A Simplified Kropp Procedure for Incontinence

Long-term outcomes of the Kropp and Salle urethral lengthening bladder neck reconstruction procedures

INTRODUCTION

The Kropp and Salle procedures have shown good short-term outcomes for managing neuropathic urinary incontinence. However, few studies have assessed their long-term results.

OBJECTIVE

This study aimed to evaluate the long-term outcomes of Kropp and Salle procedures, including: dryness, secondary interventions for incontinence or complications, upper urinary tract changes, and use of urethral catheterizations.

STUDY DESIGN

Consecutive patients undergoing Kropp and Salle procedures at the present institution (1983-2012) were retrospectively reviewed. Patients with <1-year follow-up or prior bladder neck (BN) continence procedures were excluded. Data were collected on postoperative dryness per urethra at 4-hourly and 3-hourly intervals, secondary interventions, lab tests, and imaging. Non-parametric tests were used for statistical analysis.

RESULTS

Thirty-eight patients had Kropp (K: 30 boys) and 12 had Salle procedures (S: 8 boys). Patients underwent surgery at similar median ages (K: 7.4 vs S: 8.7 years old, P = 0.51) and had similar median follow-up (6.9 vs 10.3 years, P = 0.10). Most patients had myelomeningocele, a prior/concomitant bladder augmentation (K: 73.7%, S: 58.3%) and catheterizable channel (K: 81.6%, S: 50.0%). Differences in all outcomes between Kropp and Salle procedures were statistically non-significant. The majority of patients did not have additional BN procedures for dryness (K: 84.2%, S: 66.7%). Of this group, K: 81.3% and S: 75.0% were dry for ≥4 h, K: 93.8% and S: 87.5% were dry for ≥3 h between catheterizations (Table). Of the minority of patients who underwent additional BN procedures for dryness (K: 15.8%, S: 33.3%), most achieved dryness for ≥4 h (K: 66.7%, S: 100%) and ≥3 h (100% for both). Among patients without an initial catheterizable channel, 57.1% had one subsequently created after a Kropp procedure, and 33.3% after a Salle. Among patients without bladder augmentation, approximately half underwent delayed augmentation (K: 50.0%, S: 40.0%). Ultimately, most patients required a secondary intervention under anesthesia for incontinence or complications (K: 79.0%, S: 66.7%). Few patients developed worsening hydronephrosis, vesicoureteral reflux or renal function (K: 2.6%, S: 0.0%). At the end of follow-up, few patients catheterized per urethra (K: 10.5%, S: 33.3%).

DISCUSSION

This was a retrospective study without urodynamic data. Originating from a tertiary center, the results may not apply to other clinical settings.

CONCLUSIONS

At the present institution the Kropp and Salle procedures attained similar dryness in 75-81% at 4-hourly intervals and 88-94% at 3-hourly intervals without additional BN procedures. Few patients required subsequent BN procedures to achieve dryness. However, the overall need for secondary procedures during long-term follow-up was high for both procedures.

Urologic care of the neurogenic bladder in children

Initial care of newborns with spina bifida centers on preventing bladder and upper tract damage from detrusor leak point pressure of greater than 40 cm H(2)O. The authors recommend using urodynamic-based management to select patients with elevated pressures for anticholinergic therapy and intermittent catheterization (CIC), using diapers and observation with biannual renal sonography for the remainder. At the age of toilet training, children who have urodynamic evidence of uninhibited contractions or rising pressure during filling are started on anticholinergics and CIC, or have their dosage increased until pressures less than 40 cm H(2)O and areflexia are achieved. Sphincter incompetency is diagnosed in incontinent children with pressures less than 40 cm H(2)O and areflexia or stress incontinence. Augmentation is indicated in patients with hydronephrosis or reflux and end-filling pressures or DLPP less than 40 cm H(2)O despite medical management to the point of patient tolerance. A minority of patients, not yet well-defined, will also need augmentation after bladder outlet surgery for similar postoperative indications.

Urologischer Erkrankungen bei Patienten mit Meningomyelozele

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

Pediatric Urinary Incontinence: Evaluation of Bladder Wall Wraparound Sling Procedure

PURPOSE

In 1996 a surgical procedure for sphincter deficiency was reported in patients with neurogenic urinary incontinence. To our knowledge we report the first series that assesses this procedure since it was initially described.

MATERIALS AND METHODS

Seven female and 7 male patients with spinal dysraphism and neurogenic intrinsic sphincter deficiency underwent surgery between 1997 and 2005. All patients had an associated poorly compliant or small capacity bladder. Patient age ranged from 8 to 22 years (mean 14) and all patients presented with persistent urinary incontinence despite intermittent catheterization and pharmacotherapy. Evaluation was based on clinical examination, as well as preoperative and postoperative urodynamic assessments. The surgical procedure involved wrapping a pedicle strip of anterior bladder wall around the bladder neck and fixing it on the pubic symphysis. Bladder augmentation cystoplasty was also routinely performed during the same procedure.

RESULTS

Of 14 patients 13 were completely dry and 1 had stress incontinence. Followup was 2 to 8 years (mean 5). Postoperative urodynamic evaluation showed a maximum urethral pressure increase of 40%. We also observed an increase in bladder capacity of 105% and improved bladder compliance (7 ml/cm H(2)O preoperatively vs 35 ml/cm H(2)O postoperatively).

CONCLUSIONS

The bladder wall wraparound sling procedure provides excellent results for continence in association with bladder augmentation.

Miniature Intravesical Urethral Lengthening Procedure for Treatment of Pediatric Neurogenic Urinary Incontinence

PURPOSE

Resistance to flow in a fluid conduit is proportional to tube length divided by the radius to the fourth power (Poiseuille's law). We report the results of a miniature intravesical urethral lengthening procedure where outlet resistance is increased by minimizing the diameter of the intravesical urethral tube.

MATERIALS AND METHODS

Nine pediatric patients with preoperative intractable incontinence underwent the miniature intravesical urethral lengthening procedure along with continent catheterizable stoma (9 patients) and bladder augmentation (8). The intravesical portion of the urethral lengthening was 3 cm (traditionally 6 cm), and the urethra was tubularized around an 8Fr feeding tube (traditionally a 16Fr catheter). After the tubularized caudal portion was tunneled under the trigone the cephalad part of the urethra was placed as an onlay to the posterior bladder wall without ureteral reimplantation.

RESULTS

At a mean followup of 31 months (range 10 to 47) 8 patients reported dry intervals of 3 hours or more, with minor leak per urethra only if they were overdue on the catheterization schedule. Mean postoperative abdominal leak point pressure was 71 cm H(2)O (range 28 to 116). Upper tracts were well preserved in all patients. One patient required bladder neck closure for intractable incontinence.

CONCLUSIONS

The miniature intravesical urethral lengthening procedure requires minimal bladder tissue and is easy to perform. It appears to be an effective alternative in bladder neck reconstructive techniques, avoiding the need for ureteral reimplantation due to its small size, while functioning as a pop-off valve when the bladder is overly full. This procedure should be avoided in patients who lack a trigonal bar.

The rectus myofascial wrap in the management of urethral sphincter incompetence

OBJECTIVE

To review our experience with a modified rectus/pyramidalis myofascial sling, described more than a century ago for treating refractory urinary incontinence in children with neurogenic sphincteric incompetence.

PATIENTS AND METHODS

Thirty-seven patients (23 females and 14 males, aged 8-21 years) presented with urinary incontinence which failed to respond to medical treatment. In 36 patients the cause of the incontinence was a neurogenic bladder; one patient had sustained a traumatic injury to the bladder neck and urethra. Patient selection was based on videocysto-urethrographic detection of an incompetent bladder neck, and a low maximum closure pressure during urethral pressure profilometry. The bladder was augmented in 33 of the 37 patients.

RESULTS

Of the 37 patients, 34 (92%) are dry between catheterizations; the follow-up was 0.5-10 years. Two of the male patients continued to have persistent incontinence requiring bladder neck closure and creation of a continent stoma. One of the female patients developed stress incontinence after 4 years of being dry, with a rectus sling.

CONCLUSION

The rectus myofascial sling provides long-term satisfactory dry intervals between catheterizations in patients with neurogenic sphincteric incompetence. The cinch-wrap modification appears to enhance the occlusive effect of the sling, particularly in males.

Surgical reconstruction of exstrophy-epispadias complex: analysis of 13 patients

BACKGROUND

Because exstrophy-epispadias complex is uncommon and satisfactory surgical reconstruction outcomes are difficult to achieve, the surgical repairs by one surgeon (PS) were analysed over a 14-year period.

METHODS

Retrospective analysis was performed on 13 patients with the complex who underwent surgery between January 1986 to August 2000. Cosmesis and continence were evaluated. Complications including wound dehiscence and urethrocutaneous fistula were reported.

RESULTS

Of six patients with classical exstrophy who underwent functional bladder closure, all had good cosmesis except one who had partial dehiscence. Four patients with isolated epispadias had satisfactory cosmesis. Urethrocutaneous fistula was found in one boy in the classical exstrophy group. Continence was achieved in three out of four patients who had bladder neck reconstruction. One girl whose bladder neck was severely obstructed after functional bladder closure, had continent catheterizable stoma.

CONCLUSION

Functional bladder closure yielded satisfactory cosmetic outcome. Bladder neck reconstruction made the patient dry in 75% of cases.

Vesical continence in bilateral ectopic single ureters

PURPOSE

We explore the possibility of gaining suitable vesical capacity and continence in bilateral single ureters without having to resort to urinary diversion or bladder neck reconstruction.

MATERIALS AND METHODS

In the last 10 years we treated 6 girls with bilateral ectopic ureters, and 2 with a single kidney and urethral ectopic ureter. Both ureters were ectopic in the urethra in 3 cases, and 1 ureter was inserted in the urethra and 1 in the bladder neck in the other 3. Preoperative examinations included ultrasonography, cystography, excretory urography and endoscopy in all cases, and magnetic resonance imaging in 2. Patient age at intervention ranged from 1 month to 8 years.

RESULTS

Cross-trigonal reimplantation of the ectopic ureters through a correctly positioned neomeatus was performed in 7 cases. In 2 patients it was impossible to reach the ureteral insertion from inside the bladder (1 ureter in 1 and both ureters in 1), and so the distal tract of these ureters was resected extravesically as close as possible to the urethra. One patient with a single kidney also had an anorectal malformation and a rectovaginal fistula. She had pelvic renal ectopia and the ureter was inserted beneath the urogenital diaphragm causing minimal bladder capacity. Therefore, a sigmoid neobladder with appendicostomy was constructed according to the Mitrofanoff principle. A Young-Dees bladder neck plasty was done in 2 patients at the same time as ureteral reimplantation and 3 years later in 1. Followup urodynamics revealed more than acceptable continence. Bladder capacity was insufficient in only 1 polyuric patient.

CONCLUSIONS

A bladder with bilateral ureteral ectopia is not necessarily useless, and the majority of patients can achieve normal bladder function and capacity along with normal transurethral voiding and satisfactory continence.

Bladder neck reconstruction in children

Bladder neck reconstruction in children is a challenging undertaking. Goals must be established for each patient, either continence or dryness. Knowledge of the various types of bladder neck reconstructive procedures and what they are designed to do is important when considering bladder neck reconstruction. A detailed description of urethral lengthening, reimplantation, and other bladder neck reconstructive procedures is presented.