Bladder neck suspension for stress incontinence as an outpatient procedure

Simplified but effective operative techniques have made surgery for stress incontinence less hazardous and traumatic and more acceptable to these patients. Transvaginal needle vesical neck suspensions, by avoiding splitting of the fascia of the abdominal wall, decrease postoperative discomfort and convalescence. Various modifications of the original Pereyra needle vesical neck suspension are currently in use. Probably the simplest and most effective is a technique reported by Raz, which the authors employ as an outpatient procedure and describe here.     

Bladder neck closure for treating pediatric incontinence

AIMS OF STUDY: In order to evaluate the effects of bladder neck closure (BNC) for treatment of pediatric incontinence, on the quality of life of those children, we reviewed the files of 17 children who underwent this procedure during the last 5 years. Information on previous surgery before BNC, continence and complications after BNC and patient satisfaction are gathered. MATERIAL AND METHODS: During the study period, 17 children (9 male, 8 female) underwent BNC with continent diversion. Ten children (5 male, 5 female) suffered neurogenic incontinence in meningomyelocele, 5 children (4 male, 1 female) had bladder exstrophy, 1 girl suffered iatrogenic incontinence after treatment of an ectopic ureterocele and 1 girl suffered structural incontinence after pelvic fracture. Previous surgery for incontinence was done in 12 children with 36 procedures. Primary BNC was done in 5 children. For continent diversion the appendix was used in 13, the ureter in 2, a Monti procedure in 1, and an ileal valve in 1. In 9 children, ileal bladder augmentation was performed at the time of BNC. Four children were augmented before. Mean age at time of operation was 13.5 years. Mean follow-up is 35 months. RESULTS: After BNC, all patients were completely dry. One girl suffered some stomal incontinence during the night. This disappeared after recent bladder augmentation. Patient satisfaction is extremely high after surgery. All patients feel happy with their stoma and do not regret the choice they made. As for complications, urinary tract infections were seen in 9 patients. Stomal complications were seen in 8 patients. Three patients had some difficulty with catheterization, which could be solved with dilatation. Appendiceal polyps, which could be removed under local anesthesia, were seen in 3 and stomal stenosis which needed re-intervention in 2. In 1 patient, three revisions of the stoma were done, in the other patient, two surgical corrections. Out of 8 patients showing stomal complications, only 2 needed revision under anesthesia. All complications are seen in the first 6 months after the continent diversion. CONCLUSIONS: We present a series of patients who underwent BNC for treatment of incontinence. BNC is the ultimate bladder neck reconstruction. However, regarding the high success rate, the low complication rate and the high patient satisfaction, we must consider BNC as an important procedure for the reconstructive surgeon. If reconstruction fails, closure must be considered. Compared to most other procedures for bladder neck reconstruction, BNC gives the highest continence rate. Good patient compliance and strict medical follow-up of the upper tract is mandatory in these patients.     

Teflon injections in post-prostatectomy incontinence

Twenty-five males with post-prostatectomy incontinence due to sphincter damage underwent transperineal or transurethral Teflon injections. The results were classified into three grades: good, moderate, and poor. Good or moderate results were obtained in 24%. No major immediate complications or longterm side-effects were observed. This intervention is associated with a minimum of discomfort for the patient and hospitalization can be limited to 48-72 hours. The results are not so good as those obtained in female incontinence, and the procedure cannot be recommended as first choice treatment in patients with post-prostatectomy incontinence, but because of the simplicity of the procedure, it is considered to be a valuable alternative in patients not suitable for prosthetic surgery.     

Head and neck reconstruction using lateral thigh free flap: flap design

Eleven lateral thigh free flaps were used in head and neck reconstruction, transferred on the basis of the second perforator as well as the third perforator of the profunda femoris artery. The lateral thigh free flap was useful and reliable in head and neck reconstruction and was versatile in flap design. Due to the wide cutaneous territory of the lateral thigh flap, the skin island could be designed freely in the lateral thigh region. Careful patient selection is mandatory for good results. The pinch test and an understanding of the variety of subcutaneous thicknesses in the lateral thigh region are helpful in designing a skin island of adequate thickness. Other considerations in flap design are discussed.     

Long anterior urethral reconstruction using a jejunal free flap

We report the case of a transgender patient who was referred to our department for management of chronic strictures of his neophalloplasty. We successfully used a free jejunal flap for a long anterior urethral reconstruction. He achieved a patent and functional urethra with satisfactory urinary control and was happy with the cosmetic outcome.     

Long-term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias

In the paediatric section this month several important issues are addressed. The authors from Lyon describe the results of bladder neck reconstruction for incontinence in children with bladder exstrophy and incontinent epispadias. They indicate the unpredictability of bladder neck reconstruction and discuss the results of the other techniques used for urinary continence.

OBJECTIVE

To review the long‐term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve ‘continence’ (which implies active mechanisms) but only ‘dryness’ (which implies passive mechanisms).

PATIENTS AND METHODS

Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young‐Dees‐Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow‐up of 11 years. All patients were treated and followed in the same institution.

RESULTS

In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty‐eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery.

CONCLUSION

We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.

     

The pedicled extended serratus anterior myocutaneous flap for head and neck reconstruction

A new "extended" myocutaneous flap has been designed by fasciocutaneous extension anteriorly and inferiorly from the 6th to 8th slips of the serratus anterior muscle. This flap has been used as a pedicled flap for various types of head and neck reconstructions and satisfactory results obtained. This article describes the anatomy of the flap, surgical technique and typical cases.     

Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra

Vaginal flap urethral reconstruction was done in 10 women who sustained total or partial loss of the urethra, and extensive damage to the vesical neck and trigone due to operative complications. In all patients a neourethra was constructed by rolling a vaginal flap into a tube and covering the anastomosis with a labial pedicle fat pad graft and vaginal flap. Five patients underwent a concomitant pubovaginal sling procedure, 3 had a modified Pereyra operation and 1 had a modified Kelly plication. Postoperatively, 9 of the 10 patients had a satisfactory neourethra but 3 required a generous meatotomy to facilitate micturition. Two patients required temporary intermittent self-catheterization. Of the 10 patients 6 were completely continent after a single reconstruction, which included an anti-incontinence repair. Of the patients with postoperative incontinence 2 subsequently were cured with a pubovaginal sling and 1 had a vesicovaginal fistula that was successfully repaired transvaginally. These results support our contention that a vaginal flap urethral reconstruction combined with an appropriate anti-incontinence operation offers a viable and simple alternative to bladder flap urethral reconstruction.     

Results of treatment of post-prostatectomy incontinence using the Kaufman prosthesis

The results of inserting 55 Kaufman prostheses into 45 patients with post-prostatectomy incontinence have been reviewed. Twenty-seven patients (60%) were continent and 3 were greatly improved. Ten patients were dry after their first prosthesis, 11 required 'topping up' of the device, and 5 were after the first prosthesis had been replaced. Results improved in the later part of the series. The Kaufman prosthesis is a valuable device in the treatment of post-prostatectomy incontinence.     

Vaginal reconstruction using urinary bladder flap in a patient with cloacal malformation

We report a case of vaginal reconstruction using a flap from urinary bladder in a young girl. This girl was born with cloacal malformation and hemivaginas connected to the urinary bladder. Repeated urinary tract infection and vesicoureteral reflux were noted. At the age of 9 months, she received posterior sagittal anorectoplasty for rectum pull-through, but the urogenital part was not corrected. She had repeated urinary tract infection. Detrusor areflexia and large bladder volume were demonstrated by cystometry. Cystoscopy showed a common channel longer than 3 cm. Urogenital reconstruction was performed at 14 months of age. A part of the urinary bladder wall, which was connected to the vaginas, was used to lengthen the vagina so that the latter was able to pull down to the perineum. The patient received vaginal dilatation and intermittent catheterization after the surgery.     

Anterior bladder tube flap reconstruction of the urethrovesical neck after radical retropubic prostatectomy.

Difficulty with urethrovesical neck anastomosis after radical retropubic prostatectomy led us to form an anterior bladder tube flap for anastomosis to the transected urethra in 5 selected cases. We found that combining the anterior bladder tube flap technique with radical retropubic prostatectomy facilitates the urethrovesical neck anastomosis and improves the transient postoperative incontinence sometimes encountered. Results of the 5 patients in whom this technique was used form the basis for a brief discussion of the technique.     

Adjustable perineal male sling using tissue expander as an effective treatment of post-prostatectomy urinary incontinence

Purpose

To report our intermediate experience in treating patients with severe incontinence using an adjustable perineal male sling with a tissue expander.

Materials and Methods

An adjustable male sling procedure was performed on 21 patients with severe incontinence. The underlying etiology of urinary incontinence was radical prostatectomy in 13 patients, open prostatectomy in 5 patients and transurethral prostate resection in 3 patients. The difference between the classical and the adjustable sling is that in the latter there is a 25 mL tissue expander between the two layers of polypropylene mesh with an injection port. Adjustment of the sling was performed with saline via an inflation port, in case of recurrence or persistence of incontinence.

Results

The mean age of the patients was 66.2±7.3 (50-79) years and mean pad usage was 6.4±0.6 per day. The mean follow-up time was 40.1±23.2 (6-74) months. The balloon was postoperatively inflated on average with 11.6±5.7 (5-25) mL. After the mean 40.1 months of follow-up, 16 of the 21 patients (76.2%) were dry (11 patients, 0 pads; 5 patients using safety pads), 3 patients (14%) had mild and 2 (9.8%) had moderate degree post-prostatectomy urinary incontinence (PPI). The average maximum urine flow rate of the patients was 15.6±4.7 (10-31) mL/s. No residual urine was found. In 2 patients, all parts of the device were removed due to infection and discomfort, and in 3 patients only the inflation component was removed due to local scrotal infection.

Conclusions

Our results show that using an adjustable perineal male sling with a tissue expander seems to be an efficient, and safe surgical treatment option in patients with PPI.     

Bladder neck suspension for stress incontinence: long-term evaluation

Remembering that the diagnosis of stress urinary incontinence is essentially clinical, the authors describe the fundamental stages of their technique, i.e. the musculo-aponeurotic suspension of the bladder neck (Goebell-Stoeckel technique). This operation has enabled them to have good results in 88% of their cases. The long-term study of these results shows slight deterioration of the success rate which becomes stable after 2 years.     

Lower abdominal wall reconstruction using the anterior thigh fasciocutaneous flap.

Full thickness defects of the lower abdominal wall are uncommon. They can occur in congenital abdominal wall defects, acute trauma and following resection of soft tissue tumours. In reconstruction of defects not amenable to primary closure, three problems need to be addressed: (i) the fascial layer needs to be reconstructed; (ii) stable and sensate skin coverage is needed as the lower abdominal waistline area is subject to pressure; (iii) it is desirable to restore the contour of the abdominal wall.We present a case with a large area of radiation dermatitis and recurrence of a malignant ovarian tumour in the lower abdominal wall. After en bloc resection the 25 x 6 cm lower abdominal defect was reconstructed with a sensate anterior thigh fasciocutaneous flap. The vascular supply was reliable and the outcome was good. The reasons for using this fasciocutaneous flap in preference to the other options are discussed.     

Primary bladder closure and bladder neck reconstruction in classical bladder exstrophy

The surgical results of 28 consecutive initial bladder closures and 25 consecutive initial bladder neck reconstructions performed for classical bladder exstrophy at our hospital between 1975 and 1982 are presented. Partial bladder prolapse occurred in 2 cases and complete wound dehiscence never occurred following the initial primary bladder closure. Urinary continence following bladder neck reconstruction was assessed from parental interviews. An excellent surgical result was defined either as achievement of a daytime dry interval for more than 3 hours or less than 1 incontinent episode per day. According to these parameters, an excellent surgical result was achieved in 86 and 80 per cent of children, respectively. In 21 children evaluated with excretory urograms between 1/2 and 6 years after bladder neck reconstruction 10 per cent of the renal units showed significant hydronephrosis and deterioration of function. The 2 patients who had upper tract deterioration were not followed postoperatively at our institution and the diagnosis of bladder outlet obstruction was delayed when excretory urograms were not obtained during the first postoperative year. This review of the surgical results following primary bladder closure and bladder neck reconstruction for classical bladder exstrophy demonstrates that secure abdominal wall closure and urinary continence can be achieved with minimal morbidity and with infrequent deterioration of renal function following staged functional bladder closure.     

Bladder neck reconstruction in classic bladder exstrophy: the role of osteotomy in the development of continence

OBJECTIVE: To assess the role of osteotomy at the time of bladder neck reconstruction (BNR) for continence in classic bladder exstrophy, in which closure of the pelvic ring and reconstitution of the pelvic diaphragm may affect eventual continence. PATIENTS AND METHODS: The results of using osteotomy at the time of BNR in 29 children were reviewed. The mean bladder capacity before BNR was 76 mL. The indications for osteotomy were a wide pubic diastasis and a soft intersymphyseal bar. After osteotomy, all children were maintained in external fixation and lower-extremity traction for 6-8 weeks. RESULTS: Complications of osteotomy were limited to a partial femoral nerve palsy (one patient) and delayed union of fragments (one patient). Complications of BNR included urethral stricture (five patients) and bladder calculi (six patients). Continence results were modest, with 11 of 29 children (38%) dry during the day (dry interval >3 h) and eight of 29 (28%) dry at night. Eight children had daytime dry intervals of approximately 3 h. The mean preoperative bladder capacity in children who were dry both day and night was 101 mL. CONCLUSIONS: The preoperative bladder capacity remains a key determinant for the attainment of continence after BNR in the reconstruction of classic bladder exstrophy. Osteotomy allows pelvic closure and thus improves cosmesis of the mons and stabilizes the BNR in patients with a soft intersymphyseal bar, but seems to have no effect on continence when performed at the time of bladder neck plasty.