Functional outcome and specific complications of gastrocystoplasty for failed bladder exstrophy closure.

PURPOSE: The encouraging initial results of gastrocystoplasty led us to perform it for failed bladder exstrophy closure. We assess the functional outcome of the augmented bladder and evaluate complications related directly to use of the stomach in this specific group of children. MATERIALS AND METHODS: We performed gastrocystoplasty in 22 children an average of 9.5 years old with a small, poorly compliant bladder after staged reconstruction of bladder exstrophy failed. Followup ranged from 6 months to 6 years (mean 3 years). RESULTS: Complete urinary continence was achieved in 14 children (64%). Voiding via the urethra was possible in 13 patients (60%) but post-voiding residual urine was significant in 12. Bladder capacity increased from a mean of 77 to 270 ml. Bladder capacity decreased during followup in 3 children, requiring repeat augmentation. Six children had isolated dysuria and 2 had dysuria with hematuria. Perforation of the gastric patch and a bleeding gastric ulcer occurred in 1 patient each. CONCLUSIONS: The disadvantages of gastrocystoplasty outnumber its advantages after failed bladder exstrophy closure. Urethral sensation makes dysuria a major discomfort. Safety is not optimal, since perforation may occur. Voiding is not efficient because gastrocystoplasty provides continence only when it is associated with intermittent catheterization. Bladder capacity is insufficiently augmented and inconsistent during followup. We believe that the use of gastrocystoplasty in cases of failed bladder exstrophy closure should be reconsidered.

Transurethral puncture of ureterocele associated with single collecting system in neonates.

BACKGROUND/PURPOSE: It is believed by some investigators that transurethral puncture (TUP) of single-system intravesical ureterocele (SSU) is the treatment of choice in totally asymptomatic patients who receive this diagnosis in utero, but its success depends on the incision technique and type of the uroterocele incised. METHODS: Experience with 20 SSU in 17 asymptomatic newborns detected by prenatal ultrasound scan is reviewed. TUP of the SSU was performed as treatment of choice in 12 (60%) renal units (RU). RESULTS: Decompression of the ureterocele was achieved in 100% of cases, and a vesicoureteral reflux was created in three (25%) RU. Surgery was performed in only 30% of patients who underwent TUP of the ureterocele. Our experience confirms that short (2 to 3 mm) TUP achieves decompression of the affected renal unit and that this procedure can be performed in neonates as outpatient procedure. In addition, it is often the only procedure to perform. CONCLUSION: The authors believe that TUP should be considered the treatment of choice in the management of single-system ureteroceles.

Stomach versus sigmoid colon in children undergoing major reconstruction of the lower urinary tract.

A review of 50 patients who underwent intestinocystoplasty (ICP) or gastrocystoplasty (GCP) replacement at our department during an 8-year period is presented. The most common diagnoses were neurogenic bladder and bladder exstrophy. A total of 48 patients underwent augmentation cystoplasty and 2 had total bladder replacement. Mean follow-up time was 42 months. The clinical and metabolic aspects of the two types of ICP are reported. Hyperchloremic acidosis requiring therapy was not encountered, although mild degrees were seen after sigmoid augmentation in 36% of patients. A dysuria-hematuria syndrome (DHS) was seen in 50% of the patients who underwent GCP. Operative mortality rate was nil. Significant surgical complications occurred in 36% of the patients. The overall success rate for ICP and GCP in this series was 79.15%. ICP gives effective results when used to increase the compliance of the lower urinary tract, but problems related to electrolyte absorption, stones, and mucus production are often encountered. In GCP electrolyte absorption is practically eliminated, so that this technique can be used in patients with renal damage. In addition, patients with a normal bladder plate (bladder exstrophy) can achieve normal voiding with time. The authors believe that patients must be made aware of the possibility of DHS and that this syndrome needs further investigation.

A transvesical approach to mullerian duct remnants

Surgical extirpation is the treatment of choice for symptomatic mullerian duct remnants (prostatic utricle, PU), and several surgical approaches have been described for the treatment of this pathology. A group of 11 patients with symptomatic PU were observed and treated. Associated anomalies included proximal or penoscrotal hypospadias in all patients and cryptorchidism in 9 (81.8%). In all cases the PU needed surgical correction, as the patients had recurring symptomatology. Surgery was carried out transvesically in 10 (91%) cases and in 1 a perineal approach was used. There were no surgical complications, and at follow-up all patients showed complete resolution of the symptoms. We believe the transvesical approach, compared to other techniques, is more advantageous in the treatment of this pathology, as it permits excellent exposure, ease of surgery, good reconstruction, and good functional results with no sequelae.

A transvesical approach to müllerian duct remnants.

Surgical extirpation is the treatment of choice for symptomatic müllerian duct remnants (prostatic utricle, PU), and several surgical approaches have been described for the treatment of this pathology. A group of 11 patients with symptomatic PU were observed and treated. Associated anomalies included proximal or penoscrotal hypospadias in all patients and cryptorchidism in 9 (81.8%). In all cases the PU needed surgical correction, as the patients had recurring symptomatology. Surgery was carried out transvesically in 10 (91%) cases and in 1 a perineal approach was used. There were no surgical complications, and at follow-up all patients showed complete resolution of the symptoms. We believe the transvesical approach, compared to other techniques, is more advantageous in the treatment of this pathology, as it permits excellent exposure, ease of surgery, good reconstruction, and good functional results with no sequelae.

[Persistent urination disorders after treatment of posterior urethral valve: incidence and semiology]. / Les troubles mictionnels persistant après traitement d'une valve de l'urètre postérieur: incidence et sémiologie.

Micturition disorders were studied retrospectively in a series of 165 children over a period of 15 years. Among patients without lesions of the upper tract at the time of diagnosis (group A, n = 131), 18 (14%) had persistent nocturnal and diurnal enuresis: one urethral stenosis and six vesicoureteric reflux required surgery; three experienced persistent pollakiuria and enuresis. Among patients with upper urinary tract damage at the time of diagnosis (group B, n = 34), seven presented with recurrent urinary tract infection, five with nocturnal and diurnal enuresis and three with urolithiasis. In the long term, only 52% of them had normal renal function and two were successfully transplanted. Micturition disorders following treatment of posterior urethral valves are frequent and usually related to the so-called valve bladder syndrome. Iatrogenic complications and mortality rate have dramatically decreased during the recent years but long-term renal function impairment remains the most critical problem.

How prenatal ultrasound can change the treatment of ectopic ureterocele in neonates?

The authors present a series of 25 neonates with duplex ureterocele diagnosed in utero. Initial treatment was endoscopic incision (El) of the ureterocele in 18 cases (72%). Ureterocele was bilateral in one case. El achieved satisfactory decompression of ureterocele in 100% (1 bilateral). Reflux in the upper pole (UP) was created in 44.4%, and UP was preserved in 44.4%. Reconstruction of the lower urinary tract was accomplished in 15 (83.3%) patients who had had endoscopic treatment. No incontinence was observed. El of the ectopic ureterocele should be considered as a first choice approach in neonates. Prompt intervention allows successful decompression of ureterocele and can sometimes improve the function of the renal moiety involved.

Ectopic ureter with complete ureteric duplication: conservative surgical management.

To assess the outcome of conservative procedures, the authors reviewed their experience in the management of 31 ectopic ureters with complete ureteric duplication. Twenty-eight girls and three boys (aged 19 days to 10 years; mean, 30 months) were operated on between 1968 and 1994. Twenty-four of the children presented for evaluation of dribbling urinary incontinence and/or febrile urinary tract infections; seven presented after prenatal ultrasonographic diagnosis of hydronephrosis. The location of the ectopic orifice was identified in 25 children: bladder neck (6), posterior urethra (6), vagina (7), and vestibule (6). Upper pole nephroureterectomy was performed in 16 children who had nonfunctioning renal segments. Ureterovesical reimplantation was performed in 10 children who had functioning segments. In five borderline cases, temporary cutaneous ureterostomy was performed, followed by ureteropyelostomy (2), ureterovesical reimplantation (2), and upper pole nephrectomy (1). Histological examination of the polar nephrectomy specimens showed lesions of dysplasia in only four cases (24%). The follow-up period ranged from 6 months to 20 years (mean, 66 months). All children who presented with incontinence became continent after polar nephrectomy or conservative surgery. One child required surgical revision of the ureteropyelostomy anastomosis. Of the 12 children who had ureterovesical reimplantation, none needed further procedures. Ectopic ureters in duplex systems with functioning renal segments should be conserved.

Metabolic consequences of sigmoidocystoplasty in children.

Recent reports have shown that metabolic acidosis is a possible complication in patients who undergo augmentation enterocystoplasty. We studied 30 patients with neurogenic bladder who underwent sigmoidocystoplasty. Follow-up ranged from 1 to 10 years; all the patients showed normal renal function. We found significant hyperchloremic acidosis in 10% and borderline acidosis in 27% of the patients. Abnormalities of calcium and phosphorus balance were noted in 16.5% and 43% of the patients respectively, and more frequently in acidolic patients, which might be the result of activation of the bony buffers and might cause delayed growth in children. Close follow-up of all patients with enterocystoplasty is required, and oral bicarbonate is indicated when acidosis is detected.

The use of gastrocystoplasty in patients with bladder exstrophy.

The authors report the use of a stomach segment vascularized via the right gastroepiploic artery in order to increased bladder capacity in 18 patients with bladder exstrophy. The morphological and functional results were good in 15 patients (83.4%); 13 (72.2%) continue to use intermittent catheterization to empty the bladder, while 5 (27.7%) have spontaneous voiding. Seven patients are completely continent, 8 partially continent (<3 h), and 2 are still incontinent. We encountered no metabolic complications and no patient complained of mucus production. Ten patients had a dysuria-hematuria syndrome, 8 only slight and 2 marked. We believe that even though gastrocystoplasty is a valid alternative compared with other tissues used to date for bladder augmentation, attention should be paid to this new pathological sequela, which has proved to occur quite frequently, as seen from the long- and short-term follow-up of patients who have had this operation.

Vesicostomy in childhood: indications and results.

The authors report their experience with 27 patients who underwent cutaneous vesicostomy (CV) diversion for either lower tract disorders or obstruction. The indications for CV included 18 cases of neurogenic bladder, 3 pseudo-prune belly syndrome, 3 bladder exstrophy, 2 vesicoureteral reflux, and 1 posterior urethral valves. A Lapides-type technique with minor changes was performed in all cases. Improvement of renal function occurred after CV in all but 3 patients (11.1%). No early surgical complications were observed. Late complications occurred in 8 patients (29.6%): 4 (14.8%) had a stomal stenosis and 4 (14.8%) urinary tract infections. The overall revision rate was 7.4%. We believe this technique is simple to perform, tubeless, easy to manage, and readly reversible. Our experience tends to confirm CV to be an easy, effective, and reversible means to treat children and infants with selected pathology of the lower urinary tract. Results and complications are discussed.

Gastrocystoplasty in the treatment of bladder exstrophy.

A wedge-shaped segment of stomach based on the right gastroepiploic artery was used for bladder augmentation in 11 patients. Initial diagnosis in these 11 patients was bladder exstrophy. Indications for the use of stomach in bladder reconstruction were important bilateral upper tract deterioration in 10 patients, dederivation in 1. A continent appendicostomy (Mitrofanoff) has been performed in all patients. In post-operative follow-up (average 24 months), all patients have stable upper tract X-rays and stable or improved renal function. All patients require intermittent clean catheterization, 8 are totally continent, 2 are partially continent, 1 patient is still incontinent. No serious digestive problem was encountered. The increase in bladder capacity was 300 to 500% after 6 months. Mucus production is reduced relative to other intestinal segments and the patients require no bladder irrigation. The authors recommend the use of stomach for urinary tract reconstruction in compromised patients.

Posterior hypospadias: the French operation.

We describe a new technique for complete repair of severe posterior hypospadias in one stage. The operative technique includes some innovative points penile straightening is realized by urethral mobilization to excise the chordee, and then urethroplasty according to Duplay procedure and glanduloplasty are performed. We report our results in 34 patients. Preservation of urethral plate in hypospadias repair is a principle with significant implications to an extended variety of hypospadias.

[Kidney injuries in children]. / Traumi renali nell'infanzia.

Over the past 4 years 18 children were observed at the La Timone-Enfants Hospital in Marseille with renal lesions consequent to nonpenetrating abdominal traumas. Hematuria was reported in 14 cases (7 macroscopic and 7 microscopic) and all cases suffered from abdominal and/or lumbar pain. In relation to the diagnostic iter used: 18 echographies, 15 urographies, 13 TAC, 2 ascendant pyelographies, 2 scintigraphies with DMSA, 1 echo-Doppler and one angiography were performed. Renal lesions were classified as: 8 type 1, 5 type 2, 4 type 3, 1 type 4. Four cases were operated and one case underwent percutaneous drainage of an urohematoma. Following an analysis of these case and a revision of the literature, the authors emphasise that the evolution and progress in the diagnosis and treatment of this important aspect of traumatic pathology in children enables an almost complete recovery of kidney function in almost all cases.

[Urethral stenosis in children: treatment using urethroplasty with a vesical or oral mucosal graft]. / Sténoses urétrales chez l'enfant: traitement par urétroplastie avec greffon de muqueuse vésicale ou buccale.

Urethral strictures are rare in children and correspond to either congenital membranes, post-traumatic (endoscopy). The precise diagnosis is obtained by voiding cystometrography at the end of urography or by retrograde opacification. Congenital membranes should be treated by dilatation and limited strictures should be treated by urethrotomy. The other cases warrant urethroplasty with a free vesical or oral mucosal flap. Good results are obtained in about 90% of cases.

Urethral stricture in children: treatment by urethroplasty with bladder mucosa graft.

Urethral strictures in children, which are not frequent, often require urethroplasty when dilations and/ or urethrotomies have failed. A bladder mucosa graft was used successfully for urethral reconstruction to treat posterior hypospadias. We describe our experience with a bladder mucosa graft during urethroplasty for acquired urethral strictures in 8 children. Urethral strictures secondary to the treatment of hypospadias were excluded. Bladder mucosa was used successfully as an onlay or patch graft urethroplasty in 7 patients. One patient had a tubularized graft with secondary stenosis treated successfully by dilation.

Surgical management of duplex ureteroceles.

We reviewed the cases of 95 children with duplex ureteroceles treated in this department over an 18-year period. There were 101 ureteroceles (6 bilateral). Diagnosis and treatment were analyzed. Special attention was paid to newborns screened in utero. We always strove to preserve functional renal tissue whenever possible. In keeping with this goal, three surgical techniques were used: (1) upper pole heminephrectomy; (2) ureterocele excision, bladder neck reconstruction, and ureter reimplantation with or without cutaneous ureterostomy of the upper pole ureter; and (3) endoscopic ureterocele incision. Follow-up studies using x-ray and radionuclide imaging demonstrated satisfactory renal function in 86.6% of patients. These findings support a conservative approach to ureteroceles using endoscopic ureterocele incision as the primary treatment. Lower urinary tract reconstruction may be associated in cases involving urinary tract infection, obstruction or incontinence. Upper pole heminephrectomy should be performed only after functional evaluation following ureterocele incision or cutaneous ureterostomy.

A novel technique for reconstruction of the abdominal wall in the prune belly syndrome.

There is currently widespread enthusiasm for abdominal wall reconstruction in patients with the prune belly syndrome. We have devised an operation that appears to offer some advantages over those proposed by Ehrlich and Randolph. The technique preserves the umbilicus, and thickens and strengthens the anterior abdominal wall. By narrowing the waist, it also produces a better cosmetic appearance. After full thickness resection of a varying amount of skin from the central abdomen, the anterior wall is sutured in double-breasted fashion, thus, preserving all vascularization and the umbilicus. Since 1969 we have successfully performed this procedure on 9 prune belly patients including 1 girl. The results were excellent in terms of duration and cosmetic appearance.