P.G. Duffy

The clinical application of the malone antegrade colonic enema

Continent, catheterizable enterostomies (Malone stomas) have been formed in 25 patients. A reversed appendicocecostomy was used for the majority, although experience has led to modifications of this procedure. Antegrade enemas are regularly administered via these stomas in the treatment of fecal incontinence and intractable constipation. There have been only two important surgical complications, and the technique has proved to be highly successful. Follow-up of the patients has shown that individual requirements can be met with variations in the administration of the enemas.

Long-term outcome of peritoneal dialysis in infants

Debate continues concerning the treatment of infants with end-stage renal disease. We evaluated progress and outcome of 20 infants with a mean age of 0.34 year (range, 0.02-1 year) in a long-term peritoneal dialysis program at a single center. Mean weight at the start of dialysis was 4.8 kg (range, 1.7-11.4 kg), and the duration of dialysis was 17.3 months (range, 1-59 months). Eleven infants received renal transplants, 4 were switched to hemodialysis and then received transplants, 4 died, and 1 continues to receive peritoneal dialysis. There was significant co-morbidity in 6 infants who died or required hemodialysis. Catheter interventions were frequent, with 12 infants requiring at least one replacement. There were 1.1 episodes of peritonitis per patient-year; 70% of infants had 0 to 1 episode. Mean weight standard deviation score (SDS) was -1.6 at the start, -0.3 at 1 year (P =.0008), and 0.3 at 2 years (P =.0008). Height SDSs were -1.8 at the start, -1.1 at 1 year (P =.046), and -0. 8 at 2 years (P =.06). Head circumference SDSs were -1.9 at the start, -1.3 at 6 months (P =.003), and -0.9 at 1 year (P =.015). Fourteen of 16 survivors are achieving normal developmental milestones or attend mainstream school. Peritoneal dialysis in infancy is a demanding treatment, but outcome for growth, development, and transplantation justifies this intensive approach. When parents are counseled, the importance of non-renal co-morbidity must be emphasized.

The role of percutaneous nephrolithotomy in the management of pediatric renal calculi.

PURPOSE Minimally invasive techniques for the treatment of urinary calculi in children are recommended due to an increased probability of recurrence. Percutaneous nephrolithotomy is well established in adults but to our knowledge this procedure has not been reported previously in a large series of children. We review our experience with percutaneous nephrolithotomy in children. MATERIALS AND METHODS From 1987 to 1995 percutaneous nephrolithotomy was performed in 25 children 3 to 16 years old (median age 8). Indications for percutaneous nephrolithotomy were an obstructed kidney in 10 cases, large stone size or staghorn calculus in 8, failed extracorporeal shock wave lithotripsy in 4 and residual stones after open surgery in 3. There were 15 solitary renal, 4 staghorn and 2 upper ureteral stones, and 5 children had multiple renal calculi. RESULTS Percutaneous nephrolithotomy was performed once in 22 patients, and 2, 3 or 5 times in the remainder. Of the 25 patients 17 (68%) were stone-free at hospital discharge or shortly thereafter following a single session of percutaneous nephrolithotomy. Retained calculi after a single percutaneous nephrolithotomy treatment were much more common with staghorn stones (2 of 4 cases or 50%) and multiple stones (3 of 5 or 60%) compared to solitary renal stones (2 of 15 or 13.3%). With subsequent extracorporeal shock wave lithotripsy or repeat percutaneous nephrolithotomy the stone clearance rate was as high as 92%. At a 2 to 66-month followup (average 23) no late complications were noted. Radioisotope scans available in 10 cases before and after percutaneous nephrolithotomy revealed unchanged differential function and evidence of significant renal scars in only 1. CONCLUSIONS Percutaneous nephrolithotomy is a suitable and safe procedure for treating renal stones in children.

The Yang–Monti ileovesicostomy: a problematic channel?

Objective To compare the differences in the quality of Mitrofanoff channels created using appendix and re‐tubularized small bowel (the Yang–Monti ileovesicostomy).

The relationship between early renal status, and the resolution of vesico-ureteric reflux and bladder function at 16 months.

Objective To examine, in infants presenting with vesico‐ureteric reflux (VUR), the relationship between the presence of initial renal abnormalities with the outcome of VUR and bladder function at 16 months of age.

The functional sequelae of sacrococcygeal teratoma

Twenty-seven patients with sacrococcygeal teratoma were followed for a mean period of 5 years (range, 2 to 12 years). Eleven (41%) had some form of functional impairment. Fecal and/or urinary incontinence was present in nine children and two had weakness of the lower limbs secondary to sciatic nerve palsy. Tumors with large intrapelvic extensions requiring an abdominoperineal approach for resection were associated with a higher incidence of functional sequelae (67%). It is recommended that patients with sacrococcygeal teratoma (particularly those with a presacral extension) be closely monitored for functional deficits so that early treatment can be instituted.

Combined Mitrofanoff and Antegrade Continence Enema Procedures for Urinary and Fecal Incontinence

PURPOSE Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children undergoing major reconstructive urological operations. To treat double incontinence or the combination of wetting and severe constipation, we constructed a Mitrofanoff conduit and a channel for antegrade continence enemas in 18 patients between 1989 and 1995. We review the underlying pathological conditions, various surgical techniques and outcomes of these operations. MATERIALS AND METHODS Underlying abnormalities mainly included spinal lesions, bladder exstrophy, imperforate anus and various cloacal anomalies. Patient age ranged from 2 to 18 years (average 8.4). In 13 patients both procedures were done simultaneously. The appendix was used to construct the antegrade continence enema channel in 8 cases and the Mitrofanoff channel in 5. It was long enough to be divided and used for both procedures in 2 cases but it was missing or unsuitable in 3. Alternative antegrade continence enema conduits were cecal flap in 7 patients and ileum in 1, while the ureter, ileum and detrusor tube were used to establish Mitrofanoff channels in 5, 5 and 1, respectively. Stomas were constructed according to the V-flap or V. Z. Q. technique and situated in close proximity in the right lower abdominal quadrant in 13 cases. RESULTS Convalescence was uneventful except for 1 abscess near an antegrade continence enema stoma. Ten patients needed dilation or minor revisions due to difficulty in catheterizing the antegrade continence enema (5), Mitrofanoff (3) or both conduits (2). Subsequently 3 patients underwent repeat operations for reconstruction of 2 antegrade continence enema channels (cecal flap and ileum) and 1 detrusor tube Mitrofanoff channel. Currently 15 patients are dry on regular clean intermittent catheterization using 10 to 12F catheters. Outcomes of the antegrade continence enema channels are satisfactory in 15 patients who are clean or rarely soil. Failure occurred in 1 patients with severe constipation necessitating colostomy and 2 (1 noncompliant who stopped catheterizing regularly) in whom the channels subsequently closed. CONCLUSIONS Synchronous construction of antegrade continence enema and Mitrofanoff channels is successful in the majority of doubly incontinent patients. Selection of patients with high motivation is important to obtain satisfactory results.

Long-Term Followup of Bladder Mucosa Graft for Male Urethral Reconstruction

Autologous bladder mucosa was used as a free graft for complex urethral reconstruction in 95 male patients, ranging in age from 1 to 21 years. Primary indications for surgery include previous failed hypospadias repair in 68 cases, primary hypospadias in 11, bladder exstrophy/epispadias complex in 10 and others in 6. Patients were divided into 3 groups based on the configuration of the bladder mucosa replacement. Group 1 (37 patients) underwent complete urethral replacement to the tip of the glans. Group 2 (16 patients) underwent placement of a bladder mucosa onlay patch graft. Group 3 (42 patients) underwent a combined repair using tubularized bladder mucosa proximally and either a pedicled preputial tube (6), free preputial or penile skin tube (13), local glandular skin flaps (15), or intact glandular urethra or tubularized urethral plate (8) distally to avoid a terminal segment of bladder mucosa. All patients were followed for a mean of 3.4 years (range 6 months to 8 years). An overall good functional and cosmetic result was eventually achieved in 81 patients (85%). However, 63 patients (66%) required between 1 and 9 (mean 2.7) additional procedures to treat complications before achieving a good result. The most common complications were meatal stenosis and/or prolapse. Meatal problems were significantly more common in group 1 (68%) than in those who underwent a patch or combined procedure (12 and 36%, respectively). Although bladder mucosa provides an excellent and readily available material for urethral substitution in these challenging cases, the urologist should be aware of the significant incidence of postoperative problems and their management. The high incidence of meatal problems suggests that bladder mucosa should not be incorporated as a circumferential terminal urethral segment.

The role of ureter in the creation of Mitrofanoff channels in children

PURPOSE Since 1980 numerous variations of the Mitrofanoff principle have been described. We report on 22 children in whom a ureteral Mitrofanoff channel was created. MATERIALS AND METHODS Between 1986 and 1995 a ureteral Mitrofanoff channel was constructed as a catheterizable conduit in 22 children 2 to 15 years old (average age 6.5) with various abnormalities of the lower urinary tract, mainly exstrophy and neurogenic bladder. Indications included unavailability or unsuitability of the appendix, preference for appendix as a catheterizable colonic stoma for antegrade washouts or concomitant removal of a nonfunctioning kidney, leaving the ureter available for use. Surgical technique was based on the principles of appendicovesicostomy and in 9 cases the ureteral Mitrofanoff channel was reimplanted. RESULTS Followup ranged from 1 to 72 months (average 30.5). Complications included stenosis of the conduit that caused difficult catheterization in 3 patients, necessitating dilation or minor revision in 2 and complete replacement by appendix in 1. Urinary leakage from the Mitrofanoff channel in 5 patients was treated with polydimethylsiloxane injection or oxybutinin. In 1 patient the channel was reimplanted, since the catheter struck the bladder neck during catheterization and caused severe pain. CONCLUSIONS Results of the ureteral Mitrofanoff channel seem somewhat less satisfactory than those of appendicovesicostomy but they remain acceptable and even comparable, strongly supporting its use in certain circumstances.

The Use of the Mitrofanoff Principle in Achieving Clean Intermittent Catheterisation and Urinary Continence in Children

The Mitrofanoff principle has been used to achieve clean intermittent catheterisation (CIC) and urinary continence in 28 children. The mean age at operation was 10.1 years (range, 1 to 19 years). A catheterisable conduit was created using the appendix (19), ureter (8), or vas deferens (1). CIC was commenced 10 to 28 days postoperatively (median, 15 days). After a mean follow-up of 13 months (range, 2 to 45 months), 24 children (86%) have achieved successful CIC and urinary continence. Use of the Mitrofanoff principle is a valuable adjunct to the treatment of urinary incontinence in children and may allow successful CIC in patients who are unable to catheterise urethrally.