Zoran I. Radojicic

Is it Reasonable to Treat Refractory Voiding Dysfunction in Children With Botulinum-A Toxin?

PURPOSE We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies. MATERIAL AND METHODS Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection. RESULTS Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications. CONCLUSIONS The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.

‘Pseudospongioplasty’ in the repair of a urethral diverticulum

To describe a technique for repairing urethral diverticula which includes neourethral reconstruction and increasing the mechanical support of the neourethra.

Buccal Mucosa Grafts for Repair of Stenotic Catheterizable Continent Stoma

PURPOSE Different tubular structures have been used to create cutaneous catheterizable continent urinary stomas. The most common complication is stomal stenosis on the cutaneous end of the tubes. We present a variant of stomal stenosis repair that uses a buccal mucosa graft. MATERIALS AND METHODS Between January 2000 and March 2006 stenotic stomal repair was performed in 10 patients between 3 and 17 years old (mean age 6). A Mitrofanoff channel was created from a bladder tube in 4 patients, from appendix in 3, from ileum in 2 and from the ureter in 1. The procedure involved the removal of scar tissue and the creation of well vascularized dermal beds by skin de-epithelialization (epidermis removal). After that we formed 2 elliptical dermal flaps. Two elliptical buccal mucosa grafts were quilted to the recipient bed (the dermal flap) and anastomosed with the mucosa of the normal part of the channel. The flaps were joined, tubularized and sutured to the skin. An indwelling catheter was left in the channel for 2 weeks. Postoperatively the buccal mucosa was wetted with saline solution for 4 consecutive days. RESULTS Followup was between 12 and 39 months (mean 22). There was no partial or total graft necrosis. None of the patients experienced repeat stenosis. The stoma was visible (uncovered) and the esthetic appearance was satisfactory in all patients. CONCLUSIONS Repair of Mitrofanoff stomal stenosis using a buccal mucosa graft is a minor procedure. It is a good salvage procedure that excludes the need to create a new channel.

Calibration and dilatation with topical corticosteroid in the treatment of stenosis of neourethral meatus after hypospadias repair

To assess the early disclosure and treatment of meatal stenosis after hypospadias repair, using calibration of the neourethral meatus at regular intervals to detect stenosis, and to assess the curative effects of dilatation with topical corticosteroids.

Objective Long-Term Evaluation after Bladder Autoaugmentation with Rectus Muscle Backing

PURPOSE Bladder autoaugmentation with rectus muscle backing is an efficient surgical technique for bladder augmentation. We evaluated long-term outcomes to determine the value of this procedure. MATERIALS AND METHODS Between August 1999 and June 2004 autoaugmentation was performed in 16 girls and 7 boys 4 to 13 years old (median age 8). The indication was neurogenic bladder with small capacity and poor compliance due to myelomeningocele in 18 patients, tethered cord in 3 and sacral agenesis in 2. Detrusorectomy usually involved the whole upper half of the bladder. The prolapsed bladder urothelium was hitched to the 2 rectus muscles to prevent retraction and provide easier bladder emptying with voluntary muscle contractions. RESULTS At the median early followup of 27 months (range 9 to 49) bladder volume had increased significantly in all 23 patients (median 338 ml, range 190 to 462). At the current median long-term followup of 134 months (range 94 to 159) bladder volume continued to be significant compared to median bladder capacity preoperatively (median 419 ml, range 296 to 552). Voluntary voiding was achieved in 14 patients without post-void residual urine. Nine patients used clean intermittent catheterization, of whom only 4 could not empty the bladder voluntarily and relied only on clean intermittent catheterization. CONCLUSIONS Detrusorectomy with a rectus muscle hitch and backing is a minimally invasive, completely extraperitoneal, simple and safe procedure. However, the technique is indicated only in select cases without anterior abdominal wall anomalies.

A prospective randomised non-blinded comparison of conventional and Dorgan's crossed pins for paediatric supracondylar humeral fractures.

BACKGROUND Closed reduction and percutaneous pinning are the preferred treatment of displaced supracondylar humeral fractures in children. The purpose of this study is to evaluate the non-standard Dorgans method and compare its results with those of the standard percutaneous cross pinning method in treatment of unstable or irreducible Gartland type II and III supracondylar humeral fractures in children. PATIENTS AND METHODS This was a prospective evaluation of 138 consecutive patients with Gartland type II or III extension supracondylar humeral fractures referred to University Childrens Hospital during a four-year period. The patients were randomized into two groups: the first group, comprised of 71 patients, was treated with standard pin configuration and the second group, comprised of 67 patients, underwent Dorgans method. The study included 88 boys and 50 girls aged 1.5-11.4 years (mean 6.5±2). At initial presentation 8.7% (n-12) fractures were classified as Gartland type IIa, 25.4% (n-35) as Gartland type IIb and 65.9% (n-91) as Gartland type III. RESULTS Flynns criteria were used to evaluate the results. An excellent clinical outcome was reported in about 90% of patients (n-90) treated with standard pin configuration and 89.5% (n-60) of patients treated with Dorgans method. There were no statistically significant differences in outcomes between the groups in terms of their gender, age, fracture types, function and cosmetics. Neurological lesions were observed in 9.9% of patients (n=7) who were treated using the standard configuration Kirschner pins, while in those treated by Dorgans method neurological complications were not observed. However, the procedure time was longer (mean 36.54±5.65min) and radiation exposure significantly higher (mean 10.19±2.70 exposures) in the group that was treated using Dorgans method, compared to the conventional method (mean 28.66±3.76min and 7.54±1.63 exposures). CONCLUSION Two laterally inserted crossed pins provide adequate stability with good functional and cosmetic outcome for most unstable paediatric supracondylar humeral fractures with no risk of iatrogenic ulnar nerve injury.

Impact of bowel management in alleviating symptoms of urinary incontinence in patients with spina bifida associated with overactive bladder and detrusor sphincter dyssynergia

To examine the effects of bowel management on urinary incontinence in patients with spina bifida associated with overactive bladder (OAB) and detrusor sphincter dyssynergia (DSD).