MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

Purpose

We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion.

Materials and Methods

Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed.

Results

Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion).

Conclusions

Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Outcomes of continent catheterizable stomas for urinary and fecal incontinence: comparison among different tissue options

OBJECTIVE: To retrospectively review the outcome of appendix, transverse tubularized intestine segments, caecal flap, gastric tube and others tissue options used as a continent stoma for urinary and fecal incontinence. PATIENTS AND METHODS: Between January 1993 and January 2003 we created 179 continent stomas to treat urinary and fecal incontinence in 135 patients (81 females and 54 males; mean age at surgery 13 years, 118, 87%, aged <17 years). We used either appendix (112), a short segment of bowel following the Yang-Monti technique (49), gastric augment single pedicle tube (eight), caecal flap (seven), Casale continent vesicostomy (two) and Meckel's diverticulum (one). Thirty-six patients had both urinary and fecal continent stomas created. RESULTS: The mean follow-up for the appendix group was 46 months for the urinary stoma and 23 months for the Malone antegrade continent enema (MACE) stoma. Stoma-related complications occurred in 24 of 112 (21%) patients; there was complete channel fibrosis in five (4%). The mean follow-up for the Yang-Monti group was 38 months for the urinary and 59.2 months for the MACE stoma. There were stoma-related problems in 11 of 49 (22%) patients, with complete channel fibrosis in three (6%). Overall, in the long-term follow-up, there were stoma-related complications in 42 of 179 (23.5%) procedures. CONCLUSIONS: Continent catheterizable stomas are a feasible and reliable method for treating urinary and fecal incontinence. Long-term success can be accomplished with appendix, transverse tubularized intestinal segments and caecal flaps, with similar complication rates in all groups. Surgeon preference and individual patient status should determine the surgical technique to be used.     

Long-term followup and outcome of continent catheterizable vesicocstomy using the Rink modification

PURPOSE: Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. RESULTS: Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. CONCLUSIONS: Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.     

The Malone Antegrade Colonic Enema Enhances the Quality of Life in Children Undergoing Urological Incontinence Procedures

Purpose

Functional alterations of the gastrointestinal and genitourinary tracts, and physical limitations in children with spina bifida, imperforate anus and spinal cord injury challenge the ability to have independent fecal and urinary continence. Urologists have successfully helped these patients achieve urinary continence. We report our experience with the antegrade colonic enema procedure, which allows select individuals to achieve continence of stool, enhancing quality of life.

Materials and Methods

Since December 1992, 18 antegrade colonic enema procedures were performed in 12 female and 6 male patients 5 to 31 years old of whom 14 had spina bifida, 2 had imperforate anus and 2 had spinal cord injury. Simultaneous urological continence procedures were performed in 8 patients, including appendicovesicostomy in 4, augmentation cystoplasty in 2 and augmentation cystoplasty plus an ileal Mitrofanoff procedure in 2. Four patients previously underwent urological reconstruction.

Results

In 24 months of followup (average 6.6) all patients with a functioning stoma remained continent of stool and 17 were continent of urine. Complications related to the antegrade colonic enema procedure occurred in 4 children (22 percent) of whom 3 required further surgery. Three patients (17 percent) had minor stomal stenosis.

Conclusions

The antegrade colonic enema procedure is easily performed and it should be considered for any child with significant physical limitations and/or refractory fecal incontinence before urological continence promoting procedures are done.     

Continent catheterizable conduits: which stoma, which conduit and which reservoir?

OBJECTIVE: To assess the outcome of the various methods used in creating continent catheterizable conduits. PATIENTS AND METHODS: The case notes were reviewed from 89 patients who underwent the formation of 112 continent catheterizable conduits. RESULTS: Sixty-five conduits were Mitrofanoff and 47 were antegrade colonic enema (ACE); 21 patients had both. At a mean follow-up of 34 months, 95 (85%) conduits were still in use. There was no difference in complications between the Mitrofanoff and ACE conduits; 109 (97%) conduits were continent and stomal stenosis occurred 35 (31%). There was no significant difference relating to the conduit used, the reservoir, the stoma type or the stoma site. Only 39% of patients required no revisional surgery. CONCLUSION: Although urinary and fecal continence can be achieved in most patients there is a high burden of complications and revisional surgery. All patients should be counselled accordingly.     

Transverse retubularized ileovesicostomy continent urinary diversion to the umbilicus

The transverse retubularized ileovesicostomy is useful as a continent urinary diversion when the appendix is unusable or unavailable for an appendicovesicostomy continent urinary diversion. Eight patients (mean age 29 years) with difficulty catheterizing their native urethras underwent creation of a transverse retubularized ileovesicostomy continent urinary diversion to the umbilicus. Diagnoses included myelomeningocele (3), multiple sclerosis (1), and spinal cord injury (4). Concomitant procedures included ileocystoplasty, antegrade continence enema procedure, and pubovaginal sling. All patients were able to catheterize their ileovesicostomy conduit and stoma easily with a 14F catheter. Six patients were completely dry, and two patients needed to catheterize every 3 to 4 hours to prevent urinary leakage. Mean follow-up was 3 years. Experience with the transverse retubularized ileovesicostomy continent urinary diversion to the umbilicus has been favorable. When the Mitrofanoff appendicovesicostomy continent urinary diversion is not an option, the transverse retubularized ileovesicostomy has several advantages as a second choice.     

ANTEGRADE CONTINENCE ENEMA FOR THE TREATMENT OF FECAL INCONTINENCE IN ADULTS: USE OF GASTRIC TUBE FOR CATHETERIZABLE ACCESS TO THE DESCENDING COLON

PURPOSE: We describe the use of a gastric segment in performing the antegrade continence enema procedure in patients with refractory fecal incontinence. MATERIALS AND METHODS: The antegrade continence enema procedure was performed in 4 women and 3 men with refractory neurogenic fecal incontinence. Preoperative evaluation included defecography and anorectal manometry. Operative technique involves tunneling a 10 cm. segment of tubularized stomach isolated along the greater curve with preservation of the right gastroepiploic vessels through the anterior tenia of the colon just distal to the splenic flexure. After the stoma is mature the patient passes a catheter and runs 1 to 2 l. warm tap water through it while seated on the toilet. Digital stimulation may be required to initiate bowel emptying and irrigation is continued until clear. RESULTS: Creation of a nonrefluxing catheterizable gastric tube to the descending colon was successful in all 7 patients. At a mean postoperative followup of 22.4 months all patients are continent and use antegrade continence enema irrigation every other day on average. One patient required early revision because of stomal stenosis. Special measures include application of a generic antacid tablet to the stoma and use of a skin barrier. CONCLUSIONS: Catheterizable access to the descending colon for the antegrade continence enema procedure more closely approximates normal defecation patterns by emptying ("unloading") the left side of the colon. The stomach is a suitable option in close proximity for this purpose and is especially advantageous when the appendix is not available. The antegrade continence enema procedure using a gastric segment can be safely and effectively performed, and is well suited for use by reconstructive surgeons who are familiar with the Mitrofanoff principle.     

Concealed umbilical stoma: long-term evaluation of stomal stenosis

PURPOSE: The technique of forming a concealed umbilical stoma has been described previously and includes a posterior umbilical flap for improved cosmesis and stenosis prevention. We assessed long-term stomal stenosis. MATERIALS AND METHODS: We reviewed retrospectively the charts of 46 patients (mean age at surgery 14 years) of whom 35 had undergone concealed umbilical stoma creation and 11 the Malone antegrade continence enema procedure for continent urinary diversion. Urinary stomas were created from appendix in 20 cases, ileum in 8, sigmoid colon in 5, bladder in 1 and stomach in 1. Malone antegrade continence enema stomas were constructed from appendix in 10 cases and sigmoid colon in 1. A total of 21 patients underwent urinary diversion and augmentation cystoplasty. RESULTS: At followup of 12 to 84 months (median 3.4 years) 93.5% of patients had an intact stoma with no need for surgical revision. Of the remaining patients 3 (6.5%) required revision of the stoma at skin level for stomal stenosis at 1, 4 and 38 months after initial surgery and 2 had a brief period of indwelling catheterization for correction of stenosis. CONCLUSIONS: The concealed umbilical stoma technique provides an excellent cosmetic result with a low rate of stomal stenosis in patients requiring intermittent bladder or bowel catheterization.     

TRANSVERSE RETUBULARIZED SIGMOIDOVESICOSTOMY CONTINENT URINARY DIVERSION TO THE UMBILICUS

PURPOSE: The most widely used conduit when creating continent urinary diversion based on the Mitrofanoff principle has been appendicovesicostomy. However, appendix is not always available and it is increasingly used for the antegrade continence enema in situ appendix procedure. In 1993 the technique of transverse retubularization of the ileum to create a continent catheterizable conduit for an ileal reservoir was described and in 1997 this technique was studied in an animal model. Larger patients may need 2 ileal segments in series to bridge the distance between the umbilicus and bladder. To avoid using 2 segments we used transverse retubularized sigmoid colon to create a catheterizable sigmoidovesicostomy to the umbilicus. METHODS AND METHODS: In 5 children 6 to 19 years old (mean age 15) with neurogenic bladder secondary to spina bifida a transverse retubularized sigmoidovesicostomy to the umbilicus was performed. In all patients an antegrade continence enema procedure was done for refractory constipation and overflow fecal incontinence secondary to neurogenic bowel. Laparoscopy was performed to mobilize the appendix in patients who requested a low Pfannenstiel incision for better cosmesis. Additional procedures included the pubovaginal sling placement and sigmoid colocystoplasty. RESULTS: Mean length of the sigmoidovesicostomy, which was equal to the circumference of the sigmoid before retubularization, was 13 cm. (range 10 to 15). This sigmoid conduit reached the umbilicus easily in all cases. All sigmoidovesicostomies were easily catheterized and all were continent. One patient with morbid obesity (body mass index 40.4) had a mucocutaneous anastomotic breakdown 3 months postoperatively. Minimum followup was 1 year (mean 1.5). CONCLUSIONS: Transverse retubularized sigmoidovesicostomy is effective for creating a continent urinary diversion to the umbilicus in patients with neurogenic bladder secondary to spina bifida. Dilating the sigmoid colon from neurogenic bowel creates a long conduit based on the Yang-Monti principle and 2 ileal segments with an anastomosis are not required. Additional benefits are that the sigmoid colon is readily accessible via a low Pfannenstiel incision and may also be used for augmentation in select cases.     

CONCOMITANT MODIFIED BLADDER NECK CLOSURE AND MITROFANOFF URINARY DIVERSION

PURPOSE: We describe a modification of bladder neck closure for managing urinary incontinence in children. MATERIALS AND METHODS: In 11 patients with intractable urinary incontinence that persisted after multiple failed surgical procedures we performed modified bladder neck closure with construction of a catheterizable continent conduit. RESULTS: Mean followup is 3 years. All patients were continent after the procedure and none had a fistula or urinary leakage. One patient required stomal and conduit revision, and bladder stones in 3 necessitated endoscopic removal. CONCLUSIONS: We recommend this modified technique of bladder neck closure as an option for managing urinary incontinence in a complex group of children because it allows the achievement of continence with minimal morbidity.     

The Malone Antegrade Continence Enema Procedure in the Management of Patients with Spina Bifida

Background: In patients with spina bifida, traditional bowel management programs such as suppositories, retrograde enemas, and manual disimpaction have been largely unsatisfactory. The Malone antegrade continence enema (ACE) procedure has largely changed our approach to bowel management in this patient group.

Study Design: Over a 3-year period between January 1994 and January 1997, 27 patients with spina bifida underwent the Malone ACE procedure at our institutions. At the time of their ACE procedure, four patients underwent simultaneous continent urinary diversion and three had simultaneous small-bowel bladder augmentation. All the patients were evaluated for 9 months or more after their procedure, and 10 of the patients have been followed for more than 2 years.

Results: Postoperatively, predictable bowel control and continence were achieved in 19 of the 27 patients, but 6 had some rectal soiling requiring a sanitary pad. All patients were out of diapers and none reported stomal leakage. Eighteen of the 27 patients were able to manage independently and 9 required assistance. Two patients had stopped using their ACE stoma despite good technical results. The appendix was used as a catheterizable stoma in 15 of the 27 patients. The appendix was not available in 12 patients, so a tubularized cecal flap was used in 9 and a small-bowel neoappendix was created in 3. Complications included stomal stenosis in 5 patients, cecal-flap necrosis in 1, and stomal granulations in 3.

Conclusions: We believe that the ACE procedure provides reliable colonic emptying and avoids fecal soiling in the majority of individuals, and we find it widely and enthusiastically accepted by patients with spina bifida.     

Periurethral injection therapy for urinary incontinence using a laparoscopic port

In a 14-year-old boy with bladder augmentation, Mitrofanoff appendicovesicostomy, Malone antegrade enema stoma, and bladder neck reconstruction, urinary continence was restored by injection of Teflon with a Veress needle and the aid of a 2-mm laparoscopic port. The method has since been used for nine treatments in six children and has been successful in all.     

Colonic tubes for the antegrade continence enema: comparison of surgical technique

PURPOSE: The Malone antegrade continence enema has revolutionized the management of intractable fecal incontinence and constipation. When the appendix is absent, surgical options are limited. Small series with short-term followup have demonstrated the feasibility but not the reliability of the continent colonic tube. We present our experience with a lateral based colonic tube. We also compared lateral based colonic tubes to medial based tubes. MATERIALS AND METHODS: The medical records of patients treated with a continent colonic tube for intractable fecal incontinence were reviewed. We identified 8 patients who underwent the procedure between July 2000 and February 2003. The literature was reviewed to compare lateral vs medial based tubes. RESULTS: Average followup was 28 months (range 10 to 41). Stomal stenosis developed in 4 patients (50%) within 3 to 6 months of surgery. Passive dilation at the clinic corrected the problem in 3 patients and 1 required operative stomal revision. All 8 patients reported almost complete relief of rectal incontinence and constipation. A literature review demonstrated a significantly higher rate of stomal stenosis in lateral vs medial based colonic tubes (40% vs 12%). CONCLUSIONS: The continent colonic tube is a safe and effective alternative in patients with refractory fecal incontinence and constipation who do not have an available appendix. These results appear durable during the described period. We believe that this technique is an alternative to the cecostomy button and it should be offered to suitable patients. The lateral based colonic tube appears to have a higher rate of stomal stenosis than medial based colonic tubes, which may be attributed to the local blood supply of the colon.     

Intermittent Self-Catheterization by Quadriplegic Patients Via a Catheterizable Mitrofanoff Channel

Purpose

Neurogenic bladder due to cervical spinal cord injury is often best managed by clean intermittent catheterization. Limited upper extremity function makes patients with quadriplegia dependent on caregivers for clean intermittent catheterization. The Mitrofanoff umbilical appendicovesicostomy provides easy access to the bladder in patients with all types of access difficulty. We evaluated the Mitrofanoff umbilical appendicovesicostomy in 7 patients with quadriplegia.

Materials and Methods

Four men and 3 women with cervical spinal cord injury underwent the Mitrofanoff umbilical appendicovesicostomy with appendix (5) or ileum (2).

Results

All patients are continent and able to self-catheterize via the umbilical stoma. In 1 patient with an ileal Mitrofanoff umbilical appendicovesicostomy umbilical incontinence was repaired surgically and stomal stenosis developed in 1, which required stomal revision. All patients use the stoma regularly. Four patients have moved out of care facilities and are living more independently.

Conclusions

The Mitrofanoff catheterizable channel is a valuable option for bladder management in patients with quadriplegia. Clean intermittent self-catheterization allows these patients independent function and facilitates their return to productive lives outside care facilities.     

A LONG CONTINENT ILEOVESICOSTOMY USING A SINGLE PIECE OF BOWEL

PURPOSE: In 1981 Mitrofanoff presented a procedure to create a continent urinary stoma for intermittent catheterization. Since then, several other methods have been introduced, including the Yang-Monti ileovesicostomy. The length of these ileovesicostomies is limited by the circumference of the bowel segment used, which is inadequate in some cases. We developed a procedure to double the length of the Yang-Monti ileovesicostomy using a single section of bowel. MATERIALS AND METHODS: A 3.5 cm. section of ileum is isolated on its mesentery. The bowel is divided into 2 segments for 80% of its circumference, leaving the bowel intact over the mesentery. Each ring of bowel is then divided adjacent to the mesentery but on opposite sides, allowing the bowel to be unfolded and reconfigured in a single long strip that may then be tubularized. The blood supply to the tube is excellent and it is in the center of the reconfigured ileum. The ends may be trimmed or widely spatulated as necessary. RESULTS: We have performed this procedure in 8 patients. The resulting ileovesicostomy created from a 3.5 cm. section ofileum is 10 to 14 cm. long and accepts a 12F catheter. A larger tube may be created from a longer piece of ileum. All patients are dry and they perform catheterization easily. CONCLUSIONS: This form of ileovesicostomy allows the creation of a long bowel tube that is easily catheterized. The longer length of the tube increases application of the continent stoma principle to more patients and enables reconstruction to be performed with optimal placement and without tension.     

The Macedo-Malone antegrade continence enema procedure: early experience

PURPOSE: The successful treatment of fecal incontinence can dramatically improve the quality of life of affected children. The introduction of the Malone antegrade continence enema provides the opportunity to manage previously resistant cases. However, using the to create this catheterizable channel is not always possible, and the duration of these antegrade enemas is a source of concern for the patients. We describe a new approach to create left continent colonic access to shorten the duration of these enemas, and report the experience gained from the first 9 cases managed at our institution. MATERIALS AND METHODS: During a 5-year period 9 patients underwent a Macedo-Malone antegrade continence enema at our institution. Incontinence was associated with myelomeningocele in 7 patients and anorectal malformation in 2. The antegrade continence enema procedure is begun by isolating a 2 cm flap in a tenia on the left colon (spleen flexure). A 12Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow tubularization of the plate with interrupted polyglycolic acid 3-zero transverse sutures, creating an efferent tubular conduit. Antegrade colonic washouts were started 2 weeks after surgery with saline solution or tap water in all patients. RESULTS: Followup of our 9 cases ranged from 8 to 33 months (average 20.7). Enema volume varied from 250 to 800 ml, with administration taking from 45 to 60 minutes, and colonic evacuation occurred within 30 to 60 minutes of enema administration. Of the 9 patients 8 were completely continent and 1 was partially continent. Four patients experienced difficulty with catheterization initially because of stenosis of the stomal track. The affected stomas were dilated, which was successful in 1 case. Three patients subsequently required stomal revision. CONCLUSIONS: The Macedo-Malone procedure is a relatively straightforward operative approach providing an effective washout technique that is acceptable to parents and children.     

Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy

PURPOSE: Salvage prostatectomy after full dose radiation therapy is associated with a high risk of urinary incontinence. We evaluated the complications of salvage prostatectomy with continent catheterizable reconstruction and its impact on urinary incontinence. MATERIALS AND METHODS: Between August 1995 and February 1999, 13 patients with biopsy proved, locally recurrent prostate cancer after radiation therapy underwent salvage prostatectomy with complete bladder neck closure and reconstruction with an appendicovesicostomy to the native bladder in 9 and ileovesicostomy in 4. RESULTS: There were no intraoperative complications. Four patients had serious complications necessitating reoperation, including a vesicourethral fistula requiring delayed cystectomy, wound dehiscence with disruption of the appendicovesical anastomosis, leakage from the small bowel anastomosis that resulted in sepsis and death, and stomal stenosis requiring delayed stomal revision in 1 each. Of 12 patients 2 (17%) used pads for incontinence, while 10 were dry during the day and night with a catheterization interval of 2 to 6 hours. CONCLUSIONS: Salvage prostatectomy with continent catheterizable reconstruction is a technically challenging operation with the potential for serious complications. The postoperative continence rate is excellent and appears superior to those in the literature for salvage prostatectomy and vesicourethral anastomosis.     

Creation of an appendicovesicostomy mitrofanoff from a preexisting appendicocecostomy utilizing the spilt appendix technique

Continent catheterizable channels have revolutionized reconstructive surgery to achieve both urinary and fecal continence. The Mitrofanoff and Malone antegrade continent catheterizable channels offer improved quality of life relative to permanent incontinent stomas. A frequently employed surgical option for creating a Mitrofanoff when an existing appendicocecostomy exists involves harvesting a separate piece of intestine. If however the Malone has preceded the creation of a Mitrofanoff, we describe a surgical technique that may avoid the need for a bowel harvest and resultant anastomosis. We report our series of patients utilizing a novel alternative strategy in the select clinical circumstance of an existing appendicocecostomy to expand the armamentarium of the urologic reconstructive surgeon.     

Treatment of severe chronic constipation through the antegrade continent enema procedure

The antegrade continent enema procedure was first described in 1990 by Malone for the treatment of severe fecal neurogenic incontinence in children. Since then, this technique has been successfully carried out in adults, as well as in patients with refractory constipation. The procedure provides a continent and catheterizable channel, generally an appendicostomy, through which antegrade washouts are given to produce colonic emptying. We describe the case of a 23-year-old man with severe constipation and overflow fecal incontinence who underwent an appendicostomy. There were no immediate postoperative complications and saline washouts were started on the fourth day. Since then, the patient has had a bowel movement between 1 and 3 hours after each washout, has recovered continence, and no longer wears an absorbent pad.     

Feasibility and early outcomes of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in patients with prune belly syndrome

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? There is a single case reported in the literature describing this approach in prune belly syndrome. To our knowledge there are two case reports and two series in which laparoscopic appendicovesicostomy using the da Vinci robotic system was performed with good results. There are also several case reports of appendicovesicostomy creation using a pure laparoscopic approach. Additionally, several case reports have described combined procedures involving pure laparoscopic and robotic assisted techniques, including appendicovesicostomy with concurrent augmentation, nephrectomy, orchiopexy, antegrade continence enema and cecostomy tube placement. Nguyen et al. have a similar experience in terms of number of patients (ten) who have undergone RALMA, but have not operated on patients with PBS. To our knowledge this is the largest series of patients undergoing RALMA in patients with prune belly syndrome.

OBJECTIVES

? To evaluate the feasibility and report our initial experience with Robotic‐ Assisted Laparoscopic Mitrofanoff Appendicovesicostomy (RALMA) in patients with prune belly syndrome. ? The Mitrofanoff appendicovesicostomy procedure uses the appendix to create an easily accessible continent, catheterizable channel into the urinary bladder. Historically, the procedure is performed by an open surgical approach in prune belly patients. We describe our initial experience herein.

MATERIALS AND METHODS

? Between October 2008 and February 2010 three patients with prune belly syndrome underwent RALMA. ? The appendicovesicostomy anastomosis was performed on the anterior bladder wall and the stoma was brought to the umbilical site or right lower quadrant. ? At least 4 cm of detrusor backing was ensured. ? The appendicovesicostomy stent was left in place for 4 weeks postoperatively before initiation of catheterization.

RESULTS

? Mean age at surgery was 9.7 years (range 5–14 years). ? Blood loss volume was 20 mL in each case. Overall mean operative time was 352 min (range 319–402 min). There were no intraoperative complications and no open conversions. ? There was one postoperative complication in the form of wound infection. ? All patients are catheterizing their stomas and are continent at an average follow‐up of 14.7 months (range 5–21 months).

CONCLUSION

? In our initial experience, RALMA is a feasible option with encouraging early experience for creating a continent catheterizable channel into the urinary bladder in patients with prune belly syndrome.