Left-colon antegrade enema (LACE): Long-term experience with the Macedo-Malone approach.

AIMS: We evaluated the long-term results with a left antegrade continence enema (LACE) approach: "Macedo-Malone (MM) procedure" to define parameters such as clinical durability of the technique and patients' compliance with the method. METHODS: We reviewed the medical records of all patients that underwent the MM procedure in our institution since 2001 and conducted a telephonic interview to investigate the use of the enema and satisfaction with the procedure. RESULTS: Thirty-five MM procedures were performed, but eight patients lost to follow-up were excluded. Fifteen patients (55%) were female. Myelomeningocele was the clinical diagnoses in 25 (93%). Mean age at surgery was 9 years (3-27 years) and mean follow-up was 75 months (median: 56 months). The indication for LACE was clinically intractable constipation with fecal leakage. Most patients still used the stoma regularly to do the enema (74%). Mean washout time was 27 min (2-90 min). The revision rate due to stenosis was 22.2% (6/27) and all underwent suprafascial revision. We performed one classical MACE by infrafascial approach as a salvage procedure. Overall reoperation rate was 25.8% and fecal continence was 89%. There were no reports of leakage through the stoma. Among patients who still used the stoma, 74% were satisfied with surgery and would strongly recommend the procedure to another patient. CONCLUSIONS: The MM procedure is a straightforward procedure, which can be performed in 15-20 min, avoids additional entero-entero anastomosis, precludes the use of the appendix, and has shown comparable results to either "classical" MACE or other LACE variants. Neurourol. Urodynam. 36:111-115, 2017. © 2015 Wiley Periodicals, Inc.

Is continent urinary diversion feasible in children under five years of age?

PURPOSE: To review our clinical experience with urinary continent catheterizable reservoir in children under five years of age. MATERIALS AND METHODS: A total of 23 patients (16 males, 7 females) with a median age of 3.64 years were evaluated. Among these, 6 (26.08%) had a posterior urethral valve, 9 (39.13%) myelomeningocele, 4 (17.39%) bladder exstrophy, 2 (8.69%) genitourinary rabdomyosarcoma, 1 (4.34%) had spinal tumor and 1 (4.34%) an ano-rectal anomaly. RESULTS: Perioperative complications were observed in four patients consisting of one febrile urinary tract infection, one partial operative wound dehiscence, one partial stomal dehiscence and one vesico-cutaneous fistula after a secondary exstrophy repair. The overall long-term complications rate was 40.90% and consisted of two stomal stenoses (9.09%), one neobladder mucosal extrusion (4.54%), three neobladder calculi (13.63%) and persistence of urinary incontinence in three patients (13.63%). The overall surgical revision was 36.36% and final continence rate was 95.45% with mean follow-up of 39.95 months CONCLUSION: Continent urinary diversion is technically feasible even in small children, with acceptable rates of complications.

Long-term results with a one-stage complex primary hypospadias repair strategy (the three-in-one technique).

PURPOSE: Complex primary hypospadias repair that warrants urethral plate division is treated mostly in two steps, not necessarily in two surgeries. Our aim was to review long-term results with a one-stage strategy based on reconstruction of the urethral plate with buccal mucosa graft and onlay transverse preputial flap anastomosis protected by a tunica vaginalis flap (the three-in-one concept). MATERIAL AND METHODS: We were able to report on 35 patients operated for primary scrotal, penoscrotal and perineal hypospadias between March 2002 and June 2008. We reviewed all charts and had phone interviews with patients not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, dehiscence, orchitis and parental perception. RESULTS: Surgical complications occurred in 13 patients (37%): 4 meatal stenosis, 4 diverticula, 5 fistulae and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases, reflected in fistula resolution. The reoperation rate was 31.5% consisting mostly of simple procedures like fistula closure, meatotomy and penile curvature release, and complex diverticula repair in 4 cases. Parental perception was excellent for 57% (20 patients) and good or acceptable for the remaining. Mean follow-up was 4.6 years. CONCLUSIONS: The one-step strategy is associated with 68.5% success in a single operation, whereas 31.5% will need a second repair. We recognize that meatal problems are mostly associated with fistulae and diverticula; therefore, we recommend a final acceptable proximal glandar opening that will not compromise the neourethra.

Elective appendicovesicostomy in association with Monfort abdominoplasty in the treatment of prune belly syndrome.

OBJECTIVE: To evaluate the role of elective appendicovesicostomy in association with Monfort abdominoplasty to avoid urinary tract infection (UTI) and renal damage in the post-operative follow-up of patients with prune belly syndrome. MATERIALS AND METHODS: We followed 4 patients operated in our institution (UNIFESP) (Monfort, orchidopexy and Mitrofanoff) and compared them to 2 patients treated similarly, but without an appendicovesicostomy, in a second institution (UFBA). We evaluated postoperative clinical complications, UTI and preservation of renal parenchyma. Patients were followed as outpatients with urinalysis, ultrasonography (US) and occasionally with renal scintigraphy. RESULTS: Mean follow-up was 23.5 months. Immediate post-operative course was uneventful. We observed that only one patient with the Mitrofanoff channel persisted with UTI, while the 2 patients used as controls persisted with recurrent pyelonephritis (> 2 UTI year). CONCLUSION: Our data suggest that no morbidity was added by the appendicovesicostomy to immediate postoperative surgical recovery and that this procedure may have a beneficial effect in reducing postoperative UTI events and their consequences by reducing the postvoid residuals in the early abdominoplasty follow-up. However, we recognize that the series is small and only a longer follow-up with a larger number of patients will allow us to confirm our suppositions. We could not make any statistically significant assumptions regarding differences in renal preservation due to the same limitations.

Is continent urinary diversion feasible in children under five years of age?

Purpose: To review our clinical experience with urinary continent catheterizable reservoir in children under five years of age. Materials and Methods: A total of 23 patients (16 males, 7 females) with a median age of 3.64 years were evaluated. Among these, 6 (26.08 percent) had a posterior urethral valve, 9 (39.13 percent) myelomeningocele, 4 (17.39 percent) bladder exstrophy, 2 (8.69 percent) genitourinary rabdomyosarcoma, 1 (4.34 percent) had spinal tumor and 1 (4.34 percent) an ano-rectal anomaly. Results: Perioperative complications were observed in four patients consisting of one febrile urinary tract infection, one partial operative wound dehiscence, one partial stomal dehiscence and one vesico-cutaneous fistula after a secondary exstrophy repair. The overall long-term complications rate was 40.90 percent and consisted of two stomal stenoses (9.09 percent), one neobladder mucosal extrusion (4.54 percent), three neobladder calculi (13.63 percent) and persistence of urinary incontinence in three patients (13.63 percent). The overall surgical revision was 36.36 percent and final continence rate was 95.45 percent with mean follow-up of 39.95 months Conclusion: Continent urinary diversion is technically feasible even in small children, with acceptable rates of complications.

Elective appendicovesicostomy in association with monfort abdominoplasty in the treatment of prune belly syndrome

OBJECTIVE: To evaluate the role of elective appendicovesicostomy in association with Monfort abdominoplasty to avoid urinary tract infection (UTI) and renal damage in the post-operative follow-up of patients with prune belly syndrome. MATERIALS AND METHODS: We followed 4 patients operated in our institution (UNIFESP) (Monfort, orchidopexy and Mitrofanoff) and compared them to 2 patients treated similarly, but without an appendicovesicostomy, in a second institution (UFBA). We evaluated postoperative clinical complications, UTI and preservation of renal parenchyma. Patients were followed as outpatients with urinalysis, ultrasonography (US) and occasionally with renal scintigraphy. RESULTS: Mean follow-up was 23.5 months. Immediate post-operative course was uneventful. We observed that only one patient with the Mitrofanoff channel persisted with UTI, while the 2 patients used as controls persisted with recurrent pyelonephritis (> 2 UTI year). CONCLUSION: Our data suggest that no morbidity was added by the appendicovesicostomy to immediate postoperative surgical recovery and that this procedure may have a beneficial effect in reducing postoperative UTI events and their consequences by reducing the postvoid residuals in the early abdominoplasty follow-up. However, we recognize that the series is small and only a longer follow-up with a larger number of patients will allow us to confirm our suppositions. We could not make any statistically significant assumptions regarding differences in renal preservation due to the same limitations.