- Email: [email protected]
Macedo procedure: A continent catheterizable ileum-based reservoir. Step-by-step video
Accepted Manuscript Macedo procedure: a continent catheterizable ileum-based reservoir. Step-by-step video Eduardo Tosetto Cachoeira, João Vitor Q. dos Santos, Gabriel V. da Silva, Rafael C. da Silva, Guilherme L. Motta, Fernando J. Abreu, Patric M. Tavares, Tiago E. Rosito PII:
S1477-5131(18)30181-5
DOI:
10.1016/j.jpurol.2018.04.011
Reference:
JPUROL 2832
To appear in:
Journal of Pediatric Urology
Received Date: 14 September 2017 Accepted Date: 10 April 2018
Please cite this article as: Cachoeira ET, dos Santos JVQ, da Silva GV, da Silva RC, Motta GL, Abreu FJ, Tavares PM, Rosito TE, Macedo procedure: a continent catheterizable ileum-based reservoir. Stepby-step video, Journal of Pediatric Urology (2018), doi: 10.1016/j.jpurol.2018.04.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT VIDEO BANK Macedo procedure: a continent catheterizable ileum-based reservoir. Step-by-step video Eduardo Tosetto Cachoeira a,*, João Vitor Q. dos Santos a, Gabriel V. da Silva a, Rafael C. da Silva b, Guilherme L. Motta b, Fernando J. Abreu b, Patric
RI PT
M. Tavares b, and Tiago E. Rosito c
Urology Resident of Hospital de Clínicas de Porto Alegre
b
Fellowship of Pediatric Urology of Hospital de Clínicas de Porto Alegre
c
Head of Urology and Pediatric Urology Department of Hospital de Clínicas
SC
a
de Porto Alegre
M AN U
*Corresponding author. Hospital de Clínicas de Porto Alegre, Department of Urology, Rua Ramiro Barcellos, 2350. – Bairro Santa Cecília, Porto Alegre, RS – Brazil.
E-mail address: [email protected]
TE D
Summary: This video provides a case report of a 16-year-old male patient who underwent bladder enlargement with a catheterized conduit under Macedo’s technique. This technique involves the use of a segment of the distal ileum with a flap that is used for confection of the conduit. Key points
EP
include: 1) skin incision planning; 2) bladder release to allow a tension-free anastomosis; 3) reservoir and a conduit creation with a distal ileum; and 4)
AC C
creation of a continence mechanism.
KEYWORDS
Urinary diversion;
Augmentation cystoplasty; Neurogenic bladder
Introduction In patients with a neurogenic bladder, the primary goal is preservation of renal function and prevention of urinary tract infection, with urinary continence as the secondary goal [1]. Lower urinary tract symptoms in patients with
ACCEPTED MANUSCRIPT neurogenic bladder can significantly affect patients’ quality of life. These symptoms are the result of decreased bladder capacity, abnormal compliance, detrusor overactivity, and detrusor external sphincter dyssynergia [2]. In some patients, conservative management fails in its treatment goals resulting in the need for augmentation cystoplasty and urinary diversion [1].
RI PT
Macedo and Srougi described an original procedure that enables production of a catheterizable channel made with an ileal flap tube from the same segment used to create the reservoir, this technique has the potential benefit of sparing the cecal appendix [3].
SC
Patient and methods
We present a case of a 16-year-old male patient with spinal cord injury, bladder overactivity, reduction in bladder capacity, and a urethral trauma
M AN U
resulting from clean intermittent catheterization when an urgency cystostomy was performed.
The technique consists of a skin incision just above the pubic symphysis. A 30-35 cm segment of the distal ileum is isolated, and the bowel continuity is restored with a stapler anastomosis. The intestine is
TE D
detubularized longitudinally along the antimesenteric border up to the middle of the segment. Once there, a transversal incision to the mesenteric border is used to create a flap 3 cm wide and 4.5 cm in length, and the remaining ileum is opened longitudinally along the antemesenteric border. The flap from the
EP
anterior surface of the middle part of the ileum is cranially mobilized and tubularized around a 14F Foley catheter. Valve continence is reached by
AC C
embedding the tube over a serous-lined extramural tunnel created by Ethibond 3-0 sutures as a full warp like in Nissen procedure. The reservoir is anastomosed to the bladder. The tube distal end is anastomosed to the Vshaped skin flap to avoid stomal stenosis. Ethical approval None required. Results Total operative time was 200 minutes and blood loss was estimated at 300 mL. The patient was discharged home at POD 10 with a cystostomy and Foley catheter through the Macedo catheterizable channel. After 3 weeks, the
ACCEPTED MANUSCRIPT patient was readmitted and a urologic nurse taught the patient how to perform intermittent catheterization through the stoma. Discussion The long-term results of this technique are comparable with other options of treatments with the advantages of being simpler, faster, and sparing the
RI PT
appendix for other uses [4]. The Malone antegrade continence enema provides a continent conduit on the abdominal wall with appendix through which a patient may irrigate the entire colon [5].
In our experience, Macedo’s technique achieved 82.8% conduit
SC
continence, with 3.4% stomal stenosis, and urinary fistula occurring in 13.7% of the 29 patients submitted to Macedo’s diversion with a mean follow-up time of 3.3 years.
M AN U
Conclusion
Our video demonstrates a step-by-step approach to a challenging problem in pediatric urology. The Macedo procedure may be considered an option for patients who need augmentation cystoplasty with urinary diversion and, at the same time, the appendix is needed for management of neurogenic bowel.
None. Funding None.
EP
References
TE D
Conflict of interest
[1] Stein R, Schröder A, Thüroff JW. Bladder augmentation and urinary
AC C
diversion in patients with neurogenic bladder: Surgical considerations. J Pediatr Urol 2012; 8:153-61. [2] Netto JMMN, et al. Disfunção neuropática do trato urinário inferior. Urologia Brasil. São Paulo. Planmark 2013;981-8. [3] Macedo A Jr, Srougi M. A continent catheterizable ileum-based reservoir. BJU Int 2000; 85:160-2. [4] Macedo A Jr, Damazio E, Bacelar H, Rondon A, Ottoni S, Liguori R, et al. Ten years’ minimum follow-up with the ileal continent catheterizable reservoir: A test of time. J Pediatr Urol 2013;9:272-7. [5] Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet 1990;336:1217-8.
S1477-5131(18)30181-5
DOI:
10.1016/j.jpurol.2018.04.011
Reference:
JPUROL 2832
To appear in:
Journal of Pediatric Urology
Received Date: 14 September 2017 Accepted Date: 10 April 2018
Please cite this article as: Cachoeira ET, dos Santos JVQ, da Silva GV, da Silva RC, Motta GL, Abreu FJ, Tavares PM, Rosito TE, Macedo procedure: a continent catheterizable ileum-based reservoir. Stepby-step video, Journal of Pediatric Urology (2018), doi: 10.1016/j.jpurol.2018.04.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT VIDEO BANK Macedo procedure: a continent catheterizable ileum-based reservoir. Step-by-step video Eduardo Tosetto Cachoeira a,*, João Vitor Q. dos Santos a, Gabriel V. da Silva a, Rafael C. da Silva b, Guilherme L. Motta b, Fernando J. Abreu b, Patric
RI PT
M. Tavares b, and Tiago E. Rosito c
Urology Resident of Hospital de Clínicas de Porto Alegre
b
Fellowship of Pediatric Urology of Hospital de Clínicas de Porto Alegre
c
Head of Urology and Pediatric Urology Department of Hospital de Clínicas
SC
a
de Porto Alegre
M AN U
*Corresponding author. Hospital de Clínicas de Porto Alegre, Department of Urology, Rua Ramiro Barcellos, 2350. – Bairro Santa Cecília, Porto Alegre, RS – Brazil.
E-mail address: [email protected]
TE D
Summary: This video provides a case report of a 16-year-old male patient who underwent bladder enlargement with a catheterized conduit under Macedo’s technique. This technique involves the use of a segment of the distal ileum with a flap that is used for confection of the conduit. Key points
EP
include: 1) skin incision planning; 2) bladder release to allow a tension-free anastomosis; 3) reservoir and a conduit creation with a distal ileum; and 4)
AC C
creation of a continence mechanism.
KEYWORDS
Urinary diversion;
Augmentation cystoplasty; Neurogenic bladder
Introduction In patients with a neurogenic bladder, the primary goal is preservation of renal function and prevention of urinary tract infection, with urinary continence as the secondary goal [1]. Lower urinary tract symptoms in patients with
ACCEPTED MANUSCRIPT neurogenic bladder can significantly affect patients’ quality of life. These symptoms are the result of decreased bladder capacity, abnormal compliance, detrusor overactivity, and detrusor external sphincter dyssynergia [2]. In some patients, conservative management fails in its treatment goals resulting in the need for augmentation cystoplasty and urinary diversion [1].
RI PT
Macedo and Srougi described an original procedure that enables production of a catheterizable channel made with an ileal flap tube from the same segment used to create the reservoir, this technique has the potential benefit of sparing the cecal appendix [3].
SC
Patient and methods
We present a case of a 16-year-old male patient with spinal cord injury, bladder overactivity, reduction in bladder capacity, and a urethral trauma
M AN U
resulting from clean intermittent catheterization when an urgency cystostomy was performed.
The technique consists of a skin incision just above the pubic symphysis. A 30-35 cm segment of the distal ileum is isolated, and the bowel continuity is restored with a stapler anastomosis. The intestine is
TE D
detubularized longitudinally along the antimesenteric border up to the middle of the segment. Once there, a transversal incision to the mesenteric border is used to create a flap 3 cm wide and 4.5 cm in length, and the remaining ileum is opened longitudinally along the antemesenteric border. The flap from the
EP
anterior surface of the middle part of the ileum is cranially mobilized and tubularized around a 14F Foley catheter. Valve continence is reached by
AC C
embedding the tube over a serous-lined extramural tunnel created by Ethibond 3-0 sutures as a full warp like in Nissen procedure. The reservoir is anastomosed to the bladder. The tube distal end is anastomosed to the Vshaped skin flap to avoid stomal stenosis. Ethical approval None required. Results Total operative time was 200 minutes and blood loss was estimated at 300 mL. The patient was discharged home at POD 10 with a cystostomy and Foley catheter through the Macedo catheterizable channel. After 3 weeks, the
ACCEPTED MANUSCRIPT patient was readmitted and a urologic nurse taught the patient how to perform intermittent catheterization through the stoma. Discussion The long-term results of this technique are comparable with other options of treatments with the advantages of being simpler, faster, and sparing the
RI PT
appendix for other uses [4]. The Malone antegrade continence enema provides a continent conduit on the abdominal wall with appendix through which a patient may irrigate the entire colon [5].
In our experience, Macedo’s technique achieved 82.8% conduit
SC
continence, with 3.4% stomal stenosis, and urinary fistula occurring in 13.7% of the 29 patients submitted to Macedo’s diversion with a mean follow-up time of 3.3 years.
M AN U
Conclusion
Our video demonstrates a step-by-step approach to a challenging problem in pediatric urology. The Macedo procedure may be considered an option for patients who need augmentation cystoplasty with urinary diversion and, at the same time, the appendix is needed for management of neurogenic bowel.
None. Funding None.
EP
References
TE D
Conflict of interest
[1] Stein R, Schröder A, Thüroff JW. Bladder augmentation and urinary
AC C
diversion in patients with neurogenic bladder: Surgical considerations. J Pediatr Urol 2012; 8:153-61. [2] Netto JMMN, et al. Disfunção neuropática do trato urinário inferior. Urologia Brasil. São Paulo. Planmark 2013;981-8. [3] Macedo A Jr, Srougi M. A continent catheterizable ileum-based reservoir. BJU Int 2000; 85:160-2. [4] Macedo A Jr, Damazio E, Bacelar H, Rondon A, Ottoni S, Liguori R, et al. Ten years’ minimum follow-up with the ileal continent catheterizable reservoir: A test of time. J Pediatr Urol 2013;9:272-7. [5] Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet 1990;336:1217-8.