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.

Vesicostomy button: how is it placed, in whom, and how is quality of life affected?

ABSTRACT Purpose The vesicostomy button has been shown to be a safe and effective bladder management strategy for short- or medium-term use when CIC cannot be instituted. This study reports our use with the vesicostomy button, highlighting the pros and cons of its use and complications. We then compared the quality or life in patients with vesicostomy button to those performing clean intermittent catheterization. Materials and Methods Retrospective chart review was conducted on children who had a vesicostomy button placed between 2011 and 2015. Placement was through existing vesicostomy, open or endoscopically. We then evaluated placement procedure and complications. A validated quality of life questionnaire was given to patients with vesicostomy button and to a matched cohort of patients performing clean intermittent catheterization. Results Thirteen children have had a vesicostomy button placed at our institution in the 4 year period, ages 7 months to 18 years. Indications for placement included neurogenic bladder (5), non-neurogenic neurogenic bladder (3), and valve bladders (5). Five out of 7 placed via existing vesicostomy had leakage around button. None of the endoscopically placed buttons had leakage. Complications were minor including UTI (3), wound infection (1), and button malfunction/leakage (3). QOL was equal and preserved in patients living with vesicostomy buttons when compared to CIC. Conclusion The vesicostomy button is an acceptable alternative to traditional vesicostomy and CIC. The morbidity of the button is quite low. Endoscopic insertion is the optimal technique. QOL is equivalent in patients with vesicostomy button and those who perform CIC.

Vesicostomy button: how is it placed, in whom, and how is quality of life affected?

PURPOSE: The vesicostomy button has been shown to be a safe and effective bladder management strategy for short- or medium-term use when CIC cannot be instituted. This study reports our use with the vesicostomy button, highlighting the pros and cons of its use and complications. We then compared the quality or life in patients with vesicostomy button to those performing clean intermittent catheterization. MATERIALS AND METHODS: Retrospective chart review was conducted on children who had a vesicostomy button placed between 2011 and 2015. Placement was through existing vesicostomy, open or endoscopically. We then evaluated placement procedure and complications. A validated quality of life questionnaire was given to patients with vesicostomy button and to a matched cohort of patients performing clean intermittent catheterization. RESULTS: Thirteen children have had a vesicostomy button placed at our institution in the 4 year period, ages 7 months to 18 years. Indications for placement included neurogenic bladder (5), non-neurogenic neurogenic bladder (3), and valve bladders (5). Five out of 7 placed via existing vesicostomy had leakage around button. None of the endoscopically placed buttons had leakage. Complications were minor including UTI (3), wound infection (1), and button malfunction/leakage (3). QOL was equal and preserved in patients living with vesicostomy buttons when compared to CIC. CONCLUSION: The vesicostomy button is an acceptable alternative to traditional vesicostomy and CIC. The morbidity of the button is quite low. Endoscopic insertion is the optimal technique. QOL is equivalent in patients with vesicostomy button and those who perform CIC.

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.

Suprapubic cystostomy versus nonsuprapubic cystostomy during monopolar transurethral resection of prostate: a propensity score-matched analysis.

We aim to reassess the safety of the monopolar transurethral resection of the prostate (M-TURP) without suprapubic cystostomy at our institution over the past decade. This retrospective study was conducted in patients who underwent M-TURP at Peking University First Hospital between 2003 and 2013. A total of 1680 patients who had undergone M-TURP were identified, including 539 patients in the noncystostomy group and 1141 patients in the cystostomy group. After propensity score matching, the number of patients in each group was 456. Smaller reductions in hemoglobin and hematocrit (10.9 g vs 17.6 g and 3.6% vs 4.7%, respectively) were found in the noncystostomy group. In addition, patients undergoing surgery without cystostomy had their catheters removed earlier (4.6 days vs 5.2 days), required shorter postoperative stays in the hospital (5.1 days vs 6.0 days), and were at lower risk of operative complications (5.7% vs 9.2%), especially bleeding requiring blood transfusion (2.9% vs 6.1%). Similar findings were observed in cohorts of prostates of 30-80 ml and prostates >80 ml. Furthermore, among patients with a resection weight >42.5 g or surgical time >90 min, or even propensity-matched patients based on surgical time, those with cystostomy seemed to be at a higher risk of operative complications. These results suggest that M-TURP without suprapubic cystostomy is a safe and effective method, even among patients with larger prostates, heavier estimated resection weights, and longer surgical times.

Reconstruction after ureteral resection during HIPEC surgery: Re-implantation with uretero-neocystostomy seems safer than end-to-end anastomosis.

INTRODUCTION: Resection of the pelvic ureter may be necessary in cytoreductive surgery for peritoneal carcinomatosis in combination with hyperthermic intraperitoneal chemotherapy (HIPEC). As the morbidity for cytoreductive surgery with HIPEC has decreased, expert teams have begun to perform increasingly complex surgical procedures associated with HIPEC, including pelvic reconstructions. After ureteral resection, two types of reconstruction are possible: uretero-ureteral end-to-end anastomosis and uretero-vesical re-implantation or uretero-neocystostomy (the so-called psoas hitch technique). By compiling the experience of three surgical teams that perform HIPEC surgeries, we have tried to compare the effectiveness of these two techniques. METHODOLOGY: A retrospective comparative case-matched multicenter study was conducted for patients undergoing operation between 2005 and 2014. Patients included had undergone resection of the pelvic ureter during cytoreductive surgery with HIPEC for peritoneal carcinomatomosis; ureteral reconstruction was by either end-to-end anastomosis (EEA group) or re-implantation uretero-neocystostomy (RUC group). The primary endpoint was the occurrence of urinary fistula in postoperative follow-up. RESULTS: There were 14 patients in the EEA group and 14 in the RUC group. The groups were comparable for age, extent of carcinomatosis (PCI index) and operative duration. Four urinary fistulas occurred in the EEA group (28.5%) versus zero fistulas in the RUC group (0%) (P=0.0308). CONCLUSION: Re-implantation with uretero-neocystostomy during cytoreductive surgery with HIPEC is the preferred technique for reconstruction after ureteral resection in case of renal conservation.

Continent Catheterizable Vesicostomy: An Alternative Surgical Modality for Pediatric Patients With Large Bladder Capacity.

OBJECTIVE: To present a modified technique and early outcomes of a continent catheterizable vesicostomy in pediatric patients with either flaccid neurogenic bladder or intractable voiding dysfunction and large capacity bladder. METHODS: Six patients underwent the procedure from October 2014 to December 2015. A 4-cm Pfannenstiel incision was made, avoiding intraperitoneal dissection. After adequate mobilization, a 2-cm vertical flap at the dome of the bladder was identified and tubularized over a 12Fr catheter with 4-0 vicryl suture. The tubularized flap was then intussuscepted into the bladder with four 4-0 polydioxanone sutures, creating a continent mechanism. The catheterizable channel was then tunneled to the umbilicus, the channel ostomy matured, and the cystotomy closed in two layers. RESULTS: The median patient age was 8 (interquartile range [IQR] 12) years. All patients had urinary dysfunction requiring drainage from etiologies that included Eagle-Barrett syndrome (n = 2), Noonan syndrome (n = 1), Lennox-Gastaut syndrome (n = 1), and Spina bifida (n = 2). Median hospital length of stay was 8 (IQR 3) days. One patient had a superficial wound infection treated with antibiotics, and 1 patient required balloon dilation of the catheterizable channel at 3 months postoperatively, secondary to difficulty self-catheterizing. Five patients were successfully self-catheterizing at last follow-up. Median follow-up was 6 (IQR 5) months and there were no intra- or perioperative complications. CONCLUSION: Continent catheterizable vesicostomy is a novel technique for urinary drainage in patients with large bladder capacity that spares use of the appendix or ileum. Early results are encouraging, providing a catheterizable channel through the umbilicus without urinary leakage between catheterization.

Robot-assisted Laparoscopic Augmentation Ileocystoplasty and Mitrofanoff Appendicovesicostomy in Children: Updated Interim Results.

BACKGROUND: Robot-assisted laparoscopic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy (RALIMA) may protect the upper urinary tract and reestablish continence in patients with refractory neurogenic bladder. Robotic assistance can provide the benefits of minimally invasive surgery without the steep learning curve of pure laparoscopy. OBJECTIVE: To highlight the interim outcomes of RALIMA with salient tips and technical modifications through comparison with patients undergoing open augmentation ileocystoplasty (OAI). DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective chart review of 17 patients undergoing robot-assisted laparoscopic augmentation ileocystoplasty (RALI) and 13 patients undergoing OAI by a single surgeon at an academic center from 2008 to 2012 (OAI) or 2014 (RALI). SURGICAL PROCEDURE: RALI and all concomitant procedures were performed completely intracorporeally using the da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes of interest included change in bladder capacity, operative time, pain medication use, hospitalization time, and perioperative complication rates. RESULTS AND LIMITATIONS: Of 17 patients selected, 15 successfully underwent RALI. Overall, 11, 6, and 4 patients had a concomitant Mitrofanoff appendicovesicostomy, antegrade colonic enema channel, and bladder neck closure, respectively. The median operative time was significantly longer in RALI (623 vs 287 min; p<0.01). Median length of stay (LOS) was shorter in RALI (6 vs 8 d; p=0.01). The postoperative percentage increase in bladder capacity, narcotic use, and complication rates did not differ between RALI and OAI. Limitations include the retrospective study design and the small cohort of patients. CONCLUSIONS: RALI appears to offer functional outcomes similar to OAI. Although it is a significantly longer procedure, it may decrease LOS and avoid epidural use. Further refinements may reduce operative time. PATIENT SUMMARY: In this report, we examined outcomes after robotic bladder augmentation surgery in children. We found that the robotic approach may eliminate epidural analgesia use and decrease hospitalization time after surgery.

The initial experience of pneumovesicoscopic bladder stone removal using a laparoscopic entrapment sac.

INTRODUCTION: In this article, we aim to present our novel experience of bladder stone removal under pneumovesicoscopic field using a laparoscopic entrapment sac. TECHNICAL CONSIDERATIONS: We retrospectively reviewed the medical records of 21 patients who had pneumovesicoscopic bladder stone removal to assess a variety of patient characteristics and surgical outcomes. We considered stone burden, stone removal time including pneumovesicoscopic procedure time, postoperative catheter indwelling duration, postoperative hospital stay, and complications. The procedure was performed in the following steps: Under cystoscopy filled with saline solution, a 10-mm suprapubic transvesical trocar was inserted. After changing optical transmission medium from saline to CO(2) gas, pneumovesicoscopic procedure was performed to put stones in an entrapment sac inserted through the trocar. The stones trapped in the sac were extracorporeally broken with a lithotripter via the suprapubic route. The mean patient age was 58.95 ± 22.03 years. The mean stone burden was 4.88 ± 2.63 cm. Eleven patients had a single stone, whereas 10 had multiple stones. All stones were completely removed. The mean operative time was 31.66 ± 7.25 minutes, including the pneumovesicoscopic procedure time of 13.81 ± 7.30 minutes. In all but 6 patients with a cystostomy or a combined transurethral resection of the prostate, the urethra catheter was removed on the day after surgery; the mean postoperative hospital stay was 1.67 ± 0.49 days. There were 5 postoperative complications of Clavien grade I or II. CONCLUSION: We report the technical feasibility of pneumovesicoscopic bladder stone removal using a laparoscopic entrapment sac as a minimally invasive method. This technique will likely become more important as a useful option for treating bladder stones.

Outcomes of incontinent ileovesicostomy in the pediatric patient.

PURPOSE: Ileovesicostomy is a reconstructive option in complex urological cases but pediatric specific outcomes are lacking. We report our results with pediatric ileovesicostomy. MATERIALS AND METHODS: We retrospectively evaluated patients younger than 18 years undergoing incontinent ileovesicostomy at Vanderbilt University. History, urinary tract management and operative course were reviewed in the electronic medical record. Particular attention was given to immediate and long-term postoperative complications. RESULTS: Nine patients underwent incontinent ileovesicostomy between 2000 and 2013 at a mean age of 10.3 years (range 1.4 to 15.5). Surgical indication was sequelae of neurogenic or nonneurogenic neurogenic bladder (such as infection or worsening hydronephrosis) in 5 patients, reversal of vesicostomy in 3 and closure of cloacal exstrophy in 1. All 9 patients were thought incapable of reliable clean intermittent catheterization due to family unwillingness, poor social support or patient refusal. Median followup was 11.5 months (mean 48.2, range 1.3 to 144.8). Immediate postoperative complications included ileus requiring total parenteral nutrition and a wound infection in 1 patient. Long-term complications included urinary tract infection in 2 patients (febrile in 1 and positive culture for foul smelling urine in 1), stomal issues in 2 and temporary urethral leakage in 1. Constipation affected 3 children in long-term followup (all with neurogenic bowel preoperatively). Postoperative creatinine was stable or improved in all patients. CONCLUSIONS: Ileovesicostomy is a viable approach in children left with few other options, particularly those who are noncompliant or physically/socially unable to handle catheterization. This operation can help keep such patients out of diapers.

A new extra-abdominal channel alternative to the Mitrofanoff principle: experimental and preliminary clinical experience.

INTRODUCTION: The appendix is the gold-standard channel for the Mitrofanoff principle in pediatric urology, but the search for alternatives is justified considering it may not be available or preferably used for colonic stomas (Malone antegrade continence enema). The aim of this study is to report on technical feasibility of a new approach for creating catheterizable channels in a rabbit model and to present our preliminary clinical experience. MATERIAL AND METHODS: We configured a tube from two rectangular skin flaps 1x4 cm opposite each other in the middle line of the lower inferior abdomen. The channel was anastomosed to the bladder dome with embedding sutures to create a valvular mechanism. The experimental study consisted of 12 rabbits, divided in 4 groups according to the sacrifice schedule at 2, 4, 8 and 12 weeks. At 30th postoperative day, an urodynamic evaluation was performed to record continence of the stoma. A histological analysis of the specimens stained with hematoxylin-eosin, Masson trichrome and Picrosirius red was also done in group 2 (sacrifice at 4 weeks postoperatively). We used this method in 3 patients with congenital non-neurogenic bladder disease presenting with massive residual volumes without compliance deficits. RESULT: The technique proved feasible in all animals, 9 of 12 could be easily catheterized and underwent urodynamic study. No stoma leakage was observed in 7 animals at high bladder pressures (> 50 cm H20) and only 2 animals had some leakage at 40 cm H20. Urodynamics performed through the stoma showed urethral leakage at 20 cm H20, therefore demonstrating the efficacy of the valvular mechanism. Histological analysis confirmed good integration between the tube and the bladder. Mean follow-up of the clinical series (3 patients) was 7.2 months. Two patients remained continent up to 4 hours, whereas 1 patient had some leakage after 2 hours. CONCLUSION: We were able to confirm feasibility of a new extra-abdominal channel based on the Mitrofanoff principle and successfully reproduced the method in a clinical setting. Follow-up was short and long term results are required before any conclusive judgment can be made.

A new extra-abdominal channel alternative to the mitrofanoff principle: experimental and preliminary clinical experience

INTRODUCTION: The appendix is the gold-standard channel for the Mitrofanoff principle in pediatric urology, but the search for alternatives is justified considering it may not be available or preferably used for colonic stomas (Malone antegrade continence enema). The aim of this study is to report on technical feasibility of a new approach for creating catheterizable channels in a rabbit model and to present our preliminary clinical experience. MATERIAL AND METHODS: We configured a tube from two rectangular skin flaps 1x4 cm opposite each other in the middle line of the lower inferior abdomen. The channel was anastomosed to the bladder dome with embedding sutures to create a valvular mechanism. The experimental study consisted of 12 rabbits, divided in 4 groups according to the sacrifice schedule at 2, 4, 8 and 12 weeks. At 30th postoperative day, an urodynamic evaluation was performed to record continence of the stoma. A histological analysis of the specimens stained with hematoxylin-eosin, Masson trichrome and Picrosirius red was also done in group 2 (sacrifice at 4 weeks postoperatively). We used this method in 3 patients with congenital non-neurogenic bladder disease presenting with massive residual volumes without compliance deficits. RESULT: The technique proved feasible in all animals, 9 of 12 could be easily catheterized and underwent urodynamic study. No stoma leakage was observed in 7 animals at high bladder pressures (> 50 cm H20) and only 2 animals had some leakage at 40 cm H20. Urodynamics performed through the stoma showed urethral leakage at 20 cm H20, therefore demonstrating the efficacy of the valvular mechanism. Histological analysis confirmed good integration between the tube and the bladder. Mean follow-up of the clinical series (3 patients) was 7.2 months. Two patients remained continent up to 4 hours, whereas 1 patient had some leakage after 2 hours. CONCLUSION: We were able to confirm feasibility of a new extra-abdominal...

Robotic pediatric urology.

Robotic-assisted minimally invasive surgery is penetrating pediatric urology. The freedom afforded by the "surgical actuators" has led to the expanding adoption of robotics, and it is unlikely that much of laparoscopy will not trend toward some iteration of robotic influence. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) provides delicate telemanipulation, coalesced with three-dimensional visualization and superior magnification. It has bridged the gap between laparoscopy and open surgery. Nonetheless, a confident understanding of pure laparoscopy is paramount in the event that mechanical malfunction is experienced. Robotic pediatric urologic procedures such as pyeloplasty, ureteral reimplantation, abdominal testis surgery, and partial or total nephrectomy with or without ureteral stump removal are routinely performed at select centers offering robotic expertise. Complex reconstructive surgeries such as appendicovesicostomy, antegrade continent enema creation, and augmentation cystoplasty can be performed but are still in their infancy.

Litiasis vesical secundaria a migración de dispositivo intrauterino. Reporte de un caso / Bladder lithiasis secondary to intrauterine device migration. Case report

Objetivo: Presentar un caso clínico de litiasis vesical secundaria a la migración de un dispositivo intrauterino, su sintomatología, los medios empleados para su diagnóstico y el tratamiento aplicado. Método/Resultado. Paciente de 30 años de edad, que al cabo del año de colocársele un dispositivo intrauterino (T de cobre), luego de interrupción de embarazo mediante legrado endometrial, comenzó a presentar síntomas urinarios irritativos bajos. Se le trató durante dos años como si tuviese cistitis infecciosa con varios ciclos de diferentes antibióticos. Por la persistencia de las molestias asiste a la consulta de Urología, y se le detecta, mediante ultrasonido y radiografía ántero-posterior de la pelvis, una litiasis intravesical de cinco por tres centímetros de tamaño, con una T de cobre en su interior. Se le realizó la cistolitotomía suprapúbica, presentando una buena evolución y regresión total de los síntomas. Conclusión. La migración de un dispositivo intrauterino a la vejiga, es una causa infrecuente de litiasis vesical secundaria a cuerpo extraño. No obstante, debemos pensar en esta posibilidad ante la cronicidad de síntomas urinarios irritativos bajos, en toda mujer que emplee este método anticonceptivo (AU)

Objective: To report one clinical case of bladder lithiasis secondary to the migration of an intrauterine device, its symptoms, diagnostic tests employed and treatment. Methods/Results: 30 year old female patient who presented lower urinary tract irritative symptoms. One year before she underwent insertion of an intrauterine device (copper T) after endometrial curettage for pregnancy interruption. She received treatment for infection cystitis over two years, with various antibiotic cycles. The persistence of symptoms led her to the urology clinics, and a 5x 3 cm intravesical lithiasis with a copper T inside was detected by ultrasound and pelvic anterior-posterior x-ray. Suprapubic cystolithotomy was performed with a good outcome and disappearance of the symptoms. Conclusions: The migration of an intrauterine device to the bladder is an unfrequent cause of bladder lithiasis secondary to foreign body. Nevertheless, we must consider this possibility in front of chronic lower urinary tract irritative symptoms in every female using this birth control method (AU)

Rectus sheath tunnels for continent stomas.

Continent stoma rectus sheath tunnel (CSRST) has been used in antegrade colonic enema (ACE) and urinary continent cutaneous diversion (UCCD) stomas to reduce leakage and to support a straight track for the continent conduit. All patients that underwent CSRST between 1995 and 2005 were identified and their case notes retrospectively reviewed. Patients were divided into two groups: the ACE group and the UCCD group. Demographic data, age at surgery and complications including stenosis and leakage were recorded. Forty patients underwent CSRST between 1995 and 2005. The mean age and standard deviation (SD) at surgery was 6.8 (2.1) years. Eighteen patients underwent ACE with a mean (SD) follow-up of 7.6 (3.1) years. No patient has faecal leakage. No patient had stomal revision, but one patient (5.5%) required an indwelling gastrostomy button to maintain patency. Twenty-two patients underwent UCCD with a mean (SD) follow-up of 8.1 (2.8) years. No patient developed urinary leakage. Two patients (9%) required revision of the stoma and one (4.5%) required an indwelling catheter because of recurring stomal stenosis. CSRST prevents stoma leakage. Revision surgery rate after CSRST is low, particularly after ACE reconstruction.

Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida.

OBJECTIVES: At our institution, the use of cecostomy tubes has provided a successful method for managing severe constipation in patients with spina bifida, with good patient and caretaker satisfaction and minimal morbidity. We have developed a modified technique to allow placement of the cecostomy tube under direct vision during laparoscopic appendicovesicostomy. We present our initial experience and technique. METHODS: Patients with a normal bladder capacity and compliance who were scheduled for creation of an appendicovesicostomy and who also had refractory constipation were offered concurrent cecostomy tube placement. At the laparoscopic procedure, we performed percutaneous placement of the cecostomy tube through the abdominal wall under direct visualization. Subsequently, dissection of the appendix with its mesentery was performed. The detrusor muscle was dissected and a trough for the appendix created. Laparoscopic anastomosis of the appendix to the bladder mucosa and approximation of the detrusor over the appendix created a nonrefluxing channel. RESULTS: Three patients have undergone concurrent cecostomy tube placement at appendicovesicostomy. No complications have been encountered thus far. On follow-up, the cecostomy tube scar has been well concealed and appears no different from the ones placed under radiologic guidance. The patients have been using the catheterizable channel to access the bladder and dry performing intermittent catheterization without difficulties. CONCLUSIONS: In patients with a neurogenic bladder who do not qualify for major bladder reconstructive procedures, such as augmentation cystoplasty or bladder neck repair, social continence and independence can be achieved with minimally invasive surgery. Concomitant laparoscopic appendicovesicostomy and cecostomy tube placement may be a suitable surgical option.

Role of suprapubic drainage in the transurethral resection of prostate (TUR-P).

We assessed some clinical parameters and biochemical changes during TUR-P under suprapubic trocar aspiration system with suction. 18 patients underwent TUR-P with active aspiration and other 17 using Iglesias type resectoscope. The mean values of Sodium, Potassium and hematocrite did not differ significantly between the groups before surgery and 20 minutes after the beginning of resection. At the end of surgical intervention changes in hematocrit values were insignificant and blood electrolyte showed marginal statistical difference. The mean time of operation and resection in study group was 45.38 min and 37.31 min respectively, and in control group 56.25 min and 47.83 min respectively. Average weight of resected prostate tissue in study group was 67.92 g versus 58.75 g in control group. The time needed for the resection of 1 g prostate in a study group was 0.55 min versus 0.81 min in control group (p=0.05). The time needed for the removing of 1 g prostate tissue was 0.67 min and 0.96 min respectively (p<0.01). Our data supports that suprapubic trocar suction reduces the duration of the operation on the other hand, the mean time to remove one gram of prostate is much shorter comparing to conventional technique.