Modern staged repair of bladder exstrophy: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and many repairs are now offered. The purpose of this study was to evaluate long-term outcomes in a select group of patients in whom modern staged repair (MSRE) was undertaken.Patients and methodsFrom an institutionally approved database were extracted 189 patients who had undergone primary closure between 1988 and 2004. The records of 131 patients (95 males) who underwent MSRE with a modified Cantwell-Ransley repair by a single surgeon in 1988–2004 were reviewed with a minimum 5-year follow up.ResultsSixty-seven patients with a mean age of 2 months (range 6 h to 4 months) underwent primary closure, and 18 underwent osteotomy at the same time. Mean age at epispadias repair was 18 months (8–24). Mean age at bladder neck reconstruction (BNR) was 4.8 years (40–60 months) with a mean capacity of 98 cc (75–185). Analysis of bladder capacity prior to BNR revealed that patients with a mean capacity greater than 85 cc median had better outcomes. Seventy percent (n = 47) are continent day and night and voiding per urethra without augmentation or intermittent catheterization. Social continence defined as dry for more than 3 h during the day was found in 10% (n = 7). Six patients required continent diversion after failed BNR. Seven patients are completely incontinent. The mean time to daytime continence was 14 months (4–23) and the mean time to night-time continence was 23 months (11–34). No correlation was found between age at BNR and continence.ConclusionsPatients with a good bladder template who develop sufficient bladder capacity after successful primary closure and epispadias repair can achieve acceptable continence without bladder augmentation and intermittent catheterization.     

Single-stage repair of bladder exstrophy in older children and children with failed previous repair

AimEvaluation of cosmetic and functional outcome of single-stage exstrophy–epispadias complex repair in older children and those with previously failed repair.Materials and methodsThis study comprised 15 children (12 boys and 3 girls) with classic bladder exstrophy and a mean age at repair of 8.6 months (range 2–24 months). Eight children had a previously failed repair. All children underwent complete primary repair using the single-stage Mitchell technique. Half of the boys had complete penile disassembly, while in the others a modified Cantwell–Ransley technique for epispadias repair was used. Anterior iliac osteotomy was performed and hip spica used for immobilization in all children.ResultsOne child had urethral stricture treated by endoscopic visual urethrotomy. Three children had penopubic fistulae that closed spontaneously. No bladder dehiscence or prolapse was encountered. Vesicoureteral reflux was present in 20 renal units but ureteral reimplantation was not performed. Average bladder capacity after closure was 134 cm³ (range 110–160 cm³) with only two partially continent and six incontinent children. Mean follow-up period is 2 years (range 1–3 years).ConclusionsSingle-stage repair was performed in children with previously failed repair and those presenting at an older age with satisfactory results. Acceptable bladder and genital anatomy and function were achieved together with preservation of renal function. The impact of this technique on continence is not encouraging, but needs to be determined in a longer follow-up period.     

Impact of epispadias repair on bladder growth in boys with classic bladder exstrophy

ObjectiveGrowth of the bladder in children with bladder exstrophy is primarily responsible for later ability to void continently. Improvement in bladder capacity has been noted in some boys following epispadias repair. Does the timing of epispadias repair influence the ability of the bladder to grow?MethodsData were collected regarding bladder volume measurements, obtained under anesthesia using a standard technique, during yearly follow-up of boys with classic bladder exstrophy. Volume prior to epispadias repair was compared to the next volume measure following repair. Timing of epispadias repair was compared to changes in bladder capacity in 30 boys. Monthly increases in bladder capacity were calculated in boys repaired at <12 (4), 13–24 (12) and 25–48 (14) months.ResultsPatients who had surgery prior to 12 months of age had the highest rate of monthly increase in bladder capacity (2.40 cc/month). Monthly growth rates were 1.91 cc/month for patients repaired at 13–24 months and 1.18 cc/month for those repaired at 25–48 months.ConclusionsEpispadias repair does lead to early increase in bladder capacity in boys with classic bladder exstrophy. The monthly increases in bladder capacity are greater in boys <12 months. Improvement in bladder volume is less likely when epispadias is repaired after age 29 months.     

Outcome of bladder exstrophy repair based on age and technique. Single center experience

PurposeReconstruction of bladder exstrophy remains a challenge. We evaluated our experience with different techniques in different age groups.Material and MethodsA retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. 61 patients (21 females and 40 males) with classic bladder exstrophy were included. Age of presentation ranged from 24 hours to 14 months. 51 patients underwent complete primary repair and 11 patients had staged repairs. Mean follow up was 3 years (1 month to 7 years). Mortality involved one male & one female (3.2%). 29 patients underwent anterior innominate osteotomy and 9 underwent posterior osteotomy. Patients were evaluated for continence, upper tract dilatation and cosmetic result.ResultsIn the primary repair group, 8 (15.6%) had failed closures and 5 (9.8%) had fistulas. In the staged repair group, 1 (0.9%) had a failed closure and 1 had an epispadic fistula. Evaluation of continence excluded 9 patients recently operated on and 17 patients not followed up at our center. The primary repair group had 15 of 25 dry patients (11 females and 4 males). In the staged repair group, 4 of 10 patients were continent. 4 of our staged cases became dry following augmentation cystoplasty. Upper tract changes were mild during our study (44% of complete repair group and 12.5% in the staged group) with all patients having normal serum creatinine.ConclusionsPatients may require more than one procedure for reconstruction. Continence was better in females than males with primary or staged repairs.     

Perioperative anesthetic and analgesic management of newborn bladder exstrophy repair

ObjectiveReconstruction of bladder exstrophy in newborn infants requires immobilization, sedation and pain management to prevent distracting forces from compromising the repair. We present a 6-year review of our experience.Subjects and methodsWe reviewed the perioperative management of newborn infants undergoing reconstruction between November 1999 and October 2006. Data are presented as means ± SD.ResultsTwenty-three newborn infants underwent surgery under a combined epidural and general anesthetic technique. Tunneled caudal epidural catheters were inserted in all patients and intermittently injected with 0.25% bupivacaine with 1:200,000 epinephrine. Postoperatively, a continuous infusion of 0.1% lidocaine, 0.8–1 mg/kg/h was administered for 15 ± 8 (range 4–30) days. Children were sedated with diazepam for 20 ± 13 (range 2–40) days. Central venous catheters were maintained for 20 ± 9 (range 1–34) days for fluids, drug administration and blood sampling. No patient experienced bladder prolapse or wound dehiscence.ConclusionPerioperative management with tunneled epidural and central venous catheters in newborn infants with bladder exstrophy facilitates immobilization, analgesia and sedation, resulting in an excellent cosmetic repair with no case of bladder prolapse or wound dehiscence.     

Outcome of complete primary bladder exstrophy repair: Single-center experience

ObjectiveReconstruction of bladder exstrophy remains a challenge. We evaluated our experience with complete primary repair in classic bladder exstrophy.MethodsA retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. Fifty-one patients (21 females and 30 males) with classic bladder exstrophy were included. Age of presentation ranged from 24 h to 14 months. Mean follow up was 3 years (1 month–7 years). Patients were evaluated for continence, upper tract dilatation and cosmetic result.ResultsEight patients (15.6%) had failed closures and six (11.7%) had fistulae. Evaluation of continence excluded 16 patients not followed up at our center. Thirty-seven percent were continent on clean intermittent catheterization after the age of 5 years. Patients became dry only after augmentation cystoplasty. Upper tract changes were mild during our study with all patients having normal serum creatinine.ConclusionPatients may require more than one procedure for reconstruction. In our series, augmentation was required to achieve acceptable dryness. Early promising results with dry intervals in young patients did not translate to continence in older patients.     

Management of bladder exstrophy in adulthood: Report of 5 cases

ObjectiveTo report our experience in the management of adult classic bladder exstrophy.Patients and methodsDuring 1977‒2006 we treated five adult males presenting with classic exstrophy–epispadias complex. Patient age at presentation ranged from 17 to 30 with a mean age of 23 years. Four patients had received no previous treatment and one underwent previous ureterosigmoidostomy. Work-up included evaluation of upper tract and bladder biopsy. Bladder patch condition was variable. Surgery involved bladder preservation in the three patients who underwent primary repair, including bladder closure, bladder neck reconstruction and epispadias repair; two of them also had augmentation ileocystoplasty. The remaining two patients underwent ureterosigmoidostomy, cystectomy and epispadias repair. Abdominal wall closure was by fasciocutaneous M-plasty. Osteotomy was not done in any case.ResultsIn patients with bladder preservation, one patient was continent (>3 h) and voided normally whereas the other two showed day and night continence (2–3 h) with mild stress incontinence. Patients were satisfied with functional outcome. Ultrasound and intravenous pyelography showed preservation of upper tract. Follow-up period ranged from 1 to 8 years.ConclusionPatients with bladder exstrophy presenting in adulthood should not be denied the opportunity of primary reconstruction with bladder preservation in the absence of significant histological changes in the bladder mucosa.     

Long-term follow up of enteric bladder augmentations: the risk for malignancy

ObjectiveTo determine the risk of bladder cancer following enteric bladder augmentation.Materials and methodsPatients followed for care after an enteric bladder augmentation have been entered into a registry; individuals followed for a minimum of 10 years were evaluated.ResultsThe study criteria were met by 153 patients. Indications for bladder augmentation were neurogenic bladder in 97, exstrophy in 38 and posterior urethral valves in 18. There was a median follow-up interval of 27 years (range 10–53). A total of seven cases of malignancy developed. Median time to tumor development following augmentation was 32 years (range 22–52). Two patients with neurogenic bladder developed transitional cell carcinoma; both were heavy smokers (>50 pack per year history). Two patients with a history of posterior urethral valves and renal transplantation developed adenocarcinoma of the enteric augment. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the augmented bladder. Two patients remain alive, 5 and 6 years following radical cystoprostatectomy; five died of cancer-specific causes.ConclusionsMalignancy following enteric bladder augmentation arose in 4.5% (7/153) of our patients and was associated with coexisting carcinogenic stimuli (prolonged tobacco/chronic immunosuppressive exposure), or alternatively with the inherent risk of malignancy existing with bladder exstrophy.     

Bladder capacity as a predictor of voided continence after failed exstrophy closure

ObjectiveTo evaluate potential predictors of voided continence among bladder exstrophy patients with a history of a failed closure.Patients and methodsThe authors reviewed all patients who underwent a bladder neck reconstruction (BNR) with a history of one or more failed exstrophy closures between 1979 and 2007. The following data were collected for each patient: number of failures, site of surgery, mode of failure, presence of osteotomy, bladder capacity, need for additional procedures, and continence status.ResultsAmong patients who underwent successful reclosure following one or more failed closures, 52 patients underwent BNR, and 24 (46%) were continent at last follow-up. Bladder capacity was the only variable predictive of voided continence. The median bladder capacity at the time of BNR differed between those who achieved continence (100 mL) and those who did not (65 mL) (p = 0.005). ROC analysis showed an optimal pre-BNR bladder capacity cutoff for predicting future BNR success of between 80 and 100 mL.ConclusionAs previously shown in patients with successful primary closure of exstrophy, these data suggest that bladder capacity also has predictive value in the success of BNR after failed exstrophy closure.     

Penile ischemic injury in the exstrophy/epispadias spectrum: New insights and possible mechanisms

ObjectivePartial or complete penile loss following bladder exstrophy and/or epispadias repair has been reported in the literature progressively more frequently.Patients and methodsThe authors report new cases of penile injury following bladder exstrophy and/or epispadias repair referred to their centers and not previously published. They review the literature on this subject and offer an explanation as to the likely mechanism for the penile injury and recommendations to avoid this complication.ResultsSeven new cases of partial or complete penile loss following bladder exstrophy or epispadias repair have been recently referred to the authors’ institutions. Twenty-one patients have previously been reported in the literature. Altogether, 24 cases occurred after bladder exstrophy closure: 23 after complete primary repair of exstrophy (Mitchell repair) and one after first-stage radical soft-tissue mobilization (Kelly repair). Nineteen of 24 patients did not have a pelvic osteotomy at the time of primary closure. Four cases occurred after epispadias repair: two following the second-stage radical soft-tissue mobilization (Kelly repair) and two following penile disassembly epispadias repair (Mitchell repair).ConclusionExstrophy closure combined with epispadias repair can be followed by ischemic penile injury, particularly when osteotomy is not performed. Compression of the pudendal vessels after pubic apposition and/or direct injury to the pudendal vessels play an important role in the pathogenesis of this complication.     

Laparoscopic inguinal herniotomy in bladder exstrophy: A new solution to an old problem?

ObjectiveLaparoscopy is now the established management for infants with inguinal hernia at our institution. Open inguinal herniotomy in children with bladder exstrophy can be a difficult operation and is associated with a high rate of recurrence (15%). Here, we report our initial experience with laparoscopic repair of inguinal hernia in three children with bladder exstrophy.Materials and methodsThree boys with repaired bladder exstrophy presented with inguinal hernia during follow up. The clinical presentation was bilateral in one and findings at surgery were bilateral open internal rings in two. Under general anaesthesia, pneumoperitoneum of 10 mmHg was raised with a Hasson port at the umbilicus. Two further instruments were inserted in the right and left flanks without ports. Two 4/0 Prolene™ purse string sutures were placed to securely close the internal ring. The umbilicus was closed with an absorbable suture, and the skin incisions were closed with Indermil Glue™.ResultsAll infants made an uneventful recovery, being discharged within 24 h. There were no complications. There has been no sign of recurrence during a mean follow up of 16 months.ConclusionLaparoscopic inguinal herniotomy is a technically straightforward and effective way to treat inguinal hernias in children with bladder exstrophy.     

Comparison of traditional enterocystoplasty and seromuscular colocystoplasty lined with urothelium

ObjectiveTo evaluate long-term outcomes between various methods of augmentation cystoplasty.MethodsA retrospective analysis was performed of patients undergoing seromuscular colocystoplasty lined with urothelium (SCLU, n = 26), and their outcomes compared to a similar population of patients in the same institution who had received traditional forms of bladder augmentation (colocystoplasty and ileocystoplasty, n = 32). Measurements included efficacy of the procedure in increasing bladder capacity and achieving urinary continence, and the need of subsequent surgery for complications.ResultsThere was no statistically significant difference in achieved bladder capacity, subjective urinary continence and the rates of subsequent surgery for stones, vesicoureteral reflux, augment failure, bladder neck continence and catheterizable channel. None of the patients in the SCLU group had spontaneous perforation or small bowel obstruction.ConclusionPatients with SCLU are at decreased risk for bowel obstruction and spontaneous perforation, but are not devoid of other long-term complications including bladder stones, vesicoureteral reflux and augment failure. Most of the risks and benefits of augmentation cystoplasty performed using ileum, colon, or SCLU appear similar.     

Safety and efficacy of staged pelvic osteotomies in the modern treatment of cloacal exstrophy

Introduction and objectiveStaged pelvic osteotomy (SPO) prior to bladder closure has been shown to be a safe and effective method for achieving pubic approximation in cloacal exstrophy (CE) patients with extreme diastasis. However, SPO outcomes have never been compared to those for combined pelvic osteotomy (CPO) at the time of closure in CE patients.MethodsA prospectively maintained database of 1208 exstrophy–epispadias complex patients was reviewed for CE patients treated with pelvic osteotomies. Inclusion criteria were osteotomy at the authors' institution and closure within two months of osteotomy. After inclusion, patients were separated into four groups depending on osteotomy procedure (SPO vs. CPO) and whether their osteotomy occurred with primary closure or re-closure. Patient demographics, closure history, pre-operative diastasis measurement, most recent post-operative diastasis measurement, and outcomes were recorded and compared by chi-squared tests and ANOVA.ResultsAmong 116 CE patients reviewed, 46 met inclusion criteria. With primary closure or re-closure, 27 had SPO and 19 had CPO. No SPO re-closure patients had previous osteotomy; 4 CPO re-closure patients had a previous osteotomy with closure. Median time between osteotomy and closure in SPO patients was 14 days. Median follow-up after SPO and CPO were 4 and 11 years, respectively. SPO significantly reduced the pre-operative diastasis compared to CPO on most recent diastasis measurement (3.5 cm vs. 0.4 cm, p = 0.003). There were no significant differences in the overall complication rate, or the rates of each specific complication, between the SPO and CPO groups. No patients had wound dehiscence or prolapse. One CPO patient was able to intermittently catheterize per urethra while all other patients required continent urinary diversion to achieve continence.ConclusionsTo the authors' knowledge, this is the first study comparing SPO and CPO outcomes in CE patients. SPO reduces pre-operative diastasis more than CPO, and does not appear to incur increased rates of complication, closure failure, or incontinence. Due to its apparent safety and greater efficacy, SPO should be considered in all CE patients with extreme diastases undergoing primary closure or re-closure.     

Total endoscopic management (TEM approach) of children with non-compliant neuropathic bladder: a preliminary report

PurposeWe prospectively evaluated the efficacy and durability of a combination of intradetrusor botulinum-A toxin (BTX-A) and endoscopic treatment of vesicoureteric reflux (VUR) to manage children with myelomeningocele (MMC) and non-compliant refluxing bladders who were not responding to standard conservative therapy. We also evaluated whether this combined therapy can lower intravesical pressure, increase bladder capacity, gain social continence and protect the upper tract from recurrent urinary tract infection.Material and methodsA total of 10 patients with a mean age of 5.9 ± 3.6 years (range 2–12 years) with MMC (eight females and two males) were prospectively involved in the study. All patients were fully compliant to clean intermittent catheterization, and all were non-responders (failed to gain continence and/or poor compliance) to the maximum tolerable dose of anticholinergics and catheterization. All patients were subjected to cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) of BTX-A in an infection-free bladder. They all had VUR (16 refluxing ureters, six patients with bilateral VUR) and did not show resolution in the pretreatment voiding cystourethrogram; accordingly, submucosal injection of Deflux^® was performed either with the second BTX-A treatment (initial four patients) or with the first BTX-A treatment (the other six patients). The grade of reflux was G III, IV and V in three, seven and six ureters, respectively.ResultsThe maximum bladder capacity increased significantly from 79 ± 49 to 155 ± 57 ml (p < 0.022), and the maximum detrusor pressure decreased significantly from 55 ± 16 to 37 ± 11 cm H₂O (p < 0.001). Fifteen out of 16 (93.75%) refluxing ureters were completely resolved (one of them on second attempt), and one (6.25%) (GV reflux) remained unchanged despite of two attempts. Of six incontinent patients, five reached complete dryness between catheterizations and one showed partial improvement.ConclusionsA combination of BTX-A and endoscopic correction of VUR is a simple and effective way to overcome the increased risk of high intravesical pressure and recurrent UTI. This treatment decreases the incidence of renal damage in children on whom conservative management fails to help, in a minimally invasive way.     

Endoscopic injection of submucosal bulking agents for the management of incontinent catheterizable channels

BackgroundUrinary and fecal continence can be achieved by constructing catheterizable continent channels that provide access to the bladder and bowel. Some patients develop persistent stomal leakage. A minimally invasive method of injection with a bulking agent for treatment of stomal incontinence was evaluated.MethodsA retrospective review identified patients with incontinence of their catheterizable continent urinary channel (CUC) and/or antegrade continence enema (ACE). All patients underwent circumferential endoscopic sub-mucosal injection of the channel with a bulking agent, performed at the level of the continence mechanism. The type of injected material, number of procedures required, and success rates were evaluated.ResultsOut of 157 patients with a CUC and/or ACE (total of 164 stomas), eight patients underwent the minimally invasive therapy (total of nine stomas). The initial reconstructive procedure was appendicovesicostomy in one patient, ileovesicostomy (Monti) in seven patients, and ACE in two patients. Amount of bulking agent injected varied from 1.4 to 7 cc (mean 3.72 cc). Follow up ranged from 1 to 39 months (median 15 months). Two patients received multiple injections. One patient had injection of both a CUC and ACE. At the time of final follow up, 6/7 (86%) patients with a CUC and 1/2 (50%) with an ACE were continent per catheterizable channel.ConclusionInjection of a bulking agent provides an excellent minimally invasive treatment alternative for incontinence of a catheterizable channel.     

Failed exstrophy closure: Management and outcome

ObjectiveIn a series of failed exstrophy closures, to identify determinants of successful repeat closure and the impact of failed closure on the fate of the lower urinary tract and continence status.Patients and methodsWe performed a retrospective review of operative notes and medical records of patients with a history of one or more failed exstrophy closures in 1978–2007. The primary surgical endpoints were failure rate of repeat closure attempts, mode of continence surgery and continence outcome. Continence was defined as achieving a dry interval of >3 h and voiding through the urethra.ResultsWe identified 122 patients (85 male/37 female) who had undergone repeat closure following failure. The success rate of repeat closure attempts at our institution was 98%.Of the 94 patients who had undergone successful repeat closure, definitive continence management and had their dryness evaluated, 38 were candidates for bladder neck reconstruction and 17(18%) were continent. Of the remaining patients, 90% were able to attain dryness, but at the expense of clean intermittent catheterization and continent urinary diversion.ConclusionA failed exstrophy closure has significant implications for long-term surgical outcome. Reclosure can be accomplished in the majority of cases. In comparison to patients with successful primary closure, the rates of urethral continence following successful repeat closure were lower.     

Our initial experience with the technique of complete primary repair for bladder exstrophy

ObjectiveWe reviewed our initial results with complete primary repair of exstrophy in regard to continence status and the need for subsequent continence procedures.Patients and methodsWe performed a retrospective review of our surgical records from 1996 to 2008 to identify all patients with bladder exstrophy managed at our center.ResultsSixteen children were closed successfully. Six patients (37.5%) experienced complications: umbilical hernias in two, transient penopubic fistula in three, and subcoronal fistula due to meatal stenosis in one. Of the 12 males, seven (58.3%) were left with a hypospadias at the time of primary closure. Two (22.2%) children required a formal bladder neck reconstruction to achieve continence. Bladder augmentation and continent catheterizable stoma was performed in four cases (44.4%), and bladder neck injection in one case (11.1%). Bladder neck closure was also performed in another child following primary closure. Three of these children are continent and void spontaneously (33.3%). The remaining six require clean intermittent catheterization four to six times a day, resulting in four (44.4%) being continent. The number of continence procedures and mean number per patient were 15 and 1.66, respectively.ConclusionOur early experience with this technique has been encouraging, with few major complications, a highly successful closure rate and a cosmetically normal result.     

Repeat pelvic osteotomy in cloacal exstrophy: applications and outcomes

PurposePelvic osteotomies have been shown to enhance success rates for classic exstrophy patients when closed primarily or secondarily after initial failure. Primary closure of cloacal exstrophy also benefits from osteotomy but this has yet to be shown for re-closure of cloacal exstrophy failures. This study looks at the applications, complications, and long-term success rates in this very select group of patients.MethodsWe extracted from an institutionally approved exstrophy database 15 patients who had undergone repeat pelvic osteotomy and analyzed patient history, complications and orthopedic outcomes.ResultsAll patients who underwent reclosure at our institution remain closed. Major complications were seen in two patients and minor complications in four patients. Urinary continence was achieved in 10 patients with augmentation and continent stoma formation, urinary diversion was performed in two patients and three patients await a continence procedure.ConclusionsRepeat pelvic osteotomy in cloacal exstrophy is successful and the complication rate is low. Pelvic osteotomy is associated with enhanced success rates of primary and secondary closure with better cosmesis of the abdominal wall and genitalia. Intrasymphyseal plates along with gradual reduction of the extreme diastasis utitlizing an external fixation device can be beneficial prior to further genitourinary surgery.     

Pneumovesicoscopic diverticulectomy in children and adolescents: Is open surgery still indicated?

ObjectivesSurgical treatment of a congenital bladder diverticulum is indicated in symptomatic children. Diverticulectomy can be performed by an open or a laparoscopic approach. We report our recent experience in using the pneumovesicoscopic approach for accomplishing vesical diverticulectomy.MethodsWe operated on three boys with a mean age of 11.6 years (10–14 years) during August 2006 to February 2007. In all children, a ureteric catheter was introduced first by cystoscopy followed by intravesical CO₂ insufflation at a pressure of 12–15 mmHg. Three trocars were inserted under visual control in the bladder. Diverticulectomy was performed. The defect was closed by interrupted sutures. Bladder drainage was achieved using a urethral catheter for 2 days.ResultsThe mean operative time was 133.3 min (100–180 min). Oral intake began after a mean of 5.3 h (4–6 h). Minimal blood loss was encountered. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3–6 months).ConclusionPneumovesicoscopic diverticulectomy is a feasible procedure. It does not require a long learning curve, and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as vesicoureteral reflux, and may replace open surgery.     

Bladder augmentation and artificial sphincter implantation: urodynamic behavior and effects on continence

ObjectiveTo quantify changes in bladder capacity, pressure and compliance after isolated bladder augmentation or augmentation associated with implantation of an artificial sphincter, and to compare the various types of augmentation.Patients and methodsPreoperative and postoperative urodynamic studies were performed in a group of 38 patients (18 males and 20 females; age range 2–19 years), who underwent a type of bladder augmentation.ResultsThe bladder improved in capacity in all patients (mean values: initial 137 ml, final 336 ml, individual increase 229 ml; 434%) except two, in which the augmentation was done with ureter. The mean pressure improved (initial 32 cm of H₂O, final 14, decrease per patient 18 cm of H₂O; 49%). The curve of compliance, progressively increasing typical of hyperreflexia and poor compliance, present in 70% of the cases preoperatively, improved in 78% cases postoperatively, although there were several different patterns. Urodynamic behavior was analyzed with regard to the tissue used for augmentation (ileum, ureter or sigmoid colon). In the sigmoid colon group, there were no significant differences in the urodynamic behavior of the bladder neo-reservoir in relation to the configuration used.ConclusionWith bladder augmentation comes an increase in bladder capacity, a reduction in pressure, and an improvement in compliance and continence. The level of change in capacity, pressure and compliance varies with the tissue used and the length and caliber of the insert. When the procedure is carried out using sigmoid colon tissue, there are no noteworthy differences among the various possible configurations.