Rafael Gosalbez

Clinical applications of the monti procedure as a continent catheterizable stoma

OBJECTIVESnMonti et al. recently described a technique for the construction of a continent catheterizable conduit using short segments of small bowel in a canine model. We review our experience with 25 adult and pediatric patients in whom the Monti procedure was used in their reconstructive efforts.nnnMETHODSnSince October 1995, 25 patients (13 males and 12 females), aged 4 to 67 years (median 29), underwent the construction of 29 catheterizable stomas with a short (2.5 cm) segment of bowel following the Monti technique. Twenty-seven tubes were created as urinary stomas and two as part of the Malone antegrade continent enema procedure (MACE). Continence is based on the Mitrofanoff flap valve mechanism. Tubes were created when the appendix was unavailable as part of urinary reconstructive efforts or after exenterative oncologic surgery of the lower urinary tract. Tubes were created using ileum (24) and sigmoid colon (5). Ten tubes (34.5%) were done in combination with a simultaneous bowel patch in the same pedicle for bladder augmentation. Tubes were implanted in the ileum (13), bladder (9), sigmoid colon (3), stomach (1), and descending colon (1). The two tubes created to do a MACE procedure were anastomosed into the cecum. Double tubes were necessary in 7 adult patients for adequate length. The length of the tubes varied from 6 to 14 cm.nnnRESULTSnFollow-up ranged between 3 and 26 months (mean 13). One adult patient (4%) with bladder cancer died of myocardial infarction 14 days postoperatively. Three patients (12%) received a new Monti tube because of ischemic stenosis of the tube. All of them were continent at a follow-up of 1, 6, and 20 months, respectively. Two patients (8%) experienced leakage through the stoma, requiring additional procedures and pharmacologic manipulation to become continent. All patients used intermittent catheterization through the stoma without problems.nnnCONCLUSIONSnAlthough the appendix remains the tissue of choice, the Monti procedure has substantial advantages over other efferent catheterizable tubes, including the need for a very short segment of bowel (2.5 cm), adequate lumen size (16F to 18F), length, reliable blood supply, and the versatility to combine with a simultaneous bowel patch in the same pedicle for bladder augmentation.

Ureterocystoplasty with preservation of ipsilateral renal function

Recently the ureter has been used for bladder augmentation in selected patients with abnormal bladders and dilated upper tracts. The ureter has several advantages over other forms of bladder augmentation because it alleviates electrolyte disturbances, mucous production, and the disruption of the gastrointestinal tract. Initial reports emphasized the use of the entire ureter and renal pelvis in patients with an ipsilateral dilated nonfunctioning renal unit. Herein the authors report five cases of ureterocystoplasties performed since July 1993, in which the ipsilateral renal unit was preserved. All patients underwent preoperative videourodynamic studies, which showed small-for-age bladder capacity and poor compliance. Three patients underwent unilateral ureterocystoplasty, and two had bilateral ureterocystoplasty. Transureteroureterostomy (TUU) was performed in all patients, and most of the ipsilateral dilated ureter was used for augmentation. In two patients who had partial unilateral duplication, ipsilateral upper-to-lower ureteropyelostomy was done in addition to the TUU to maximize the amount of ureter available for augmentation. The follow-up period ranges from 6 to 24 months. All patients are continent and free of vesicoureteral reflux. All show stabilization or improvement of their upper tracts. Pressure-specific bladder capacity (bladder capacity at 30 cm of water pressure) increased by 350% (from a mean of 142 mL to 500 mL). The ureter is an excellent choice for augmentation cystoplasty in selected patients. An ipsilateral functioning renal unit is not a contraindication for ureterocystoplasty.

Defining the role of the bladder-neck sling in the surgical treatment of urinary incontinence in children with neurogenic incontinence

Abstract Patient selection for the creation of a fascial sling procedure to increase outlet resistance has been somewhat controversial. We review our experience with the fascial sling technique and report our patient selection process. Since 1991, 30 patients, including 6 males and 24 females aged 4–20 years (mean 10 years), underwent a rectus fascial sling procedure as part of their reconstructive efforts for continence. The underlying cause of incontinence was neurogenic in 28 patients. All males were prepubertal. Videourodynamics were performed in all patients preoperatively. Criteria for enhancement of bladder-outlet resistance included a detrusor leak-point pressure (LPPd) of <50 cmH2O; a stress leak-point pressure (LPPs) of <100 cmH2O; an open bladder neck, irrespective of LPP; and clinical evidence of stress incontinence, irrespective of videourodynamic parameters. Technical aspects of the procedure are discussed. Augmentation cystoplasty was performed in 29 patients with poor bladder compliance. In 18 patients a catheterizable stoma was also created. The period of follow-up currently ranges from 2 to 70 (mean 37) months. In all, 28 patients (93%) became continent and 2 female patients remain incontinent with a low LPP. All patients are on clean intermittent catheterization (CIC); 12 patients (40%) are catheterizing per urethra without difficulty. All prepubertal males are completely dry. The fascial sling repair has many advantages over other methods for increasing outlet resistance, including simplicity of technique, effectiveness, minimal likelihood of erosion, and low cost.

A Renal Protocol for All Ages and All Indications: Mercapto-Acetyl-Triglycine (MAG3) With Simultaneous Injection of Furosemide (MAG3-F0): A 17-Year Experience

Current clinical requirements mandate the existence of a renal diuretic protocol, which is fast and easy, applicable in all ages and for all indications, convenient for both the patient and the technologist, and provides diagnostic as well as prognostic information. Seventeen years ago a 25-minute protocol, after oral hydration, with no bladder catheterization, and simultaneous injection of mercapto-acetyl-triglycine (MAG(3)) and furosemide (MAG(3)-F(0)), was initiated. It initially was used for the evaluation of drainage and emerged as a protocol to also evaluate the renal parenchyma. Results of this protocol have been published individually, per clinical application. MAG(3)-F(0) was instrumental in the evaluation and prognosis of congenital disorders. For obstruction, in the newborn, an increasing renogram mandates intervention, whereas a downsloping one predicts spontaneous resolution. In children or adults, preoperatively or postoperatively, when the cortex was visualized and drained normally, there was no obstruction, even if urine was retained within a dilated collecting system or an extrarenal pelvis. For diseases of the renal parenchyma, the protocol enabled the diagnosis of acute pyelonephritis (APN) revealing the regional parenchymal dysfunction, diagnostic of APN. Diffuse parenchymal diseases were characterized by increased residual cortical activity (RCA), and their progression was manifested as a deterioration of RCA. End-stage renal disease was characterized by lack of accumulation and retention. Trauma and leaks were identified with specific patterns. In renovascular hypertension (RVH), an increase in RCA after angiotension-converting enzyme inhibitors is diagnostic of RVH and prognostic of the beneficial effect of angioplasty on hypertension. In renal colic, stratification was possible into (1) complete or severe obstruction requiring immediate intervention, (2) mild obstruction allowing waiting, (3) spontaneous decompression (stunned kidney), and (4) no recent obstruction. In transplants, it enabled differentiation of acute tubular necrosis, acute or chronic rejection and nephrotoxicity, and identified infarcts, RVH, leaks and obstruction. Finally, this method allows for a quick semiquantification of renal function. The clinical usefulness of the MAG(3)-F(0) protocol in most congenital or acquired renal problems is proven through long-term clinical experience and has resulted in a substantial utilization of the test at our Center.

Inflammatory Myofibroblastic Tumor of the Epididymis: Case Report and Review of the Literature

The inflammatory myofibroblastic tumor (IMT) is a rare benign tumor, known by several names and found in several locations throughout the body, including the lungs and genitourinary system (mostly the bladder). We report a case of a paratesticular IMT in a 17-year-old boy. Although the initial clinical diagnosis was rhabdomyosarcoma, the histopathologic examination revealed it to be an IMT. The preoperative diagnosis of a scrotal mass should differentiate between benign and malignant tumors. A definitive diagnosis of a scrotal mass should be established by surgical exploration and resection. It is important to counsel patients with scrotal masses regarding the possibility of orchiectomy, even in the case of a benign tumor such as IMT.

Retención urinaria transitoria en el reimplante ureteral extravesical bilateral simultáneo

OBJETIVOSnSe realiza un estudio retrospectivo a los pacientes sometidos a reimplante ureteral bilateral extravesical simultaneo y se reportan los resultados y la incidencia de retencion urinaria transitoria.nnMETODOSnSe evaluan a 127 pacientes con reflujo vesicoureteral primario a los que se les realizo reimplante ureteral bilateral simultaneo en un periodo de 8 anos. El sexo fue femenino en 92 (72,4%) y masculino en 35 (27,6%). En todos los pacientes, al terminar el procedimiento, se dejo un cateter uretral tipo Foley en vejiga entre 24 y 72 horas. Postoperatoriamente se evaluaron con ultrasonidos del tracto urinario en el primer mes y con cistograma miccional en el tercero.nnRESULTADOSnEl seguimiento postoperatorio medio fue de 4.01 anos. No hubo ningun caso de obstruccion ureteral. El cistograma postoperatorio demostro la resolucion del reflujo vesicoureteral bilateral en 122 (96%) pacientes y persistencia del mismo en 5 (4%). Al retirar la sonda vesical postoperatoria 7/127 (5.5%) pacientes presentaron retencion urinaria. Se han dividido los pacientes en dos grandes grupos basados en el tiempo y en las variantes tecnicas quirurgicas empleadas. El primero (junio de 1998 a enero de 2001) lo constituyen 57 reimplantes extravesicales bilaterales con 5 (8.7%) casos de retencion urinaria transitoria, comenzando a miccionar de forma normal a las 24 horas, 48 horas, 72 horas, 5 dias y 4 semanas cada uno de los ninos. El segundo grupo (febrero de 2001 a Octubre de 2006) lo forman 70 reimplantes extravesicales bilaterales y hubo solo 2 (2.85%) casos de retencion urinaria transitoria, comenzando a orinar los dos de forma normal a las 24 horas.

RECONSTRUCTION AND UNDIVERSION OF THE SHORT OR SEVERELY DILATED URETER: THE ANTIREFLUX ILEAL NIPPLE REVISITED

PURPOSEnPatients undergoing reconstruction of short or severely dilated aperistaltic ureters are at significant risk for mechanical or functional obstruction and reflux, particularly when the ureters are being reimplanted into gastric or intestinal segments. For this problem we describe a simple handsewn, stapleless antireflux ileal nipple, which serves as a useful bridge between a short ureter and the bladder or reservoir.nnnMATERIALS AND METHODSnA total of 12 patients, 4 to 42 years old (mean age 19), 9 with severely dilated and 3 with short ureters have received the stapleless antireflux ileal nipple as part of various reconstructive efforts. Briefly, a 12 to 15 cm. segment of ileum is isolated and the mesentery is stripped from the middle 8 cm. of the isolated segment, preserving the blood supply to the proximal and distal 2 cm. of ileum. Intussusception is created and maintained with multiple (5 to 7) circumferential rows of 4 to 6 interrupted seromuscular stitches of 3-zero silk.nnnRESULTSnMean followup is 27.5 months (range 6 to 60). Upper tract dilatation has stabilized or improved in all patients, deteriorating temporarily in 1 who had distal nipple stenosis. All patients underwent followup video urodynamic studies, which demonstrated no reflux. Nipple related complications included nipple stenosis in 1 patient and dessusception in another. Both complications were corrected without sequelae. Ureteroileal stenosis or stone formation has not occurred.nnnCONCLUSIONSnThe stapleless antireflux ileal nipple is safe and reliable in preventing reflux. It is a versatile adjunct to urinary reconstruction in patients with short or severely dilated, aperistaltic ureters in whom the alternative of a tapered reimplantation into a segment of bowel or stomach poses a significant complication threat.

THE USE OF URETER FOR VAGINAL RECONSTRUCTION

Cloaca1 exstrophy represents the most severe defect associated with an abnormality of the cloacal membrane. It remains today one of the ultimate challenges to modern pediatric surgery and pediatric urology. Genital anomalies in genetically female patients with cloacal exstrophy include a bifid uterus, vaginal duplication, exstrophic vagina, covered vaginal opening, vaginal agenesis, divergent mons pubis and bifid clitoris. Different reconstructive techniques have been described for the treatment of vaginal agenesis.l-3 To our knowledge we report the first use of ureter to create a neovagina.

Use of Buccal Mucosa in Hypospadias Repair

Hypospadias is an embryological disorder that results in an abnormal ventral positioning of the urethral meatus. Among multiple surgical techniques described to correct this anomaly, the use of buccal mucosa grafts has gained popularity among pediatric urologists, pediatric surgeons and plastic surgeons. Buccal mucosa grafts have shown favorable histological changes that result in an excellent scaffold for urethral reconstructive surgery. This review describes the evolution of the use of buccal mucosa grafts in hypospadias repair.

Prenatal renal parenchymal area as a predictor of early end-stage renal disease in children with vesicoamniotic shunting for lower urinary tract obstruction

BACKGROUNDnVesicoamniotic shunting (VAS) and other bladder drainage techniques for fetal lower urinary tract obstruction (LUTO) have been proven to ameliorate pulmonary hypoplasia and increase survival in patients with an initial poor prognosis. Currently there are limited prognostic tools available during gestation to evaluate and predict postnatal renal function.nnnOBJECTIVEnThe aim was to describe the prenatal growth of the renal parenchymal area (RPA) in patients with LUTO and determine its application as a predictor of renal function at one year of life.nnnSTUDY DESIGNnThe study population comprised a retrospective cohort of all infants who survived the fetal VAS to birth. Renal growth and size were measured using imageJ software to calculate the RPA in sequential prenatal ultrasounds. The parenchymal area was measured from the image of each kidney with the greatest longitudinal length. These measurements were further correlated and analyzed as a predictor of end-stage renal disease (ESRD) within the first year of life.nnnRESULTSnEtiologies of LUTO in the 15 male fetuses included eight posterior urethral valves, four Eagle-Barrett/prune belly syndrome, two urethral atresia, and one megacystis microcolon intestinal hypoperistalsis syndrome. All patients had patent shunts, in place, at birth. Furthermore, ultrasonographic parameters such as oligohydramnios, keyhole sign, and bladder wall thickness showed no statistical difference between groups. Renal parenchymal growth correlated with postnatal renal function in both the ESRD (rxa0=xa00.409, pxa0=xa00.018) and the non-ESRD (rxa0=xa00.657, pxa0<xa00.001) groups. Most notably, RPA during the 3rd trimester predicted ESRD with the best cut-off point determined to be 8xa0cm2 (sensitivity, 0.714; specificity, 0.882; and positive likelihood ratio, 6.071) (Table).nnnDISCUSSIONnDespite definitive VAS for LUTO, postnatal morbidity and mortality remain high, emphasizing the role of renal dysplasia in postnatal renal failure, in spite of urinary diversion. Renal growth statistically differs between groups in the 3rd trimester of gestation; RPA development appears stagnant in patients that developed ESRD within the first year of life. In contrast, patients that did not develop ESRD continued to have renal parenchymal growth in a linear fashion. This suggests that prenatal RPA may be predictive of postnatal ESRD.nnnCONCLUSIONSnRPA measurement during the prenatal period could play an important role as a non-invasive tool to predict postnatal renal function and to anticipate postnatal clinical interventions.