to our findings of the anatomical morphology of the bladder outlet (bladder neck/urethra) during the filling phase of videourodynamic studies at 20 cm. water filling detrusor pressure was the most reliable parameter to predict continence outcome after detubularized augmentation ileocystoplasty.

Adolescent↗

PubMed2002

Improved continence after radical retropubic prostatectomy using two pubo-urethral suspension stitches.

OBJECTIVES: To determine if placement of urethral suspension stitches during radical retropubic prostatectomy improves postoperative urinary continence. METHODS: Between January 1997 and January 1998 we performed radical retropubic prostatectomy on 50 men. The first 25 consecutive men had their surgery without urethral suspension stitches while the next 25 received placement of two anastomotic urethral suspension stitches anchored to the lower portion of the pubic bone. Patients were interviewed six months postoperatively and each underwent valsalva leak-point pressure measurement. Patients were categorized as either completely continent (requiring no pads and having no measurable valsalva leak point), socially continent (zero or one pad per day), or incontinent (two or more pads per day). RESULTS: In the urethral suspension group, 8/25 (32%) patients were completely continent and did not have a measurable valsalva leak-point pressure while 3/25 (12%) without urethral suspension were completely continent. Of the remaining patients in the urethral suspension group, 13/17 (76%) patients were socially continent while 4/17 (24%) were incontinent. The mean valsalva leak-point pressure in the 17 patients with suspension stitches was 89.6 +/- 21.6 cm H2O. In the patients without urethral suspension, there were 22 patients who had some degree of incontinence. Among non-stitch patients, 13/22 (59%) were socially continent while 9/22 (41%) were incontinent. The average valsalva leak-point pressure in these patients was 74.0 +/- 16.7 cm H2O, which was significantly lower than those with the suspension (p = 0.015). CONCLUSIONS: Placement of anastomotic urethral suspension stitches during radical retropubic prostatectomy may increase the likelihood of complete postoperative urinary continence. The urethral suspension stitches also increase valsalva leak-point pressure, which may improve the percentage of patients with socially acceptable incontinence.

Humans↗

PubMed2000

Continence mechanism based on a modified ileocecal valve.

PURPOSE: We describe the technique and results of a simply constructed continence mechanism for continent urinary diversion to the skin based on the ileocecal valve. MATERIALS AND METHODS: During a 3-year period 28 patients underwent construction of a continent stoma using the ileocecal valve; 23 patients were available for evaluation. The various indications for lower urinary tract reconstruction in this patient population included malignancy (4), neurogenic bladder (11), and urethral dysfunction (8). The continence mechanism is provided by the ileocecal valve, with tapering of the distal ileal segment with an absorable stapling device and then securing the catheterizable ileal segment to the serosa of the cecum along an opened taenia to provide an additional level of continence to the ileocecal valve. RESULTS: Continence was achieved in 83% (19 of 23) of patients. Two patients required revision and are now dry, and two patients have not undergone revision and remain wet. No patients have had problems with difficult or traumatic catheterization of the limb or peristomal hernia. One case of stomal stenosis was identified and treated with an outpatient revision. CONCLUSIONS: This technique for construction of a continence mechanism for a continent cutaneous urinary reservoir is simple to create, reliable, and without excess morbidity.

Adult↗

PubMed1998

Bowel-flap tubes for continent cutaneous urinary diversion.

The appendix stoma for Mainz-pouch continent cutaneous urinary diversion is reliable and easy to perform. Two new continence mechanisms were developed for patients in whom the appendix is not available or usable. A seromuscular tube was used in 27 patients (12 women, 15 men, mean age 63 years) and a bowel-wall tube was used in 24 patients (13 women, 11 men, mean age 57 years) as the continence mechanism for continent cutaneous urinary diversion. At a mean follow-up of 32 months (range 2-68 months), 93% of patients with a seromuscular tube and 92% of those with a bowel-wall tube are continent day and night. Four early and nine late stoma-specific complications have occurred, requiring seven open surgical revisions. Thus far, both techniques have fulfilled all requirements as continence mechanisms for continent cutaneous urinary diversion. However, the reliability, advantages, and disadvantages of these techniques have to be confirmed in further long-term studies.

Cecum↗

PubMed2004

Comparison of orthotopic sigmoid and ileal neobladders: continence and urodynamic parameters.

OBJECTIVES: The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments. METHODS: Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups. RESULTS: The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7-32) ml/s, IN group 25.5 (range 5-35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night. CONCLUSION: A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.

Adult↗

PubMed1997

Continent urinary diversion: the Children's Hospital experience.

PURPOSE: Continent urinary diversion has become increasingly important for treating childhood urinary tract pathology that cannot be managed by direct reconstructive techniques. We review our 9-year experience with continent diversion. MATERIALS AND METHODS: Since 1986 continent diversions were created in 74 patients 3 to 38 years old (mean age 13.7). The underlying pathological condition was the exstrophy/epispadias complex in 34 patients, neurological disorders in 23, malignancy in 13 and other congenital anomalies in 4. Followup averaged 5.2 years after the last procedure. Nonbladder reservoirs in 39 patients (53%) were fashioned from ileocolic (17), colic (7), gastrocolic (6), sigmoid (3), gastrosigmoid (2), ileosigmoid (2), ileal (1) and gastroileac (1) segments. When possible, the native bladder was incorporated into the reconstructive strategy. A total of 26 patients underwent bladder augmentation with intestine or stomach, including ileal (11), gastric (8), sigmoid (3), gastroileac (2) and ileocolic (2) segments. Nine other patients did not require bladder augmentation. Continence mechanisms were a flap valve (Mitrofanoff principle) in 50 patients, nipple valve in 15 and ileal plication (Indiana pouch) in 9. When the Mitrofanoff principle was used with a native bladder reservoir in 30 cases, outlet resistance was altered by bladder neck division (15), fascial sling placement (6) or Young-Dees-Leadbetter bladder neck reconstruction (2). In the remaining 7 patients the bladder neck remained intact. RESULTS: Excellent continence was obtained. The Mitrofanoff principle initially provided continence in 41 patients (82%). Six of the 9 incontinent patients were dry after a single revision. A total of 13 patients (87%) with nipple valves and 7 (78%) with Indiana pouches were dry, and the remaining 5 were cured after a single revision. Ultimately continence was achieved in 71 of the 74 patients (96%) after a maximum of 2 operations. Of the 48 complications in 29 patients the most common were difficulty in catheterizing (11), stones (11), infection (8) and upper tract deterioration (4). CONCLUSIONS: Many options exist for reconstructing complex anomalies. Choices must be individualized based on patient anatomy. The dry state may be achieved in most cases without resorting to a bag on the abdomen.

Adolescent↗

PubMed1995

Bladder neck closure in association with continent urinary diversion.

Bladder neck closure is not a standard part of continent urinary diversion. When bladder augmentation and continent urinary diversion are done simultaneously, it is frequently convenient and advantageous to leave the native bladder neck intact as long as there is a reasonable degree of intrinsic continence. Even in patients with marginal control the effect of lowering intravesical pressure and increasing intravesical volume will often produce acceptable continence. At times, particularly in patients who have undergone multiple surgical procedures involving the bladder neck, there is poor intrinsic resistance. To provide acceptable continence in these cases bladder neck closure is a necessary part of continent diversion. Between 1990 and 1993 we treated 6 male and 7 female patients, most of whom underwent simultaneous bladder augmentation and continent urinary diversion, and they had poor intrinsic outlet resistance. Patient age ranged from 8 to 22 years. Underlying diagnoses included thoracic myelomeningocele in 5 patients, bladder exstrophy in 5, bladder leiomyosarcoma in 1 and extensive pelvic trauma in 1 as well as 1 previously separated conjoined twin. Three patients had artificial urinary sphincter failure and 3 had failure of urethral sling procedures. A clean intermittent catheterization program had failed in 12 patients and all 13 had diurnal incontinence. Bladder neck and urethral resistance was evaluated using voiding cystourethrography and urodynamics to measure leak point pressure and bladder capacity. Reliable bladder neck closure is historically difficult to achieve and is best done at the time of diversion. We have had initial success in 12 of our 13 cases and subsequently in all 13 using a technique of bladder neck division, 2-layer closure and omental interposition between the bladder neck closure and urethra.

Adolescent↗