Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex.

BACKGROUND: Male epispadias is a rare congenital urogenital anomaly in which the meatus is ectopically located along the dorsal midline of the penile shaft. In cases associated with severe curvature, functional and cosmetic outcomes could be accomplished by lengthening the shorter dorsal surface with the use of corporal grafting. Various graft materials have been used in the past for hypospadias repair including tunica vaginalis, dermis, and small intestinal submucosa (SIS). The use of SIS grafting for corporoplasty during epispadias repair has rarely been described in the literature. OBJECTIVE: To report the experience in the management of dorsal corporal body grafting using SIS in children with severe penile curvature due to epispadias. STUDY DESIGN: The authors retrospectively reviewed the charts of all patients with epispadias or bladder exstrophy/epispadias complex and severe dorsal chordee (>40°) who underwent epispadias repair with single-layer SIS for corporal body grafting. Clinical variables, surgical technique, and outcomes were analyzed. RESULTS: A total of nine consecutive patients underwent staged epispadias repair with dorsal corporal single-layer SIS grafting (summary figure). Of these, four (44.4%) had primary penopubic epispadias, one (11.1%) had mid-shaft epispadias, and four (44.4%) had bladder exstrophy/epispadias complex. The mean age at surgery was 13.4 ± 6 months. After phalloplasty with SIS grafting, there were no reported complications related to the graft during the post-operative period or follow-up visits. DISCUSSION: Although traditional techniques for epispadias repair allow some degree of corporal lengthening, they also result in abrupt medial rotation of the corporal bodies leading to torqueing and potential unsatisfactory cosmetic results. In contrast, the authors use single-layer SIS for corporal body grafting, and this study technique results in a more gradual inward rotation thus allowing more anatomical accuracy. Furthermore, an advantage of the use of SIS over other grafting materials is that there is no need to harvest an autologous graft such as tunica vaginalis or dermis. CONCLUSION: Epispadias repair using single-layer SIS corporal body grafting is an effective, safe, and feasible method, which provides satisfactory cosmesis and correction of dorsal curvature in congenital epispadias in children. Furthermore, a more normal penis appearance, without a decrease in the corporal length or diameter, is achieved with this technique.

Bladder exstrophy closure in the newborn period with external pelvic fixation performed without osteotomy: A preliminary report.

BACKGROUND: Successful primary bladder closure is the most crucial element for urinary continence in patients with classic bladder exstrophy (CBE). In the newborn period, bladder closure can be performed in the first 48 h without pelvic osteotomy or external fixation, but requires postoperative lower extremity immobilization (i.e., spica cast, Bryant's or Buck's traction). OBJECTIVE: To present a novel surgical approach for primary bladder closure for CBE using two-pin external fixation without pelvic osteotomy, and without postoperative lower extremity immobilization. STUDY DESIGN: A retrospective chart review of patients with CBE was performed at the current institution from 2000 to 2016, including all primary bladder closures with external fixation and without osteotomy or lower extremity immobilization. Patients were discharged with the external fixator in place, which was later removed in clinic. Baseline clinical and demographic variables, and follow-up data were recorded. RESULTS: Thirteen patients were analyzed; eight (61.5%) were male. Pre-operative intersymphysial distance was 3.68 ± 1.0 cm (2.0-5.0). Mean follow-up was 56.8 ± 40.3 months (10-131). One patient had a partial bladder neck dehiscence, due to pin displacement on postoperative day 1: he had the lowest gestational age of 34 weeks (Summary table). DISCUSSION: This approach used external fixation to bring the pubic bones together intra-operatively, and to decrease the tension in closing the pelvic ring and abdominal wall without osteotomy. External fixation with osteotomy and long-term immobilization, or using a spica cast without osteotomy offered the added advantage of improved wound care, due to lack of lower limb immobilization, less patient discomfort, and facilitation of mother/caregiver and newborn bonding. CONCLUSION: The two-pin external fixator without osteotomy as an adjunct to primary bladder closure in CBE patients was technically feasible. At the current institution this approach had an equivalent success rate to previous reports in the literature for primary bladder closure, decreased the length of hospital stay, and precluded the need for lower extremity immobilization. Early data for bladder capacity were encouraging.

Pieloplastia sin drenaje intrarrenal en pacientes pediátricos / Pyeloplasty Without Intrarenal Stent in Pediatric Patients

Objetivos: A pesar del avance de cirugías mínimamente invasivas, la pieloplastia desmembrada a cielo abierto sigue siendo una cirugía muy utilizada en Pediatría, especialmente en niños pequeños. El propósito de este trabajo es presentar nuestra experiencia en la realización de esta técnica a través de una mínima incisión y sin dejar catéteres intrarrenales transanastomóticos. Materiales y métodos: Revisión retrospectiva desde julio de 1992 a julio de 2009, tiempo en el que 348 pacientes fueron operados de pieloplastia desmembrada a cielo abierto. Un total de310 pacientes (89%), 223 niños y 87 niñas, fueron intervenidos sin dejar catéter intrarrenal. La incisión fue de 2 a 2,5 cm en flanco. En todos los pacientes se dejó drenaje perirrenal y sonda vesical, esta última las primeras 24 h. Resultados: En total se realizaron 319 pieloplastias sin catéteres intrarrenales, 174 (54,5%) del lado izquierdo, 127 (39,8%) del lado derecho y 9 (5,6%) bilaterales. El intervalo de edad fue de14 días a 18 años, siendo el 58% de los niños menor de 12 meses. Con un seguimiento medio de 6,7 años (17 años a 11 meses), 312 pieloplastias (97,8%) fueron realizadas con éxito, con persistencia del patrón obstructivo en 7 pacientes que precisaron una nueva pieloplastia a cielo abierto (2,2%). Otras complicaciones fueron: drenaje prolongado (6), infección de herida (1) y fiebre/infección urinaria (2). La estancia media fue de 22 h. Conclusiones: La pieloplastia desmembrada a cielo abierto es altamente efectiva en el tratamiento de la estenosis pieloureteral en niños, y prescindir de los catéteres intrarrenales no perjudica su éxito (AU)

Purpose: In spite of advances in minimally invasive endoscopic surgery, open dismembered pyeloplasty continues to be used in many pediatric centers, especially in small children. The purpose of this work is to present our experience in the performance of this technique using a minimally invasive open pyeloplasty without intrarenal stents. Material and methods: A retrospective review was made of patients between July 1992 and July 2009. During this time, 348 patients underwent open dismembered pyeloplasty. A total of 310 patients (89%), 223 boys and 87 girls, underwent open pyeloplasty without intrarenal stent. The incision was from 2 to 2.5 cm in the flank. An extrarenal drain (3-5 days) and a bladder catheter (< 24 hs) were placed in all patients. Results: A total of 319 pyeloplasties were performed without intrarenal catheter in our Service. Of these, 174 (54.5%) were on the left side, 127 (39.8%) on the right side and 9 (5.6%) were bilateral. Age interval was 14 days to 18 years, 58% of the children being younger than 12months at the time of surgery. With a mean follow-up of 6.7 years (17 years to 11 months), 312pyeloplasties (97.8%) were successful, with persistence of the obstructive patient in 7 patients who required a new open pyeloplasty (2.2%). Other complications were: prolonged drainage (6), wound infection (1), and urinary infection (2). Mean stay was 22 hours. Conclusions: Open dismembered pyeloplasty is a safe and effective treatment choice for pyeloureteral stenosis in children and can be done without intrarenal stents with no detriment to its success (AU)

[Pyeloplasty without intrarenal stent in pediatric patients]. / Pieloplastia sin drenaje intrarrenal en pacientes pediátricos.

PURPOSE: In spite of advances in minimally invasive endoscopic surgery, open dismembered pyeloplasty continues to be used in many pediatric centers, especially in small children. The purpose of this work is to present our experience in the performance of this technique using a minimally invasive open pyeloplasty without intrarenal stents. MATERIAL AND METHODS: A retrospective review was made of patients between July 1992 and July 2009. During this time, 348 patients underwent open dismembered pyeloplasty. A total of 310 patients (89%), 223 boys and 87 girls, underwent open pyeloplasty without intrarenal stent. The incision was from 2 to 2.5 cm in the flank. An extrarenal drain (3-5 days) and a bladder catheter (< 24 hs) were placed in all patients. RESULTS: A total of 319 pyeloplasties were performed without intrarenal catheter in our Service. Of these, 174 (54.5%) were on the left side, 127 (39.8%) on the right side and 9 (5.6%) were bilateral. Age interval was 14 days to 18 years, 58% of the children being younger than 12 months at the time of surgery. With a mean follow-up of 6.7 years (17 years to 11 months), 312 pyeloplasties (97.8%) were successful, with persistence of the obstructive patient in 7 patients who required a new open pyeloplasty (2.2%). Other complications were: prolonged drainage (6), wound infection (1), and urinary infection (2). Mean stay was 22 hours. CONCLUSIONS: Open dismembered pyeloplasty is a safe and effective treatment choice for pyeloureteral stenosis in children and can be done without intrarenal stents with no detriment to its success.

Transperitoneal and retroperitoneal laparoscopic heminephrectomy--what approach for which patient?

PURPOSE: We report our experience with laparoscopic heminephrectomy using the transperitoneal and retroperitoneal approaches in 48 pediatric patients. MATERIALS AND METHODS: A total of 48 laparoscopic heminephrectomies were performed in 35 girls and 13 boys 45 days to 17 years old (mean 4.08 years) between September 1998 and March 2005. The procedures consisted of 44 upper pole heminephrectomies with partial or total ureterectomies and 4 lower pole heminephroureterectomies. Surgeries were performed using a transperitoneal approach in 32 patients (67%) and a retroperitoneal approach in 16 (33%). RESULTS: Followup ranged from 0.75 to 7.25 years (mean 3.53). In the retroperitoneal group 2 procedures required conversion, 1 to open heminephrectomy and 1 to a transperitoneal laparoscopic approach. Complications were seen in 5 of 48 patients (10%). Complications in the retroperitoneal group were seen in 2 patients. One patient had a postoperative urinary leak that resolved spontaneously. Another patient had development of a urinoma that was treated conservatively. Complications in the transperitoneal group were seen in 3 patients. One patient required an intraoperative chest tube due to pneumothorax, 1 had recurrent urinary tract infection that required excision of a short ureteral remnant and 1, 6-month-old boy had development of postoperative hypertension. Four of the 5 complications (80%) were seen in patients younger than 1 year. CONCLUSIONS: Transperitoneal and retroperitoneal laparoscopic heminephrectomy can be performed for benign disease in children with minimal morbidity, improved cosmesis and short hospital stay. Complication rate does not depend on the surgical approach, but rather on the age of the patient.

[Primary vesicoureteral reflux and extravesical ureteral reimplantation in chidren]. / Reflujo vesicoureteral esencial y reimplantación ureteral extravesical en niños.

PURPOSE: to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR). MATERIALS AND METHODS: In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications. RESULTS: The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique. CONCLUSIONS: The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases.

Reflujo vesicoureteral esencial y reimplantación ureteral extravesical en niños / Primary vesicoureteral reflux and extravesical ureteral reimplantation in children

Objetivos: Conocer los resultados de la reimplantación extravesical de Lich-Gregoire en el tratamiento quirúrgico del reflujo vesicoureteral (RVU) primario. Material y Métodos: En un período de 2,5 años se realizó un estudio retrospectivo no randomizado de 141 niños con RVU esencial sometidos a reimplante ureteral: 101 niños (158 uréteres refluyentes) por la técnica de Lich-Gregoire y 40 (68 uréteres) por la de Cohen. Se analizan los datos de los reimplantes extravesicales y se valoran: edad, indicaciones cirugía, días con sonda vesical, estancia hospitalaria y complicaciones a corto y largo plazo. Resultados: El tiempo medio de control ha sido de 1,71 años (Rango 8 meses a 3,5 años). A) Complicaciones precoces. No hubo ningún caso de obstrucción ureterovesical. Cinco niños (8,6% de los operados bilateralmente de forma simultánea) presentaron retención urinaria pero sólo tres necesitaron recolocación de sonda vesical y uno sólo de sondaje intermitente temporal. Las nauseas y vómitos, el dolor y la hematuria fueron escasos. B) Complicaciones tardías. Los resultados a largo plazo son buenos en el 95%. Se observó RVU persistente en 7 uréteres (4,4%) y RVU contralateral en 3 niños (6,7% de los casos unilaterales). Sólo precisaron nuevo tratamiento quirúrgico 3 uréteres (2%) con RVU ipsilateral persistente. Se compararon los resultados de la técnica de Lich-Gregoire con la de Cohen y se observó que en la extravesical eran significativamente menores el número de complicaciones, dolor, hematuria, días con sonda vesical y estancia hospitalaria. Conclusiones: La técnica de Lich-Gregoire es un procedimiento de corta estancia hospitalaria, efectivo para la corrección del RVU, que origina menos molestias, dolor, hematuria y días de ingreso que las técnicas intravesicales. No obstante puede ocasionar disfunción vesical transitoria en los casos bilaterales

Purpose: to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR). Materials and methods: In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications. Results: The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique. Conclusions: The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases

Ureteral replacement using the Yang-Monti principle: long-term follow-up.

OBJECTIVES: To present the long-term results for 2 patients with ureteral replacement using reconfigured transversely tubularized bowel segments according to the Yang-Monti principle. METHODS: Between May 1999 and November 2001, 2 patients underwent ureteral replacement at our institution using a reconfigured ileal segment in one and colon in the other. The first patient was a 33-year-old man who had lost 6 cm of the proximal left ureter after two attempts to repair a ureteral stricture. A reconfigured small bowel tube was interposed between the proximal and distal ureteral stumps after excision of the left ureteral stricture. The second patient was a 66-year-old woman with a poorly functioning right kidney and total bilateral ureteral strictures resulting from radiotherapy for metastatic cervical cancer. She underwent complete left ureteral substitution with a double Monti sigmoid tube in association with a Boari flap. RESULTS: With a follow-up of 5.75 and 3.25 years, both patients were clinically doing well with a stable split renal function on mercaptotriglycylglycine renal scan and no evidence of obstruction. The man had required exploratory laparotomy 4 weeks postoperatively to correct a small bowel obstruction secondary to a bowel kink. CONCLUSIONS: The transverse tubularized bowel tube is an effective technique for partial and complete ureteral replacement with sustained, good, long-term results. Reconfigured tubes of small or large bowel seem to promote an equally efficient urine transport mechanism that persists unaltered for long periods.

Bladder neck sling for treatment of neurogenic incontinence in children with augmentation cystoplasty: long-term followup.

PURPOSE: We retrospectively reviewed the outcome and long-term followup (mean 4.16 years) of bladder neck slings for the treatment of neurogenic urinary incontinence in 58 patients (15 males) who also underwent bladder augmentation. MATERIALS AND METHODS: A total of 58 patients with neurogenic bladder (43 females and 15 males, median age 11.4 years) underwent a rectus fascial sling procedure as part of the reconstructive efforts for continence between July 1991 and July 2003. Criteria for enhancement of bladder outlet resistance included a detrusor leak point pressure of less than 45 cm H2O, an open bladder neck during bladder filling at low detrusor pressures and clinical evidence of stress incontinence. RESULTS: Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). A total of 51 patients (88%) obtained good continence results. Five females and 2 males remained incontinent following the sling procedure. Four females underwent a secondary open bladder neck procedure at a mean of 18 months after the initial procedure (artificial urinary sphincter in 2, bladder neck closure in 2). Two male patients (5 and 17 years old) had daily underwear staining or dampness with exercise or transfer. CONCLUSIONS: We consider bladder neck slings the procedure of choice for the enhancement of bladder outlet resistance in the majority of patients with neurogenic bladder who need augmentation cystoplasty and whom we do not expect will be capable of voiding spontaneously. In males and females satisfactory long-term continence can be expected with the use of the rectus fascial sling.

[Versatility of Snodgrass technique for the correction of different types of hypospadias]. / Versatilidad de la técnica de Snodgrass para la corrección de diferentes tipos de hipospadias.

OBJECTIVE: To present our experience with the Snodgrass technique for primary hypospadias repair and for reoperations. METHODS: From May 1996 to August 1998, the Snodgrass technique was performed on 97 patients with hypospadias; 72% were distal, 19.5% were midshaft and 8.5% were proximal. Of these patients, 8.5% had a previous hypospadias repair. The patients were followed for a period of two years. RESULTS/CONCLUSIONS: Complications, including fistulas, occurred in 4 patients. The cosmetic results were excellent and there were no complications in patients who had a previous urethroplasty.

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue.

PURPOSE: Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy. MATERIALS AND METHODS: During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed. RESULTS: We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date. CONCLUSIONS: There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Clinical applications of the Monti procedure as a continent catheterizable stoma.

OBJECTIVES: Monti et al. recently described a technique for the construction of a continent catheterizable conduit using short segments of small bowel in a canine model. We review our experience with 25 adult and pediatric patients in whom the Monti procedure was used in their reconstructive efforts. METHODS: Since October 1995, 25 patients (13 males and 12 females), aged 4 to 67 years (median 29), underwent the construction of 29 catheterizable stomas with a short (2.5 cm) segment of bowel following the Monti technique. Twenty-seven tubes were created as urinary stomas and two as part of the Malone antegrade continent enema procedure (MACE). Continence is based on the Mitrofanoff flap valve mechanism. Tubes were created when the appendix was unavailable as part of urinary reconstructive efforts or after exenterative oncologic surgery of the lower urinary tract. Tubes were created using ileum (24) and sigmoid colon (5). Ten tubes (34.5%) were done in combination with a simultaneous bowel patch in the same pedicle for bladder augmentation. Tubes were implanted in the ileum (13), bladder (9), sigmoid colon (3), stomach (1), and descending colon (1). The two tubes created to do a MACE procedure were anastomosed into the cecum. Double tubes were necessary in 7 adult patients for adequate length. The length of the tubes varied from 6 to 14 cm. RESULTS: Follow-up ranged between 3 and 26 months (mean 13). One adult patient (4%) with bladder cancer died of myocardial infarction 14 days postoperatively. Three patients (12%) received a new Monti tube because of ischemic stenosis of the tube. All of them were continent at a follow-up of 1, 6, and 20 months, respectively. Two patients (8%) experienced leakage through the stoma, requiring additional procedures and pharmacologic manipulation to become continent. All patients used intermittent catheterization through the stoma without problems. CONCLUSIONS: Although the appendix remains the tissue of choice, the Monti procedure has substantial advantages over other efferent catheterizable tubes, including the need for a very short segment of bowel (2.5 cm), adequate lumen size (16F to 18F), length, reliable blood supply, and the versatility to combine with a simultaneous bowel patch in the same pedicle for bladder augmentation.

Defining the role of the bladder-neck sling in the surgical treatment of urinary incontinence in children with neurogenic incontinence.

Patient selection for the creation of a fascial sling procedure to increase outlet resistance has been somewhat controversial. We review our experience with the fascial sling technique and report our patient selection process. Since 1991, 30 patients, including 6 males and 24 females aged 4-20 years (mean 10 years), underwent a rectus fascial sling procedure as part of their reconstructive efforts for continence. The underlying cause of incontinence was neurogenic in 28 patients. All males were prepubertal. Videourodynamics were performed in all patients preoperatively. Criteria for enhancement of bladder-outlet resistance included a detrusor leak-point pressure (LPPd) of < 50 cmH2O; a stress leak-point pressure (LPPs) of < 100 cmH2O; an open bladder neck, irrespective of LPP, and clinical evidence of stress incontinence, irrespective of videourodynamic parameters. Technical aspects of the procedure are discussed. Augmentation cystoplasty was performed in 29 patients with poor bladder compliance. In 18 patients a catheterizable stoma was also created. The period of follow-up currently ranges from 2 to 70 (mean 37) months. In all, 28 patients (93%) became continent and 2 female patients remain incontinent with a low LPP. All patients are on clean intermittent catheterization (CIC); 12 patients (40%) are catheterizing per urethra without difficulty. All prepubertal males are completely dry. The fascial sling repair has many advantages over other methods for increasing outlet resistance, including simplicity of technique, effectiveness, minimal likelihood of erosion, and low cost.

Refashioned short bowel segments for the construction of catheterizable channels (the Monti procedure): early clinical experience.

PURPOSE: We report the early results of a new surgical procedure to construct a catheterizable stoma from a small segment of bowel according to the Monti technique. MATERIALS AND METHODS: Since November 1996, 4 male and 4 female patients with a mean age of 14 years have undergone the Monti procedure in association with other reconstructive efforts. Indications included the unavailability of appendix because of concomitant ACE Malone appendicocecostomy in 2 patients, atretic appendixes in 3, previous appendectomy in 2 and technical difficulties during appendix isolation in 1. In no patient was small bowel used instead of a suitable appendix. Other simultaneous surgical procedures included bladder augmentation in 4 patients in whom the bowel tube and patch for augmentation were created with the same mesenteric pedicle (ileum in 3 and sigmoid colon in 1). RESULTS: Followup ranged from 3 to 11 months (mean 7). No patient has had difficulty with catheterization or any other problems related to the stoma. In 2 patients stomal leakage required additional procedures and pharmacological manipulation. CONCLUSIONS: The appendiceal Mitrofanoff procedure remains the technique of choice for the construction of catheterizable continent stomas. In the absence of a suitable appendix a catheterizable bowel conduit based on the Monti technique appears to be the best alternative in our early experience. The short segment of bowel required for conduit construction, excellent blood supply throughout its length, and the possibility of developing the tube and bowel patch for simultaneous augmentation from the same pedicle are some of the clear advantages of this technique.

Ampliaciones vesicales con uéter en pediatría / Bladder augmentation with ureter in children

Las ampliaciones vesicales son eficaces para aumentar la capacidad y mejorar la acomodación vesical en pacientes que no responden al tratamiento farmacológico con oxibutinina. Se publicaron varias clases de complicaciones con ampliaciones con segmenbtos gastrointestinales y logra buenos resultados urodinámicos ; no obstante, su indicación está limitada fundamentalmente por la superficie uretral disponible. De un total de 68 ampliaciones y reemplazos vesicales realizados durante un período de 9 años, en 5 de ellos se utilizó uréter detubularizado con o sin una nefrectomía unilateral, en niños de entre 6 y 8 años de edad. Los controles postoperatorios oscilan entre 2 y 50 meses. Cuatro de los pacientes realizan cateterismo intermitente limpio y uno orina espontáneamente. El último precedimiento se realizó por vía extraperitoneal. En todos los pacientes la función renal se mabtuvo estable o mejoró , con disminución de la hidronefrosis y desaparición del reflujo vesicoureteral. La capacidad vesical aumentó entre 120 y 300 por ciento con presión del detrusor de 30 cm de H2O. La ureterocistoplastia logra una buena acomodación y capacidad vesical evitando el uso de la mucosa extraurinaria

Ampliaciones vesicales con uéter en pediatría / Bladder augmentation with ureter in children

Las ampliaciones vesicales son eficaces para aumentar la capacidad y mejorar la acomodación vesical en pacientes que no responden al tratamiento farmacológico con oxibutinina. Se publicaron varias clases de complicaciones con ampliaciones con segmenbtos gastrointestinales y logra buenos resultados urodinámicos ; no obstante, su indicación está limitada fundamentalmente por la superficie uretral disponible. De un total de 68 ampliaciones y reemplazos vesicales realizados durante un período de 9 años, en 5 de ellos se utilizó uréter detubularizado con o sin una nefrectomía unilateral, en niños de entre 6 y 8 años de edad. Los controles postoperatorios oscilan entre 2 y 50 meses. Cuatro de los pacientes realizan cateterismo intermitente limpio y uno orina espontáneamente. El último precedimiento se realizó por vía extraperitoneal. En todos los pacientes la función renal se mabtuvo estable o mejoró , con disminución de la hidronefrosis y desaparición del reflujo vesicoureteral. La capacidad vesical aumentó entre 120 y 300 por ciento con presión del detrusor de 30 cm de H2O. La ureterocistoplastia logra una buena acomodación y capacidad vesical evitando el uso de la mucosa extraurinaria(AU)