Transversely tubularized ileal segments for the Mitrofanoff or Malone antegrade colonic enema procedures: the Monti principle

Ileal neoappendicostomy for antegrade colonic enema (ACE) in the treatment of fecal incontinence and chronic constipation: a systematic review

BACKGROUND

Antegrade colonic enema (ACE) via an appendicostomy is a recognised method of treatment for medically intractable fecal incontinence and/or constipation. In case of a missing appendix, ileal neoappendicostomy (INA) is considered a suitable alternative. The aim of this study was to review the postoperative complications, functional outcome, stoma-related complications and quality of life of patients treated with this method.

METHODS

A systematic literature search was performed in Embase, MEDLINE, PubMed (NCBI) and Cochrane Library from inception to September 2020 using the search terms "antegrade enema" OR "continence enema". Studies on children and adults with fecal incontinence, constipation or a combination of both, who underwent ileal neoappendicostomy for ACE due to the failure of medical treatment and/or anal irrigation were included in the studies, which reported one or more of the following primary outcomes: postoperative complications, functional results, and stoma-related complications.

RESULTS

A total of 780 studies were identified, 8 of which, comprising 6 studies in adults and 2 in children, were eligible for review. Overall, 139 patients were included. All studies were retrospective and the methods for reporting outcomes were highly heterogeneous. Improvements in incontinence and constipation were reported in all studies, together with an improved quality of life when reported (5 studies). Stomal stenosis and leakage rates were 0-29% and 14-60%, respectively. Postoperative complications were relatively common and included potentially life-threatening complications.

CONCLUSIONS

Taking into consideration that studies of INA were few and of poorly quality; ACE via an INA had a positive impact on bowel function and quality of life. Stoma-related complications and postoperative complications remain a concern.

[The paraplegic patient-Characteristics of diagnostics and treatment in visceral surgery]

BACKGROUND

Patients with paraplegia develop syndrome-specific complications relevant to visceral surgery, which occur in the context of the acute spinal shock or as a consequence of the progressive neurogenic bowel dysfunction (NBD) with the formation of an elongated colon and/or megacolon. Moreover, acute abdominal emergencies, such as acute appendicitis, cholecystitis, diverticulitis and ileus images, pose particular challenges for the clinician when the clinical signs are atypical or even absent. The expansion of indications for obesity surgery to include patients with a paraplegic syndrome, whose independence and quality of life can be impaired due to the restricted mobility, especially by obesity, is becoming increasingly more important.

OBJECTIVE

This article provides an overview of the special requirements and aspects in the treatment of this special patient collective and to show the evidence of paraplegia-specific visceral surgery treatment.

MATERIAL AND METHODS

Targeted literature search in Medline and Cochrane library (German and English, 1985-2020).

RESULTS AND CONCLUSION

The clinical treatment of paraplegic patients requires in-depth knowledge of the pathophysiological changes at the different height of the paraplegia (upper versus lower motor neuron) and the phase of the disease (spinal shock versus long-term course). Missing or atypical clinical symptoms of acute diseases delay a quick diagnosis and make early diagnosis essential. The evidence for surgical treatment of the acute and chronic consequences of NBD is based on small retrospective series and case reports, as is that for special indications such as obesity surgery.

Clinical practice guidelines from the French National Society of Coloproctology in treating chronic constipation

Chronic constipation is a common symptom that regularly affects the quality of life of adult patients. Its treatment is mainly based on dietary rules, laxative drugs, perineal rehabilitation and surgical treatment. The French National Society of Coloproctology offers clinical practice recommendations on the basis of the data in the current literature, including those on recently developed treatments. Most are noninvasive, and the main concepts include the following: stimulant laxatives are now considered safe drugs and can be more easily prescribed as a second-line treatment; biofeedback therapy remains the gold standard for the treatment of anorectal dyssynergia that is resistant to medical treatment; transanal irrigation is the second-line treatment of choice in patients with neurological diseases, but it may also be proposed for patients without neurological diseases; and although interferential therapy may be a new promising treatment, it needs further evaluation.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Transplantation of autologous minced bladder mucosa for a one-step reconstruction of a tissue engineered bladder conduit

Surgical intervention is sometimes needed to create a conduit from the abdominal wall to the bladder for self-catheterization. We developed a method for tissue engineering a conduit for bladder emptying without in vitro cell culturing as a one-step procedure. In a porcine animal model bladder, wall tissue was excised and the mucosa was minced to small particles. The particles were attached to a tube in a 1 : 3 expansion rate with fibrin glue and transplanted back by attaching the tube to the bladder and through the abdominal wall. Sham served as controls. After 4-5 weeks, conduits were assessed in respect to macroscopic and microscopic appearance in 6 pigs. Two pigs underwent radiology before termination. Gross examination revealed a patent conduit with an opening to the bladder. Histology and immunostaining showed a multilayered transitional uroepithelium in all cases. Up to 89% of the luminal surface area was neoepithelialized but with a loose attachment to the submucosa. No epithelium was found in control animals. CT imaging revealed a patent channel that could be used for filling and emptying the bladder. Animals that experienced surgical complications did not form conduits. Minced autologous bladder mucosa can be transplanted around a tubular mold to create a conduit to the urinary bladder without in vitro culturing.

Successful pregnancy and delivery following a Malone antegrade continence enema procedure

Malone antegrade continence enema (MACE) procedures are an effective treatment for both intractable faecal incontinence and constipation of neurogenic aetiology and have traditionally been used in a paediatric setting. MACE procedures are now being performed more commonly in adults suffering idiopathic chronic constipation where they are also effective. Increasing use in otherwise healthy adult females raises concerns about the durability of the appendiceal conduit should the patient become pregnant. We report the first case of successful pregnancy after a MACE procedure with an umbilical stoma and discuss the impact of the pregnancy on MACE function.

Bowel management for paediatric patients with faecal incontinence

This review assesses the incidence and aetiology of faecal incontinence in childhood. We then systematically address the presentation, clinical assessment, investigation and management of these children. Under management, both medical and surgical approaches and their complications are discussed.

Use of customized MIC-KEY gastrostomy button for management of MACE stomal complications

OBJECTIVES

Severe bowel dysfunction often accompanies neurogenic bladder, and Malone antegrade continence enema procedures can lead to improvement in the quality of life for these patients. The most commonly reported complication has been stomal stenosis of the conduit. We report our experience with the use of the MIC-KEY gastrostomy button for the management of this complication.

METHODS

A retrospective cohort study of 53 consecutive children who had undergone the Malone antegrade continence enema (ACE) procedure from 2000 to 2006 was performed. The records of patients with stomal complications were assessed for presentation, management, and outcomes.

RESULTS

We identified 20 patients (38%) with stomal stenosis. Stomal dilation and stenting alone was successful in 4 patients, and stomal revision was necessary in 16 (30%). Six children required placement of the MIC-KEY gastrostomy button into the ACE stoma for recurrent stomal stenosis (n = 5) or a buried stoma (n = 1). All patients were successfully treated with placement of a MIC-KEY button to continue their bowel irrigation. The size of the button was determined by the endoscopic assessment of the length and width of the ACE stoma and was custom made by the manufacturer. The average time that the button was in place was 26 months, and it was generally changed every 3 months.

CONCLUSIONS

In the rare subset of patients with recurrent stomal stenosis or a buried stoma, the MIC-KEY gastrostomy button was found to be a practical and easy method for the management of these conditions and to preserve the ACE conduit.

Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique

PURPOSE

Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation.

METHODS

Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles' operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H(2)-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap.

RESULTS

During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P<0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P<0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6-40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux.

CONCLUSIONS

Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy.

Laparoscopic antegrade continence enema using a two-port technique

BACKGROUND

The antegrade continence enema is an effective method of treatment of fecal incontinence. We report our experience of a laparoscopic antegrade continence enema procedure and describe a simple approach to this procedure using a two-port technique.

MATERIALS AND METHODS

Over a 3-year period, 12 children with intractable constipation and fecal soiling underwent the antegrade continence enema procedure laparoscopically. All cases had full bowel preparation the day before surgery. This procedure was done through one 5-mm camera port and two 5-mm working ports in 8 cases, and using the camera port and only one additional 5-mm working port in 4 cases. The appendix was used in 5 cases and the cecum in 3 cases with the threeport technique while the appendix was used in all 4 cases with the two-port technique. The appendix or cecum was delivered extracorporeally through the 5-mm port site in the right lower quadrant. The mucocutaneous anastomosis was stented using a gastrostomy button.

RESULTS

Between 2001 and 2004, 12 children (10 male, 2 female) underwent a laparoscopic antegrade continence enema procedure at a median age of 10.5 years (range, 7-14 years). This procedure was easy to perform and no case required conversion to an open procedure. The wash-outs via the MIC-KEY gastrostomy button (MIC-KEY, Kimberly-Clark) were commenced at a median of 3.5 days (range, 1-5 days). Median postoperative hospital stay was 2 days (range, 1-5 days). This procedure was effective in completely resolving fecal incontinence in 9 cases and partially resolving it in 3 cases. There were no episodes of stomal stenosis, leakage, or herniation. However, one case required a revision of antegrade continence enema due to wound breakdown and leakage of irrigation fluid around the stoma. The median follow-up period was 15.5 months (range, 5-32 months).

CONCLUSION

The laparoscopic technique is a simple and effective approach in creating an antegrade continence enema. The use of a gastrostomy button can potentially reduce some of the complications commonly associated with an antegrade continence enema. We describe a procedure that incorporates the advantages of both laparoscopy and a button device, which is simple and easy to perform using just two ports.

Malone antegrade colonic irrigation: ileal neoappendicostomy is the preferred procedure in adults

BACKGROUND

Antegrade colonic enema, via a caecal access [Malone antegrade continence enema (MACE)], is proposed to selected patients suffering from incontinence and/or constipation when other therapeutic modalities have failed.

METHODS

We compared complication rates after three MACE techniques: appendicostomy, caecal neoappendicostomy, and ileal neoappendicostomy in 28 adult patients having 31 MACE operations.

RESULTS

Stenoses and leakages occurred more frequently after appendicostomy and caecal flap than after ileal neoappendicostomy. This latter technique appears to reduce morbidity for adult patients.

A multicentre study of the management of disorders of defecation in patients with spina bifida

Patients with spinal dysraphism may have severe constipation and faecal incontinence. The impact of antegrade colonic enema (ACE) in the management of patients with spina bifida (SB) is analysed. In a multicentre cross-sectional study, constipation, faecal incontinence and faecal management were described. Cases surgically treated were identified. Data were collected from 423 patients, of whom 230 did not use any manoeuvre or laxatives to assist evacuation. Conventional treatment was used in 193 patients, including digital extraction in 39%, retrograde enema in 21% and oral laxatives in 52%. For intractable constipation and overflow of faecal incontinence, 47 patients were treated with ACE, of whom 41 used the method at a mean time of interview of 4.1 +/- 1.9 years after ACE operation; six abandoned ACE for conventional management. With ACE, faecal continence was significantly improved compared with conventional management, and neither retrograde rectal enema nor digital extraction were required. The conduit was fashioned to the right colon in 32 cases and to the left colon in nine cases. This study provides information on a multicentre experience in bowel management in SB patients. Whatever the technique used, ACE has improved faecal status compared with conventional therapy.

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

PURPOSE

Abdominoperineal resection, with iliac colostomy, remains the gold standard treatment for very low-lying rectal cancer, but it alters patients' quality of life. Alternatives to iliac colostomy need to be experimented. Antegrade enemas via a cecal access (Malone operation) obtains a colonic emptying and improves continence for incontinent patients. Continence and quality of life after abdominoperineal resection and perineal colostomy associated to a Malone antegrade continence enema were studied.

METHODS

After abdominoperineal resection for cancer, 18 patients had a digestive reconstruction by perineal colostomy and Malone antegrade continence enema. Patients performed antegrade enemas every 24 to 48 hours with tap water. After six months, continence (Cleveland Clinic score) and quality of life (Fecal Incontinence Quality of Life scale) were recorded.

RESULTS

Morbidity was 5 percent (1 appendix necrosis). All patients could perform antegrade enemas by themselves. Mean continence score was 6.41/20 (standard error, 2.31). Fecal Incontinence Quality of Life scores were: lifestyle 3.18/4 (standard error, 0.83); coping/ behavior 2.99/4 (standard error, 0.83); depression/self-perception 3.11/4 (standard error, 0.83); embarrassment 2.84/4 (standard error, 0.63).

CONCLUSIONS

After abdominoperineal resection, Malone antegrade continence enema associated to perineal colostomy provided an acceptable continence. It preserved patients' body image and resulted in a satisfying quality of life. It could become an alternative to iliac colostomy in selected patients.

COLONIC TUBES FOR THE ANTEGRADE CONTINENCE ENEMA: COMPARISON OF SURGICAL TECHNIQUE

PURPOSE

The Malone antegrade continence enema has revolutionized the management of intractable fecal incontinence and constipation. When the appendix is absent, surgical options are limited. Small series with short-term followup have demonstrated the feasibility but not the reliability of the continent colonic tube. We present our experience with a lateral based colonic tube. We also compared lateral based colonic tubes to medial based tubes.

MATERIALS AND METHODS

The medical records of patients treated with a continent colonic tube for intractable fecal incontinence were reviewed. We identified 8 patients who underwent the procedure between July 2000 and February 2003. The literature was reviewed to compare lateral vs medial based tubes.

RESULTS

Average followup was 28 months (range 10 to 41). Stomal stenosis developed in 4 patients (50%) within 3 to 6 months of surgery. Passive dilation at the clinic corrected the problem in 3 patients and 1 required operative stomal revision. All 8 patients reported almost complete relief of rectal incontinence and constipation. A literature review demonstrated a significantly higher rate of stomal stenosis in lateral vs medial based colonic tubes (40% vs 12%).

CONCLUSIONS

The continent colonic tube is a safe and effective alternative in patients with refractory fecal incontinence and constipation who do not have an available appendix. These results appear durable during the described period. We believe that this technique is an alternative to the cecostomy button and it should be offered to suitable patients. The lateral based colonic tube appears to have a higher rate of stomal stenosis than medial based colonic tubes, which may be attributed to the local blood supply of the colon.

Laparoscopic Assisted Reconstructive Surgery:: A 7-Year Experience

PURPOSE

Laparoscopic assisted surgery results in an improved cosmetic appearance by allowing complex reconstruction without a midline upper abdominal incision. We report technique and outcomes in patients undergoing laparoscopic assisted reconstruction during a 7-year period.

MATERIALS AND METHODS

A total of 31 consecutive patients with a mean age of 14 years (range 1 to 36) underwent laparoscopic assisted reconstructive surgery through a lower midline or Pfannenstiel incision by a single surgeon (SGD) between June 1995 and July 2002. Diagnoses included myelomeningocele (17), sacral agenesis (2), posterior urethral valves (2), classic bladder exstrophy (5), complicated ectopic ureter with ureterocele (1) and quadriplegia due to trauma (4). A total of 29 patients had 39 continent stomas (antegrade continence enema [ACE] or Mitrofanoff) created as part of the reconstruction. One case was converted to an open procedure due to dense adhesions and was excluded from the study. Continent stoma construction included Mitrofanoff stomas created from appendix (17), ileum (3), sigmoid (5) and bladder (1), and ACE stomas from appendix (12) and ileum (1). Ten patients underwent concurrent Mitrofanoff and ACE procedures. Laparoscopy was used for lysis of adhesions, mobilization of colon and/or harvesting the appendix, nephrectomy in preparation for ureteral augmentation, division of pedicle for gastrocystoplasty takedown and harvesting of omentum for interposition. Bladder augmentation (15), bladder neck reconstruction (7), fascial sling (3), ureteral reimplants (1), revision of epispadias (2) and/or redo orchiopexy (1) were concurrently performed in 19 patients. Data were obtained through chart review and personal communication.

RESULTS

Median hospital stay was 6 days (range 2 to 20). Mean followup was 32 months (range 3 to 57). Revisions were required in 3 stomas (7.7%) at a mean of 19 months (range 8 to 36) postoperatively. Minor procedures were required in 10 stomas (25.6%) consisting of indwelling catheterization, dilation, collagen injection and cystoscopy. Of the 39 stomas 37 (94.9%) were continent of urine and/or stool, and easily catheterizable at last followup. Adequate capacity and compliance were maintained in all augmented bladders. No patient experienced delayed small bowel obstruction or other sequela of abdominal adhesions.

CONCLUSIONS

At almost 3 years of mean followup laparoscopic assisted reconstructive surgery offers functional outcomes at least equivalent to conventional open surgery in complicated cases with excellent cosmesis. Laparoscopic assisted surgery remains our approach of choice for children and adults who require lower urinary tract reconstruction with a continent catheterizable stoma.

Hemi-T pouch modification for pediatric urinary diversion

PURPOSE

When the appendix is unavailable, there are limited reliable methods for continent urinary diversion. After successful application of double-T pouch urinary diversion in adults we modified the technique for bladder augmentation and continent diversion.

MATERIALS AND METHODS

A 10-year-old male underwent bladder augmentation and continent urinary diversion with a hemi-T augment. Modifications of the T pouch technique are described in detail. We also reviewed the literature on tapered ileal diversions, such as the Yang-Monti procedure.

RESULTS

One year after surgery the patient was continent. He was free of infection and bilateral hydronephrosis resolved. Urodynamics demonstrated a continent 350 ml reservoir without reflux.

CONCLUSIONS

For patients who require concomitant bladder augmentation and continent diversion a hemi-T augment is a suitable option when the appendix is unavailable. It is especially true when there is minimal bladder available for implantation of a Yang-Monti conduit.

Laparoscopic antegrade continence enema (Malone) procedure: description and illustration of technique

The antegrade continence enema (ACE Malone) procedure has improved the lives of many patients who struggle with intractable forms of constipation. We describe a laparoscopic approach to this technique and review the literature.

Continent vesicostomy in the absence of the appendix: three methods in 16 children

OBJECTIVES

To review our experience with three methods of continent vesicostomy and to examine the morbidity and long-term outcome of each method. In the absence of an appendix, the surgical options for constructing continent vesicostomies include the use of the ureter, retubularized ileum, or stomach, a Benchekroun valve, or creation of a continent stoma from the reservoir itself.

METHODS

Between 1984 and 1999, 16 children, 14 with neurogenic bladder, 1 with cloacal malformation, and 1 with valve bladder, required access to their continent reservoir other than the urethra. The appendix was unavailable in all, either because it had been removed surgically at an earlier date or it had been used for an antegrade continent enema procedure. Eighteen continent vesicostomies were performed in 16 children. In 5 children, a Benchekroun valve was constructed. Two were subsequently replaced by tapered small bowel. In 7 children, a segment of small bowel was harvested, retubularized, and reimplanted in the reservoir in a submucosal or seromuscular tunnel. In 6 children, a flap of bowel forming the reservoir was raised, tubularized, and then a Nissen valve was constructed.

RESULTS

The early results of the Benchekroun valve were satisfactory; however, the results with long-term follow-up were disappointing because 4 of 5 children developed stomal stenoses and one subsequent valve perforation. One of the 5 children continued to do well 6 years postoperatively. The 7 children in whom a segment of small bowel was retubularized (Monti procedure) continued to do well and to catheterize their stomas without difficulty. At last follow-up, 1 child was awaiting collagen implant of her bladder neck for urinary incontinence. Five of the 6 children with a Nissen valve were doing well 1 to 8 years postoperatively. One child did well initially, but was lost to follow-up 1 year later.

CONCLUSIONS

The appendix is the preferred conduit for a catheterizable stoma. In its absence, our experience with the Benchekroun valve was disappointing. The retubularized ileum provided an excellent and reliable alternative to the appendix and is preferable if the bladder capacity is marginal. The Nissen valve constructed out of the reservoir has the advantage of avoiding intraperitoneal dissection and the use of additional small bowel. The two latter methods appear to be reliable in the long-term and are viable options when the appendix is not available.

Surgical management of the neuropathic bladder

In a simplified view, the "normal" bladder, through a multifaceted neuromuscular event, allows the basic functions of urinary storage and emptying. More specifically, the urinary bladder accommodates increasing urinary volume with little to no increase in vesicular pressure while maintaining continence. The normal act of emptying integrates the relaxation of the urinary sphincters (external and internal) with the subsequent bladder contraction to void to completion when full. There are a multitude of conditions, both congenital and acquired, that can affect the bladder's ability to perform these functions in a smooth and coordinated fashion. The most common causes of pediatric bladder dysfunction necessitating surgical intervention are those associated with spina bifida/myelodysplasia, posterior urethral valves, and bladder exstrophy. Over the last 2 decades, the evolution of complex reconstruction for lower urinary tract dysfunction has resulted in an improved quality of life for children afflicted with upper urinary tract changes or incontinence despite maximum utilization of nonoperative therapies. Because each patient represents a unique therapeutic entity, an individualized approach to each child is recommended.

SYNCHRONOUS BLADDER RECONSTRUCTION AND ANTEGRADE CONTINENCE ENEMA

PURPOSE

We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients.

MATERIALS AND METHODS

We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver.

RESULTS

A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision.

CONCLUSIONS

It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

Synchronous bladder reconstruction and antegrade continence enema

PURPOSE

We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients.

MATERIALS AND METHODS

We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver.

RESULTS

A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision.

CONCLUSIONS

It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

What is new in urinary diversion

There have been some suggestions for changes in technique and investigations of the quality of life. As experience has grown, there have been increasing numbers of reports of complications. Careful attention to technique, especially in nerve-sparing cystectomy and orthotopic cystoplasty may reduce the rate of incontinence. Increasing awareness of quality of life issues should improve preoperative counselling of patients, especially those whose underlying condition is not life-threatening.

Bladder substitution

Preliminary data have shown that composite reservoirs consisting of gastric segments in combination with ileum or colon may reduce metabolic problems. Orthotopic neobladders are the most natural way to reconstruct the urinary bladder and are a safe option in selected male and female patients. Experimental and preliminary clinical data about new methods using autologous muscle transfer and tissue engineering are promising.