RESUMO
INTRODUCTION: Patients with anorectal malformations (ARMs) have a high incidence of genitourinary anomalies. Those with a recto-bladder neck fistula may represent a high-risk group, but their long-term urologic outcomes are poorly described. OBJECTIVE: To evaluate the clinical and urodynamic outcomes in a large cohort of patients with an ARM subtype of recto-bladder neck fistula. MATERIALS AND METHODS: A retrospective cohort study was performed of patients who had been treated for a recto-bladder neck fistula at the present institution since 2007. The primary outcomes were the ability to achieve urinary continence after 4 years of age, and development of a mildly decreased glomerular filtration rate (GFR) or worse (<89 ml/min/1.73 m2). Continence was defined as the ability to store urine for 3-4 h during the day and 8 h overnight without leakage. RESULTS: Demographic and clinical data are provided in the Summary Table. The most recent urodynamic findings included the presence of detrusor overactivity in 30 (75%) patients, median leak point pressure of 56.0 cmH2O (range, 14-140), median functional cystometric capacity at 40 cmH2O of 125.5% age-expected capacity (range, 36-473%), and median maximum cystometric capacity of 131.0% age-expected capacity (range, 44-473%). A mildly decreased GFR or worse developed in 13 (24%) patients. Of the 52 (78%) patients who were followed by pediatric urology at the present institution with a median follow-up of 30.9 months (range, 0.0-86.8), 35 (67%) were at least 4 years of age and could be assessed for continence. Continence was achieved in five (14%) patients voiding spontaneously and 15 (43%) performing CIC. Recurrent urinary tract infections (UTI) (OR 0.70, P = 0.006) were an independent predictor of incontinence, while urethral anomalies (OR 1.40, P = 0.03) were an independent predictor of chronic kidney disease (CKD) on multiple logistic regression analysis. DISCUSSION: The findings favorably compared with other studies, but were more robust due to the size of the cohort and breadth of urologic evaluation. Limitations included the retrospective design at a single institution. Incomplete clinical data and misclassification of continence may have lead to bias. CONCLUSIONS: This large cohort of patients with an ARM subtype of recto-bladder neck fistula had a high incidence of genitourinary anomalies. They were rarely able to achieve continence with spontaneous voiding alone and were at risk of developing CKD, both of which were likely multifocal in origin. Long-term urologic follow-up is warranted for patients with a recto-bladder neck fistula.
Assuntos
Malformações Anorretais/fisiopatologia , Malformações Anorretais/cirurgia , Fístula Retal/fisiopatologia , Fístula Retal/cirurgia , Fístula da Bexiga Urinária/fisiopatologia , Fístula da Bexiga Urinária/cirurgia , Malformações Anorretais/complicações , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Fístula Retal/complicações , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Fístula da Bexiga Urinária/complicações , Incontinência Urinária/etiologia , Incontinência Urinária/prevenção & controle , UrodinâmicaRESUMO
BACKGROUND: Rectobladder neck fistula is the highest and most complex anorectal malformation in boys and the only one that requires an abdominal approach, open or laparoscopic, for repair. The aim of this study was to describe the unique characteristics of rectobladder neck fistulas that warrant special attention and to describe the associated anatomic variants in the genitourinary tract. METHODS: The database of a tertiary medical center was retrospectively reviewed for all patients treated for rectobladder neck fistula, by our team in 1980-2011. Data on surgical history, associated and functional defects, treatment and outcome were collected by chart review. RESULTS: The study group included 111 patients. The most common anatomic urologic defect was a single kidney in 37 patients (33.3%) and the most common functional urologic defect was vesicoureteral reflux in 40 patients (36%), including 11/37 patients with a single kidney (29.7%). Of the 40 patients who underwent cystoscopy, 16 (40%) had a higher than normal location of the verumontanum. Follow-up ranged from 2 to 290months (median 59). Urinary continence was achieved in 40 of the 61 patients (65.5%) for whom data were available, and fecal continence was achieved in 9 of the 69 patients (13%) for whom data were available. A sacral ratio of 0.4 or less was associated with lower rates of urinary control (23%) and fecal control (0%), relative to higher ratios. Twenty stomas (18%) were found to be located too distally, limiting the availability of the bowel for a pull through. CONCLUSIONS: Rectobladder neck fistula carries a poor prognosis for bowel control and is associated with a high rate of urinary malformations that require long-term care. Pediatric surgeons need to be aware of these complications in order to provide proper treatment and parental counseling. Intra-vesical verumontanum is found in a surprisingly high percentage of patients. The combination of a single kidney with vesicoureteral reflux is common and should be closely followed to avoid renal deterioration. Special attention should be given to colostomy construction to avoid complications and unnecessary procedures. A sacral ratio of 0.4 or less is an indicator of poor fecal and urinary control.
Assuntos
Malformações Anorretais/diagnóstico , Fístula Retal/congênito , Fístula da Bexiga Urinária/congênito , Malformações Anorretais/patologia , Malformações Anorretais/fisiopatologia , Malformações Anorretais/cirurgia , Seguimentos , Humanos , Recém-Nascido , Masculino , Prognóstico , Fístula Retal/diagnóstico , Fístula Retal/fisiopatologia , Fístula Retal/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Fístula da Bexiga Urinária/diagnóstico , Fístula da Bexiga Urinária/fisiopatologia , Fístula da Bexiga Urinária/cirurgiaAssuntos
Acidose/etiologia , Anastomose Cirúrgica/métodos , Azotemia/etiologia , Cistectomia/métodos , Íleo , Fístula Intestinal , Jejuno , Fístula da Bexiga Urinária , Feminino , Humanos , Íleo/patologia , Íleo/cirurgia , Fístula Intestinal/sangue , Fístula Intestinal/complicações , Fístula Intestinal/diagnóstico , Fístula Intestinal/fisiopatologia , Fístula Intestinal/cirurgia , Jejuno/patologia , Jejuno/cirurgia , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Fístula da Bexiga Urinária/sangue , Fístula da Bexiga Urinária/complicações , Fístula da Bexiga Urinária/diagnóstico , Fístula da Bexiga Urinária/fisiopatologia , Fístula da Bexiga Urinária/cirurgiaRESUMO
Ileovesical fistulas (IVFs) are an uncommon complication of Crohn's disease. The aim of this study is to compare long-term surgical outcomes, assess quality of life, and quantify patient satisfaction after IVF repair. A retrospective chart review followed by a prospective survey was carried out. Survey questions focused on patient satisfaction and quality of life after repair of IVF. Fifty-one patients were identified from an administrative database. Mean follow-up was 4.3 years with a response rate of 51 per cent. At the time of the study, 0 per cent mortality and 16 per cent morbidity were recorded. No recurrence was noted. There was no statistical significance in incidence of complications between laparoscopic and open surgery. Statistically significant differences in single-stage versus multistage operations were found in postoperative day of discharge (P < 0.001) and patient satisfaction (P = 0.049). Ninety-eight per cent of patients reported extreme satisfaction with their surgery and an improvement in quality of life. A low incidence of morbidity and recurrence supports early surgical intervention in IVFs.
Assuntos
Fístula Intestinal/cirurgia , Satisfação do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Qualidade de Vida , Fístula da Bexiga Urinária/cirurgia , Adulto , Idoso , Estudos de Coortes , Doença de Crohn/complicações , Doença de Crohn/diagnóstico , Bases de Dados Factuais , Feminino , Humanos , Íleo/cirurgia , Fístula Intestinal/etiologia , Fístula Intestinal/fisiopatologia , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparotomia/efeitos adversos , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Fístula da Bexiga Urinária/etiologia , Fístula da Bexiga Urinária/fisiopatologiaRESUMO
INTRODUCTION: Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. MATERIALS AND METHODS: We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. RESULTS: Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. CONCLUSION: Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration.
Assuntos
Anus Imperfurado/complicações , Epididimite/etiologia , Doenças Urológicas/etiologia , Adolescente , Adulto , Malformações Anorretais , Anus Imperfurado/fisiopatologia , Anus Imperfurado/cirurgia , Criança , Pré-Escolar , Cistoscopia , Epididimite/fisiopatologia , Epididimite/cirurgia , Humanos , Lactente , Masculino , Recidiva , Estudos Retrospectivos , Bexiga Urinária/fisiopatologia , Fístula da Bexiga Urinária/fisiopatologia , Bexiga Urinaria Neurogênica/etiologia , Bexiga Urinaria Neurogênica/fisiopatologia , Bexiga Urinaria Neurogênica/cirurgia , Urodinâmica , Doenças Urológicas/fisiopatologia , Doenças Urológicas/cirurgia , Adulto JovemRESUMO
Introduction Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. Materials and Methods We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. Results Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. Conclusion Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration .
Assuntos
Adolescente , Adulto , Criança , Pré-Escolar , Humanos , Lactente , Masculino , Adulto Jovem , Anus Imperfurado/complicações , Epididimite/etiologia , Doenças Urológicas/etiologia , Anus Imperfurado/fisiopatologia , Anus Imperfurado/cirurgia , Cistoscopia , Epididimite/fisiopatologia , Epididimite/cirurgia , Recidiva , Estudos Retrospectivos , Urodinâmica , Fístula da Bexiga Urinária/fisiopatologia , Bexiga Urinaria Neurogênica/etiologia , Bexiga Urinaria Neurogênica/fisiopatologia , Bexiga Urinaria Neurogênica/cirurgia , Bexiga Urinária/fisiopatologia , Doenças Urológicas/fisiopatologia , Doenças Urológicas/cirurgiaRESUMO
A 43-year-old male patient with follicular B-cell lymphoma was referred for a FDG PET/CT scan due to severe left lower abdominal pain to rule out recurrent cancer. These FDG PET/CT images and previous FDG PET/CT images 5 months ago both revealed an air bubble in the urinary bladder on the CT images. He had a recurrent urinary tract infection history for 6 months. A list-mode dynamic data acquisition with diuresis intravenous injection revealed linear FDG activity extending from the upper-left portion of the bladder to a soft tissue mass in the lower-left pelvic region. An enterovesical fistula was confirmed by surgery.
Assuntos
Diurese , Doença Diverticular do Colo/diagnóstico por imagem , Fluordesoxiglucose F18 , Fístula Intestinal/diagnóstico por imagem , Linfoma de Células B/diagnóstico por imagem , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Tomografia Computadorizada por Raios X , Fístula da Bexiga Urinária/diagnóstico por imagem , Adulto , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/fisiopatologia , Humanos , Fístula Intestinal/complicações , Fístula Intestinal/fisiopatologia , Linfoma de Células B/complicações , Linfoma de Células B/fisiopatologia , Masculino , Fístula da Bexiga Urinária/complicações , Fístula da Bexiga Urinária/fisiopatologiaAssuntos
Acidentes de Trânsito , Fístula Cutânea/etiologia , Pelve/lesões , Fístula Retal/etiologia , Fístula da Bexiga Urinária/etiologia , Ferimentos não Penetrantes/complicações , Fístula Cutânea/fisiopatologia , Fístula Cutânea/cirurgia , Seguimentos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/fisiopatologia , Hemorragia Gastrointestinal/cirurgia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Motocicletas , Traumatismo Múltiplo/complicações , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/cirurgia , Doenças Retais/etiologia , Doenças Retais/fisiopatologia , Doenças Retais/cirurgia , Fístula Retal/fisiopatologia , Fístula Retal/cirurgia , Medição de Risco , Resultado do Tratamento , Fístula da Bexiga Urinária/fisiopatologia , Fístula da Bexiga Urinária/cirurgia , Ferimentos não Penetrantes/diagnósticoRESUMO
The conventional management of urogenital fistulas is surgical but a recent review of world data showed a high efficacy of hormonal manipulation by the induction of amenorrhea in the treatment of vesicouterine fistulas (VUFs). In fact, VUFs were first demonstrated to be hormonally regulated due to the fistulous canal being lined by endometrium. In this report, we suggest and discuss that, in women of reproductive age, the phenomenon of hormonal regulation is likely to be present in other fistulas communicating with the uterus, like ureterouterine and enterouterine fistulas.
Assuntos
Fístula/fisiopatologia , Hormônios Esteroides Gonadais/fisiologia , Doenças Uterinas/fisiopatologia , Feminino , Fístula/tratamento farmacológico , Hormônios Esteroides Gonadais/uso terapêutico , Humanos , Fístula da Bexiga Urinária/tratamento farmacológico , Fístula da Bexiga Urinária/fisiopatologia , Doenças Uterinas/tratamento farmacológicoAssuntos
Doenças do Colo/diagnóstico , Fístula Intestinal/diagnóstico , Tuberculose Gastrointestinal/diagnóstico , Fístula da Bexiga Urinária/diagnóstico , Pré-Escolar , Doenças do Colo/fisiopatologia , Humanos , Fístula Intestinal/fisiopatologia , Masculino , Tuberculose Gastrointestinal/fisiopatologia , Fístula da Bexiga Urinária/fisiopatologiaRESUMO
Vesicouterine fistula is one of the less common acquired urogenital fistula and a rare event in obstetrics. We report a case which occurred after a vaginal delivery followed by manual removal of placenta in a woman who had a previous cesarean section. The fistula was successfully repaired 5 weeks after delivery.
Assuntos
Placenta Retida/fisiopatologia , Fístula da Bexiga Urinária/fisiopatologia , Doenças Uterinas/fisiopatologia , Útero/lesões , Adulto , Cesárea , Feminino , Hematúria , Humanos , Laparotomia , Ocitocina/uso terapêutico , Placenta Retida/complicações , Gravidez , Tomografia Computadorizada por Raios X , Fístula da Bexiga Urinária/cirurgia , Doenças Uterinas/cirurgia , Útero/cirurgiaRESUMO
OBJECTIVE: To assess the feasibility of carrying out a urodynamic investigation in patients with a urogenital fistula and to establish the incidence of abnormal lower urinary tract function in such patients. PATIENTS AND METHODS: Of 38 patients referred within the last 3 years with a diagnosis of lower urinary tract genital fistula, 30 were investigated by dual-channel subtracted cystometry before surgical treatment of their fistula; in addition, urethral pressure profilometry was carried out in 19 patients. Fourteen of the patients had fistulae into the vaginal vault; the urodynamic findings in this subgroup were compared with those of 12 patients with bladder neck and urethrovaginal fistulae. Twenty-six of the 30 patients underwent surgical treatment and 24 (92%) were cured anatomically by their first procedure. Ten patients complained of residual lower urinary tract symptoms and were re-investigated. RESULTS: Of the 38 patients, 47% had genuine stress incontinence, 40% showed systolic detrusor instability and 17% impaired bladder compliance. Half had evidence of voiding dysfunction; most appeared to be of a hypotonic detrusor type, although four cases showed an obstructive pattern. Fifteen patients had more than one abnormality and only five (17%) had entirely normal urodynamic findings. The overall incidence of functional abnormality was highest in the patients with urethral or bladder neck fistulae, with only one showing entirely normal urodynamic findings. Genuine stress incontinence was found more than twice as often associated with urethral or bladder neck fistulae and detrusor instability was also more common in this group. Voiding dysfunction of both hypotonic and obstructive types was found equally in the two groups. After surgical treatment, most patients became continent and free from lower urinary tract symptoms, although one complained of residual stress incontinence and nine of urgency or urge incontinence. Of the latter, six were found to have detrusor instability, one after repair of vault fistula, three after urethral or bladder neck fistulae and the other two after mid-vaginal fistulae. CONCLUSION: There is a high incidence of abnormal lower urinary tract function in patients with urogenital fistulae. Patients with urethral or bladder neck fistulae had a higher incidence of both detrusor instability and genuine stress incontinence than those with fistulae into the vaginal vault. Many of these abnormalities appear to resolve after successful repair of the fistula, although detrusor instability may persist and require further treatment in some women. These findings are relevant to the counselling of patients before repair and may be of medico-legal significance.
Assuntos
Doenças dos Genitais Femininos/etiologia , Fístula Urinária/etiologia , Adulto , Idoso , Estudos de Viabilidade , Feminino , Doenças dos Genitais Femininos/fisiopatologia , Doenças dos Genitais Femininos/cirurgia , Humanos , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Recidiva , Reoperação , Fístula da Bexiga Urinária/etiologia , Fístula da Bexiga Urinária/fisiopatologia , Fístula da Bexiga Urinária/cirurgia , Fístula Urinária/fisiopatologia , Fístula Urinária/cirurgia , Incontinência Urinária por Estresse/etiologia , Incontinência Urinária por Estresse/fisiopatologia , Incontinência Urinária por Estresse/cirurgia , Urodinâmica , Fístula Vaginal/etiologia , Fístula Vaginal/fisiopatologia , Fístula Vaginal/cirurgia , Fístula Vesicovaginal/etiologia , Fístula Vesicovaginal/fisiopatologia , Fístula Vesicovaginal/cirurgiaRESUMO
OBJECTIVES: To evaluate fertility of women following surgical closure of vesicouterine fistula. STUDY DESIGN: Long-term retrospective investigation combined with a follow-up in the setting of an academic department. Operative hospital records (15,718) were reviewed for a 12-year period. RESULTS: Sixteen women with a vesicouterine fistula at reproductive age entered the study. Five pregnancies were recorded after repair, of which four resulted in a full term delivery. In comparison with the data reported to date this series showed significantly higher rates of pregnancy (31.25% vs. 9.7%; P = 0.012) and term deliveries (25% vs. 6.2%; P = 0.01). The majority of women were afraid of recurrence if pregnant again. CONCLUSIONS: Fertility after repair of vesicouterine fistula can be much better than previously described.
Assuntos
Fertilidade , Fístula/fisiopatologia , Gravidez , Fístula da Bexiga Urinária/fisiopatologia , Doenças Uterinas/fisiopatologia , Adulto , Feminino , Fístula/cirurgia , Humanos , Prognóstico , Inquéritos e Questionários , Fístula da Bexiga Urinária/cirurgia , Doenças Uterinas/cirurgiaRESUMO
Pneumaturia, an air-filled urinary bladder with or without passage of gas in the urine, is a rare phenomenon in the general population, but is more frequent in defined high-risk subgroups. Relevant symptomatology may be hardly noticeable for a relatively long period; however, the outcome may be serious and sometimes fatal. We present three such cases and discuss diagnostic and therapeutic aspects.