The Monti procedure: applications and complications

Simultaneous placement of fecal and urinary continent channel stomas in the umbilicus: Single-center experience

INTRODUCTION

In patients with urinary continent channel (UCC) and Malone Antegrade Continent Enema (MACE) procedures, two separate abdominal stomas are needed. The umbilicus is a preferred site for single channel stomas given the ability to conceal the stoma. However, there are no studies describing outcomes of both stomas being created in the umbilicus. We aimed to describe our experience in patients who underwent UCC and MACE stomas both placed in the umbilicus.

METHODS

A retrospective review from 2009 to 2020 was performed in our institution for patients who underwent the creation of UCC and MACE stomas simultaneously in the umbilicus. The variation in the technique involves two V-skin shaped flaps in the umbilicus; the MACE and UCC stomas are delivered from both flaps and placed at the right and left side respectively. Patients with greater than 3 months of follow-up were included in the study.

RESULTS

There were 17 patients identified with the median age of 13.5 years and a median follow-up of 32.8 months. The mean BMI percentile was 89.5%. Monti technique and split appendix with cecal extension were utilized in 8 (47.1%) and 7 (41.2%) patients respectively and 13 (76.5%) patients required concurrent urological procedures. All channel-related complications occurred within a mean time of 15.7 months. Skin-level stenosis in the MACE occurred in 5 (29.4%) events, and all were successfully managed by placing an indwelling catheter for up to two weeks. There were 2 (11.8%) complications related to UCC, which required subfascial minor surgical revision. The rate of patients with symptomatic UTI decreased 35.3% postoperatively, and no new onset of UTI occurred in patients without a prior history of UTI. During follow-up, all patients remained dry between CIC, however one had occasional leakage related to delay in catheterization. Total fecal continence was achieved in 14 (82.3%) patients. Additionally, 3 (16.6%) patients experienced improvement in fecal continence with sporadic soiling episodes.

COMMENTS

Placement of UCC and MACE stomas in the umbilicus demonstrate a percentage of complication of 7/34 (20.6%) with only 2 patients requiring surgical intervention, comparable to the standard. UTI rate decreased in patients with a prior history of UTI. We believe the patients' perspective and degree of satisfaction will fully determine the benefits of this technique.

CONCLUSIONS

Simultaneous UCC and MACE stomas placed at the umbilicus showed good functional outcomes and similar complication rates to traditional approach where stomas were placed separately in the abdominal wall.

Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels

INTRODUCTION

Many patients with certain conditions require catheterizable channels for bladder and bowel management. There are a variety of accepted techniques for creating these channels; the split appendix technique enables the use of this organ for both procedures, obviating the need for more complex surgical procedures. Studies comparing outcomes across catheterizable channel types are limited.

OBJECTIVE

The aim of this study was to compare the urinary channel complication rates of the split appendix, intact appendix and transverse ileal tube (Monti) channels. We hypothesized that complication rates would be the same across all channel types.

STUDY DESIGN

We retrospectively reviewed consecutive patients who underwent surgical creation of a urinary continent catheterizable channel. We recorded demographics, underlying diagnosis, body mass index, stoma location, surgical techniques, and surgical revisions. The primary outcome was complication (stenosis, leakage, or both) with or without surgical revision, and to compare the three different catheterizable channel types using time to event analysis.

RESULTS

From January 2014-July 2018, 107 patients underwent creation of a continent catheterizable urinary channel; 86 (80.4%) patients also underwent simultaneous procedure for antegrade bowel management. The mean age was 7 years; 66 (60.8%) were females. Intact appendices were used in 46 (43.0%), Monti channel in 25 (23.4%), and split appendix technique in 36 (33.6%). The corresponding complication rates with or without surgical revision was 21.7%, 36.0%, and 47.2%, respectively. The only independent factor associated with increased risk of complication was the split appendix technique; these channels were more than twice as likely to require surgical revision with an adjusted hazard ratio of 2.32 (Table 4). The majority of revisions in all groups were skin level (58.3%). The most common indication for surgical revision was stenosis (55.6%).

DISCUSSION

This analysis shows a statistically significant increase in risk of all complications, including an increase in need for surgical revision, in patients who underwent split appendix technique for simultaneous bladder and bowel catheterizable channels. This finding should be balanced with the fact that a bowel anastomosis is not required in cases where individuals need both a bowel and bladder catheterizable channel. This study is unique in its separation of split and intact appendix channels, and inclusion of patients experiencing complications that have not yet required surgical revision. Limitations of this study include its retrospective design, inclusion of a single institution, and the lack of consistency in documenting baseline appendiceal length.

CONCLUSION

Split appendix catheterizable channels have a higher rate of channel complications than other techniques. The authors acknowledge that the split appendix technique has been proven feasible and effective, however recognize that it may not be appropriate for all patients and include counseling of the risks of its use.

Outcomes according to channel type for continent catheterizable channels in patients undergoing simultaneous urinary and fecal reconstruction

INTRODUCTION

When creating a continent catheterizable channel (CCC) the choice of bowel segment used as the conduit should be tempered with the morbidity associated with it. The split-appendix technique allows the creation of both a urinary and fecal CCC without the need for a bowel anastomosis. However, there is concern that by splitting the appendix there is compromise to its blood supply and may affect outcomes. We aim to compare what affect the bowel segment used for urinary and fecal CCCs has on perioperative and long-term outcomes in patients undergoing simultaneous urinary and fecal reconstruction.

METHODS

A retrospective review was performed analyzing all patients that underwent simultaneous continent catheterizable urinary and fecal CCC between the years 2010-2016. Patient demographics, channel characteristics, perioperative complications and clinical success rate were analyzed.

RESULTS

A total of 106 patients were identified that had simultaneous fecal and urinary CCC created at time of reconstruction. For urinary CCC, there were 64 patients (60.4%) that underwent a split-appendix technique, 27 patients (25.4%) underwent a Monti, and 15 patients (14.2%) had the appendix used only for the urinary channel. Those patients undergoing a split-appendix technique had median operative time of 447 min compared to 619 min when a Monti channel was created. The median length of hospital stay was 9 days for the split-appendix technique compared to 12 and 13 day median hospital stay when the appendix was used only for the urinary channel or a Monti was created, respectively. There was no difference seen in revision free survival of the channel following surgery of any of the channels with median follow-up of 44.5 months. However, there were more subfascial revisions of urinary CCC in those that underwent a Monti (5 patients, 18.5%) compared to other bowel segments (0 patients).

CONCLUSIONS

Utilizing a split-appendix approach for creation of urinary and fecal CCCs does not affect 30-day complications or long-term revision rates compared to other established techniques. This technique minimizes the potential surgical morbidity of a bowel anastomosis and provide shorter operative times, when feasible, at time of simultaneous creation of fecal and urinary CCC.

Application of the "Yang-Monti principle" in children with iatrogenic ureteral injuries

BACKGROUND

Iatrogenic ureteral injuries in children are rare, due to its retroperitoneal position. The Yang -Monti ileal substitution serves as a good surgical option in such injuries associated with long segment defects of the ureter.

OBJECTIVES

To review our experience using the Yang Monti principle of ileal ureter substitution in children with long segment ureteric defects and analyse its intermediate term outcomes.

STUDY DESIGN

This was a prospective study, conducted from 2014 to 2019. All children with iatrogenic ureteral injuries with delayed presentations, undergoing the Yang Monti principle of ileal ureter substitution, were included (as illustrated in summary image). These injuries were divided into upper, mid, and distal ureteral injuries and were diagnosed based on a standardized protocol. At follow up, findings of the CT urogram, functional isotope renogram, and renal functions were the key points monitored. The demographic, clinical profile, operative, post-operative complications and follow up data were collated and analyzed.

RESULTS

22 children were diagnosed with iatrogenic ureteral injuries. Of these, 14 children with delayed presentations underwent the Yang Monti principle of ileal ureter substitution. The primary pathology was gangrenous appendicitis (9 cases), calculus cholecystitis (3 cases) and torsion ovary (2 cases). Laparoscopic procedures were the commonest approach for the injury (10). The average age was 11.5 years, with a male predominance. The right ureter was affected in 12 cases. The average time to detection was 7 days. All children underwent an ultrasound guided nephrostomy tube insertion at presentation and the mid ureter (9) was most affected. The mean length of ureteric injury was 3.75 cm. Intra operatively, one ileal segment (2), two ileal segments (11) and three ileal segments (1) were used according to the length of the ureteric defect. Complications were urinary tract infections (2), adhesions (3) and leak (2) which were conservatively managed with no redo surgeries. The median follow up period was 4 years. At follow up CT urogram and isotope diuretic renogram were normal, with preserved renal functions and no metabolic complications in all.

DISCUSSION & CONCLUSION

In children associated with iatrogenic ureteral injuries of long lengths, the "Yang Monti ileal substitution" serves as a good and simple option with lesser complications permitting the preservation of the renal function at follow up.

Comparison of Yang-Monti ileal ureter-bladder anastomosis versus Yang-Monti ileal ureter-ureteral anastomosis for the treatment of ureteral stenosis: a randomized controlled trial in a miniature pig model

BACKGROUND

The aim of the present study was to establish an animal model of Yang-Monti ileal ureter-bladder anastomosis and Yang-Monti ileal ureter-ureteral anastomosis and compare the advantages and disadvantages of the two surgical methods.

METHODS

Fourteen 12-month-old male Chinese miniature pigs weighing 21 ± 1.38 kg were randomly divided into two groups. Group A (n = 7) underwent end-to-end anastomosis of the left Yang-Monti ileal ureter, left ileal ureter and left lower ureter; group B (n = 7) underwent anastomosis of the left Yang-Monti ileal ureter, left ileal ureter and bladder. In both groups, the contralateral kidney was removed at 1 week postoperatively. The incision length and operation time of the two groups were compared. Changes in serum creatinine and urea nitrogen were observed preoperatively, and at 2, 6 and 12 weeks postoperatively. Venous pyelography and cystography were performed at 12 weeks postoperatively to determine the ureteral patency and vesicoureteral reflux. At 12 months postoperatively, urinary culture was performed, and the diameter and histological changes of the intestinal ureter were assessed.

RESULTS

Surgery was successfully completed in all 14 pigs. In group A, one pig died due to an anesthetic accident, and one pig died from a lung infection on postoperative day 4. In group B, one pig died from adhesive intestinal obstruction on postoperative day 7. The overall survival rate was 78.6%, and the 11 surviving pigs had no urinary or intestinal fistulae. Compared with group B, group A had a significantly longer surgical incision (30.86 ± 2.41 cm versus 26.71 ± 3.64 cm; p = 0.01) and shorter operation time (181.29 ± 15.10 min versus 157.71 ± 20.49 min; p = 0.02). The serum creatinine and urea nitrogen concentrations did not significantly differ between groups. All pigs had normal renal function pre- and postoperatively. There was no stenosis or obstruction on venous pyelography. The narrowest diameter of the ureter was significantly smaller in group B (5.90 ± 0.30 mm) than in group A (7.26 ± 1.06 mm; p = 0.01), but no contrast agent returned to the upper urinary tract in either group. Escherichia coli was detected on urine culture. In group A, one pig had obstruction of the ureteral ureter, while another had stenosis of the lower ureteral anastomosis. In group B, one pig had pelvic and intestinal ureteral dilatation; however, all anastomoses were patent. The ileal ureteral diameter was significantly larger in group A (9.40 ± 2.35 mm) than group B (6.62 ± 0.37 mm; p = 0.02). Two pigs in group A had separation of the transitional epithelium and columnar epithelial mucosa, with granulation tissue hyperplasia. The pigs with stenosis and obstruction had smooth fibrous tissue and smooth muscle of the anastomosis. In both groups, the two types of epithelial tissue were close together, and the intestinal villi were mildly atrophied and shortened.

CONCLUSIONS

An animal model of Yang-Monti ileal ureter-bladder anastomosis was successfully established. Compared with Yang-Monti ileal ureter-ureteral anastomosis, Yang-Monti ileal ureter-bladder anastomosis is simpler, more reliable, and results in fewer complications.

No Appendix is Too Short-Simultaneous Mitrofanoff Catheterizable Vesicostomy and Malone Antegrade Continence Enema (MACE) for Children with Spina Bifida

OBJECTIVE

To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method.

MATERIALS AND METHODS

Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children-simple division of the appendix, 4 children-appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall.

RESULTS

Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix).

CONCLUSION

The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Advances in Pediatric Urinary Diversion

Pediatric urinary diversion is performed for a unique set of indications with many options to consider. Although surgical intervention has decreased in necessity overall due to advances in expectant management, it remains an important tool. There are many options and various factors to consider in choosing the right type of diversion for an individual and these patients require lifelong follow-up with a pediatric urologist and eventually an adult urologist. This article provides a detailed review of the most relevant techniques used by pediatric urologists for urinary diversion.

Cervicovaginal agenesis treated with modified Yang-Monti technique in two steps: Case report and literature review

INTRODUCTION

Müllerian duct anomalies are rare with less than 200 cases published in the literature. Recently, the implementation of the Yang-Monti principle for the creation of the neovagina has been used in 10 previous published cases. Here, we report the first case of cervicovaginal agenesis treated with the modified Yang-Monti technique in two steps in México.

PRESENTATION OF CASE

A 14-year-old female presented to the pediatric consult with a history of primary amenorrhea and a chronic-cyclic pelvic pain. She had normal external genitalia and secondary sexual characteristics, with a small vaginal pouch. Pelvic ultrasonography and magnetic resonance showed the absence of cervix and proximal vagina. The surgical approach was carried out in two steps. In the first, a neovagina was created with the modified Yang-Monti technique. On a second step one year after, the neovaginal dome was anastomosed with the uterus in a diamond shape, using Gore-tex^® in the cervicovaginal anastomosis, and a Foley catheter to prevent stenosis. After an 18-month follow-up, no complications have been observed. She has been taking Drospirenone and Ethinyl Estradiol with regular menstrual cycles.

DISCUSSION

The surgical treatment of cervicovaginal agenesis has evolved. The advantages of the modified Yang-Monti technique lie in the possible diminution of the tension on the vascular pedicle, and the gained length of the neovagina. To perform this procedure in two steps, likely diminishes the risk of neovaginal ischemia and leakage of the anastomosis.

CONCLUSION

The two-steps modified Yang-Monti technique represents a safe alternative for the management of cervicovaginal agenesis.

Recent Advances in Urinary Tract Reconstruction for Neuropathic Bladder in Children

Neuropathic bladder usually causes several limitations to patients’ quality of life, including urinary incontinence, recurrent urinary tract infections, and upper urinary tract damage. Its management has significantly changed over the last few years. The aim of our paper is to address some salient features of recent literature dealing with reconstructive procedures in pediatric and adolescent patients with lower urinary tract dysfunction.

Surgical approach to vesicourethral anastomotic stricture following radical prostatectomy

INTRODUCTION

Vesicourethral anastomotic stricture following prostatectomy is uncommon but represents a challenge for reconstructive surgery and has a significant impact on quality of life. The aim of this study was to relate our experience in managing vesicourethral anastomotic strictures and present the treatment algorithm used in our institution.

PATIENTS AND METHODS

We performed a descriptive, retrospective study in which we assessed the medical records of 45 patients with a diagnosis of vesicourethral anastomotic stricture following radical prostatectomy. The patients were treated in the same healthcare centre between January 2002 and March 2015. Six patients were excluded for meeting the exclusion criteria. The stricture was assessed using cystoscopy and urethrocystography. The patients with patent urethral lumens were initially treated with minimally invasive procedures. Open surgery was indicated for the presence of urethral lumen obliteration or when faced with failure of endoscopic treatment. Urinary continence following the prostatectomy was determinant in selecting the surgical approach (abdominal or perineal).

RESULTS

Thirty-nine patients treated for vesicourethral anastomotic stricture were recorded. The mean age was 64.4 years, and the mean follow-up was 40.3 months. Thirty-three patients were initially treated endoscopically. Seventy-five percent progressed free of restenosis following 1 to 4 procedures. Twelve patients underwent open surgery, 6 initially due to obliterative stricture and 6 after endoscopic failure. All patients progressed favourable after a mean follow-up of 29.7 months.

CONCLUSIONS

Endoscopic surgery is the initial treatment option for patients with vesicourethral anastomotic strictures with patent urethral lumens. Open reanastomosis is warranted when faced with recalcitrant or initially obliterative strictures and provides good results.

Analgesia-free flexible ureteroscopic treatment and laser lithotripsy for removal of a large urinary stone: a case report

INTRODUCTION

Urinary stone formation is a frequent complication after continent urinary tract diversion and can require complex surgical management. Therapy options include open, percutaneous, transurethral, or transstomal stone fragmentation and extraction. The transstomal approach is considered to be one of the more complex treatment modalities. The patient's individual anatomy, minor stoma diameter, and the existing continence mechanism in the majority of cases cause substantial technical challenges for the surgeon. We present here what we believe to be the first description of an analgesia-free flexible endoscopic removal of a large pouch stone in an out-patient care setting. Additionally, we provide a brief overview of competing techniques.

CASE PRESENTATION

A 30-year-old Caucasian woman with a history of lower urinary tract reconstruction with an ileal pouch and a continent umbilical stoma was admitted to our department with pouch urolithiasis in the urinary reservoir. We employed a minimally invasive approach to extract the stone using flexible ureteroscopy via a modified access sheath and laser lithotripsy. No analgesia is needed with this procedure and it can be performed in an out-patient setting.

CONCLUSION

The described clinical case highlights the difficulties of treating this high-incidence problem in patients with continent urinary diversions. Our presented technique is of particular interest to urologists and family doctors, and could improve the treatment of such patients by lowering the morbidity of the intervention.

Laparoscopic reconstruction of the extrahepatic bile duct using a jejunal tube: an innovative, more physiological and anatomical technique for biliodigestive derivation†

The incidence of bile duct injuries has increased as a consequence of the increasing number of cholecystectomies. However, the results of biliodigestive derivation currently used for bile duct reconstruction are unsatisfactory. We report here the case of a patient with iatrogenic Bismuth II bile duct injury and propose a new technique that permits more anatomical and physiological reconstruction of extensive bile duct injuries using transverse retubularization of a pedicled jejunal segment interposed between the bile duct and duodenum.

Creation of an appendicovesicostomy Mitrofanoff from a preexisting appendicocecostomy utilizing the spilt appendix technique

Continent catheterizable channels have revolutionized reconstructive surgery to achieve both urinary and fecal continence. The Mitrofanoff and Malone antegrade continent catheterizable channels offer improved quality of life relative to permanent incontinent stomas. A frequently employed surgical option for creating a Mitrofanoff when an existing appendicocecostomy exists involves harvesting a separate piece of intestine. If however the Malone has preceded the creation of a Mitrofanoff, we describe a surgical technique that may avoid the need for a bowel harvest and resultant anastomosis. We report our series of patients utilizing a novel alternative strategy in the select clinical circumstance of an existing appendicocecostomy to expand the armamentarium of the urologic reconstructive surgeon.

Colovaginoplasty using the Yang-Monti modification

OBJECTIVE

Bowel vaginoplasty is particularly difficult in patients who are extremely obese or those with an android pelvis. This report evaluates the use of the Yang-Monti principle as a viable alternative in the reconstruction of these patients.

METHODS

Upon retrospective chart review of patients who underwent bowel replacement vaginoplasty between 1980 and 2008, 4/60 were identified who underwent the Yang-Monti modification. The neovagina was created with an 8‒10-cm segment of descending colon which was detubularized and then retubularized using the Yang-Monti principle. This was sewn in place in the perineum. Outcome was evaluated by physical examination data and clinical information on postoperative sexual function.

RESULTS

Three of the four patients had an XY karyotype and an android pelvis, and of these two were failures of previous ileovaginoplasties and one was a failed colovaginoplasty. The fourth was a case of primary mullerian failure (XX) in a morbidly obese individual. All four were discharged without complication following surgery. With a median follow-up of 6 years (range 4-9), none showed evidence of introital stenosis or required dilation. Two were engaged in vaginal intercourse at last consultation, and they reported vaginal length was adequate. No further procedures were required in any of the patients at the end of the follow-up period.

CONCLUSION

The Yang-Monti modification, when used as an adjunct to colovaginoplasty, can be an effective reconstructive technique in this subset of patients. It allows for lengthening of the neovagina, without perpetuating tension on the vascular pedicle.

Comparative study between ligature with thread or metallic clamping by means of laparoscopy with the purpose of experimental biliary obstruction in swines

PURPOSE

To induce a total extra-hepatic obstructive jaundice in swines, by ligation of the common bile duct by laparoscopic surgery.

METHODS

Eight swines of the Landrace race, 36-day-old, originated from the same matrix, distributed in two groups. Group A: was used titanium metal clip to the common bile duct ligation in three animals; group B: were ligated with 2-0 cotton thread in five animals.

RESULTS

The ligation of the biliary ducts was performed successfully in all animals, with easy identification of the common bile duct by laparoscopy. There weren't difficulties in the procedures, mainly due to the increased surgical field provided by the excellent quality of light and image of the appliance. The clinical signs of jaundice were evident in the animals in seven days. In group A, two animals showed bile duct perforation near the clip, probably due to ischemic necrosis, progressing to peritonitis and death. In group B, five animals showed obstructive jaundice without any amendment.

CONCLUSION

Under the conditions of this study, we therefore recommend the use of unabsorbed wires to experimental biliary obstruction, in order to avoid complications, such as ischemia and necrosis, followed by perforation of the wall of the bile ducts.

Umbilical rotation: a new technique for the cutaneous fixation of continent catheterizable vesicostomies

PURPOSE

For cutaneous fixation of the continent catheterizable vesicostomy we present a new technique, in which the umbilicus is rotated caudally by 180° and the catheterizable channel is sutured to the umbilical cone. This procedure reduces the distance between the stoma entrance and the bladder.

MATERIALS AND METHODS

Between 2001 and 2008, 67 patients underwent construction of a continent catheterizable vesicostomy. In 82% (n = 55), this was an appendicovesicostomy according to the Mitrofanoff principle. For 21 of these patients, later in the series (2005 onwards), the procedure involved rotation of the umbilicus. We evaluated cosmetic outcome and channel-related complication rates and compared the results between the two groups, with and without umbilical rotation.

RESULTS

The overall complication rate was 22.4% (n = 15); stoma stenosis occurred in eight cases. In the majority of cases with complications, endoscopic treatment was sufficient. The complication rate was significantly lower in the group with umbilical rotation compared to the other group (14.3% vs 26.1%, P < 0.02).

CONCLUSIONS

Umbilical rotation always enables cutaneous implantation of the vesicostomy in the umbilical pit and is a safe and straightforward procedure.

Use of mitrofanoff and yang-monti techniques as ureteric substitution for severe schistosomal bilateral ureteric stricture: a case report and review of the literature

Distal ureteric stricture is a common complication of urinary schistosomiasis which is a disease more prevalent in the tropics and subtropics. The surgical management of this complication is more challenging when it affects more than half of both ureters. We report the case of a 17-year-old Nigerian with a long standing recurrent painless terminal hematuria associated with bilateral colicky loin pains. Ultrasound scan showed bilateral hydro ureters and hydro nephrosis with deranged biochemical renal function. The patient had bilateral tube nephrostomy and antibiotic therapy. Definitive bilateral ureteric substitution was done using Mitrofanoff technique for the right ureter and Yang-Montie technique for the left ureter. The patient′s renal function became normal and he was discharged home without complication. The related literatures were reviewed. Surgical nonurothelial ureteral substitution is necessary for long, extensive, severe bilateral ureteric strictures so as to prevent progressive renal damage and end stage renal failure.

Split-appendix technique for simultaneous appendicovesicostomy and appendicocecostomy

PURPOSE

Surgical treatment of urinary and fecal incontinence with appendicocecostomy (AC) and appendicovesicostomy (AV) has high success in achieving continence. Usually, the appendix can only be used for one of these, requiring the second channel to be constructed from alternative tissue. We describe our outcomes using the split-appendix technique for simultaneous creation of AC and AV.

METHODS

We reviewed records for all patients that underwent simultaneous AC and AV from the appendix alone from 1999 to 2009. When anatomy permitted, the appendix was divided into 2. The proximal end was kept in continuity with the cecum for an AC, whereas the distal end was used for AV. The appendiceal length, continence status, and subsequent need for surgical revision were recorded.

RESULTS

Of 394 children who underwent reconstructive surgery with a Mitrofanoff channel, 43 patients (11%) used the split-appendix technique. After a mean follow-up of 40 months, 43 of 43 ACs and 41 of 43 AVs are continent. Of the 86, 16 (19%) channels created required surgical revision.

CONCLUSIONS

The channels created from split-appendix technique have outcomes and revision rates comparable with those of other described techniques. This technique is applicable to a minority of children undergoing continent reconstruction; however, it has the benefit of avoiding a bowel resection and its accompanying risks.

Testicular histology after intestinal pedicle flap (cecum) apposition in rats

PURPOSE

Histological study of vascularization between a cecal pedicle flap and the testicle of Wistar rats.

METHODS

Fifty-three rats were studied. G1: submitted to celiotomy (a), mobilization of the right testicle (RT) to the abdomen (b), cecal flap suture to the RT (d) and cavity closure. G1: procedures a, b and d and fixation of RT into abdomen. G3: procedures a, b and d, exposition of RT to air and reposition into scrotum. G4: not operated. Euthanasia and histology was done after 20 days. Histometry and lesions score classification was done. Testicular vascularization was studied with comparison between G1 and G3. A p < .05 was considered significant.

RESULTS

The G1 RT diameters were not different to G2 RT and all have decreased size in comparison with RT of G3 and G4. The lesions score in the RT was 5.83 in G1 and 3.3 in G2 without statistical difference. The vascularization's average in G1 was 16.9 vessels in 400X field in the RT. In the G3 this average was 0.96 to the RT and 0.92 to left testicles. The weight's average in G1 was similar with G2 but different of G3 and G4.

CONCLUSION

A significant increase of vascularization was observed between the intestinal flap and the rat testicle.

Bowel management for the treatment of pediatric fecal incontinence

Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process.

Treatment of fecal incontinence with a comprehensive bowel management program

PURPOSE

Many articles describe the antegrade continence enemas (ACEs), but few refer to a bowel management program. A successful ACE may not help a patient without such management. Valuable lessons were learned by implementation of bowel management in 495 fecally incontinent patients.

METHODS

We previously reported 201 patients. Thereafter, another 294 patients participated in our program. On the basis of a contrast enema and symptoms, they were divided as follows: (a) 220 constipated patients and (b) 74 patients with tendency toward diarrhea. Colonic stool was monitored with abdominal radiographs, modifying the management according to the patient's response and radiologic findings. For constipated patients, the emphasis was on using large enemas. For patients with tendency toward diarrhea, we used small enemas, a constipating diet, loperamide, and pectin. Diagnoses included anorectal malformation (223), Hirschsprung's (36), spina bifida (12), and miscellaneous (23).

RESULTS

The management was successful in 279 patients (95%)-higher in constipated patients (98%) and less successful in patients with tendency toward diarrhea (84%).

CONCLUSIONS

The key to a successful bowel management program rests in tailoring the type of enema, medication, and diet to the specific type of colon. The best way to determine the effect of an enema is with an abdominal film. The ACE procedures should be recommended only after successful bowel management.

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.

Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature

PURPOSE: Interposition of a jejunal tube between the common bile duct and duodenum. METHODS: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. RESULTS: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. CONCLUSION: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.

The challenge of pediatric continent urinary diversion

OBJECTIVE

Continent urinary diversion (CUD) may be required for refractory incontinence in children with various malformations. We review our experience with CUD to identify determinants of success and ongoing challenges.

METHODS

Retrospective chart review of 43 consecutive patients undergoing CUD since 1991 at British Columbia Children's Hospital.

RESULTS

Our preferred surgery was intestinal cystoplasty and either appendicovesicostomy (77%) or ileal-vesicostomy. Concomitant bladder neck surgery was performed in 67%. Mean follow-up was 2.5 years. There was a 16% revision rate for persistent leakage, the most common being cystoscopic injection of bulking agents. Continence was ultimately achieved in 88%. Early major and minor postoperative complications each occurred in 21% of cases. Delayed minor complications requiring surgical intervention occurred in 30% including stomal stenosis in 6 patients and stomal prolapse in 2. Urolithiasis required intervention in 5 patients.

CONCLUSIONS

Pediatric CUD is a challenging endeavor. Most patients achieve continence although many require additional minor procedures to do so. Early major and minor complications are common. A significant minority of patients require reoperation for delayed minor complications. Patients and families should be informed of these frustrations as part of their preoperative counseling. A high degree of family motivation and commitment is essential.

Transverse Retubularized Ileal Vaginoplasty: A New Application of the Monti Principle—Preliminary Report

OBJECTIVE

The surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge. Herein we present our successful experience with vaginal reconstruction by the use of a modified ileal segment according to the Monti principle.

METHODS

Six patients aged from 23 to 41 years (mean 33 years) were referred to our institution for vaginal stenosis. In our series, ileum has been used to create the neovagina: the isolated segment has been longitudinally detubularized and transversally retubularized in order to configure the roof of the neovagina.

RESULTS

The mean operating time was 220 min. No intra-operative complication occurred. The mean follow-up of this series was 16 months. At the latest follow-up, all patients had patent moist neovaginas, but excessive vaginal mucous was not a problem in any patient in our series.

CONCLUSIONS

Neovaginal creation using isolated ileal segments according to the Monti channel principle provide excellent tissue for vaginal replacement, providing excellent patient satisfaction and relatively low morbidity. Cosmetic, functional and anatomical results were encouraging. In our opinion our technique may be indicated for all cases of vaginal absence: congenital abnormalities in the pediatric population, vaginal stenosis after treatment of pelvic tumors, severe vaginal scarring secondary to chronic inflammatory disease or in case of secondary correction after failure gender surgery.

Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals

OBJECTIVES

To describe 3 cases of successful laparoscopically assisted vaginal reconstruction using an ileal segment in patients with complete neovaginal stenosis.

METHODS

We evaluated 5 male-to-female transsexual patients who required laparoscopic-assisted vaginal replacement for complete neovaginal stenosis after sex reassignment surgery. We performed complete laparoscopic vaginal isolation and mobilization, external configuration of the vagina, and laparoscopic-assisted vaginal anastomosis.

RESULTS

No intraoperative complications occurred, and laparotomy conversion was not necessary. The mean length of the neovagina at the first postoperative visit was 13 cm. At a mean follow-up of 14 months, all patients were sexually active and completely satisfied with the operation.

CONCLUSIONS

Our results have confirmed the feasibility of laparoscopic perineal neovagina construction by ileal colpoplasty. The cosmetic, functional, and anatomic results were encouraging. Isolated ileal segments provided excellent tissue for vaginal replacement, resulting in excellent patient satisfaction and relatively low morbidity. Furthermore, we report a modified surgical approach to conventional ileal vaginoplasty according to the Monti channel principle.

The Use of Transversely Tubularized Bowel Segment for Segmental Ureteral Replacement

The aim of the present study was to evaluate the results of the use of a new technique, i.e. transversely tubularized bowel segment (TTBS) for segmental ureteral replacement in pigs. Eight pigs had segmental left ureteral replacement with the TTBS technique, via midline incision in 5 and flank incision in 3. The right ureters were left untouched and used as controls. The pigs were evaluated by excretory urography approximately 3 months after surgery and then sacrificed thereafter, harvesting the kidneys, ureters, and the bladders en bloc for macroscopic and histologic examination. Three pigs died in the early postoperative period. The remaining 5 pigs were followed for 82-112 days. Postoperative intravenous urograms revealed moderate ureterohydronephrosis in 2, mild ureteral dilation in 1, and normal upper tracts in 2. The 2 pigs with moderate ureterohydronephrosis had had midline incisions, and examination after having sacrificed these pigs revealed many intestinal adhesions to the anastomotic region. Easy catheterization of each left ureter through ileal ureteral segment and histologic examination thereafter demonstrated that all ileal ureteral segments including anastomotic sites were patent. Adjacent to the junctional area, metaplastic transitional epithelium covered atrophic villi and in some regions crypts as well. Ureteral replacement by the TTBS technique seems to be a safe and effective surgical treatment option in segmental ureteral defects in short term. However, long-term follow-up studies are needed.

Laparoscopic ileocytoplasty and continent ileovesicostomy in a porcine model

BACKGROUND AND PURPOSE

Bladder augmentation with autologous bowel is commonly accompanied by a continent ileovesicostomy (the Monti procedure). Herein, we describe our initial experience with laparoscopy-assisted ileocystoplasty and continent ileovesicostomy in a porcine model.

MATERIALS AND METHODS

Thirteen Yucatan minipigs with an average weight 49 lb underwent a laparoscopy-assisted ileocystoplasty and ileovesicostomy (Monti procedure) using a four-port technique. After catheter removal at 3 weeks, the animals underwent twice-daily catheterization of the ileovesicostomy until complete occlusion of the ileovesicostomy occurred.

RESULTS

All animals survived the initial surgery, with 10 animals being available for catheterization at 3 weeks. The average Monti anastomotic time, average ileal patch-bladder anastomotic time, and average total surgery times were 47 minutes, 89 minutes, and 307 minutes, respectively. Eight of ten animals developed stomal stenosis after catheter removal (average time to complete occlusion of 6 days; range 1-13 days), with two animals also demonstrating partial obstruction at the Monti-bladder anastomosis and four partial obstruction at the fascial level of the Monti tube. Pathologic review of select bladder augmentation and Monti tube specimens revealed moderate to severe acute and chronic inflammation with severe scarring at the Monti-skin stoma site in the majority of specimens.

CONCLUSIONS

We have demonstrated the feasibility of laparoscopic ileocystoplasty and continent ileovesicostomy in a porcine model. The development of stomal stenosis may be related to the intrinsic properties of the pig skin, but additional investigation is required prior to human studies of this novel surgical technique.

Bridging long ureteral defects using the Yang-Monti principle

PURPOSE

A new technique for replacing the ureter based on the Yang-Monti principle is introduced to overcome the drawbacks of the classic ileal ureter.

MATERIALS AND METHODS

Between March 2001 and June 2002 ureteral replacement by ileum was indicated in 10 patients, including 9 with long or multiple strictures due to bilharzial (6), tuberculosis (3) and a low grade lower ureteral tumor (1). The technique involved isolation of a 5 to 7.5 cm. ileal segment, which was further subdivided into 2 or 3 equal parts. Paramesenteric incision along the longitudinal axis of these segments followed by unfolding resulted in a 12 to 18 cm. ileal strip. Tubularization of this strip led to the formation of an ileal tube with a suitable caliber. The latter was implanted into the bladder by submucosal (nonrefluxing) ileovesicostomy.

RESULTS

Mean followup +/- SD was 9.6 +/- 2.4 months (range 6 to 13). Mean serum creatinine remained stable in all patients. Split kidney function (mercaptoacetyltriglycine clearance) was stable in 7 cases and improved in 3. Antegrade urography revealed dynamic unidirectional nonobstructed flow. Reflux was noted in only 1 case. Excretory urography and/or magnetic resonance urography showed excellent configuration of the substitute without evidence of dilatation or obstruction.

CONCLUSIONS

The new technique offers certain distinct advantages. A short bowel segment is included with the consequent absence of metabolic complications. It allows construction of an ileal ureter with a suitable cross-sectional diameter without the need for tailoring and makes possible the use of an antireflux technique.

[Appendix-ureteroplasty in a child: report of a case]

The use of vermiform appendix as a tube to replace right ureteral segment has been reported, rarely in child. Herein is reported a case of right ischemic ureteral stenosis following a reimplantation of the ureter for high grade reflux secondary to posterior urethral valves with only one functioning kidney. A long ureteral defect was bridged successfully by appendix interposition and then reimplanted in the bladder at four years of age. The interest of ureteroappendiculoplasty provides temporary solution to repair long ureteral defect, in spite of uncertain future, especially in childhood.

Tube sigmoidostomy: a modification of the antegrade colonic evacuation

BACKGROUND

The Malone appendicostomy enema has established its place in the treatment of paediatric faecal incontinence. More recently, the laparoscopic appendicostomy enema has gained favour. In the situation where the appendix has already been removed, caecal stomal tubes can be constructed to facilitate antegrade colonic wash-outs. These techniques may not provide an accept-able result if there is a significant time delay from the introduction of the enema to the result. Wash-outs through the more distal colon -- either by retrograde techniques with a rectal tube or, more recently, through a plastic stomal device inserted percutaneously into the sigmoid colon (the Chait tube) -- can result in rapid evacuation. Rectal wash-outs may not provide an adequate lavage and can be technically difficult for some children to perform, while many other children find external devices cosmetically unacceptable. We present a modification of this distal colonic technique that can allow greater control, can be used in the absence of an appendix and avoids the need for an external device.

METHODS

Two paediatric patients with spina bifida and faecal incontinence underwent tube sigmoidostomy formation. In both patients, the appendix was not available to be used for colonic wash-outs.

RESULTS

Both patients reported excellent success with this procedure. They are continent, able to cannulate the stoma and irrigate independently.

CONCLUSIONS

The technique can provide excellent continence control in patients who are not successful with a right-sided Malone appendicostomy. It also overcomes the need for a catheterizable appendix, and an external device.

Dysfunction of the lower urinary and distal gastrointestinal tracts in pediatric patients with known spinal cord problems

Destruction of the urinary tract in children with elimination, storage, and holding dysfunction of the lower urinary and the distal GI tracts is caused primarily by high intravesical pressure. UTI accelerates this process. The LPP and the status of the urethral control mechanism and its relationship to the detrusor are the primary determinants of intravesical pressure. Intravesical pressures of more than 40 cm H2O are dangerous because they cause a pressure gradient that is transmitted proximally to the renal papillae, which results in the cessation of renal blood flow and a loss of renal function over time. Hydroureteronephrosis, VUR, UTI, urinary incontinence, and calculi formation also may occur. If these dangerously high intravesical pressures remain untreated, renal failure is likely to occur over time. These children then require dialysis or renal transplantation to survive, which is tragic and represents an enormous economic cost to society. Renal failure and upper urinary tract damage is nearly 100% preventable with early and appropriate evaluation and treatment. CIC is a crucial part of the management of these children and has been shown to be safe and effective, even in newborn boys. The use of the Credé maneuver (i.e., manual compression) to empty the bladder is obsolete and should be abandoned. The distal GI tract is inseparable from the lower urinary tract and must be treated simultaneously. Failure to treat the distal GI tract yields poor clinical results and much patient dissatisfaction and makes it difficult or impossible to treat the child's urinary tract problem successfully. Bowel-management programs must include daily high water and fiber intake, together with digital perianal stimulation or fecal extraction. Neuropathic bladder and bowel problems that are intractable to conservative medical and mechanical (i.e., CIC and digital perianal stimulation or fecal extraction, respectively) management almost always can be corrected surgically with high success rates in cooperative patients. Finally, neuropathic bladder and bowel problems can be extremely isolating and debilitating problems. Psychologic counseling and emotional support must be provided as needed. The care that these patients receive must be organized, comprehensive, and correlated with these patients' lifestyles. If these children are evaluated and treated early, they have the potential to live long, healthy, and productive lives.

Simultaneous Malone antegrade continent enema and Mitrofanoff principle using the divided appendix: report of a new technique for prevention of stoma complications

PURPOSE

We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level.

MATERIALS AND METHODS

Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique).

RESULTS

All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1.

CONCLUSIONS

The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.

Simultaneous Malone antegrade continent enema and Mitrofanoff principle using the divided appendix: report of a new technique for prevention of stoma complications

PURPOSE

We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level.

MATERIALS AND METHODS

Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique).

RESULTS

All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1.

CONCLUSIONS

The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.