Continent urinary reconstruction in rhabdomyosarcoma: a new approach

Macedo ileal catheterizable reservoir adding the scissors maneuver of channel continence: Long term follow-up

INTRODUCTION

The Macedo ileal catheterizable channel was published in 2000 and consists of an enterocystoplasty with a catheterizable channel that precludes the need of the appendix for the efferent channel. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed exclusively by the author in a non-teaching hospital facility after the latest modifications of the procedure.

MATERIALS AND METHODS

Since 2008, we have refined our technique with the following modifications: small skin transverse incision instead of longitudinal one, with a semicircular flap for further stoma creation in the midline and importantly the scissors maneuver. This maneuver consists of crossing two 2 cm rectus abdominis muscle flaps in the midline to create a neosphincter over the catheterizable channel. Follow-up was defined as the interval between the date of surgery and last visit to the clinic. We defined stoma continence if the dry interval between catheterization was 4hs. Early and late complications were reported as well as the reintervention rate. Additional procedures in association with bladder augmentation were also appointed.

RESULTS

We have treated 49 patients. Indications were spinal dysraphism (71.4%), mainly myelomeningocele (65.3%), and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed bladder pressure of high risk for upper urinary tract involvement (66%), urinary incontinence (24.5%), conversion of incontinent urinary diversion (3.8%), one exstrophy patient not considered (1.9%). Mean age at surgery was 88 months (7.3 years), 21 patients had additional surgeries in addition to Macedo ileal catheterizable channel: Macedo-Malone LACE procedure in 21 patients and bladder neck surgery to improve continence in 5 patients. Urinary stoma continence was 93.9% (46/49) after first surgery, one patient had a serous line valve revised, two patients still leak after 2 h and await revision. Overall enterocystoplasty complications rate was 12.24% and consisted of urinary leakage in 3 cases and channel/stoma stricture in 3 cases. All patients treated for sphincteric deficiency associated with bladder reconstruction are continent per urethra. Urinary stoma revision for stricture was done in 2 cases and consisted on suprafascial approach and reanastomosis, one patient resolved with dilatation of the channel to the stoma. Mean follow up is 100 months (8.3 years).

CONCLUSION

We confirmed in a long term follow-up based on face-to-face visits with 8.3 years mean follow-up that the Macedo procedure associated with the scissors maneuver is associated with 93.9% continence of the stoma. Overall complications rate was 12.24%. The cosmetic aspect with a small transverse incision and a midline stoma is another strength of the technique.

Late secondary urological reconstruction of separated ischiopagus twins with exstrophic bladder and urinary incontinence

We report a case of secondary urinary reconstruction of previously separated conjoined twins with exstrophic bladder and urinary incontinence. Patients were male and aged 13-year-old. Twin one had a history of failed enterocystoplasty that extruded and was visible like an exstrophic neobladder. He underwent a procedure to close bladder neck and reconfigure abdominal wall. After the procedure the patient developed a fistula that was treated, but it persisted and, for this reason, a catheterizable pouch was constructed and native bladder was discarded. Twin two required the immediately construction of catheterizable pouch using the Macedo’s technique. Currently, both patients are continent at 4 hour intervals. The mean follow-up was 8 months. Modern continent urinary diversion techniques offer new perspectives and hope for such complex population.

Appraisal of the role of radical prostatectomy for rhabdomyosarcoma in children: oncological and urological outcome

The latest multimodal protocols for treatment of bladder/prostate rhabdomyosarcoma (RMS) have shifted the goal of treatment from patient survival to bladder preservation. Consistently, partial resections, such as radical prostatectomy (RP), are favoured when surgery is deemed necessary. We sought to determine the oncological risks - that is, failure to achieve disease control - and the possible benefits in terms of urinary continence associated with RP in RMS patients based on a review of our experience and the data reported in the literature. We identified 18 children undergoing RP for RMS (3 at our institution, 15 in the literature). In five cases, a pubectomy/symphisiotomy was performed to improve surgical exposure. Two cases experienced local relapse, suggesting that this approach can be viable to achieve local control. No clear-cut indications could be extrapolated from the literature, however, to determine how to select the patients most suitable for this approach. We offered this treatment to patients with evidence of disease localized only within the prostate on radiological and endoscopic re-assessment after chemo-/radio-therapy. Eight of the 18 cases (44%) eventually required lower urinary tract reconstruction, suggesting that often this approach does not allow for the preservation of urinary continence with volitional voiding. Finally, data about additional interesting outcomes such as erectile function and fertility in RMS patients undergoing RP are extremely sparse.

Oncologic outcome and urinary function after radical cystectomy for rhabdomyosarcoma in children: role of the orthotopic ileal neobladder based on 15-year experience at a single center

PURPOSE

We determined the oncologic and urological outcomes in patients with bladder/prostate rhabdomyosarcoma according to the type and timing of urinary tract surgery, with emphasis on the role of the Padua orthotopic ileal neobladder.

MATERIALS AND METHODS

We retrospectively analyzed oncologic and urological outcomes of 11 consecutive patients treated at our institution between 1998 and 2012.

RESULTS

Two patients underwent urethrectomy and placement of a heterotopic catheterizable ileal neobladder. The membranous urethra was preserved in 9 patients, 6 underwent primary Padua ileal neobladder at radical cystectomy, 2 underwent delayed Padua ileal neobladder and 1 underwent bilateral cutaneous ureterostomy. Four of these 9 patients experienced disease recurrence, including local recurrence in 2 despite negative intraoperative biopsies. Survivors undergoing heterotopic catheterizable ileal neobladder or primary Padua ileal neobladder learned to empty the bladder to completion without long-term upper tract deterioration. Both cases managed by delayed Padua ileal neobladder required clean intermittent catheterization eventually. Erections were reported in 5 of 6 surviving males.

CONCLUSIONS

The Padua ileal neobladder allowed preservation of volitional urethral voiding in all survivors in whom it was placed at radical cystectomy. Nevertheless, local recurrence was noted in 2 of the 9 cases where the membranous urethra was preserved. By comparison, patients undergoing delayed Padua ileal neobladder after attaining disease-free status never achieved voiding per urethra. Therefore, a heterotopic reservoir might be a more reliable choice under these circumstances. Erectile function is preserved in the majority of cases.

Ten years' minimum follow-up with the ileal continent catheterizable reservoir: a test of time

OBJECTIVE

To evaluate long-term efficacy of an original technique of catheterizable ileal reservoir designed for bladder augmentation and/or substitution, precluding the need to use a Yang-Monti channel or appendix.

MATERIALS AND METHODS

Our series comprised 19 patients, operated in 1998-2000, with a mean age of 10.1 years (1.6-30). Two were excluded from analysis because lost to follow-up after 1.5 and 7 years of surveillance. The primary disease was posterior urethral valves (9), myelomeningocele (4), anorectal malformation (1), rhabdomyosarcoma (1), medullary astrocytoma (1) and urethral stricture (1). Surgery consisted of creating a continent catheterizable ileum-based reservoir from a 35-cm ileum segment.

RESULTS

Mean follow-up was 11.2 years (10-12.4). All 16 patients eligible for final evaluation of the procedure were continent, excluding two lost of follow-up and one that underwent undiversion. Complications noted were: stomal stenosis (3), leakage associated with false passage (1) and false passage (1). One patient underwent a Bricker undiversion procedure, an appendicovesicostomy was performed in 2, and 1 patient received a Monti channel to replace the outlet conduit. The overall complication rate was 29.4% (5/17).

CONCLUSION

We have confirmed the long-term efficacy of the technique. The results are comparable to other 'gold standard' treatments, with the advantage of being simpler, faster and sparing the appendix for other uses (Malone antegrade continent enema), as well as precluding the need to create a Monti channel.

The efferent segment in continent cutaneous urinary diversion: a comprehensive review of the literature

OBJECTIVE

To critically assess the biophysical properties and current status of outlet formation in heterotopic intestinal urinary diversion. As despite three decades of clinical experience with continent cutaneous urinary diversion through bowel segments, no consensus has been reached for the optimal efferent segment although its function largely determines patient satisfaction.

METHODS

A comprehensive Medline literature search using the Medical Subject Headings database (search terms: continent urinary diversion followed by either efferent segment, nipple, Mitrofanoff, Yang-Monti, Benchekroun, tapered ileum, intussuscepted ileum, Kock pouch, T-valve, or Ghonheim) was conducted to identify all full-length original articles addressing the various principles and techniques of outlet formation as well as their outcomes and complications. Examined series were published in English between 1966 and 2010. All studies were systematically evaluated using a checklist (study design, number of patients, etc.) and rated according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence (LoE).

RESULTS

While there was a continuous flow of publications over the last three decades, the vast majority of studies were retrospective case series with numerous confounding factors and poorly defined, non-standardized outcomes (LoE, 3). Only a few investigations compare different efferent segments (LoE, 2a). No randomized studies exist. The major biophysical principles are based on the use of flap, nipple, and hydraulic valves. Vermiform appendix, intussuscepted ileal nipple, and the Yang-Monti tube are the most popular techniques and have well-established data on outcomes, complications, and failure rates. Artificial sphincter systems and tissue engineering have provided disappointing results thus far. Most reconstructive strategies are subject to a process of on-going improvement.

CONCLUSIONS

The continuous quest for optimization has not led to a single universally applicable efferent segment in continent cutaneous urinary diversion. While all techniques have their unique set of advantages and disadvantages, they will always remain a compromise. Success depends on selecting the optimal strategy for individual patients. A major change in principles in the near future is unlikely.

Sexual function in teenagers after multimodal treatment of pelvic rhabdomyosarcoma: A preliminary report

OBJECTIVE

The multimodal approach to treatment of genitourinary rhabdomyosarcoma (RMS) has improved survival rates, but there is now a focus on the effect on quality of life. Our aim was to evaluate erectile function in children with rhabdomyosarcoma (RMS) who underwent chemotherapy, radiotherapy, cystectomy and continent urinary diversion.

MATERIAL AND METHODS

We evaluated four eligible patients (age > 14 years) from our genitourinary RMS database. In two patients the reservoir was constructed at the same time of the cystectomy and in two after undiversion of an ileal conduit. All patients were treated with chemotherapy and radiation therapy before cystectomy. We used a questionnaire to estimate erectile function in adolescents and young adults. There were four questions, each one to be scored 1-5, assessing capability to masturbate.

RESULTS

Mean follow up after cystectomy was 9.75 years. We considered that two patients had erections of good quality (scores 18 and 20) and two of moderate quality (scores 8 and 10). One patient had a good response to sildenafil administration.

CONCLUSION

Our data demonstrate that it is possible to keep erectile function during masturbation in children with RMS who have undergone chemotherapy, radiotherapy, cystectomy and continent urinary diversion.

Is continent urinary diversion feasible in children under five years of age?

PURPOSE

To review our clinical experience with urinary continent catheterizable reservoir in children under five years of age.

MATERIALS AND METHODS

A total of 23 patients (16 males, 7 females) with a median age of 3.64 years were evaluated. Among these, 6 (26.08%) had a posterior urethral valve, 9 (39.13%) myelomeningocele, 4 (17.39%) bladder exstrophy, 2 (8.69%) genitourinary rabdomyosarcoma, 1 (4.34%) had spinal tumor and 1 (4.34%) an ano-rectal anomaly.

RESULTS

Perioperative complications were observed in four patients consisting of one febrile urinary tract infection, one partial operative wound dehiscence, one partial stomal dehiscence and one vesico-cutaneous fistula after a secondary exstrophy repair. The overall long-term complications rate was 40.90% and consisted of two stomal stenoses (9.09%), one neobladder mucosal extrusion (4.54%), three neobladder calculi (13.63%) and persistence of urinary incontinence in three patients (13.63%). The overall surgical revision was 36.36% and final continence rate was 95.45% with mean follow-up of 39.95 months

CONCLUSION

Continent urinary diversion is technically feasible even in small children, with acceptable rates of complications.

DOES THE LESS AGGRESSIVE MULTIMODAL APPROACH OF TREATING BLADDER-PROSTATE RHABDOMYOSARCOMA PRESERVE BLADDER FUNCTION?

PURPOSE

The treatment of bladder-prostate rhabdomyosarcoma has evolved into multimodal therapy, including chemotherapy, radiotherapy and organ sparing surgery with bladder preservation. We investigated bladder function in children who underwent multimodal therapy at our institution and retained the original bladder for at least 6 months after treatment ended.

MATERIALS AND METHODS

We evaluated 8 children with bladder-prostate rhabdomyosarcoma treated at our institution between 1999 and 2003 according to inclusion criteria. All patients underwent history, physical examination and urodynamic study at least 6 months after completion of treatment (range 6 to 39 months).

RESULTS

All patients were treated following the same chemotherapy and radiotherapy scheme. Three patients (37.5%) were asymptomatic and had normal urodynamic studies, and 1 had only dysuria (this patient later underwent continent urinary diversion with transverse colon). The 4 remaining patients had urological complaints, and the urodynamic findings were reduced bladder capacity in 4, overactivity plus sensory urgency in 2, sensory urgency only in 1 and suprapubic pain during filling in 1.

CONCLUSIONS

Among 8 patients 3 had normal urinary function and 4 had minor tolerable alterations. Cystectomy and urinary diversion were later necessary in only 1 patient due to disabling dysuria. The fact that the original functioning bladder was preserved in 7 of 8 patients suggests the feasibility of multimodal therapy. Long-term followup will still be necessary for definite conclusions, since we recognize that the deleterious effects, mainly of radiotherapy, may take longer to become evident.