Luiz Alberto P. Araujo

NONSECRETORY SIGMOID CYSTOPLASTY: EXPERIMENTAL AND CLINICAL RESULTS

We report the results of experimental and clinical studies in which a de-epithelialized segment of sigmoid colon was used to cover the bladder dome where the mucosa was exposed (auto-augmentation) to increase bladder capacity. Experimentally, the technique was performed in 10 healthy female mongrel dogs and the intestinal segments established continuity perfectly over the exposed bladder mucosa. Histology 30 and 60 days postoperatively showed transitional epithelium lining the intestinal segment at the site of implantation. One island of intestinal mucosa was found. The technique was performed in 10 patients, including 9 with neurogenic bladder secondary to myelomeningocele and 1 with posterior urethral valves. Bladder capacity improved in all cases and intravesical pressure was reduced. Followup ranged from 6 to 43 months. The technique is proposed as a valuable alternative to traditional full-thickness patches of the digestive tract and auto-augmentation.

Combined Use of Enterocystoplasty and a New Type of Artificial Sphincter in the Treatment of Urinary Incontinence

PURPOSE We report the results of the combination of enterocystoplasty and a periurethral expander, a simplified type of artificial sphincter, in the treatment of urinary incontinence. MATERIALS AND METHODS The new 1-piece device has an adjustable cuff connected to a port positioned at the subcutaneous space in the abdomen. The cuff is adjusted to the bladder neck and the pins are fixed according to the diameter of the urethra. The port is punctured percutaneously and saline is injected until continence is achieved. Eight boys and 3 girls underwent nonsecretory sigmoid cystoplasty and placement of the device at a single operation. Nine patients had neurogenic bladder and in 2 exstrophy reconstruction had failed. Followup ranged from 4 to 26 months. RESULTS All patients were continent with improved bladder compliance 6 to 8 weeks after the operation, when the device was activated. In 1 case the device was extracted after 2 months due to frequent episodes of hematuria and edema at the port site. Two patients had erosion of the skin at the port site. Urodynamics were repeated at the time of activation. Maximal urethral closing pressure increased from 16.27 to 157.44%. Two patients needed a second injection to achieve continence. The patients with exstrophy void spontaneously and those with neurogenic bladder are on clean intermittent catheterization. CONCLUSIONS Although more followup is needed, the combination of these procedures seems to offer a new option for the treatment of urinary incontinence in children.

A wet dressing for hypospadias surgery

INTRODUCTION One of the main problems faced by surgeons involved in male genitalia surgeries, in particular in children with hypospadias, is the type of dressing and its use during the post-operatory period. MATERIALS AND METHODS From a multidisciplinary project involving the use of sugarcane biopolymer membrane developed in the last 10 years, produced by bacterial action over sugarcane molasses, we developed a multiperforated pellicle that, when applied around the penis, protects the surgical field. It is a proven inert material that does not induce any reaction on the surgical field and can be left in situ maintaining the same characteristics during a long period of time without the need of replacement. This multiperforated tape can involve several times the penis shaft and due to its adhesiveness it hardly loosens. We compared the use of this dressing with a commercial one (made by polyurethane). Thirty patients with hypospadias were randomly selected for the use of this new type of dressing in the last 18 months. A similar group of patients used a similar commercial dressing made of polyurethane (Tegaderm) according to the same criteria of use. For safety reasons, we applied one or two sutures without the inclusion of the skin using an absorbable suture in order to prevent early detachment. A small gauze was left for 24 hours in order to absorb any possible bleeding. We recommended the irrigation of the dressing with water or saline at least three or four times a day and the patient was allowed to bath. The dressing did not need any special care and if not removed it usually detached spontaneously after 10 to 14 days. RESULTS The tolerance to the material was satisfactory and there were no adverse reactions on the penile surface. In two cases of the biopolymer group the dressing detached spontaneously on the first and third days, respectively. In two cases of the polyurethane group it was observed major edema. The grade of satisfaction of the patients and their relatives was excellent on the biopolymer group. CONCLUSION This dressing produced by a polysaccharide is a promising alternative for the treatment of children and adolescents submitted to genital surgery. Its main advantage is the possibility of several washes along the day without the need of any other manipulation.

Nonsecretory Intestinocystoplasty: A 15-Year Prospective Study of 183 Patients

PURPOSE Children and young adults treated with augmentation procedures with total intestinal flaps are at increased risk for specific complications in the long term. The aim of the present study was to demonstrate the long-term results of demucosalized bladder augmentation. MATERIALS AND METHODS A total of 183 patients (92 males and 91 females) were treated with bladder augmentation with the use of de-epithelialized intestinal segments. Patient age ranged from 3 months to 53 years, with a mean of 13.51 years (median 11.0). Of the patients 121 (66.1%) presented with neurogenic bladder, 50 (27.3%) with bladder exstrophy, 7 (3.8%) with tuberculosis, 4 (2.2%) with posterior urethral valves and 1 (0.5%) with female hypospadias. A mold over which the de-epithelialized segment of bowel was applied was used in all patients. A total of 151 cases were augmented using sigmoid colon and 32 using ileum. Data from bladder capacity and compliance were used to evaluate the results. RESULTS Mean followup was 75.6 months (range 2 to 189). A total of 23 cases (12.6%) were considered failures. Mean bladder capacity was 250.0 ml. An increase of 342.4% was observed postoperatively. Median preoperative compliance was 1.6 ml/cm/H2O. An increase of 762.5% was observed during followup. Seven patients presented with bladder stones. Spontaneous bladder perforation was seen in 2 cases. CONCLUSIONS Significant increase in bladder capacity and compliance was achieved and maintained in the long term. The number of complications was lower compared to traditional methods of augmentation.

Experience with demucosalized ileum for bladder augmentation

Objective To assess the use of demucosalized ileum for bladder augmentation, following the same principles previously used with the sigmoid colon.

Total bladder replacement with de-epithelialized ileum: experimental study in dogs

OBJECTIVE To assess the value of the silicone modeler in preventing graft retraction in dogs undergoing bladder replacement with de-epithelialized ileum. MATERIALS AND METHODS Twelve female dogs underwent total cystectomy and bladder replacement by neobladder made of demucosalized ileal segment, comparing the group with modeler (group I) and the group without modeler (group II). Cystometry data, graft epithelization and radiological assessment (cystography and excretory urography) were analyzed. RESULTS Neobladder capacity, at 2 months, ranged from 50 to 250 mL (mean 191 mL) and from 5 to 60 mL (mean 22 mL) and at 6 months, from 60 to 270 mL (mean 202.5 mL) and from 5 to 75 mL (mean- 30.5 mL), respectively in groups I and II, with a statistically significant difference between groups. After 30 days, postoperatively the presence of transitional epithelium was observed in all fragments obtained by biopsy. CONCLUSION The use of the intravesical silicone modeler prevented the retraction of the neobladder of de-epithelialized ileum.

How to perform enterocystoplasty without opening the intestine.

OBJECTIVES To introduce a new technique for intestinal anastomosis when performing demucosalized enterocystoplasty. METHODS In 8 dogs, a vascularized seromuscular patch of sigmoid colon was harvested without opening the bowel lumen. The bowel mucosa was invaginated into the intestinal lumen and the sigmoid musculature was reapproximated. Twelve patients underwent a nonsecretory sigmoid cystoplasty following the same principle. RESULTS No complications occurred in the experimental animals. The animals were fed normally starting on the first postoperative day. Prolapse of the excess mucosa occurred in 3 cases and disappeared spontaneously. In the clinical group, the postoperative course was normal. Oral intake was resumed on the first day after the operation. The hospital stay was shorter than that of patients in whom the bowel lumen was opened. CONCLUSIONS The use of demucosalized intestinal patches without opening the intestinal lumen appears to be feasible and is expected to reduce perioperative morbidity. Extensive bowel preparation can be reduced, as can the prophylactic use of antibiotics.

Use of the monti principle for constructing a continent gastrostomy

OBJECTIVE To research technical alternatives for permanent gastrostomy that minimizes the drawbacks and complications reported by several authors. MATERIALS AND METHODS An experimental model was developed where the material was divided into 2 groups: the study group (SG) composed of 12 half-breed dogs where the proposed technique was applied, and the control group (CG) composed of 10 animals where a gastrostomy as proposed by Webster in 1974 was applied. On the 90th postoperative day, both groups underwent tests for assessing competence concerning leakage. These were performed under general anesthesia and following sacrifice. RESULTS In the SG, under anesthesia only one animal had leakage through the gastrostomy. Following sacrifice, leakage was observed in 2 animals. In the CG, under anesthesia, 2 animals had leakage and, following sacrifice, only 1 animal did not present leakage. On histopathological analysis of the SG, gastric mucosa was evidenced around the jejunal tubes, with normal features, moderate inflammatory mononuclear infiltrate in jejunal tubes and only slight infiltrate around the gastrostomy stoma. In the CG, ulceration was constant around the external stoma of the gastrostomy tubes. In the corium, the inflammatory infiltrate was less intense than in the SG. The SG proved to be more efficacious than the CG concerning leakage, and this efficacy is attributed to the submucous valvular system. CONCLUSIONS The featured technique showed competence concerning leakage, allowing its clinical applicability as an alternative for permanent gastrostomy.