916 LONG-TERM MULTI-INSTITUTIONAL EVALUATION OF CHARLESTON POUCH I CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN

Vol. 183, No. 4, Supplement, Monday, May 31, 2010

914 WHAT IS EVENTUAL OUTCOME FOLLOWING SURGICAL REVISION OF MALONE ANTEGRADE CONTINENCE ENEMA (MACE) CHANNEL? Brian A VanderBrink*, Fishers, IN; Mark P Cain, Martin Kaefer, Kirstan K Meldrum, Rosalia Misseri, Richard C Rink, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Difficulty catheterizing the Malone antegrade continence enema (MACE) channel is a known complication that can occur in a significant number of patients. It can occur either at the skin level from stomal stenosis or as a result of a channel stenosis due to obliteration ⫾ false passage. Surgical revision is necessary in a subset of these patients. Reports of the results of these surgical interventions are limited. We describe our clinical results following surgical revision of MACE in a large number of patients. METHODS: We retrospectively identified patients undergoing MACE revision for at our institution between 1997- 2009. Type of MACE (in situ appendicocecostomy (AC), ileocecostomy (IC), cecal flap (CF)) performed was recorded, time from creation to revision, site of revision (skin vs. subfascial) were recorded. Need for repeat surgical revision was noted. RESULTS: Of a total of 308 patients that underwent creation of MACE during the study period, 49 patients required surgical revision yielding a surgical revision rate of 16%. Of these 49 patients, 37 had underwent AC, 9 had IC and 3 had CF. Mean time from MACE creation to revision was 19 months. Mean follow-up after revision was 44 months. Seventy-one revision procedures were performed in the 49 patients. Skin level stomal revisions accounted for 52/71 (73%) procedures in 42 patients while 19 subfascial revisions were performed in 15 patients. Sixteen patients (32%) required more than one revision and 4 patients (8%) required more than two procedures. Of all 49 patients that underwent revision, 40 (82%) have a catheterizable MACE channel. Of the 16 patients that underwent more than one revision, 12 (75%) have a catheterizable MACE channel. Eight of the 49 patients that had undergone revision (16%) no longer use their MACE for a variety of reasons and use a cecostomy button (n⫽4) or colostomy (n⫽4) to manage their bowels. CONCLUSIONS: The need for surgical revision following MACE creation exists in a minority of patients. Revision at the skin level accounts for nearly three-fourths of MACE revisions in those requiring revision. A third of patients in our series undergoing MACE revision required more than one revision procedure to alleviate catheterization problems. Source of Funding: None

915 SPLIT-APPENDIX TECHNIQUE FOR SIMULTANEOUS APPENDICOVESICOSTOMY AND APPENDICOCECOSTOMY Brian A VanderBrink*, Fishers, IN; Mark P Cain, Martin Kaefer, Kirstan K Meldrum, Rosalia Misseri, Richard C Rink, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Urinary and fecal incontinence can coexist in neurologic conditions causing significant distress to patients and their families. Surgical intervention with appendicocecostomy (AC) and appendicovesicostomy (AV) can help in achieving continence. Usually the appendix can only be utilized for a single channel requiring additional channel being constructed from different tissue (i.e. ileum). We describe our outcomes using the spilt-appendix technique for simultaneous creation of AC and AV. METHODS: A retrospective review of operative records at our institution from 1999-2009 with an emphasis on simultaneous creation of AC and AV from the appendix alone was performed. Our technique was when appendiceal vascular supply and length permitted; the appendix was divided with the proximal end kept in continuity with the cecum for an in situ AC while the distal end utilized for AV. The appendiceal length, utilization of stapler for appendicocecal extension to lengthen functional AC channel length, continence status, and subsequent need for surgical revision, if necessary, was recorded.

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RESULTS: Of 394 children that underwent creation of continent catheterizable channels, 43 patients (11%) were identified that used the split appendix technique. Appendiceal length was available in 27 patients and was 10 ⫾ 2 cm. The appendix was approximately divided in half in 34 patients while asymmetrical separation with stapled appendicocecal extension utilized in 9 patients. Mean length of appendix used for AV and AC was 6 cm and 4 cm, respectively. With a mean follow-up of 40 months, 43/43 AC and 41/43 AV are continent. Sixteen of the 86 channels (19%) created required surgical revision. AC and AV revisions occurred in 6 patients each, while 2 patients required surgical revision of both channels. Use of the stapler for appendicocecal extension did not result in increased need for channel revision. CONCLUSIONS: To our knowledge this is the largest clinical series describing the split appendix technique for creation of AC & AV in a pediatric population. The channels created from split appendix have durable short-term outcomes and comparable revision rates to other described techniques. The split appendix technique is applicable to a minority of children undergoing continent reconstruction, however has the benefit of avoiding a bowel resection and its accompanying risks. Source of Funding: None

916 LONG-TERM MULTI-INSTITUTIONAL EVALUATION OF CHARLESTON POUCH I CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN Hisham Hammouda*, Assiut, Egypt; Nabil Bissada, Little Rock, AR; Ian Aaronson, Charleston, SC INTRODUCTION AND OBJECTIVES: Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children. METHODS: A total of 35 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2008. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and long term functional status. RESULTS: Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 11 patients (31.4%), neurogenic bladder in 21 (60%) and cloacal abnormalities in 3 (8.6 %). Mean followup was 82.5 months. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.6 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch 3 – 4 times weekly in the 1st year and adjusted for individual patients thereafter. Four patients (11.4%) had pouch stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance were satisfactory. CONCLUSIONS: Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals (a desirable characteristic in children). Both child and parent acceptance were good with satisfactory complication rates.

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918 THE USE OF AN INTRAVESICAL SILICON INFLATABLE BALOON DEVICE IMPROVES RESULTS OF BLADDER AUTOAUGMENTATION TECHNIQUE: LONG TERM FOLLOW UP Flavio Trigo-Rocha*, Marcos Machado, Cristiano Gomes, Frederico Mascarenhas, Homero Bruschini, Jose Alaor Figueiredo, Miguel Srougi, Sao Paulo, Brazil

Source of Funding: None

917 INCREASED NEED FOR SUBFASCIAL REVISION WITH CONTINENT CATHETERIZABLE CHANNEL IMPLANTED INTO BLADDER AUGMENTATION INTESTINAL SEGMENT Brian A VanderBrink*, Fishers, IN; Mark P Cain, Martin Kaefer, Kirstan K Meldrum, Rosalia Misseri, Matthew Mellon, Richard C Rink, Indianapolis, IN INTRODUCTION AND OBJECTIVES: The Mitrofanoff principle revolutionized urinary tract reconstruction when it was introduced. Its original description involved tunneling the continent catheterizable channel (CCC) into the bladder. However, in certain clinical situations placement of the CCC into the detrusor muscle may not be feasible. Therefore implantation into an intestinal augmentation segment to allow bladder drainage is an alternative option. We reviewed our experience with CCC implanted into the intestinal segment of an enterocystoplasty. METHODS: A retrospective review of CCC procedures from 1999-2009 was performed. Operative records that noted implantation of CCC into a bowel segment when detrusor was present were noted. Type of CCC utilized, intestinal segment used for implantation, continence outcome and need for surgical revision was recorded. RESULTS: We reviewed 394 children that underwent CCC procedure and 30 patients (8%) were identified that had CCC implanted into an intestinal segment that augmented the bladder. The CCC was Monti ileovesicostomy in 21, appendix in 8 and Monti sigmoidvesicostomy in 1. The most common GI segment of the enterocystoplasty implanted into was ileum (n⫽17), followed by stomach (n⫽7) and colon (n⫽6). A seromuscular trough was created via an extraluminal approach to provide a tunnel for the continence mechanism in the majority of patients (n⫽26). Three patients had creation of intestinal implanted CCC at the time of revision of prior bladder implanted CCC with no need for subsequent surgery. Stomal continence was achieved in 14/17 (82%) CCC implanted into ileum, 6/7 (86%) and 6/6 (100%) CCC implanted into stomach and colon, respectively. However with a mean follow-up of 4.5 years, six patients (20%) required a total of 8 surgical revisions. Revisions were necessary in 4/17 (24%) CCC implanted into ileum, 2/7 (28%) and 0/6 CCC implanted into stomach and colon, respectively. 50% of the revisions were necessary for incontinence from CCC. 6/8 revisions (75%) necessitated subfascial approach for correcting loss of antirelux tunnel or angulation of CCC at entry into segment. CONCLUSIONS: Creation of a CCC by implantation into the intestinal segment of bladder augmentation is effective as a primary or secondary procedure. CCC implanted into colon resulted in highest continence and lowest revision rate compared to stomach or colon. The surgical revision rate in this series is comparable to that for a CCC implanted into detrusor, however when revision was necessary a higher need for a subfascial approach existed. Source of Funding: None

INTRODUCTION AND OBJECTIVES: The majority of the authors have reported disappointing results with auto augmentation surgeries for the treatment of low capacity, low compliance neurogenic. The failure may be due to the diverticulum’s ischemia of the as well as the shrink of mucosa in the early postoperative period. We investigate if the use of a silicone balloon (Silimed®) inside the bladder after auto augmentation could prevent shrink and ischemia of the mucosa thus improving surgical results. METHODS: We have compared our results of standard bladder auto augmentation carried in a group of 12 neurogenic bladder children (group I) with another group of 10 children submitted to the same surgery using a bladder conformer (group II). The bladder conformer was a silicon balloon filled with 50 to 100 ml of saline left inside the bladder for two weeks. The balloon had a conduct and a port to allow its removal. The main indication for surgery in all patients was poor bladder compliance resulting urinary leakage between intermittent catheterism. Four patients in group one and two in group two had upper urinary tract dilation (UUTD). Pre and postoperative evaluation included a voiding diary, ultrasound and urodynamics. RESULTS: Mean follow-up is 61.4 months (range 42 to 132 months). In the group I just one patient becomes dry, 4 presented little improvement in continence, four remained unchanged and three got worse. In group II 6 patients become continent without medication (60%), 2 (20%) become continent with oxybutinin and 2 remained unchanged. Bladder capacity in group two changed from 140 ml (mean) to 240 ml (mean) and the compliance increased from 15.6 ⫾ 16.8 ml/cmH2O to 34.3 ⫾ 22.8 ml/cmH2O; p ⫽ 0.02. From the four patients with UUTD in group I just one showed improvement. In group II the two patients showed regression of the dilation. No significant complications were observed in any patient. CONCLUSIONS: The use of a bladder silicone model significantly improved our results with bladder auto-augmentation in a long term follow up. A larger number of patients may be necessary to confirm this procedure as a safe and effective alternative to bladder in order to reduce surgical morbidity. Source of Funding: None

919 THE USE OF FLUORESCENCE IMAGING FOR DETERMINING THE ETIOLOGY OF BLADDER PERFORATION IN ILEAL AUGMENTED BLADDER Brian Minnillo*, Arzu Sencan, Aydin Sencan, Andres Silva, Alan Retik, Hiep Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: Augmentation cystoplasty is performed to increase bladder capacity, improve bladder compliance, and reduce storage pressure in order to achieve urinary continence and avoid damage to the upper tracts. However, its usage is not without significant associated complications, the most concerning being perforation of the augmented bladder. The purpose of our study was to determine the etiology of bladder perforation in the ileal augmented bladder using fluorescent molecular imaging and to compare the various open and laparoscopic techniques. METHODS: Fourteen swine underwent augmentation cystoplasty using 15cm of ileum. Various operative techniques were used including open vs. laparoscopic, W- vs. U-patch, and single vs. 2-layer closure. Fluorescent molecular imaging (FMI) with indocyanine green (ICG) was used intra- and post-operatively to assess vascular perfusion of the bowel patch and the bowel-bladder anastomosis. Perfusion was visualized with the guidance of a photodynamic eye, which en-