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TREATMENT OF INCONTINENCE IN CHILDREN WITH BLADDER EXSTROPHY AFTER RECTAL URINARY DIVERSION: THE ANAL SLING PROCEDURE
0022-5347/01/1665-1904/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 166, 1904 –1905, November 2001 Printed in U.S.A.
TREATMENT OF INCONTINENCE IN CHILDREN WITH BLADDER EXSTROPHY AFTER RECTAL URINARY DIVERSION: THE ANAL SLING PROCEDURE V. V. NIKOLAEV From the Department of Pediatric Surgery, Russian State Medical University, Moscow, Russia
ABSTRACT
Purpose: An original technique for reinforcement of the anal sphincter using a sling prosthesis with a flexible fixing point that prevents incontinence and rectal prolapse is presented. Materials and Methods: Of 43 patients with exstrophy who have undergone urinary rectal diversion between 1988 and 1997 incontinence was observed in 9 boys and 5 girls. From January 1993 to December 1998 these children were treated with an original method, the anal sling procedure. Results: There were no postoperative complications. Investigations revealed no urinary or fecal incontinence after a mean followup of 3.2 years (range 6 months to 61⁄2 years). Conclusions: A short and simple operation eliminates incontinence after rectal urinary diversion in patients with bladder exstrophy. It can be used as an alternative to the formation of an isolated urinary reservoir. KEY WORDS: bladder exstrophy, urinary diversion, rectum, surgery
Rectal urinary diversion is used at some centers as definitive treatment of bladder exstrophy.1–5 Anal sphincter insufficiency is regarded as a contraindication for rectal diversion.1, 2 However, despite preoperative assessment urinary and fecal incontinence due to insufficiency of the anal sphincter still occurs in a number of cases.6 We present an original technique for reinforcement of the anal sphincter using a sling prosthesis with a flexible fixing point that prevents incontinence. MATERIALS AND METHODS
Of 43 patients with exstrophy who underwent urinary rectal diversion between 1988 and 1997 incontinence was observed in 9 boys and 5 girls. These patients who came from all around Russia were referred to the Russian Childrens’ Hospital in Moscow. There were 12 patients who were incontinent during both day and night, and 2 only at night. Anal sphincter electrostimulation and training produced no beneficial effect. From January 1993 to December 1998 these children were treated with an original method, the anal sling procedure. Preoperative examination of all patients included excretory urography, ultrasound, blood gases and serum creatinine. Concentric needle electromyography of the 4 quadrants of the external anal sphincter at rest was performed.7 The indexes of average base electrical activity of each muscle part were compared. In all patients the upper urinary tract and renal function were normal. Electromyography showed a 30% to 100% decrease in electrical activity of the anterior portion of the anal sphincter (range 0 to 104 V.) as compared with the others (96 to 238). Macerated perianal skin was treated with antiseptics, and skin protector cream and the rectum was mechanically cleaned. The patient was placed in the lithotomy position (fig. 1). Parallel parasagittal skin incisions 3 to 4 cm. long were made on each side 2 to 3 cm. lateral to the anus. An oval tunnel was formed in the subcutaneous fat surrounding the anus in the subcutaneous portion of the external anal sphincter extending posteriorly to the apex of the sacrum. There is an unAccepted for publication June 15, 2001.
FIG. 1. Skin incisions (solid lines) and position of mesh (broken line).
named median ligament between the anococcygeal body, coccyx and skin of the natal cleft that the tunnel was extended around (fig. 2). A nylon mesh band 2 cm. wide was pulled through the tunnel to form a long loop around the anus. The ends of the loop were brought together to increase anal resistance, which was controlled by digital palpation, to the level of a conscious healthy person. On inspection the anal outlet should be closed. The anal sling must enable the finger to completely stop leaking by pressing on the anterior abdominal wall. During postoperative week 1 the children received 1 mg./ kg. prednisolone daily and broad spectrum antibiotics. The rectum was drained by a tube for 3 to 5 days. RESULTS
The procedure took 15 to 25 minutes to complete. There were no postoperative complications, particularly infection or rejection of the implant. At 2 weeks postoperatively 12 chil-
1904
INCONTINENCE IN CHILDREN WITH BLADDER EXSTROPHY AFTER RECTAL URINARY DIVERSION
FIG. 2. Fixation ligament.
of
sling
prosthesis
to
unnamed
median
1905
sion other than the formation of an isolated reservoir. We believe that the proposed operation is a reasonable choice to correct anal insufficiency. Our goal is to reinforce the anterior portion of the anal sphincter with a prosthesis. The prosthesis performs a supportive function that allows the normal posterior and lateral portions of the anal sphincter to close the rectal outlet, while the slit shape of the loop facilitates normal evacuation of urine and feces. The positive effect of the operation results from the flexible fixation of the sling posterior to the anus. The implant is attached to an elastic structure that reduces the risk of necrosis in the anterior wall of the anal canal. We have not found any data on this ligament in the literature, but obviously this structure follows the median aponeurotic structures of the perineum and provides formation of the natal cleft. Historically, artificial devices around the bowel have led to erosion, and gracilis slings caused occasional infection.14 We had neither and can speculate that these effects are due to short operating time and flexible fixation of the sling. We think that nylon mesh ribbon is not the only possible material for the prosthesis and other nonabsorbable implants may be used for this purpose. In conclusion we propose a short and simple operation to eliminate incontinence after rectal urinary diversion in patients with bladder exstrophy. It can be used as an alternative to the formation of an isolated urinary reservoir. Mr. P. S. Malone provided assistance and valuable advice. REFERENCES
dren voided normally and remained continent both day and night. There were 2 patients who had considerable residual urine volume that necessitated intermittent catheterization of the rectum for 6 and 9 weeks, after which normal voiding was restored. Investigations revealed no urinary or fecal incontinence after a mean followup of 3.2 years (range 6 months to 61⁄2 years). Moderate hydronephrosis developed at 6 months postoperatively in 3 children who voided only 2 to 3 times daily. This hydronephrosis resolved when voiding frequency was increased to 6 to 7 times daily. Other patients voided 5 to 7 times daily and had normal upper urinary tracts. Intermittent acidosis occurred in 3 patients 2 to 4 years old, which was successfully treated by the drinking of alkaline solution. On rectal palpation the perianal loop produced sufficient compression of the anal canal. Patient growth caused no changes in the loop position, and evacuation of feces and urine. DISCUSSION
Controversy remains surrounding the primary management of bladder exstrophy, including staged bladder reconstruction versus urinary diversion to a rectal reservoir.1–5, 8 –13 However, agreement is increasing that diversion is the procedure of choice in patients with failed reconstruction, small bladder plate, or for those who live in remote areas or developing countries.2– 4 The incidence of urinary and fecal incontinence in patients with exstrophy undergoing rectal diversion is reported to be between 5% and 42%.4, 8 In our experience the incontinence rate is 32%, and we believe that on the basis of electromyography data this is secondary to insufficiency of the pelvic floor and anterior portion of the anal sphincter. The success of this procedure and maintenance of normal upper tracts would support our theory and contradict the Mainz hypothesis that the problem is related mainly to high pressure in the rectal reservoir. Currently, to our knowledge there are no efficient methods for preventing and treating incontinence after rectal diver-
1. Stein, R., Fisch, M., Black, P. et al: Strategies for reconstruction after unsatisfactory primary treatment of patients with bladder exstrophy or incontinent epispadias. J Urol, 161: 1934, 1999 2. Elabbady, A. A., Elabbasy, W. I., Arafa, A. F. et al: A simple technique for urinary diversion: the dismembered detubularized rectosigmoid bladder with distal colorectostomy. J Urol, 160: 714, 1998 3. Hafez, A. T., Elsherbiny, M. T., Dawaba, M. S. et al: Long-term outcome analysis of low pressure rectal reservoir in 33 children with bladder exstrophy. J Urol, part 2, 165: 2414, 2001 4. Mingin, G. C., Stock, J. A. and Hanna, M. K.: The Mainz II pouch: experience in 5 patients with bladder exstrophy. J Urol, 162: 846, 1999 5. Stein, R., Fisch, M., Black, P. et al: Strategies for reconstruction after unsuccessful or unsatisfactory primary treatment of patients with bladder exstrophy or incontinent epispadias. J Urol, 161: 1934, 1999 6. Mansi, M. K.: Continent urinary undiversion to modified ureterosigmoidostomy in bladder exstrophy patients. World J Surg, 23: 207, 1999 7. Henry, M. M. and Swash, M.: Coloproctology and the pelvic floor. In: Pathophysiology and Management. London, 1985 8. Koo, H. P., Avolio, L. and Duckett, J. W., Jr.: Long-term results of ureterosigmoidostomy in children with bladder exstrophy. J Urol, 156: 2037, 1996 9. Gearhart, J. P.: Bladder exstrophy: staged reconstruction. Curr Opin Urol, 9: 499, 1999 10. Nicholls, G. and Duffy, P. G.: Anatomical correction of the exstrophy-epispadias complex: analysis of 34 patients. Br J Urol, 82: 865, 1998 11. Stockle, M., Becht, E., Voges, G. et al: Ureterosigmoidostomy: an outdated approach to bladder exstrophy? J Urol, 143: 770, 1990 12. Fisch, M., Wammack, R., Muller, S. C. et al: The MAINZ pouch II (sigma rectum pouch). J Urol, 149: 258, 1993 13. Kock, N. G., Ghoneim, M. A., Lycke, K. G. et al: Urinary diversion to the augmented and valved rectum: preliminary results with a novel surgical procedure. J Urol, 140: 1375, 1988 14. Niriella, D. A. and Deen, K. I.: Neosphincters in the management of faecal incontinence. Br J Surg, 87: 1617, 2000
Vol. 166, 1904 –1905, November 2001 Printed in U.S.A.
TREATMENT OF INCONTINENCE IN CHILDREN WITH BLADDER EXSTROPHY AFTER RECTAL URINARY DIVERSION: THE ANAL SLING PROCEDURE V. V. NIKOLAEV From the Department of Pediatric Surgery, Russian State Medical University, Moscow, Russia
ABSTRACT
Purpose: An original technique for reinforcement of the anal sphincter using a sling prosthesis with a flexible fixing point that prevents incontinence and rectal prolapse is presented. Materials and Methods: Of 43 patients with exstrophy who have undergone urinary rectal diversion between 1988 and 1997 incontinence was observed in 9 boys and 5 girls. From January 1993 to December 1998 these children were treated with an original method, the anal sling procedure. Results: There were no postoperative complications. Investigations revealed no urinary or fecal incontinence after a mean followup of 3.2 years (range 6 months to 61⁄2 years). Conclusions: A short and simple operation eliminates incontinence after rectal urinary diversion in patients with bladder exstrophy. It can be used as an alternative to the formation of an isolated urinary reservoir. KEY WORDS: bladder exstrophy, urinary diversion, rectum, surgery
Rectal urinary diversion is used at some centers as definitive treatment of bladder exstrophy.1–5 Anal sphincter insufficiency is regarded as a contraindication for rectal diversion.1, 2 However, despite preoperative assessment urinary and fecal incontinence due to insufficiency of the anal sphincter still occurs in a number of cases.6 We present an original technique for reinforcement of the anal sphincter using a sling prosthesis with a flexible fixing point that prevents incontinence. MATERIALS AND METHODS
Of 43 patients with exstrophy who underwent urinary rectal diversion between 1988 and 1997 incontinence was observed in 9 boys and 5 girls. These patients who came from all around Russia were referred to the Russian Childrens’ Hospital in Moscow. There were 12 patients who were incontinent during both day and night, and 2 only at night. Anal sphincter electrostimulation and training produced no beneficial effect. From January 1993 to December 1998 these children were treated with an original method, the anal sling procedure. Preoperative examination of all patients included excretory urography, ultrasound, blood gases and serum creatinine. Concentric needle electromyography of the 4 quadrants of the external anal sphincter at rest was performed.7 The indexes of average base electrical activity of each muscle part were compared. In all patients the upper urinary tract and renal function were normal. Electromyography showed a 30% to 100% decrease in electrical activity of the anterior portion of the anal sphincter (range 0 to 104 V.) as compared with the others (96 to 238). Macerated perianal skin was treated with antiseptics, and skin protector cream and the rectum was mechanically cleaned. The patient was placed in the lithotomy position (fig. 1). Parallel parasagittal skin incisions 3 to 4 cm. long were made on each side 2 to 3 cm. lateral to the anus. An oval tunnel was formed in the subcutaneous fat surrounding the anus in the subcutaneous portion of the external anal sphincter extending posteriorly to the apex of the sacrum. There is an unAccepted for publication June 15, 2001.
FIG. 1. Skin incisions (solid lines) and position of mesh (broken line).
named median ligament between the anococcygeal body, coccyx and skin of the natal cleft that the tunnel was extended around (fig. 2). A nylon mesh band 2 cm. wide was pulled through the tunnel to form a long loop around the anus. The ends of the loop were brought together to increase anal resistance, which was controlled by digital palpation, to the level of a conscious healthy person. On inspection the anal outlet should be closed. The anal sling must enable the finger to completely stop leaking by pressing on the anterior abdominal wall. During postoperative week 1 the children received 1 mg./ kg. prednisolone daily and broad spectrum antibiotics. The rectum was drained by a tube for 3 to 5 days. RESULTS
The procedure took 15 to 25 minutes to complete. There were no postoperative complications, particularly infection or rejection of the implant. At 2 weeks postoperatively 12 chil-
1904
INCONTINENCE IN CHILDREN WITH BLADDER EXSTROPHY AFTER RECTAL URINARY DIVERSION
FIG. 2. Fixation ligament.
of
sling
prosthesis
to
unnamed
median
1905
sion other than the formation of an isolated reservoir. We believe that the proposed operation is a reasonable choice to correct anal insufficiency. Our goal is to reinforce the anterior portion of the anal sphincter with a prosthesis. The prosthesis performs a supportive function that allows the normal posterior and lateral portions of the anal sphincter to close the rectal outlet, while the slit shape of the loop facilitates normal evacuation of urine and feces. The positive effect of the operation results from the flexible fixation of the sling posterior to the anus. The implant is attached to an elastic structure that reduces the risk of necrosis in the anterior wall of the anal canal. We have not found any data on this ligament in the literature, but obviously this structure follows the median aponeurotic structures of the perineum and provides formation of the natal cleft. Historically, artificial devices around the bowel have led to erosion, and gracilis slings caused occasional infection.14 We had neither and can speculate that these effects are due to short operating time and flexible fixation of the sling. We think that nylon mesh ribbon is not the only possible material for the prosthesis and other nonabsorbable implants may be used for this purpose. In conclusion we propose a short and simple operation to eliminate incontinence after rectal urinary diversion in patients with bladder exstrophy. It can be used as an alternative to the formation of an isolated urinary reservoir. Mr. P. S. Malone provided assistance and valuable advice. REFERENCES
dren voided normally and remained continent both day and night. There were 2 patients who had considerable residual urine volume that necessitated intermittent catheterization of the rectum for 6 and 9 weeks, after which normal voiding was restored. Investigations revealed no urinary or fecal incontinence after a mean followup of 3.2 years (range 6 months to 61⁄2 years). Moderate hydronephrosis developed at 6 months postoperatively in 3 children who voided only 2 to 3 times daily. This hydronephrosis resolved when voiding frequency was increased to 6 to 7 times daily. Other patients voided 5 to 7 times daily and had normal upper urinary tracts. Intermittent acidosis occurred in 3 patients 2 to 4 years old, which was successfully treated by the drinking of alkaline solution. On rectal palpation the perianal loop produced sufficient compression of the anal canal. Patient growth caused no changes in the loop position, and evacuation of feces and urine. DISCUSSION
Controversy remains surrounding the primary management of bladder exstrophy, including staged bladder reconstruction versus urinary diversion to a rectal reservoir.1–5, 8 –13 However, agreement is increasing that diversion is the procedure of choice in patients with failed reconstruction, small bladder plate, or for those who live in remote areas or developing countries.2– 4 The incidence of urinary and fecal incontinence in patients with exstrophy undergoing rectal diversion is reported to be between 5% and 42%.4, 8 In our experience the incontinence rate is 32%, and we believe that on the basis of electromyography data this is secondary to insufficiency of the pelvic floor and anterior portion of the anal sphincter. The success of this procedure and maintenance of normal upper tracts would support our theory and contradict the Mainz hypothesis that the problem is related mainly to high pressure in the rectal reservoir. Currently, to our knowledge there are no efficient methods for preventing and treating incontinence after rectal diver-
1. Stein, R., Fisch, M., Black, P. et al: Strategies for reconstruction after unsatisfactory primary treatment of patients with bladder exstrophy or incontinent epispadias. J Urol, 161: 1934, 1999 2. Elabbady, A. A., Elabbasy, W. I., Arafa, A. F. et al: A simple technique for urinary diversion: the dismembered detubularized rectosigmoid bladder with distal colorectostomy. J Urol, 160: 714, 1998 3. Hafez, A. T., Elsherbiny, M. T., Dawaba, M. S. et al: Long-term outcome analysis of low pressure rectal reservoir in 33 children with bladder exstrophy. J Urol, part 2, 165: 2414, 2001 4. Mingin, G. C., Stock, J. A. and Hanna, M. K.: The Mainz II pouch: experience in 5 patients with bladder exstrophy. J Urol, 162: 846, 1999 5. Stein, R., Fisch, M., Black, P. et al: Strategies for reconstruction after unsuccessful or unsatisfactory primary treatment of patients with bladder exstrophy or incontinent epispadias. J Urol, 161: 1934, 1999 6. Mansi, M. K.: Continent urinary undiversion to modified ureterosigmoidostomy in bladder exstrophy patients. World J Surg, 23: 207, 1999 7. Henry, M. M. and Swash, M.: Coloproctology and the pelvic floor. In: Pathophysiology and Management. London, 1985 8. Koo, H. P., Avolio, L. and Duckett, J. W., Jr.: Long-term results of ureterosigmoidostomy in children with bladder exstrophy. J Urol, 156: 2037, 1996 9. Gearhart, J. P.: Bladder exstrophy: staged reconstruction. Curr Opin Urol, 9: 499, 1999 10. Nicholls, G. and Duffy, P. G.: Anatomical correction of the exstrophy-epispadias complex: analysis of 34 patients. Br J Urol, 82: 865, 1998 11. Stockle, M., Becht, E., Voges, G. et al: Ureterosigmoidostomy: an outdated approach to bladder exstrophy? J Urol, 143: 770, 1990 12. Fisch, M., Wammack, R., Muller, S. C. et al: The MAINZ pouch II (sigma rectum pouch). J Urol, 149: 258, 1993 13. Kock, N. G., Ghoneim, M. A., Lycke, K. G. et al: Urinary diversion to the augmented and valved rectum: preliminary results with a novel surgical procedure. J Urol, 140: 1375, 1988 14. Niriella, D. A. and Deen, K. I.: Neosphincters in the management of faecal incontinence. Br J Surg, 87: 1617, 2000