Psoas hitch procedure in 166 adult patients: The largest cohort study before the laparoscopic era.

Objectives: To present the short-term and long-term outcomes of the psoas hitch procedure in a large cohort with long-term follow-up. Patients and methods: A multicenter, retrospective cohort study was conducted. Patients were included if they had undergone an open psoas hitch procedure with ureteral reimplantation for different types of distal ureteral pathology between 1993 and 2017. Clinical failure was defined as radiologically-proven obstruction of the ureteroneocystostomy and/or post-operative complaints requiring additional surgery. Pre-operative demographic data and post-operative radiological imaging were collected. Complications were categorized as peri-operative, acute (<30 days), and long-term complications. Results: A total of 166 patients had undergone a psoas hitch procedure, with a median follow-up of 15 months (IQR 6-45). Indications for the procedure included intra-operative injury of the ureter during gynecological, urological or general surgery, transitional cell carcinoma of the distal ureter, fistulae, (radiation) fibrosis, and trauma. There was no significant difference in pre- and post-operative estimated glomerular filtration rate. Post-operative complications included urinary leakage, recurrent urinary tract symptoms, recurrent malignancy, and kidney failure. Postoperative imaging was available in 143 patients. Failure of the psoas hitch procedure was seen in 8% (11/143) of the patients. In 55% (6/11) of these patients, radiation fibrosis was the indication for the psoas hitch procedure. Conclusion: This study provides greater insight into the long-term complications of the open psoas hitch procedure in adults. The psoas hitch procedure can be considered a safe procedure for restoring the continuity of the ureter for different types of ureteral pathologies in adult patients. However, patients with a history of radiation therapy causing retroperitoneal fibrosis might be more prone to failure after the procedure.

SENS-U: continuous home monitoring of natural nocturnal bladder filling in children with nocturnal enuresis - a feasibility study.

INTRODUCTION: Enuresis is a common problem in children. One treatment option is a wetting alarm that provides an alarm when incontinence occurs. A drawback of this approach is that the child is still awakened by wet sheets. Recently, a wearable, wireless ultrasonic bladder sensor became available, the SENS-U, which has the potential to prevent the enuretic event by waking up the child before the bladder is full. In this first feasibility study, the aim is to perform a night-time, home-based evaluation of the SENS-U in children with monosymptomatic nocturnal enuresis (MNE). PATIENTS AND METHODS: In this study, children (6-12 years) with MNE were included for a one-night monitoring session. During the night, the SENS-U continuously (i.e. every 30 s) estimated the filling status [notifications were deactivated]. In addition, urine volume was collected in a measurement cup (or diaper weight). The total measured natural nocturnal bladder filling (NNBF) cycles was analyzed by descriptive statistics. Before and after the measurement, sleep behavior was assessed by a selection of the Children's Sleep Habits Questionnaire. RESULTS: Fifteen patients (boys/girls: 13/2) [mean age: 8.6 ± 1.5 years] have been enrolled. One patient was excluded due to inadequate sensor-to-skin contact. For 14 children, 18 NNBF cycles were recorded (voiding diary) of which three patients (21%) had more than one NNBF cycle. The SENS-U was able to successfully detect 83% of the NNBF cycles. The three missed NNBF cycles had a voided volume ≤30 ml, which was at the lower limit of the sensor's detection range. The SENS-U had no effect on sleeping behavior. CONCLUSION: The SENS-U was able to monitor the natural nocturnal bladder filling successfully in children with monosymptomatic nocturnal enuresis at home, without disturbing their sleep. Future research focuses on investigating the usability of the SENS-U for both diagnostic - and treatment purposes.

SENS-U: clinical evaluation of a full-bladder notification - a pilot study.

INTRODUCTION: Urinary incontinence is one of the most commonly treated disorders in children at school age. Recently, a new, wearable bladder sensor became available, the SENS-U Bladder Sensor. The SENS-U is a small, wireless ultrasonic sensor, which continuously monitors the bladder filling and provides a personalized notification when it is time to go to the toilet. In this study, the aim was to examine the performance of the SENS-U as a full-bladder-based notification system in children during daily life activities. PATIENTS AND METHODS: In this pilot study, children (6-16 years) who were admitted for an inpatient bladder training were included. Parallel to one training day, the child would wear the SENS-U to estimate the bladder filling and it informed the child when the bladder was almost full. When the child received a full-bladder notification, the child was taught to inform the urotherapist/researcher, in order to determine the level of response. RESULTS: Fifteen patients (boys/girls: 7/8; mean age: 11.5 ± 1.7 years) were included. Based on a personalized volume-based threshold, the SENS-U notified these children of a full bladder with a median notification rate of 92.9%. In the remaining cases, children voided before the threshold was reached (e.g. defecation). Children responded positively to the notification of the SENS-U, resulting in a median level of response equal to 100%. CONCLUSION: The SENS-U was able to monitor the natural bladder filling accurately during activities of daily living and provided a personalized notification to the children when it was almost time to go to the toilet. Future research will focus on investigating the efficacy of the SENS-U compared to daily clinical practices.

SENS-U: validation of a wearable ultrasonic bladder monitor in children during urodynamic studies.

PURPOSE: Urinary incontinence is a common problem in school-age children. Because many children remain unaware of a full-bladder sensation, the SENS-U™ Bladder Sensor was developed. The SENS-U is a small, wearable ultrasound sensor, which is positioned on the lower abdomen using a skin-friendly adhesive. The sensor continuously estimates the bladder filling status and informs the user when it is time to go to the toilet. In this study, the clinical performance of the SENS-U is evaluated in children during (video) urodynamics. MATERIAL AND METHODS: In this study, 30 children (6-12 years) were included who were scheduled for a (video) urodynamic study. During urodynamics, the SENS-U determined the average anterior-posterior (A-P) bladder dimension (every 30 s) to estimate the filling status. The correlation between the average A-P bladder dimension and the infused volume is analyzed by Spearman's correlation. RESULTS: Thirty patients (boys/girls: 15/15; mean age: 7.9 ± 1.4 years) were included, in whom the SENS-U detected the full bladder before voiding in 90% of the patients (27/30). In the other patients, the bladder was outside the detection area due to either erroneous sensor placement (n = 1) or an (relative) obese abdomen in the upright position (n = 2). There was a strong correlation (median rs = 0.94) between the average A-P bladder dimension and the infused volume. The detectable maximum bladder volume ranged between 71 and 463 ml. CONCLUSION: The SENS-U is able to detect a full bladder with a success rate of 90%. When excluding erroneous data due to sensor misplacement or an (relative) obese abdomen, the detection rate may even be higher. Future research will focus on investigating the effect of theSENS-U in incontinence training.

The Double Dutch technique: A new way of creating an ileocystoplasty with a lengthy catheterizable ileal tube.

INTRODUCTION: A tubularized conduit from an open 2-cm vascularized ileal segment is a frequently used technique to create a continent catheterizable channel in cases of an inappropriate or absent appendix. In the long term, many patients experience catheterization problems with the classic ileal segment tube, and even more with spiral or double-segment tubes. OBJECTIVE: The objective of this paper was to introduce an ileocystoplasty modification combined with a long ileal segment tube that has better support by surrounding tissue than other lengthy ileal segment tubes. Briefly summarized, this newly introduced method begins with isolating approximately 30 cm of ileum and dividing it into two parts. Two strips are then created and closed as a double-length tube. The ileal segments are opened antimesenterically and closed over the tube in the middle. The lower part of the tube is implanted with a submucosal tunnel in the bladder wall, and the ileal patch is then anastomosed with the bladder. The tube is anastomosed to the umbilicus in an ordinary way without any traction (see Summary Fig.). STUDY DESIGN: Between May 2005 and November 2012 the new technique was used at the current institution in nine children who needed an ileocystoplasty (mean age: 9 years and 3 months). Underlying etiology was neurogenic bladder in seven cases and epispadias in two. RESULTS: All patients ultimately had stomas without leakage or strictures. During follow-up, three of nine tubes developed stenoses that were corrected; four stomas in total had some sort of surgical revision. Median follow-up was 93 months. Intermittent catheterization was uncomplicated in all at this time. DISCUSSION: With this modification of the standard technique it seemed to be possible to create a more stable channel. The blood supply of the tube was secured by completely embedding the mesentery of the tube. Limitations included the small number of patients treated so far. CONCLUSION: The lengthy tubes appeared to be straight and well supported by the surrounding tissues, which prevented kinking and sacculation. It is hoped that this technique will have better results and fewer complications at long-term follow-up.

Early hypophosphatemia in preterm infants receiving aggressive parenteral nutrition.

OBJECTIVE: To report the prevalence of hypophosphatemia during the first week of life in preterm infants receiving aggressive parenteral nutrition and to analyze population variables associated with severe hypophosphatemia. STUDY DESIGN: A retrospective cohort of 61 neonates below 1250 g birth weight consecutively born at Hospital Italiano de Buenos Aires exposed to high caloric and protein intake from the first day of birth. Primary outcome was hypophosphatemia (phosphate <4 mg dl(-1)). A one-sample mean comparison test was used to compare our sample with a hypothesized population mean. RESULTS: The prevalence of hypophosphatemia was 91% (95% confidence interval (CI) 82 to 97%). The mean phosphatemia value was 2.52 mg dl(-1) (95% CI 2.18 to 2.86), significantly different from the hypothesized population mean (P<0.001). Patients with severe hypophosphatemia (<2 mg dl(-1)) were smaller. They presented with sepsis more frequently and received more vasoactive drugs and mechanical ventilation. CONCLUSION: The prevalence of hypophosphatemia in this group of preterm infants is high. The potential association with adverse clinical outcomes deserves further research.

Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre.

BACKGROUND: Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. OBJECTIVE: To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). STUDY DESIGN: The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. RESULTS: Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. DISCUSSION: There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. CONCLUSION: Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.

The colon shuffle: A modified urinary diversion.

AIM: To assess the results of a urinary diversion in patients who already have a colostomy or simultaneously require a (rectum) colon resection. The diversion is created from the distal part of the transected colon with a simultaneously created new colostomy contra-laterally (if necessary). This procedure is known in our institute as the 'colon shuffle'. MATERIALS AND METHODS: All patients who underwent a colon shuffle in the period of 2003 and 2013 in our institute (Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital) were identified. Comorbidity was scored using the Charlson comorbidity index. Local or systemic treatment prior to surgery was reported (e.g. external beam radiotherapy, systemic chemotherapy). Surgical complications were reported according to the Clavien-Dindo classification. RESULTS: Twenty-one patients (14 male; 7 female) underwent a colon shuffle procedure in our institute, with a mean age of 61.5 years. The majority (90.4%) of these patients had been subjected to radiotherapy on the pelvic region in the past. Although short-term complications (<30 days) were seen in 52.4% of these patients, major complications such as anastomotic leakage of the bowel and fecal peritonitis were not seen in this high-risk group of patients. CONCLUSION: The colon shuffle offers an elegant solution for patients who require a urinary diversion simultaneously with a colostomy or for patients who already have a colostomy from previous surgery.

Epispadias in boys with an intact prepuce.

OBJECTIVE: To present an overview of the clinical presentation and pathological anatomy, and the results of surgical correction of 7 cases of epispadias with intact prepuce; a rare condition that has only occasionally been reported in literature. PATIENTS AND METHODS: A retrospective search was performed in the surgical and diagnoses database between 1991 and 2011. Seven cases of epispadias with intact prepuce were identified. Five presented as a webbed and buried penis, 1 as phimosis and 1 with suspicion for congenital anomaly of the genitalia. RESULTS: In 3 of 7 cases, epispadias was suspected or diagnosed at first presentation and could be surgically corrected in the first intervention. In the other 4 cases, epispadias was discovered during surgery, requiring an additional intervention to perform epispadias repair in 3 cases. One boy was diagnosed with glandular, 3 with coronal, 1 with shaft and 2 with penopubic epispadias. Epispadias repair was successful with regard to cosmesis and erectile function. Five patients developed normal continence after surgery, 1 after intensive urotherapy. An under average penile length was the main reported problem during follow-up. CONCLUSION: In the diagnostic process for a concealed penis, the possibility of epispadias should be considered. If epispadias is suspected or confirmed, epispadias repair can occur in the first intervention, reducing the number of additional interventions. Epispadias with intact prepuce appears to have a better prognosis concerning urinary continence compared to classical epispadias.

Wrap plication of megaureter around normal-sized ureter for complete duplex system reimplantations.

PURPOSE: A duplex collecting system is a common congenital renal tract abnormality associated with different clinical problems. We describe our experience with ureteral reimplantations of a complete duplex collecting system where 1 megaureter needing recalibration and 1 normal-sized ureter coexisted. Recalibration of the megaureter was done by wrap plication around the normal-sized ureter. MATERIALS AND METHODS: Operative logs and case notes were reviewed of consecutive children with a complete duplex collecting system treated with wrap plication of the megaureter around the normal-sized ureter and reimplantation between 1997 and 2010. Reoperation, vesicoureteral reflux and obstruction rates were assessed. RESULTS: A total of 25 children underwent wrap plication and ureteral reimplantation. Of the cases 19 (76%) were completely successful and 6 (24%) needed reoperation. Three children (12%) had persistent high grade vesicoureteral reflux, 2 (8%) underwent endoscopic correction and 1 (4%) underwent repeat reimplantation of the duplex system. Three children (12%) had postoperative obstruction and 2 (8%) underwent endoscopic incision of the ureteral orifice. In 1 child (4%) a nonfunctioning lower moiety of the kidney developed, which was managed by heminephrectomy. CONCLUSIONS: Wrap plication of a megaureter around the normal-sized ureter before reimplantation seems to be a relatively safe method in the surgical management of children with a complete duplex collecting system of the kidney. Sufficient spatulation of the lower pole ureter seems to be crucial.

Long-term results of bulking agent injection for persistent incontinence in cases of neurogenic bladder dysfunction.

PURPOSE: We evaluated the effectiveness of bladder neck injection as a supplementary treatment for persistent low pressure incontinence after unsatisfactory fascial sling procedures in patients with neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS: A total of 89 patients with neurogenic lower urinary tract dysfunction underwent fascial sling procedures between 1992 and 2005. Because of unsatisfactory results, 27 patients received endoscopic injection of a bulking agent. All patients included in the study underwent urodynamic examination after the sling procedure, which revealed persistent low pressure transurethral leakage of urine. We retrospectively analyzed the endoscopic approach used to administer the bladder neck injection, method of postoperative catheterization and number of injections given. Efficacy of bladder neck injection was graded by the patient and the urologist. RESULTS: After a median followup of 8 years (range 2.5 to 14) only 2 patients (7%) were continent after having received a single injection of bulking agent. A total of 12 patients (44%) were given a second injection and 8 (30%) were given a third injection but these subsequent injections did not result in continence. Of the patients 16 (59%) eventually underwent bladder neck surgery, 2 (7%) were dry and 8 (30%) accepted the inconvenience. Two patients underwent ileocystoplasty and 1 patient underwent botulinum A toxin (Botox(R)) injection due to decreased bladder capacity and poor bladder compliance. Neither the endoscopic approach nor the method of postoperative catheterization affected the success rate. CONCLUSIONS: Bladder neck injection after failure of primary sling procedures has limited value in patients with neurogenic lower urinary tract dysfunction. Repeat bladder neck injection yields no additional benefits.

Detrusorectomy for neuropathic bladder in patients with spinal dysraphism.

PURPOSE: We assess the outcome of detrusorectomy in 35 patients with spina bifida who were incontinent due to poor bladder volume or poor compliance. MATERIALS AND METHODS: Of 51 patients requiring bladder augmentation 35 underwent detrusorectomy. In 3 patients ileocystoplasty was later performed as a secondary procedure because of failure of the detrusorectomy. RESULTS: A total of 35 patients (17 males, 18 females) underwent detrusorectomy. Mean patient age at operation was 9.9 years (range 0.4 to 17.8). Mean followup was 4.9 years (range 1 to 10.5). A continent catheterizable vesicostomy was constructed in 14 patients and ureteral reimplantation was performed in 8. Twenty-five patients also underwent sling and/or Burch cystourethropexy during detrusorectomy, of whom 19 are continent and 5 have some leakage between clean intermittent catheterizations. In 1 girl the sling procedure was not successful, and she was subsequently treated with bladder neck closure. Bladder compliance after operation was improved in 9 cases and unchanged in 10. Of the 16 patients in whom compliance was already acceptable before the operation and was unchanged after detrusorectomy 7 were able to stop antimuscarinic therapy. Compliance became poor in 4 cases, of which 3 required ileocystoplasty. Bladder volume (as a percentage of normal volume for age) was increased after detrusorectomy in 13 patients, unchanged in 11 and decreased in 11. Complications of detrusorectomy included bladder leakage in 2 cases. One patient needed a laparotomy because of urinary ascites shortly after the operation. CONCLUSIONS: Detrusorectomy may be combined with other procedures such as ureteral reimplantation, slingplasty and continent vesicostomy. Of 35 treated patients compliance improved in 16 (46%),volume improved in 13 (37%), 3 had no change in parameters, and 3 had a slight decrease in volume and compliance. Four patients had poor results, of whom 3 needed a secondary ileocystoplasty. Therefore, it may be concluded that detrusorectomy is a safe and probably useful procedure for improvement of bladder volume and compliance in patients with neurogenic bladder dysfunction, and may obviate the need for ileocystoplasty in a limited number of patients.

Bladder-sphincter dysfunction in myelomeningocele.

Pediatric urodynamics taught us that detrusor-sphincter dyssynergia creates a bladder outlet obstruction in about 50% of any population of children with myelomeningocele. This functional obstruction causes renal damage due to obstructive uropathy, exactly the same way as a congenital anatomical urethral obstruction does. Pediatric urodynamics also taught us that in children with myelomeningocele pelvic floor activity and detrusor activity can be abnormal (hyperactive or inactive) completely independent from each other. These insights have changed the management of myelomeningocele. Children with overactivity of the pelvic floor can be singled out at infant age, and started on clean intermittent catherization, to prevent obstructive uropathy and preserve renal function. Children with detrusor overactivity can be singled out too at very early age, and treated with anticholinergics, to prevent irreversible structural damage to the detrusor and preserve normal bladder capacity and compliance.

Results of preputial reconstruction in 77 boys with distal hypospadias.

PURPOSE: There is growing interest in preputial reconstruction combined with hypospadias repair. We retrospectively analyzed its results for future developments and patient information. MATERIALS AND METHODS: We evaluated 77 boys who underwent distal hypospadias repair combined with preputial reconstruction to determine complications, risks and failures. RESULTS: At a mean followup of 2.5 years 52 patients had an anatomically normal penis with a normal retractable foreskin, while 25 (33%) presented with a complication. The most common complications were partial dehiscence, and fistula of the prepuce and urethra. There was a complication of the reconstructed foreskin only in 16 cases (21%), a combined problem with the reconstructed foreskin and reconstructed urethra in 7 (9%), and a problem with the reconstructed urethra in 2 (3%). Of the 25 patients with complications 19 underwent reoperation with closure of the fistula or dehiscence and 5 were circumcised, while in 1 the parents accepted the minor cosmetic problem and refused reoperation. CONCLUSIONS: Preputial repair combined with hypospadias repair may lead to anatomically correct reconstruction of the penis at the cost of a 33% complication rate. Parents are informed about this risk and to date in 15% of all boys with distal hypospadias the parents have elected preputial reconstruction.

The treatment of post-urethrotomy incontinence in pediatric and adolescent females.

PURPOSE: Until 1986 many urologists performed currently outdated, redundant internal urethrotomy as standard therapy for recurrent urinary tract infection in girls. We describe the results of therapy in patients who became incontinent due to previous internal urethrotomy. MATERIALS AND METHODS: Between 1986 and 1995, 21 female patients with post-Otis urethrotomy incontinence have presented at our department with combined dysfunctional voiding, recurrent urinary tract infection and various types of urinary incontinence partially based on bladder instability and often provoked by abdominal straining. All cases were diagnosed by repeat video urodynamics and ultrasound of the open bladder neck. Endoscopy provided proof of scarring in the bladder neck and urethra. All patients except 1 underwent conservative treatment for at least 2 years, consisting of pharmacological therapy, physical therapy and biofeedback training. Surgical therapy to cure incontinence was performed in 14 cases, including a conventional Burch-type colposuspension in 5, modified needle colposuspension in 4 and complete endoscopic excision of the urethral scars followed by open reconstruction of the bladder neck and urethra in an abdominoperineal procedure in 5. RESULTS: Conservative treatment has been completely successful in 7 patients. Primary open or needle colposuspension was unsuccessful in 6 of 9 cases, including several requiring further surgery to achieve dryness. The results of excising urethral scars with bladder neck and urethral reconstruction were good in 4 of 5 patients at a followup of at least 4 years. CONCLUSIONS: When previous internal urethrotomy appears to be an important factor in the evaluation of incontinence, conservative therapy is the treatment of choice. Conservative therapy should consist of biofeedback reeducation of the voiding pattern and physical therapy. When surgery is needed, excision of the urethral scars with reconstruction of the bladder neck and urethra plus colposuspension is superior to colposuspension only.

Ectopic ureterocele: results of open surgical therapy in 40 patients.

PURPOSE: The treatment of ectopic ureterocele is controversial. In addition to debate on optimal therapy, discussion exists on whether there is further risk of deteriorating bladder function after extensive bladder surgery during the first year of life, which is a reason to postpone surgery. In a prospective nonrandomized trial we treated 40 patients regardless of age who had ectopic ureterocele with complete surgical reconstruction of the lower urinary tract and upper pole resection of poorly functioning upper pole moieties at referral. Excluded from study were 3 patients with only 1 affected renal moiety initially. MATERIALS AND METHODS: We treated 31 female and 9 male patients 0 to 8.8 years old (mean age 2.17) at surgery for ectopic ureterocele extending into the bladder neck and urethra, including 19 younger than 1 year. Primary ureterocele excision was performed in 37 cases with reconstruction of the urethra, bladder neck and trigone, and ureteral reimplantation. Because of small ureterocele size, the ureterocele was left in situ in 3 patients, leading to secondary ureterocele removal due to obstructive voiding and urinary incontinence in 1 each. A staged procedure in 5 neonates involved primary lower urinary tract reconstruction with upper pole cutaneous ureterostomies followed by upper pole resection or ureteral reimplantation a few months later. After bladder neck reconstruction in 16 cases colposuspension was also done to create a normal vesicourethral angle. All patients underwent clinical and urodynamic evaluation at least 1.25 years after surgery (mean followup 5.59). Patients who were too young for the clinical assessment of continence by January 1999 were excluded from study. RESULTS: All patients are continent. A secondary endoscopic procedure was required in 13 cases, including cystoscopy only in 2, scar incision near the ureteral orifice in 3, endoscopic reflux treatment in 4, ureterocele remnant resection in 2 and bladder neck incision for obstructive voiding in 2. Secondary open bladder reconstruction was performed in another case due to a diverticulum. Postoperatively only 1 or 2 uncomplicated episodes of urinary tract infection developed in 11 patients, while there were recurrent urinary tract infections in 4. In a patient with a preexisting loss of renal function a severe infection led to renal scarring. The voiding pattern was normal in 29 patients but 11 had dysfunctional voiding, including 5 with recurrent urinary tract infection. Urodynamic followup confirmed these clinical findings. Bladder capacity in these patients was relatively high at an average of 124% of expected capacity for age. We noted no statistically significant difference in followup parameters in patients who underwent surgery before and after age 1 year. Additional colposuspension in 16 patients did not result in any significant change in outcome compared with that in patients without this procedure. CONCLUSIONS: When compared with results in the literature, complete primary lower urinary tract reconstruction in patients with ectopic ureterocele appears to have better results than a staged approach with initial endoscopic treatment. Moreover, our study provides no proof that extensive reconstructive bladder surgery in neonates and infants leads to bladder function deterioration at a later age.

Female epispadias repair: a new 1-stage technique.

PURPOSE: Female epispadias is a rare anomaly. According to the literature it is usually treated with staged procedures, including bladder neck reconstruction, to achieve continence. We developed a 1-stage surgical technique that offers the possibility of achieving continence and a cosmetically normal appearance of the vulva. MATERIALS AND METHODS: We treated 4 patients 4 months to 8 years old. The main point of the technique is to free completely the urethral plate and bladder neck from surrounding tissue. After tubularizing the urethral plate into a urethra modified needle suspension brings the bladder neck and proximal urethra into the intra-abdominal position. The pelvic floor is then reconstructed between the anterior vaginal wall and urethra. Thus, continence may be attained by intra-abdominal positioning of the bladder neck and proximal urethra as well as by pelvic floor reconstruction. RESULTS: Of our 4 consecutive cases of primary untreated epispadias the technique proved successful in 3, while followup is too short in 1. One patient is completely dry and voids without a further procedure. Postoperatively 2 patients with 5 years or more of followup required injection of a bulking agent at the bladder neck level to achieve continence, including 1 who is damp during the day without the need to change clothes and 1 on clean intermittent catheterization twice daily because post-void residual urine volume causes recurrent urinary tract infection. CONCLUSIONS: The described technique is promising for treating this disabling anomaly.

Urinary continence and erectile function after bladder neck sling suspension in male patients with spinal dysraphism.

OBJECTIVE: To assess the outcome of using sling suspensions combined with clean intermittent catheterization (CIC) in patients with spina bifida, of whom a third are incontinent through pelvic floor paralysis. PATIENTS AND METHODS: Between March 1992 and April 1997, 14 male patients (mean age at surgery 11.7 years, range 6.5-15.2) with spina bifida and neurogenic sphincter incontinence underwent a puboprostatic sling suspension as a primary treatment. The procedure, via an abdominoperineal approach, consists of suspending the bladder neck by placing a simple U-shaped rectus abdominus fascial sling. The perineal approach is used to develop the plane between the rectum and Denonvillier's fascia, and to prepare the passage of the sling alongside the prostate. Apart from the sling procedure, eight of the 14 patients underwent autoaugmentation of the bladder and two underwent ileocystoplasty during the same operation. All patients used CIC daily. Erectile function was assessed by reports from the patients and their parents, and continence by report and urodynamic studies. RESULTS: Of the 14 patients, 13 achieved urinary continence with no additional procedures; one required a subsequent submucosal injection at the suspension site with silicone particles in povidone (Macroplastique(R)) to become continent. Two patients reported slight leakage at night. Before surgery, all but one patient reported having spontaneous or mechanically manipulated erections; none had erections on psychological stimulation. After surgery, erectile function was preserved in 13 of the 14 patients; in one there were problems establishing the right dissection plane between the rectum and prostate, but spontaneous erections returned a year after surgery. CONCLUSION: In males, the abdominoperineal puboprostatic sling suspension using rectus abdominis fascia appears to be a successful treatment for sphincter incontinence in patients with spina bifida, and safely maintains erectile function.