Antegrade continence enema procedure: impact on quality of life in patients with spinal cord injury.

STUDY DESIGN: This is a prospective cohort study. OBJECTIVES: Patients with spinal cord injury (SCI) often suffer from severe constipation/fecal incontinence. The antegrade continence enema (ACE) procedure is often used to control these distressing symptoms when medical management fails. Improvement in the quality of life (QOL) following the ACE procedure has been demonstrated in patients with fecal incontinence of various etiologies. We assess the impact of the ACE procedure on QOL in patients with fecal incontinence due to SCI. SETTING: This study was conducted in the United States. METHODS: We measured the impact of fecal incontinence on QOL in patients with SCI undergoing ACE using the validated fecal incontinence quality of life (FIQL) QOL instrument. The FIQL scores QOL in four domains: lifestyle, coping/behavior, depression/self-perception and embarrassment. Surveys were prospectively administered before and after surgery. Preoperative and postoperative survey scores were compared using two-sample T-test. RESULTS: Between 2003 and 2010, the ACE procedure was performed on 17 patients with SCI, including 10 paraplegic and seven quadriplegic patients with an average age of 33 years at the time of surgery. Scores in all four QOL realms assessed by the FIQL instrument improved significantly following the ACE procedure. Stomal stenosis requiring channel revision occurred in three patients and was the most common complication. CONCLUSIONS: This is the first study to our knowledge that assesses the impact of the ACE procedure on the QOL in patients with SCI. Using a validated questionnaire, we demonstrated significant improvement in QOL related to fecal incontinence following the ACE procedure in these patients who are severely affected by their bowel dysfunction.

Colovesical fistula resulting from a perforated colonic duplication.

Colovesical fistulas in children are most often associated with high anorectal imperforations. Acquired enterovesical fistulas in children only rarely have been reported as a consequence of an inflammatory process. We present a case of an acquired colovesical fistula formed by the erosion of an abscess at the distal end of a colonic duplication in a child who presented with fever of unknown origin.

Urologic management of spinal cord injury in children.

This overview of the management of children with spinal cord injury has focused on a program based on bladder dynamics. The bladder is modulated pharmacologically and surgically, if necessary, to create a reservoir that stores urine at low pressure, and emptying is achieved by clean intermittent catheterization. The parent assumes the responsibility for bladder emptying when the child is unable to perform catheterization. Reflex voiding in a balanced fashion is not advocated. The program described not only avoids the deleterious effects of high voiding pressures, it also obviates the wearing of a urinary collection device, which is impractical for most prepubertal boys, and it provides for emptying at predictable intervals in order to make the child more socially acceptable. This approach seems to improve the child's self-image, and it should increase the chances of useful participation in society and a fulfilling life.

Renal duplication and fusion anomalies.

Renal duplications and fusion anomalies in children often present challenging problems. The diagnostic evolution of these entities often consists of upper tract imaging to evaluate function and help diagnose obstruction, and lower tract imaging to assess reflux and at times voiding dynamics. The clinician needs to be aware of the variable presentations of these lesions, their evolution, and the therapeutic interventions that may be required to resolve problems resulting from them.

Management of the penile shaft skin in hypospadias repair: alternative to Byars' flaps.

Two variations for resurfacing the penile shaft skin after repair of hypospadias defects are described. These techniques have been used in an effort to prevent some of the skin tags, tension at the penoscrotal angle, and oblique suture lines that may occur with the traditional Byars' flaps.

Pyeloduodenal fistula: a previously undescribed complication of Stamm gastrostomy.

A variety of complications have been described after placement of a Stamm gastrostomy in infants and children, including gastric volvulus, pancreatitis, jaundice, gastroduodenal mucosal intussusception with gastric outlet obstruction, and even aortogastric fistula. However, this is the first report of pyeloduodenal fistula after Stamm gastrostomy in a 4 1/2-month-old boy. The child successfully underwent nonoperative therapy; he was treated by withdrawing the gastrostomy tube (Foley catheter) from the renal pelvis, bowel rest, and total parenteral nutrition. After the case presentation is a brief review of this rare entity, with its clinical presentation and pathophysiological differences between adult and pediatric cases. Various treatment options, both operative and nonoperative, are also described.

M inverted V glansplasty: a procedure for distal hypospadias.

Minimal hypospadias is a commonly encountered anomaly. Duckett's innovative meatoplasty and glanuloplasty (MAGPI) procedure has become a standard operation for the correction of these lesions. Although usually successful, the complication of meatal retraction has been recognized at times after a MAGPI. The M inverted V glansplasty was designed to address the factors leading to meatal retraction and the abnormal glans shape sometimes seen after the MAGPI. The M inverted V glansplasty derives its name from the initial M-shaped incision that reconfigures during the course of the procedure into an inverted V. Of 16 boys followed for more than 2 months after an M inverted V glansplasty 14 have achieved good results. The remaining 2 cases had a definite degree of meatal retraction but because of the meatal and glanular relationships they have a good cosmetic result. The technique, its indications and its limitations are described.

Chordee correction by corporal rotation: the split and roll technique.

PURPOSE: The optimal approach to correcting ventral chordee associated with severe hypospadias is controversial. Dorsal plication tends to shorten the phallus and ventrally positioned grafts often mandate a staged procedure. An alternative approach is presented using corporal rotation to correct ventral chordee associated with hypospadias. MATERIALS AND METHODS: In 6 boys with severe hypospadias the urethral plate was divided and the septum between the corpora cavernosa was partially split with a ventral midline incision. This incision facilitates corporal rotation. Access to the dorsal aspect of the corpora cavernosa was achieved by dissecting Buck's fascia with its encased neurovascular bundles, so that the bundles in the area of chordee were completely elevated and preserved. Using artificial erection as a guide nonabsorbable sutures were placed in the area of maximal curvature from the dorsolateral aspect of 1 corpus cavernosum across the midline to the other side such that, as the knots were tied, the corpora rotated toward the dorsal midline. The knots were buried by apposition of the rotated corporal bodies. RESULTS: Excellent straightening of the phallus was achieved intraoperatively in these patients. CONCLUSIONS: The split and roll technique for correcting severe chordee does not require incisions into the corporal substance, involve use of grafts or cause shortening of the phallus. The neurovascular bundles are preserved and are not compressed by the rotational sutures. The surgeon may perform 1-stage reconstruction while achieving maximal penile length.

Use of the fascial sling for neurogenic incontinence: lessons learned.

Experience using the fascial sling to manage incontinence in 10 patients with a neurogenic bladder is described. The sling was constructed from rectus abdominus fascia in the first 5 cases. Because of 2 sequential failures attributed to inadequacy of the fascial material fascia lata was used in the last 5 cases. Six patients underwent bladder augmentation concomitant with sling construction. Of the 10 patients 9 were perfectly dry immediately after surgery, although with longer followup several patients became wet. The source of the fascial material used to make the sling did not affect the long-term outcome. Of the 6 patients who underwent augmentation at the time of sling construction 4 remain dry at long-term followup. On the other hand, only 1 of the 4 patients who did not undergo augmentation when the sling was positioned had a good long-term result. Erosion of the fascial sling was suspected in 3 patients who had difficulty with catheterization after surgery. Three patients required bladder augmentation because of changes in detrusor behavior subsequent to sling construction. This series suggests that combining the fascial sling with bladder augmentation appreciably increases the likelihood of achieving dryness and that excessive compression of the urethra by the fascial sling may lead to erosion. The sling, as an isolated procedure for neurogenic incontinence, should only be used in exceptionally capacious compliant bladders.

Update on vesicoureteral reflux: pathogenesis, nephropathy, and management.

Clinical reflux was first visualized over 100 years ago. In the 1950s and early 1960s, the assumption was that surgery to relieve bladder neck obstruction would have a positive effect on bladder function and reflux. By the early 1970s it was understood that the underlying structural problems leading to primary reflux were congenitally abnormal distal ureters and orifices. Researchers in the 1960s and 1970s demonstrated the connection between reflux and renal scarring. More recently, reflux nephropathy in the absence of urinary tract infections has been observed, leading researchers to investigate an association between bladder dysfunction and reflux with resulting nephropathy. The cornerstone of management of the child with vesicoureteral reflux is antibiotic prophylaxis; treatment regimens for various grades of reflux are reviewed. Indications for surgical treatment of reflux are also discussed. Controversies regarding vesicoureteral reflux, including duration of prophylactic treatment, remain to be resolved.

Bladder augmentation in the pediatric age group.

In summary, enterocystoplasty has become an effective, safe and very useful addition to management of vesical dysfunction in children. The use of bladder augmentation has become more universally accepted with the recognition of the safety of clean intermittent catheterization and the development of efficient antireflux mechanisms when ureteral reimplantation into the bowel is required. However, the surgeon who wishes to participate in this endeavor must have a solid foundation and understanding of vesical urodynamics and must be committed to offering these children an ongoing program to manage their life-long problems associated with their primary disease as well as the special need associated with augmentation procedures.

Pitfalls in determination of leak point pressure.

To evaluate the influence of the technical aspects of leak point pressure measurement we performed water cystometry and determined the leak point pressure in 23 patients 5 weeks to 21 years old with neurogenic bladders. We initially assessed the influence of catheter size on the leak point pressure and determined that the measured pressure varied in direct proportion to the catheter diameter. We further evaluated the effect of the method of infusion (gravity drip versus pump) and the infusion rate on pressures measured by a transducer in an in vitro setting. Using the gravity drip infusion technique pressure measurement was adversely affected by smaller catheter size and rapid infusion rate. With the pump infusion system neither catheter size nor infusion rate adversely affected pressure measurement. We conclude that the clinical measurement of the leak point pressure during water cystometry is influenced by the catheter size, and it is dependent upon the technique and rate of infusion. We believe that standardization of the technical aspects of leak point pressure determination would provide for reproducible results and facilitate comparisons of reports among different investigators.

Voiding cystourethrography after uncomplicated ureteral reimplantation in children: is it necessary?

PURPOSE: Our aim was to assess whether a voiding cystourethrogram after uncomplicated ureteral reimplantation is necessary or cost-efficient. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent uncomplicated reimplantation at our institution from 1988 to 1994. We also reviewed the literature to tabulate the reflux resolution rate from all published series of more than 100 ureters reimplanted. RESULTS: At our institution 119 patients (207 ureters) underwent uncomplicated reimplantation and a postoperative voiding cystourethrogram, which documented a 98.6% initial reflux resolution rate. All persistent postoperative reflux resolved spontaneously without treatment for a final resolution rate of 100%. We reviewed 1,494 abstracts using vesicoureteral reflux as a key word and found 19 series of more than 100 ureters reimplanted. The combined results of our series and those 19 from the literature revealed 3,346 patients (5,008 ureters reimplanted). The final reflux resolution rate was 98.58%. Series that included and excluded secondary vesicoureteral reflux documented final reflux resolution rates of 98.4 and 99.04%, respectively. Reflux resolved spontaneously in 85% of the ureters in which it was noted on the initial postoperative cystogram. At our institution the cost of a voiding cystourethrogram is $610 and we perform an average of approximately 20 uncomplicated reimplantations per year. In the United States there are approximately 230 pediatric urologists. If each surgeon performed 20 reimplantations per year at the same cost per voiding cystourethrogram, a cost savings of $2.8 million per year would result if the study were not performed after surgery. CONCLUSIONS: In the hands of experienced pediatric urologists uncomplicated ureteral reimplantation has a success rate of 99.04%. The yield of postoperative voiding cystourethrography is exceedingly low and a cost savings of $2.8 million per year would result by omitting the postoperative voiding cystourethrogram.

Percutaneous vesicolithotomy: an alternative to open bladder surgery in patients with an impassable or surgically ablated urethra.

PURPOSE: Although vesical calculi are routinely treated transurethrally, open vesicolithotomy is generally performed in patients with an impassable or surgically ablated urethra. We describe a technique of percutaneous vesicolithotomy which we used in patients who had undergone urethral ablation and concomitant continent diversion by appendicovesicostomy. MATERIALS AND METHODS: Bladder stones were detected in 3 patients with neurogenic bladder who had undergone continent urinary diversion with bladder neck closure and appendicovesicostomy. To treat the stones access to the bladder was achieved percutaneously and the tract was enlarged using a balloon dilator. An Amplatz sheath was slipped over the inflated balloon and after the dilator was removed the sheath provided a working channel through which stones were fragmented and removed using a nephroscope. RESULTS: Each patient was rendered stone-free and discharged home the same day as the procedure. CONCLUSIONS: Percutaneous vesicolithotomy provides an alternative approach for bladder stone removal in patients with an impassable urethra with decreased morbidity compared to open procedures.

Distal hypospadias repair by the modified Thiersch-Duplay technique with or without hinging the urethral plate: a near ideal way to correct distal hypospadias.

PURPOSE: Various techniques have been described to correct distal hypospadias but many are best suited to patients with subtle specific nuances of meatal and/or glanular configuration. We describe a simplified approach to these defects using the modified Thiersch-Duplay technique with or without hinging the urethral plate (the Snodgrass maneuver). MATERIALS AND METHODS: Between 1990 and 1997 we performed the modified Thiersch-Duplay repair as the primary procedure for repairing hypospadias in 197 boys. We initially performed urethral plate hinging (the Snodgrass maneuver) in 1994. By 1997, 82% of our patients were undergoing repair using the hinge technique. Urethroplasty coverage was provided by a second layer of adjacent local tissue or by a pedicle of subcutaneous tissue. RESULTS: Reoperation was required in 5 boys (2.5%) with fistula and 1 (0.50%) with urinary extravasation. A fistula developed in 4 of the 63 cases (6.4%) in which adjacent local tissue was used to cover the urethroplasty and in 1 of 130 (0.80%) in which a pedicle of subcutaneous tissue was used. Overall 97% of the boys had an excellent result requiring no secondary operative procedure. CONCLUSIONS: The modified Thiersch-Duplay technique with or without urethral plate hinging is reliable for correcting distal hypospadias. The risk of fistula is almost eliminated when a vascularized pedicle of subcutaneous tissue is used to cover the repair. This technique has virtually supplanted all other methods that we used in the past to correct distal hypospadias.

Intravesical urokinase for the management of clot retention in boys.

We successfully used intravesical urokinase in 2 young boys to relieve clot retention occurring as a consequence of upper tract bleeding. Urokinase clot dissolution appears to offer a simple, minimally invasive, atraumatic solution to this infrequent problem.

Vesicoureteral reflux in boys.

The natural history of vesicoureteral reflux in children is well documented. In most series girls comprise the majority of the children followed. We reviewed the presentation and course of 86 boys with primary vesicoureteral reflux to define the nature of reflux in that selected population. Of the boys 25 per cent presented when they were less than 3 months old and the youngest tended to have the most severe reflux. Presentation was usually with urinary tract infection but 14 per cent had dysfunctional voiding symptoms without urinary tract infection. Based upon their presentation and initial evaluation the patients were allocated to 1 of 3 treatment protocols: observation, chemoprophylaxis or surgery. No renal parenchymal loss was detected in the boys on observation. Surgical therapy was free of serious complications. Over-all, this modified approach to the management of reflux in boys is acceptable although further followup will be required to confirm these initial conclusions.