Outcomes following Malone antegrade continence enema and their surgical revisions

BACKGROUND/PURPOSE

The Malone antegrade continence enema (MACE) channel is an effective means to manage patients with neurogenic bowel; however, complications may occur that may require surgical revision. Specific reports of the outcomes of these interventions are limited. We describe our clinical results following revision of MACE.

METHODS

We retrospectively identified patients undergoing MACE revision for at our institution between 1997 and 2009. Type of MACE (in situ appendicocecostomy (AC = 247), ileocecostomy (IC = 25), cecal flap (CF = 10)) performed was recorded, time from creation to revision, site of revision, and need for repeat surgical revision were recorded.

RESULTS

Of a total of 282 patients that underwent creation of MACE during the study period, 49 patients (17%) required surgical revision. Of these 49 patients, 42 had undergone AC, four had IC and three had CF. Mean time from MACE creation to revision was 19 months. Sixty-eight revision procedures were performed in the 49 patients. Skin level or endoscopic procedures accounted for 52/67 (78%) procedures. Sixteen patients (33%) required more than one revision and three patients (6%) required more than two procedures.

CONCLUSIONS

Skin level revisions accounted for over three-fourths of MACE revisions. In our series, two thirds of patients requiring revision required only a single procedure, but one third required more than one revision.

Caliceal diverticulum in pediatric patients: the spectrum of imaging findings

BACKGROUND

Caliceal diverticulum (CD) is uncommon in children. As compared to adults, most children with CD are symptomatic. Common complications include stone formation and infection. Correct diagnosis of CD is important for guiding management.

OBJECTIVE

To identify imaging findings at diagnosis and follow-up in pediatric patients with CD.

MATERIALS AND METHODS

We identified all patients from 2003 to 2010 with a diagnosis of CD. We reviewed presenting symptoms, underlying diseases, complications, management, and all pertinent radiological examinations.

RESULTS

Twenty-four patients (2.6 to 18.5 years old, 11 females) had CD. Urinary tract infection was the most common (n = 8) presentation. Diagnosis of CD was based on delayed post-contrast CT in 79% of patients with only one false-negative CT. Most patients (n = 20) had a single CD; others had either 2 CDs (n = 2) or multiple CDs (n = 2). CD diameter ranged from 1.0 to 18.3 cm and grew in five of nine patients who had follow-up studies. Seven patients developed stone in the CD. Fifteen patients (63%) underwent a surgical procedure.

CONCLUSIONS

CD is commonly solitary, often grows with time and may mimic other diagnoses, including simple cyst, complex cyst and polycystic kidney disease. Delayed postcontrast CT is highly sensitive in diagnosing CD.

Does preoperative genitography in congenital adrenal hyperplasia cases affect surgical approach to feminizing genitoplasty?

PURPOSE

Genitography has traditionally been an imperative part of radiographic evaluation in females born with congenital adrenal hyperplasia before surgical reconstruction. We evaluated the role of preoperative genitogram in surgical reconstruction planning and how it correlates with intraoperative findings.

MATERIALS AND METHODS

We retrospectively reviewed the records of 40 patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty at our institution between 2003 and 2009. Preoperative genitogram findings were recorded and correlated with operative findings.

RESULTS

A total of 42 preoperative genitograms were available for review in 40 patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty. Genitography revealed complete anatomy of the urogenital sinus in 30 cases (72%) while bladder filling alone was present in 9 (21%) and vaginal filling was noted in 2 (5%). The urogenital sinus could not be catheterized in 1 patient (2%). Vesicoureteral reflux was identified in 6 patients (15%) with a mean grade of 2. Vaginoplasty was done with a flap technique in 37 patients (more than 90%) while the remaining 3 underwent pull-through vaginoplasty. In no case did genitogram reveal anatomy that was not visible via endoscopy or at reconstruction. The vaginoplasty technique was based on endoscopic and intraoperative findings, and not on genitogram.

CONCLUSIONS

Genitography during preoperative evaluation in females with congenital adrenal hyperplasia undergoing feminizing genitoplasty did not reveal urogenital sinus anatomy completely in 25% of the patients in our series. Preoperative genitogram did not influence the surgical approach. Its value as preoperative imaging in patients with congenital adrenal hyperplasia may be limited.

The role of routine postoperative stentograms in the pediatric patient undergoing excisional tapered ureteral reimplantation

OBJECTIVE

To determine the usefulness of routine stentograms in postoperative management of pediatric patients undergoing excisional tapered ureteral reimplantation.

MATERIALS AND METHODS

A retrospective review of all pediatric patients undergoing excisional tapered ureteral reimplantation from March 2003 to March 2008 at one center was performed. One hundred patients were identified. Seventeen had stentograms performed approximately 2 weeks (1-5 weeks) after surgery. The 83 without stentograms composed the control group.

RESULTS

Of the 17 pediatric patients with postoperative stentograms, 10 (59%) had no contrast observed in the bladder. Ureteral stents were removed despite this finding. No anastamotic leaks were observed. In this group, not one had a postoperative complication at time of follow up (mean 25 months; range 4-52). Of the 83 patients without stentograms, not one had clinical signs of anastamotic leakage or obstruction at discharge. The stents were removed routinely 2 weeks (range 1-8) after surgery. Nine patients (10.8%) developed ureteral obstruction (mean 7 weeks; range 1-24) requiring intervention. Three of these patients required a second operation.

CONCLUSIONS

Since routine stentograms rarely identify ureteral leak, and poor drainage on postoperative stentogram does not indicate a risk of obstruction, these studies are not required following routine excisional tapered ureteral reimplant.

Ultrasonography and clinical findings in children with epididymitis, with and without associated lower urinary tract abnormalities

BACKGROUND

Epididymitis is most commonly idiopathic but can also be associated with urinary tract abnormalities (UTAs). The distinctive clinical and imaging findings of children with epididymitis and underlying UTAs are not known.

OBJECTIVE

To describe clinical and imaging findings in children with epididymitis and the association with UTAs.

MATERIAL AND METHODS

The study group included all children evaluated for epididymitis confirmed by scrotal US in a 6-year period. The clinical and imaging findings and disease recurrence were compared between children with and without UTAs.

RESULTS

A total of 47 boys (mean/SD 9.61/4.40 years, range 0.1 to 17.1 years) met the entry criteria, of whom 17 had UTAs. The most common UTAs were hypospadias, neurogenic bladder, and functional bladder abnormality (six each). Age at presentation and likelihood of testicular swelling or hydrocele was not different between children with and without UTAs. Marked epididymal swelling was more common in children with UTAs (9/17, 53%) than in those without UTAs (5/30, 17%; P=0.02), as was recurrent epididymitis (with UTAs, 9/17, 53%; without UTAs, 5/30, 17%; P=0.02). Chronic epididymitis (five children), presentation with scrotal mass (four), and epididymal abscess (two) occurred only in children with UTAs.

CONCLUSION

Children with epididymitis who have UTAs are more likely to present with marked epididymal swelling, develop recurrent disease, and have a more protracted course.

The Malone antegrade continence enema: single institutional review

PURPOSE

We report the long-term outcome of the Malone antegrade continence enema procedure in the treatment of chronic constipation and fecal incontinence in children with neuropathic bowel.

MATERIALS AND METHODS

We performed a retrospective chart review of 256 Malone antegrade continence enema procedures. Patient age at surgery, bowel segment used, location of stoma, number and type of revisions required, and fecal continence were documented and a database was created.

RESULTS

A total of 236 patients with at least 6 months of followup are included in this report. There were 172 in situ appendicocecostomies, 23 split appendix channels, 9 appendicocecostomies with cecal extension, 22 Yang-Monti ileocecostomies and 10 colon flap channels performed. A total of 112 males (47%) and 124 females (53%) were included in the study. Median patient age at surgery was 9 years (range 2 to 36) and median followup for the entire cohort was 50 months (6 to 115). A total of 56 surgical revisions were performed in 39 patients (17%). Median time to first revision was 9.5 months (range 1 to 105). Stomal stenosis occurred in 32 patients (14%). Overall, surgical revisions were required in 14% of in situ appendix channels (24 of 172), 22% of split appendix channels (5 of 23), 33% of appendix channels with cecal extension (3 of 9), 18% of Yang-Monti Malone antegrade continence enema channels (4 of 22) and 30% of colon flap channels (3 of 10). Independent of channel technique, surgical revisions were required in 15% of umbilical stomas and 18% of lower quadrant stomas (p = 0.516). Two patients had minimal stomal leakage, and 94% (221 of 236) achieved fecal continence with irrigations.

CONCLUSIONS

The long-term results of the Malone antegrade continence enema channel in a large cohort of patients with neuropathic bowel and chronic constipation are encouraging. Of the patients 17% will require revision surgery, and patients/parents should be counseled accordingly. In our series in situ appendicocecostomy had the lowest revision rate on long-term followup, although the difference was not statistically significant (p = 0.226).

Evaluating the in vitro and in vivo efficacy of nano-structured polymers for bladder tissue replacement applications

Bladder cancers requiring radical cystectomy, along with congenital and acquired disorders which result in obstruction of the bladder, necessitate surgical measures (including augmentation); such diagnoses bring a clinical need for effective bladder replacement implant designs. Many recent approaches for the design of soft tissue replacement materials have relied on the use of synthetic polymeric substances; unfortunately, the optimal soft tissue implant material is yet to be found. This may, in part, be because current polymeric formulations fail to sufficiently biomimic the neighboring bladder tissue. This study took a brand new approach in designing the next generation of tissue-engineered bladder constructs through the use of nanotechnology, or materials with nanometer (less than 100 nm) surface features. Results provided evidence that nano-structured polymeric scaffolds (specifically, PLGA and PU) created using chemical etching techniques are capable of enhancing the human bladder smooth muscle cell adhesion, proliferation, and the production of extracellular matrix (ECM) proteins. Preliminary in vivo results also speak to the usefulness of such nano-structured materials. In combination, these findings suggest that nano-dimensional PLGA and PU scaffolds are promising replacement materials for the human bladder wall.

A Comparison of the Monti and Casale (Spiral Monti) Procedures

PURPOSE

We present our long-term followup and comparison of outcomes between the Monti and Casale (spiral Monti) procedures in a large group of children and young adults.

MATERIALS AND METHODS

A retrospective chart review was done, including all patients undergoing the Monti or Casale procedure at our institution with a minimum followup of 6 months. Age at surgery, the bowel segment used, stomal location, the number and type of revisions or endoscopic procedures required after channel creation, problems catheterizing and channel continence were documented, and a database was created.

RESULTS

Of 188 patients identified with at least 6 months of followup 109 underwent a Monti procedure, while 79 underwent a Casale procedure. Patient age at surgery was 10 months to 31 years (mean 10.2 years). Mean followup was 43 months for the entire cohort, and 47.2 and 37.2 months for the Monti and Casale groups, respectively. A total of 43 open revisions were required in 36 patients (19.1%). Stomal revisions accounted for 18 procedures, while subfascial revisions accounted for 25 in 17 (9.0%) and 21 (11.2%) patients, respectively. A total of 21 endoscopic procedures requiring anesthesia were performed in 17 patients (9.0%). In the Monti group stomal revision was required in 11 patients (10.1%), while subfascial revisions were required in 9 (8.3%). In the Casale group stomal revision was required in 6 patients (7.6%), while subfascial revisions were required in 12 (15.2%). Of the channels 98% were completely continent at the stoma.

CONCLUSIONS

In a large population of children and young adults we report durable and reliable long-term results with the Monti and Casale procedures, including continence at the stoma. The only significant difference noted between the 2 procedures was a higher incidence of subfascial revisions for umbilical stomas in each group. The need for subfascial revision is highest in spiral Monti channels placed in the umbilicus.

A porcine model of bladder outlet obstruction incorporating radio-telemetered cystometry

OBJECTIVE

To present a novel porcine model of bladder outlet obstruction (BOO) with a standardized bladder outlet resistance and real-time ambulatory radio-telemetered cystometry, as BOO is a common condition with many causes in both adults and children, with significant morbidity and occasional mortality, but attempts to model this condition in many animal models have the fundamental problem of standardising the degree of outlet resistance.

MATERIALS AND METHODS

BOO was created in nine castrated male pigs by dividing the mid-urethra; outflow was allowed through an implanted bladder drainage catheter containing a resistance valve, allowing urine to flow across the valve only when a set pressure differential was generated across the valve. An implantable radio-telemetered pressure sensor monitored the pressure within the bladder and abdominal cavity, and relayed this information to a remote computer. Four control pigs had an occluded bladder drainage catheter and pressure sensor placed, but were allowed to void normally through the native urethra. Intra-vesical pressure was monitored by telemetry, while the resistance valve was increased weekly, beginning with 2 cmH2O and ultimately reaching 10 cmH2O. The pigs were assessed using conventional cystometry under anaesthesia before death, and samples conserved in formalin for haematoxylin and eosin staining.

RESULTS

The pigs had radio-telemetered cystometry for a median of 26 days. All telemetry implants functioned well for the duration of the experiment, but one pig developed a urethral fistula and was excluded from the study. With BOO the bladder mass index (bladder mass/body mass x 10 000) increased from 9.7 to 20 (P = 0.004), with a significant degree of hypertrophy of the detrusor smooth muscle bundles. Obstructed bladders were significantly less compliant than control bladders (8.3 vs 22.1 mL/cmH2O, P = 0.03). Telemetric cystometry showed that there was no statistically significance difference in mean bladder pressure between obstructed and control pigs (4.8 vs 6.7 cmH2O, P = 0.7), but that each void was longer in the pigs with BOO.

CONCLUSION

This new model of BOO provides a method of reliably and precisely defining the bladder outlet resistance; it induces the changes classically seen with BOO, including increased bladder mass, increased smooth muscle bundle size and decreased compliance.

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.

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.

Upregulation of both PDGF-BB and PDGF-BB receptor in human bladder fibroblasts in response to physiologic hydrostatic pressure

OBJECTIVE

Bladder outlet obstruction can lead to the deposition of extracellular matrix and a resultant decrease in bladder wall compliance. Platelet-derived growth factor (PDGF) is a potent mitogen for fibroblasts and can increase the deposition of extracellular matrix. We attempt to determine if the expression of PDGF-BB and its receptor are altered in human bladder fibroblasts and bladder smooth muscle cells when exposed to hydrostatic pressures in the physiologic range.

MATERIALS AND METHODS

Cultured human bladder fibroblasts and smooth muscle cells were evaluated in vitro by using a novel device that controls for hydrostatic pressure. Cells were exposed to pressures of 20 and 40 cmH(2)O for up to 72 h. Western blot analyses and RT-PCR were performed to evaluate expression of both PDGF-BB and PDGF-BB receptor.

RESULTS

PDGF-BB and its receptor increased up to 22-fold and 8-fold, respectively, when human bladder fibroblasts were exposed to 40 cmH(2)O sustained hydrostatic pressure, while at 20 cmH(2)O the effect was minimal until 72 h. mRNA for the PDGF-BB receptor in human bladder fibroblasts increased in comparison to control. Western blot analyses demonstrated that exposure of human bladder smooth muscle cells to a sustained hydrostatic pressure of 20 and 40 cmH(2)O for up to 72 h did not alter expression of either PDGF-BB or its receptor.

CONCLUSIONS

Both PDGF-BB and its receptor in human bladder fibroblasts were upregulated in a time- and pressure-dependent manner after as little as 24 h exposure to pressures of < or =40 cmH(2)O. Our results provide support for a potential role of both PDGF-BB and its receptor in bladder fibrosis secondary to increased intravesical pressure. Newer selective PDGF receptor antagonists may prove beneficial in preventing bladder wall fibrosis in patients with either anatomic or functional bladder outlet obstruction.