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1.
Curr Urol Rep ; 20(9): 48, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31286274

RESUMO

PURPOSE OF REVIEW: The exstrophy-epispadias complex (EEC) represents a group of congenitally acquired malformations involving the musculoskeletal, gastrointestinal, and genitourinary systems. Classic bladder exstrophy (CBE) is the most common and best studied entity within the EEC. In this review, imaging features of CBE anatomy will be presented with surgical correlation. RECENT FINDINGS: Magnetic resonance imaging (MRI) has emerged as a useful modality for pre- and postnatal assessment of the abdominal wall, pelvic floor, and gastrointestinal and genitourinary systems of children with CBE. The authors' experience supports use of preoperative MRI, in conjunction with navigational software, as a method for identifying complex CBE anatomy. Imaging facilitates surgical approach and improves visualization of complex anatomy, potentially helping to avoid complications. Continued investigation of imaging guidance in CBE repair is needed as surgical techniques improve.


Assuntos
Extrofia Vesical/diagnóstico por imagem , Extrofia Vesical/cirurgia , Epispadia/diagnóstico por imagem , Epispadia/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Imagem por Ressonância Magnética , Masculino , Procedimentos Cirúrgicos Urológicos
2.
Int Urol Nephrol ; 51(4): 579-583, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30796727

RESUMO

PURPOSE: To report current results of complete penile disassembly technique in epispadias repair. METHODS: In ten years, we have preformed 31 complete penile disassembly for proximal epispadias repair. Twenty-four patients had epispadias after primary repair of bladder exstrophy and 7 isolated penopubic epispadias. The age of the patients ranged from 10 months to 6 years (median 3 years). RESULTS: The shortening of urethral plate was found in 30 patients (97% of cases), and this shortening varied between 6 and 16 mm. However, in one patient we found a lengthening of the urethral plate of 8 mm. The narrowing of urethral plate was found in all patients, and this narrowing varied between 30 and 50% of the width of the plate. Postoperative complications encountered in our patients were dominated by fistulas and dehiscence, particularly in patients who had bladder exstrophy-epispadias complex. After dehiscence and fistulas repair, the cosmetic results were satisfying in 25 patients (80.5% of cases) with conical glans and meatus in orthotopic position without any necrosis of the glans. However, the urinary continence ≥ 1 h was observed in 6 patients (19% of cases) and only 3 patients (9.7% of cases) had a urinary continence ≥ 3 h. The mean follow-up was 61 months. CONCLUSIONS: The complete penile disassembly remains one of the best techniques for epispadias repair. However, we noticed a reappearance of the dorsal curvature of the penis in a large number of patients treated for isolated epispadias and the impact of this technique on urinary incontinence remains uncertain.


Assuntos
Epispadia/cirurgia , Pênis/cirurgia , Uretra/cirurgia , Fístula Urinária/etiologia , Anormalidades Múltiplas/cirurgia , Extrofia Vesical/cirurgia , Criança , Pré-Escolar , Epispadia/complicações , Humanos , Lactente , Masculino , Pênis/anormalidades , Deiscência da Ferida Operatória/etiologia , Uretra/anormalidades , Incontinência Urinária/etiologia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos
3.
Urology ; 125: 184-190, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30576745

RESUMO

OBJECTIVE: To investigate the diagnosis, surgical management, and outcomes in patients with variant EEC. Variant presentations of the exstrophy-epispadias complex (EEC) span a wide range of abnormalities. The rarity and diversity of EEC variants can lead to challenges in the diagnosis and subsequent management of this population. METHODS: The authors reviewed an institutional database of 1336 EEC patients from 1975 to 2018 for variant presentations of EEC. Variant presentations included those with skin covered bladder exstrophy (BE), duplicate bladders, superior vesical fistula, and epispadias with major bladder prolapse. Surgical management and outcomes were assessed. RESULTS: In total, 44 EEC variants were identified. Nineteen (43%) presented with a skin-covered BE variant. Five patients presented with duplicate BE, while 6 presented with superior vesical fistula. Fourteen patients (32%) presented with epispadias with major bladder prolapse. Overall, 36 (82%) EEC variants underwent primary bladder closure, at a median of 135 days after birth (range 1-2010), with 21 (58%) undergoing pelvic osteotomy. Primary closures were successful in 89% of cases. Continence procedures were performed in 17 patients. This includes 5 patients who underwent bladder augmentation. However even without a continence procedure, continence with volitional voiding was found in 8 patients. CONCLUSION: The most common EEC variant is the skin-covered form of BE. In order to expedite appropriate management, accurate diagnosis upon initial presentation is crucial. Still, successful surgical reconstruction often results in continence that is similar to, or better than, nonvariant EEC presentations.


Assuntos
Extrofia Vesical/diagnóstico , Extrofia Vesical/cirurgia , Epispadia/diagnóstico , Epispadia/cirurgia , Extrofia Vesical/classificação , Pré-Escolar , Epispadia/classificação , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Fatores de Tempo , Resultado do Tratamento
4.
Einstein (Sao Paulo) ; 16(4): eRC3887, 2018 Nov 08.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30427488

RESUMO

We report a case of secondary urinary reconstruction of previously separated conjoined twins with exstrophic bladder and urinary incontinence. Patients were male and aged 13-year-old. Twin one had a history of failed enterocystoplasty that extruded and was visible like an exstrophic neobladder. He underwent a procedure to close bladder neck and reconfigure abdominal wall. After the procedure the patient developed a fistula that was treated, but it persisted and, for this reason, a catheterizable pouch was constructed and native bladder was discarded. Twin two required the immediately construction of catheterizable pouch using the Macedo's technique. Currently, both patients are continent at 4 hour intervals. The mean follow-up was 8 months. Modern continent urinary diversion techniques offer new perspectives and hope for such complex population.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Gêmeos Unidos/cirurgia , Incontinência Urinária/cirurgia , Adolescente , Humanos , Masculino , Ilustração Médica , Procedimentos Cirúrgicos Reconstrutivos/métodos , Reoperação/métodos , Falha de Tratamento
5.
Urologe A ; 57(10): 1208-1213, 2018 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-30116832

RESUMO

BACKGROUND: Because sick and injured children from war and crisis areas can often only be helped to a limited extent in their countries of origin, those children with the most complex diseases often receive medical treatment in Europe. MATERIALS AND METHODS: To evaluate the postoperative outcome of reconstructive interventions in children from war and crisis areas, an evaluation of the clinic's internal database between 1997 and 2017 was carried out. The operative indication, the surgical procedure, any revisions or conversions and the overall mortality were analyzed. RESULTS: During the above-mentioned period a total of 44 (male: 32, female: 12) children aged 3-14 years from Afghanistan, Angola, Central Asia and the Caucasus were treated. Indications for the reconstructive procedures were bladder exstrophy (n = 23), neurogenic bladder dysfunction (n = 9), penile partial amputation (n = 1) and traumatic bladder dysfunction (n = 11). In 26 children, a conduit was created, 11 children received a sigma rectum pouch and 1 child an ileocecal pouch, while 5 other children received bladder augmentation and 1 child an oral mucosal urethroplasty. In total, 7 revisions or conversions due to ureteral implantation stenoses and recurrent acidosis had to be performed. Five children died in their home country due to acidosis, sepsis, end stage renal failure, accident and social exclusion. CONCLUSION: In the long term 39 of the 44 (88.6%) children live socially integrated in their home country and are regularly monitored by local aid organizations. When choosing the reconstructive intervention, the local conditions must be considered.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Bexiga Urinaria Neurogênica/cirurgia , Bexiga Urinária/lesões , Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Criança , Pré-Escolar , Europa (Continente) , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento , Uretra , Derivação Urinária/efeitos adversos , Incontinência Urinária/etiologia
6.
J Plast Reconstr Aesthet Surg ; 71(11): 1637-1643, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30154046

RESUMO

PURPOSE: To assess the importance of shortening of the urethral plate that occurred with complete penile disassembly technique in epispadias repair and its impact on cosmetic and functional results (on urinary incontinence). METHODS: From January 2009 to December 2016, 26 boys underwent complete penile disassembly technique for proximal epispadias repair. Twenty-one patients had epispadias after primary repair of bladder exstrophy, and 5 patients had isolated penopubic epispadias. The age of the patients ranged from 11 months to 6 years (median 3 years). RESULTS: After disassembling the penis in three parts, the shortening and narrowing of urethral plate were found in all patients; the shortening varied between 2 and 16 mm. However, in isolated epispadias, the urethral plate is easily extensible. The cosmetic results (after dehiscence and fistulas repair) were found to be satisfactory in 24 patients with conical glans and meatus in the orthotopic position without any necrosis of the glans. However, 18 patients (81.8% of cases) who initially had a bladder exstrophy presented a dehiscence or fistula. The urinary continence ≥ 1 h was observed in 5 patients (19% of cases), and only 3 patients (11.5% of cases) had a urinary continence ≥ 3 h. CONCLUSIONS: The complete penile disassembly procedure restores the normal anatomy of the penis. Despite the shortening and narrowing of the urethral plate, the cosmetic results were good in the majority of patients. However, its functional outcomes on urinary incontinence, particularly for epispadias with bladder exstrophy, remain uncertain.


Assuntos
Epispadia/cirurgia , Uretra/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Criança , Pré-Escolar , Epispadia/patologia , Seguimentos , Humanos , Lactente , Masculino , Satisfação do Paciente/estatística & dados numéricos , Recuperação de Função Fisiológica , Resultado do Tratamento , Uretra/patologia
7.
J Pediatr Urol ; 14(5): 431.e1-431.e6, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30031742

RESUMO

INTRODUCTION: In children who remain incontinent after reconstruction of bladder exstrophy-epispadias complex (BEEC), continent anal urinary diversion (CAD) is one option to achieve continence. Known problems after CAD are an increased stool frequency and ureterointestinal stenosis. We devised a new surgical technique of CAD that we named the "Cologne pouch procedure" (CPP) that renders the possibility of separate evacuation of urine and feces. Furthermore, we connect the bladder plate to the rectosigmoid pouch instead of performing a ureterosigmoidostomy to reduce the rate of ureterointestinal stenosis. In this study, we want to introduce the CCP and critically evaluate our results. STUDY DESIGN: In CPP a detubularized sigmoid-bladder pouch is created, which is naturally connected to the rectum. A retrospective study was performed including all patients with BEEC and CPP treated in our hospital between January 1, 2007, and December 31, 2016. Epidemiological and surgical key data, complications, and the need for alkaline supplementation were assessed. At follow-up examinations, we evaluated continence, ability of independent urine and feces evacuation, need for bicarbonate supplementation, status of the upper urinary tract, and complications such as urinary tract infections or urolithiasis. RESULTS: In total, 29 patients with BEEC and CPP were included. The mean age at surgery was 4.2 ± 3.3 years (range 0.1-12.7 years). Overall, 14 short-term complications occurred in nine patients. Postoperatively, all patients were continent for urine and feces during daytime and only one child occasionally lost small portions of urine at night. An independent evacuation of urine and feces was accomplished in 22 patients (81.5%). Continued bicarbonate supplementation was necessary in 15 patients (55.6%). During the follow-up period six patients (22.2%) had a single urinary tract infection and four patients (14.8%) calculi of the urinary tract. No urinary tract abnormalities-especially no vesicoureteral reflux (VUR) or stenosis-were detected during follow-up ultrasound examination. In two children, a preoperatively known hydronephrosis decreased after CPP. CONCLUSION: CPP is a novel technique that yields excellent results concerning continence. In contrast to other forms of rectosigmoid urinary diversion, functional separation of defecation and urination can be achieved in most patients.


Assuntos
Canal Anal/cirurgia , Extrofia Vesical/cirurgia , Epispadia/cirurgia , Bexiga Urinária/cirurgia , Coletores de Urina , Anastomose Cirúrgica/métodos , Criança , Pré-Escolar , Colo Sigmoide/transplante , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Derivação Urinária/métodos
8.
Urology ; 119: 133-136, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29807047

RESUMO

OBJECTIVE: To explore the use of concomitant bladder neck reconstruction (BNR) and creation of a continent stoma (CS) in patients who are not quite eligible for BNR but still strongly desire volitional voiding. METHODS: The authors retrospectively reviewed an institutional database of patients with exstrophy-epispadias complex who underwent BNR-CS between 2000 and 2015. Indications for a BNR-CS, perioperative outcomes, and continence status were evaluated. Method of voiding and continence status were analyzed for patients with greater than 6 months of follow-up after the BNR-CS. RESULTS: A total of 24 patients with exstrophy-epispadias complex (15 male and 9 female) underwent BNR-CS at a median age of 8.9 years (range 5.4-17.4). This included 18 patients with classic bladder exstrophy, 5 with epispadias, and 1 with a cloacal exstrophy variant. There were 5 surgical complications (20.1%) following the BNR-CS, including 3 febrile urinary tract infections, 1 superficial wound infection, and 1 urethrocutaneous fistula. The median follow-up time from the time of BNR-CS was 1.1 years (range 0.1-14.1). Seventeen of 24 patients (71%) had a follow-up greater than 6 months and were evaluated for continence. Twelve patients (71%) were completely dry for intervals greater than 3 hours following BNR-CS. Five (29%) did not achieve continence with BNR-CS. Of those 5 patients, 3 (60%) underwent subsequent bladder neck transection. CONCLUSION: Combined BNR and CS is a suitable alternative to achieve urinary continence in patients who are not ideal candidates for BNR alone. This approach can offer a select group of patients the opportunity for volitional voiding.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Bexiga Urinária/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estomas Cirúrgicos , Procedimentos Cirúrgicos Urológicos/métodos
9.
Urologiia ; (1): 126-128, 2018 Mar.
Artigo em Russo | MEDLINE | ID: mdl-29634146

RESUMO

The article reports on two cases of the total epispadias of duplicated urethra with and without penile duplication. The authors describe the clinical presentation, diagnosis, and treatment. Duplicated urethra with epispadias both with and without penile duplication must be removed. At the same time, it is necessary to restore the patency of the lower duplicated urethra.


Assuntos
Anormalidades Múltiplas/cirurgia , Epispadia/cirurgia , Pênis/cirurgia , Uretra/cirurgia , Anormalidades Múltiplas/diagnóstico , Epispadia/diagnóstico , Humanos , Lactente , Masculino , Pênis/anormalidades , Resultado do Tratamento , Uretra/anormalidades
10.
J Pediatr Urol ; 14(3): 296-297, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29657022

RESUMO

This video provides a case report of a 3 year old girl with epispadia and the highlights of the surgery. A cystoscopic guided bladder neck plication was performed to achieve continence. Key points include: (1) Skin incision planning; (2) Cutaneous flap liberation to create a new urethra; (3) Complete bladder neck release to allow a controlled plication; (4) Use of cystoscopy to achieve the ideal bladder neck closure; (5) Bladder neck manipulation to achieve continence.


Assuntos
Epispadia/cirurgia , Uretra/cirurgia , Bexiga Urinária/cirurgia , Incontinência Urinária/cirurgia , Micção/fisiologia , Procedimentos Cirúrgicos Urológicos/métodos , Pré-Escolar , Cistoscopia , Epispadia/complicações , Epispadia/diagnóstico , Feminino , Humanos , Incontinência Urinária/etiologia
11.
Urology ; 117: 137-141, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29704585

RESUMO

OBJECTIVE: To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition. METHODS: A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas. RESULTS: In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716). CONCLUSION: Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.


Assuntos
Derme Acelular , Extrofia Vesical/cirurgia , Epispadia/cirurgia , Períneo , Doenças Uretrais/prevenção & controle , Fístula da Bexiga Urinária/prevenção & controle , Fístula Vesicovaginal/prevenção & controle , Adolescente , Adulto , Extrofia Vesical/complicações , Criança , Pré-Escolar , Epispadia/complicações , Feminino , Adesivo Tecidual de Fibrina/uso terapêutico , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Retalhos Cirúrgicos , Adesivos Teciduais/uso terapêutico , Bexiga Urinária/cirurgia , Fístula da Bexiga Urinária/etiologia , Adulto Jovem
12.
JAMA Surg ; 153(7): 618-624, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29516095

RESUMO

Importance: International collaboration to alleviate the massive burden of surgical disease is recognized by World Health Organization as an urgent need, yet the surgical mission model to treat reconstructive surgical challenges is often constrained in ensuring adequate patient follow-up, optimal outcomes, and sustainability. Objective: To determine whether a collaboration predicated on long-term commitment by surgeons returning to the same institution annually combined with an experienced host surgical team and infrastructure to ensure sustained patient follow-up could provide surgical care with acceptable outcomes to treat bladder exstrophy-epispadias complex (BE) and penopubic epispadias (PE). Design, Setting, and Participants: In this prospective, observational study, long-term collaboration was created and based at a public hospital in Ahmedabad, India, between January 2009 and January 2015. The entire postoperative cohort was recalled in January 2016 for comprehensive examination, measurement of continence outcomes, and assessment of surgical complications. Seventy-six percent of patients (n = 57) who underwent complete primary repair of exstrophy during the study interval returned for annual follow-up in 2016 and formed the study cohort: 23 patients with primary BE, 19 patients with redo BE, and 11 patients with PE repair. Main Outcomes and Measures: Demographics, operative techniques, and perioperative complications were recorded. A postoperative protocol outlining procedures to ensure monitoring of study participants was followed including removal of ureteral stents, urethral catheter, external fixators, imaging, and patient discharge. Results: Of the 57 patients, 4 were excluded because they underwent ureterosigmoidostomy. Median age at time of surgery was 3 years (primary BE), 7 years (redo BE), and 10 years (PE), with median follow-up of 3 years, 5 years and 3 years, respectively; boys made up more than 70% of each cohort (n = 17 for primary BE, n = 15 for redo BE, and n = 9 for PE). All BE and 3 PE repairs (27%) were completed with concurrent anterior pubic osteotomies. Seventeen of 53 patients (32%) experienced complications. Only 1 patient with BE (4%) had a bladder dehiscence and was repaired the following year. Conclusions and Relevance: A unique surgical mission model consisting of an international collaborative focused on treating the complex diagnoses of BE and PE offers outcomes comparable with those in high-income countries, demonstrating a significant patient retention rate and an opportunity to rigorously study outcomes over an accelerated interval owing to the high burden of disease in India. Postoperative care following a systematized algorithm and rigorous follow-up is mandatory to ensure safety and optimal outcomes.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Cooperação Internacional , Modelos Teóricos , Pré-Escolar , Efeitos Psicossociais da Doença , Epispadia/patologia , Feminino , Humanos , Índia , Masculino , Estudos Prospectivos , Estados Unidos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos
13.
J Pediatr Surg ; 53(10): 1937-1941, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29555156

RESUMO

INTRODUCTION: Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of 1311 exstrophy epispadias complex patients was performed. Patients with CE who have had at least one continence procedure were included. A continence procedure was defined as bladder neck reconstruction with or without augmentation, bladder neck transection with continent urinary diversion, augmentation cystoplasty, or use of injectable bulking agents. Continence was defined as a dry interval greater than 3 hours without leakage at night. RESULTS: In total, 140 CE and CE variant patients have been managed at the authors' institution. Of the 116 CE patients, 59 received at least one continence procedure, 14 were excluded for incontinent diversion or cystectomy, and the remaining 43 patients are awaiting a continence procedure. At the time of analysis, 42 (71%) patients who underwent a continence procedure were dry. The median number of total urologic procedures to reach urinary continence was 4 (range 2-10). This included 1 bladder closure (range 1-3), 2 urinary continence procedures (range 1-4), and 1 (range 0-4) "other" genitourinary procedures. The median time to urinary continence was 11.0 years (95% CI [9.2-14.2]). CONCLUSIONS: A majority of CE patients who undergo a diversion procedure can achieve urinary continence. However multiple continence procedures are likely necessary. Of patients who are candidates for a continence procedure, half will be continent by the age of 11. LEVEL OF EVIDENCE: Level IV, Case series with no comparison group.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Incontinência Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Análise de Sobrevida
14.
J Am Vet Med Assoc ; 252(6): 732-743, 2018 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-29504860

RESUMO

CASE DESCRIPTION A 14-week-old 7.7-kg (16.9-lb) sexually intact female Golden Retriever was evaluated because of urine dripping from the caudoventral aspect of the abdomen. CLINICAL FINDINGS Ultrasonography, radiography, excretory CT urography, and vaginocystourethroscopy were performed. Results indicated eversion of the bladder through the ventral abdominal wall with exposure of the ureterovesicular junctions, pubic diastasis, and an open vulva and clitoral fossa. Clinical findings were suggestive of bladder exstrophy, a rare congenital anomaly. TREATMENT AND OUTCOME The dog was anesthetized and bilateral ileal osteotomies were performed. Two ureteral catheters were passed retrograde into the renal pelves under fluoroscopic guidance. The lateral margins of the bladder, bladder neck, and urethra were surgically separated from the abdominal wall, and the bladder was closed, forming a hollow viscus. The symphysis pubis was closed on midline with horizontal mattress sutures. The defects in the vestibule and clitoral fossa were closed. Lastly, the iliac osteotomies were stabilized. The dog was initially incontinent with right hind limb sciatic neuropraxia and developed pyelonephritis. Over time, the dog became continent with full return to orthopedic and neurologic function, but had recurrent urinary tract infections, developed renal azotemia likely associated with chronic pyelonephritis, and ultimately was euthanized 3.5 years after surgery because of end-stage kidney disease. CLINICAL RELEVANCE Bladder exstrophy and epispadias is a treatable but rare congenital abnormality. The procedure described could be considered for treatment of this condition, but care should be taken to monitor for urinary tract infections and ascending pyelonephritis.


Assuntos
Extrofia Vesical/veterinária , Doenças do Cão/cirurgia , Epispadia/veterinária , Animais , Extrofia Vesical/complicações , Extrofia Vesical/cirurgia , Doenças do Cão/diagnóstico por imagem , Cães , Endoscopia/veterinária , Epispadia/complicações , Epispadia/cirurgia , Evolução Fatal , Feminino , Osteotomia/veterinária , Procedimentos Cirúrgicos Reconstrutivos/veterinária , Tomografia Computadorizada por Raios X
15.
J Pediatr Urol ; 14(1): 33-39, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29426576

RESUMO

OBJECTIVES: Primary female epispadias encompasses a spectrum of disease, presenting with a variable degree of incontinence. We hypothesized that although perineal urethrocervicoplasty can be a successful first-line procedure in patients with normal bladder, a more radical reconstruction was necessary to achieve continence in cases lying at the most severe end of the spectrum. Our aim was to assess the results of a surgical management using perineal approach in girls with normal bladder capacity, and Kelly radical soft-tissue mobilization (RSTM) in patients with inadequate bladder, based on the assumption that bladder capacity (BC) is a reliable marker of epispadias severity. STUDY DESIGN: Prospective inclusion of incontinent girls with female epispadias referred to a single institution. Patients with normal BC were treated with perineal urethrocervicoplasty (PUCP, group 1). Patients with small bladder underwent RSTM (group 2). Follow-up was at 1, 3, 6, and 12 months postoperatively, then annually, including physical examination, renal ultrasound at each visit, continence status, and estimation of functional/maximal BC. The main study outcome was continence status at the age of 5 years or later, if postoperative follow-up was >12 months. RESULTS: From 2006 to 2017, 16 consecutive children were prospectively included in this study, at a median age of 39 months (5-102 months). Seven girls were included in group 1 and underwent PUCP; at the last follow-up, five out of seven were dry by day (4/5 day and night), although three out of five required bladder-neck injection after perineal reconstruction due to stress incontinence. Two patients with persistent incontinence and absence of BC increase after PUCP subsequently underwent RSTM. Eleven patients with low BC (56% [10-94%] of expected BC) were included in group 2 (9 without prior surgery, 2 after PUCP failure). Among the eight evaluable patients, eight out of eight achieved diurnal continence, and 3/8 were fully continent. One girl with obstructive micturition required clean intermittent catheterization. DISCUSSION: The traditional approach of female epispadias based on staged reconstruction (urethroplasty followed by bladder-neck reconstruction) raised concerns regarding the risk of non-physiological obstructive micturition. The perineal approach was suggested as an alternative, with reported diurnal continence rates of 60-80%, but less than 50% of nocturnal continence, presumably in relation with limited bladder capacity. In cases selected within the most severe end of the epispadias spectrum, the Kelly RSTM seems to offer excellent continence rates. CONCLUSION: A tailored approach to female epispadias, based on perineal reconstruction in favorable cases, and radical soft-tissue mobilization in severe cases, seems to yield good continence outcomes in the long term.


Assuntos
Epispadia/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Incontinência Urinária/etiologia , Procedimentos Cirúrgicos Urológicos/métodos , Pré-Escolar , Estudos de Coortes , Epispadia/complicações , Epispadia/diagnóstico , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Períneo/cirurgia , Estudos Prospectivos , Qualidade de Vida , Recuperação de Função Fisiológica , Medição de Risco , Resultado do Tratamento , Uretra/cirurgia , Incontinência Urinária/fisiopatologia , Incontinência Urinária/cirurgia , Urodinâmica
16.
Int Braz J Urol ; 44(3): 591-599, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29368874

RESUMO

OBJECTIVE: To assess the role of high-barrier plastic wrap in reducing the number and size of polyps, as well as decreasing the inflammation and allergic reactions in exstrophy cases, and to compare the results with the application of low-barrier wrap. MATERIALS AND METHODS: Eight patients with bladder exstrophy-epispadias complex (BEEC) that had used a low density polyethylene (LDPE) wrap for coverage of the exposed polypoid bladder in preoperative care management were referred. The main complaint of their parents was increase in size and number of polyps. After a period of 2 months using the same wrap and observing the increasing pattern in size of polyps, these patients were recommended to use a high-barrier wrap which is made of polyvinylidene chloride (PVdC), until closure. Patients were monitored for the number and size of polyps before and after the change of barriers. The incidence of para-exstrophy skin infection/inflammation and skin allergy were assessed. Biopsies were taken from the polyps to identify histopathological characteristics of the exposed polyps. RESULTS: The high barrier wrap was applied for a mean ± SD duration of 12±2.1 months. Polyps' size and number decreased after 12 months. No allergic reaction was detected in patients after the usage of PVdC; three patients suffered from low-grade skin allergy when LDPE was applied. Also, pre-malignant changes were observed in none of the patients in histopathological examination after the application of PVdC. CONCLUSION: Polyps' size and number and skin allergy may significantly decrease with the use of a high-barrier wrap. Certain PVdC wraps with more integrity and less evaporative permeability may be more "exstrophy-friendly".


Assuntos
Extrofia Vesical/cirurgia , Polietileno/uso terapêutico , Pólipos/terapia , Cuidados Pré-Operatórios/métodos , Biópsia , Extrofia Vesical/patologia , Criança , Pré-Escolar , Epispadia/patologia , Epispadia/cirurgia , Feminino , Humanos , Hipersensibilidade/prevenção & controle , Lactente , Masculino , Pólipos/patologia , Cuidados Pré-Operatórios/instrumentação , Valores de Referência , Reprodutibilidade dos Testes , Dermatopatias/prevenção & controle , Fatores de Tempo , Resultado do Tratamento
17.
Urology ; 111: 151-156, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28888749

RESUMO

OBJECTIVE: To investigate corporal tissue viability and changes in endothelial content following current techniques used for epispadias repair in an animal model. MATERIALS AND METHODS: Sixty rabbits were allocated into 3 groups: sham operation (penile degloving), complete disassembly model, and Cantwell-Ransley model. On weeks 2, 4, 12, and 24 postoperation, the penile tissue was harvested and processed for (1) Masson's trichrome staining for smooth muscle cell (SMC)-to-collagen ratios, (2) immunohistochemical staining for endothelial factor (CD31), and transforming growth factor beta 1 (TGF-ß1) (3) terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick-end labeling (TUNEL) assay to detect apoptosis. RESULTS: Masson trichrome staining of corporal tissue showed significant decrease in SMC-to-collagen ratio in complete disassembly group compared with sham operation group. The expression of CD31 was significantly lower (P <.05) in complete disassembly group compared with the other groups at all time points, whereas no significant difference was observed between the Cantwell-Ransley group and the sham operation group. Moreover, apoptotic index was markedly higher in the complete disassembly group compared with the 2 other operation groups (P <.05). Immunohistochemistry also showed a significantly higher expression of TGF-ß1 in the penile tissue after complete disassembly than Cantwell-Ransley or sham operation. CONCLUSION: Complete detachment of the urethra from the corpus cavernosa may result in endothelial dysfunction, alteration of SMC content of erectile tissue, and replacement of the native cavernosal tissue with fibrotic tissue. An increased expression of TGF-ß1, following the complete disassembly technique, might be one of the important factors causing the abovementioned alterations.


Assuntos
Epispadia/cirurgia , Pênis/patologia , Pênis/cirurgia , Fator de Crescimento Transformador beta1/fisiologia , Animais , Modelos Animais de Doenças , Masculino , Ereção Peniana , Complicações Pós-Operatórias/etiologia , Coelhos , Uretra/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos
18.
Int J Urol ; 25(2): 94-101, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28771821

RESUMO

The present review provides clinical insights and makes recommendations regarding patient management garnered by the long-term follow up of patients undergoing enteric bladder augmentation for the management of congenital anomalies. A prospectively maintained database on 385 patients that have experienced an enteric bladder augmentation, using either the ileum or colon, was reviewed. Evaluations included methods used to prevent bladder calculi formation and recurrence, the incidence and etiology of renal calculi development, the incidence and treatment of vitamin B12 deficiency, and the complications and need for surgical revisions for continent catheterizable stomas. A significantly increased risk for continent catheterizable stomal complications occurred after Monti-Yang tube formation, 70% (21/30 patients), compared with appendicovesicostomy, 41% (27/66 patients), P = 0.008. Both procedures had significantly more complications than continent catheterizable stomas using tapered ileum with a reinforced ileal-cecal valve, 21% (13/63 patients), P < 0.0001 and P < 0.013, respectively. Approximately 50% of the patient population developed a body mass index ≥30 during adulthood. The onset of obesity resulted in significantly more complications developing in patients with a Monti-Yang tube (87%; 13/15 patients) or appendicovesicostomy (55%; 18/33 patients) compared with a tapered ileum with a reinforced ileal-cecal valve (27%, 8/30 patients), P < 0.00015 and P < 0.025, respectively, with a median follow-up interval of 16 years, range 10-25 years. Long-term follow-up evaluations on patients undergoing an enteric bladder augmentation are necessary to prevent the long-term sequela of this procedure. The key to improving patient prognosis is the nutritional management of the patient as they mature, especially if a continent abdominal stoma is going to be carried out.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Disrafismo Espinal/cirurgia , Bexiga Urinária/cirurgia , Adulto , Extrofia Vesical/complicações , Epispadia/complicações , Humanos , Incidência , Apoio Nutricional , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Disrafismo Espinal/complicações , Fatores de Tempo , Bexiga Urinária/anormalidades , Derivação Urinária/efeitos adversos , Derivação Urinária/métodos , Coletores de Urina/efeitos adversos
19.
Urology ; 116: 168-171, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28958802

RESUMO

OBJECTIVE: To explore the long-term outcomes and indications for cystectomy in patients with bladder exstrophy. Although rare, cystectomy is the final surgical alternative to bladder repair among these patients with a poor quality bladder template. METHODS: A prospectively maintained database of 1298 patients with exstrophy-epispadias complex was reviewed for patients who underwent cystectomy between 1970 and 2015 at the authors' institution. Demographic data, indication for cystectomy, surgical history, postoperative outcomes, and continence status were collected. RESULTS: Eighteen (6 male; 12 female) patients with exstrophy (15 classic bladder exstrophy; 2 bladder exstrophy variants; 1 cloacal exstrophy) underwent cystectomy at a median age of 3.8 years. Six patients (33.3%) underwent primary cystectomy without attempted bladder closure. Eight patients (44.4%) had a history of failed primary closure with loss of capacity or inadequate growth after closure. Four patients (22.2%) had successful primary closure but underwent cystectomy secondary to poor bladder compliance with declining renal function or poor bladder growth or quality. Urinary diversion included 6 cutaneous ureterostomies, 4 bowel conduits (1 ileal; 3 colon), 6 continent urinary diversions with ileosigmoid reservoir, and 1 ureterosigmoidostomy. Of 8 patients who underwent a continence procedure, all were dry at a median of 25.3 months after cystectomy. CONCLUSION: Cystectomy was most commonly indicated in intrinsically diseased bladder templates that remained too small despite permitting time for interval growth. These bladders often were of poor quality and compliance and did not reduce into the pelvis on examination. It was, however, possible to achieve urinary continence in these patients with cystectomy and urinary diversion.


Assuntos
Extrofia Vesical/cirurgia , Cistectomia/efeitos adversos , Epispadia/cirurgia , Derivação Urinária/estatística & dados numéricos , Incontinência Urinária/epidemiologia , Adolescente , Extrofia Vesical/complicações , Extrofia Vesical/fisiopatologia , Criança , Pré-Escolar , Epispadia/complicações , Epispadia/fisiopatologia , Feminino , Humanos , Lactente , Masculino , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Bexiga Urinária/anormalidades , Bexiga Urinária/fisiopatologia , Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Incontinência Urinária/etiologia , Incontinência Urinária/fisiopatologia
20.
J Pediatr Urol ; 14(1): 42-46, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29150195

RESUMO

INTRODUCTION: Pre-operative physical examination of male epispadias allows for classification of epispadias level as glanular (GE), penile (PE) or penopubic (PPE), and for delineation of anatomic anomalies. The incidence of associated extragenital abnormalities, such as vesicoureteral reflux (VUR), bladder neck (BN) abnormality and abnormal pubic diastasis (PD), and their impact on urinary continence has not yet been systematically studied. OBJECTIVE: The goal of this study was to evaluate whether the more proximal level of epispadias correlated with associated extragenital anatomic anomalies seen on initial imaging or endoscopic evaluation, and whether these pre-operative findings contributed to subsequent surgical management and impacted on achieving urinary continence. It was hypothesized that the more severe forms of epispadias may be associated with a higher frequency of associated anomalies. STUDY DESIGN: The study was an IRB-approved, retrospective case study of all male patients treated initially for isolated epispadias at the current institution between 1994 and 2011. Data collection was achieved by chart and radiology review evaluating PD, BN appearance, presence of VUR, surgical treatment, and urinary continence. RESULTS: A total of 26 patients were identified and divided into three groups based on appearance at physical examination: four glanular (GE), eight penile (PE), and 14 penopubic (PPE); 17 patients had an abnormal BN. Reflux was noted in nine of 20 patients who had a voiding cystourethrogram (VCUG), two of which had an episode of pyelonephritis. Of the 22 patients past the age of toilet training, 17 were continent (64% (9/14) penopubic, 63% (5/8) penile, and 75% (3/4) glanular). DISCUSSION: Anatomic classification for male epispadias did not provide sufficient information regarding extragenital findings. This study provided new information regarding PD, BN appearance, presence of reflux, and ultimate urinary continence. Pubic diastasis and BN abnormalities were more frequently seen in more severe forms of epispadias, whereas VUR seemed more prevalent in less severe forms. A template for pre-operative evaluation was outlined. Limitations of the study were its retrospective design and relatively small cohort of patients, which reflected the rarity of the condition. CONCLUSION: Based on the information generated, additional anatomic information was generated regarding boys with epispadias. This information will help guide the evaluation and the management of these patients in the future.


Assuntos
Epispadia/diagnóstico , Epispadia/cirurgia , Qualidade de Vida , Incontinência Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Epispadia/psicologia , Humanos , Lactente , Imagem por Ressonância Magnética/métodos , Masculino , Cuidados Pré-Operatórios/métodos , Prognóstico , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Uretra/anormalidades , Uretra/cirurgia , Incontinência Urinária/diagnóstico , Incontinência Urinária/etiologia
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