Elmar W. Gerharz

The Value of the MACE (Malone Antegrade Colonic Enema) Procedure in Adult Patients

BACKGROUNDnWe report our experience with the Malone antegrade colonic enema (MACE) procedure in adult patients suffering from urinary incontinence and intractable constipation with or without fecal soiling.nnnSTUDY DESIGNnSince June 1990, the MACE procedure was initiated in 4 female and 12 male patients 14-54 years old (mean age, 29.9 years) with different pathologic conditions (myelodysplasia, n = 7; anorectal anomaly, n = 3; spinal cord lesion, n = 4; neuropathic disease of unclear cause, n = 2). Three surgical techniques were used: reversed and in situ appendix and tapered ileum). Complex simultaneous urologic continence procedures were performed in nine patients. Two patients had undergone previous operations in the lower urinary tract.nnnRESULTSnAfter 6.6 years of followup (average, 41.7 months), eight patients (50%) were still using the MACE successfully. They were completely clean day and night and were relieved of symptoms of constipation. Eleven complications related to the MACE procedure occurred in seven patients (44%). Eight patients abandoned the procedure for various reasons. The failure rate was higher in chronically constipated patients without fecal soiling.nnnCONCLUSIONSnThe MACE procedure is associated with a high failure rate when used in adults, but it may be possible to identify a subgroup of patients in whom the procedure could be beneficial. Success would depend on overcoming technical problems and difficulties with patient compliance.

Enterocystoplasty in childhood: a second look at the effect on growth

To re‐evaluate the assumption that enterocystoplasty in children has a detrimental effect on linear growth (which is almost exclusively based upon a chance finding in a retrospective study 10u2003years ago) in a larger cohort and with a longer follow‐up.

Linear growth after enterocystoplasty in children and adolescents: a review

The interposition of bowel in continuity with the urinary tract has allowed for the preservation of renal function and continence in children with bladder exstrophy, as well as neurogenic and valve bladders. Although bladder augmentation with ileum or colon has been shown to be safe, the long-term effects of metabolic acidosis in addition to abnormalities in linear growth and bone metabolism remain largely unknown. We reviewed the literature to critically examine linear growth in children who have had bladder augmentation with a particular emphasis on the correlation between acid-base status, bone mineralization and growth. The majority of studies suggest that linear growth is not affected by bladder augmentation. In the short-term, children post-augmentation have varying degrees of metabolic acidosis which, overtime, appears to resolve with no affect on linear growth. In a single study, bladder augmentation led to significant bone demineralization almost a decade after surgery, however, even in these children no decrease in linear growth was noted. No alterations in bone density levels were seen with short-term follow-up.

Skeletal growth and long-term bone turnover after enterocystoplasty in a chronic rat model

To investigate skeletal growth and bone metabolism in a chronic animal model of urinary diversion.

Animal models in urinary diversion.

Whats known on the subject? and What does the study add?

Metabolic and functional consequences of urinary diversion through intestinal segments

‘‘Perhaps, once bowel is used, a patient should never be considered normal.’’ Michael Mitchell, 1990. Ever since Ferris and Odel described the electrolyte pattern of the blood after bilateral ureterosigmoidostomy in the middle of last century [1], the ‘pathophysiology’ of urinary diversion through intestinal segments has been an intriguing intellectual exercise [2, 3, 4]. As bowel was not meant to serve as a container for urine, the use to which it is put in urology may result in numerous complications, from the clinically irrelevant to the lifethreatening, occurring in the short and long-term. The potential complications are due either to a reduction in the absorptive bowel capacity because of functional loss of those segments required for reservoir construction, or to the highly unphysiological exposure of the reconfigured bowel to urine. When the whole spectrum of metabolic complications was outlined in the classic review paper on the topic more than 10 years ago [3], clinical experience with intestinal urinary diversion was clearly limited, and some of the assumptions were therefore, by definition, preliminary. In the meantime, the indications for continent urinary diversion and reconstruction using intestinal segments have expanded greatly, and now include benign and malignant conditions in children and adults. With the increasing availability of large institutional series and meticulously documented long-term followup, a critical reappraisal has taken place, allowing a realistic appreciation of what a patient can expect, in terms both of function, as well as risk of complications [5]. While many cancer patients will not live long enough to suffer late sequelae of intestinal urinary diversion, such complications are particularly important in children and adolescents with urogenital abnormalities, because they will probably have a normal life expectancy. For this issue of the World Journal of Urology on metabolic and functional complications after urinary diversion, we invited urological surgeons and basic scientists to re-examine and update the published knowledge in their field of expertise. Farnham and Cookson review the surgical complications associated with conduit, continent cutaneous diversion and orthotopic urinary reconstruction. While increasing experience and technical refinements have led to a reduction of the well known surgical complications for all types of diversion in contemporary series, there are some ‘new’ phenomena like incisional hernia in patients with neobladder due to abdominal straining during micturition. It is quite clear now, that not all patients are candidates for one type of diversion. The best results are obtained when the procedure is tailored to the individual patient. Tanrikut and McDougal analyze acid-base and electrolyte disorders, the most prevalent and widely researched consequence of intestinal urinary diversion. These disorders can sometimes be dangerous. The syndrome of severe metabolic alkalosis in children with gastrocystoplasties is more likely to occur in those with high ambient levels of circulating gastrin when they become dehydrated and the bladder becomes distended. Most metabolic complications are best averted by maintaining a high index of suspicion and correcting the abnormality early. The preservation of renal function is both the ultimate goal and an essential prerequisite of successful urinary diversion. Kristjansson and Mansson discuss the crucial question of whether the storage of urine in bowel is inherently damaging to kidney function in the light of the new trend to abandon antirefluxing implantation of the ureters. The authors suggest that lifelong E. W. Gerharz (&) Department of Urology, Bavarian Julius Maximilians University Medical School, Oberdürrbacher Strasse 6, 97080, Würzburg Germany E-mail: Gerharz_E@klinik.uni-wuerzburg.de Tel.: +49-931-20132012 Fax: +49-931-20132013

Quality of life research in urology.

For the second half of this century we in the West have ± at least to some degree ± been preoccupied with an aspiration for a certain quality of life for ourselves and those who are dear to us. Traditionally this notion has been bound in economic and occupational terms, a postwar tradition that perhaps reached its peak in the midto late 1980s. As we approach the end of the century there are few people who would not include the idea of healthiness or a reasonable level of physical functioning as essential (or even primary) constituents of the elements that determine goodness of life or contribute to the essence of a persons happiness. This has not always been so. Moreover, although philosophers have been arguing for over a hundred years on what is meant by the term happiness, the term quality of life is fairly new. It was probably ®rst used by J.B. Priestley in his play entitled ``Daylight on Saturday (1943): The plans are already (1⁄4) maturing that would give all our citizens more security, better opportunities and a nobler quality of life. John F. Kennedys presidential commission used the term quality of life to set goals for the United States by the year 2000. He was concerned with the social and economic circumstances of people that would enable interstate comparisons of well-being. Subsequent researchers took a more individualistic line in their attempt to enumerate and weight the factors determining psychological well-being. What has emerged is an amorphous concept that results from areas as disparate as a persons ®nancial position, employment, marital and family status, hobbies and recreation, housing, friendship, ful®llment of aspirations, and physical and mental health. In addition, quality of life has been used under a variety of terms (subjective well-being, life satisfaction, social functioning, morale, and happiness) across disciplines that include geography, advertising, and literature as well as medical and social sciences. So disparate and so user-dependent is the term of quality of life that a certain re®nement is required before it can be used to evaluate health in general and urological procedures in particular. In 1947 the World Health Organization (WHO) de®ned health in a multidimensional manner that has never lost its visionary character ± as a state of complete physical, social, and emotional well-being and not just the absence of disease or in®rmity (autonomy was added to this de®nition in 1984). Most of the urological procedures to which our patients consent have as their aim a reduction in symptoms and, as a consequence, an improvement in physical, social, and emotional well-being. To demonstrate that our mutual goals have been achieved, many of us have been involved in measuring the change (or transition) in health states that our patients experience following a urological intervention. It is ®tting that at the end of the century (in line with J.F. Kennedys target) we are in a position as urologists to record both our successful and our failed attempts to capture the impact of our interventions on patients symptoms, their disease-speci®c quality of life, and their health-related and generic quality of life in the various urological specialities. In the ®rst article, John Browne introduces some of the methodological issues that are relevant to all attempts to measure health-related quality of life. He explains the conceptual framework that underpins many of the instruments that have been used to measure healthrelated quality of life in urology. He also introduces the reader to the notions of the validity and reliability of these instruments. Ruagh McDonagh is a urologist in Taunton, England. For many years he had both a practical and a research interest in measuring the changes in healthWorld J Urol (1999) 17: 191±192 Ó Springer-Verlag 1999

The transverse ileal tube as second-line modification of the Mitrofanoff principle.

Abstract With the advantages of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high mobility of the tube), minimized risk of stone formation (no use of staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice for the Mitrofanoff conduit. A longer period of follow-up is needed to determine whether it deserves a permanent place in the reconstructive surgeons repertoire.

Urinary Retention, Erectile Dysfunction and Penile Anaesthesia After Circumcision: A Mixed Dissociative (conversion) Disorder

We report on the long-term followup of a mixed dissociative (conversion) disorder after circumcision in childhood.