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The Abdominal Neourethra in Children: Technique and Long-Term Results
0022-534 7/85/1332-0244$02.00/0 THE JOURNAL OF UROLOGY
Vol. 133, February
Copyright © 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
THE ABDOMINAL NEOURETHRA IN CHILDREN: TECHNIQUE AND LONG-TERM RESULTS STEPHEN A. KOFF From the Department of Surgery, Division of Uro/,ogy, Ohio State University College of Medicine and Columbus Children's Hospita~ Columbus, Ohio
ABSTRACT
The abdominal neourethra is a continent bladder tube that is applicable to selected children with anatomical urinary incontinence or urinary retention and a nonnavigable urethra. A 5 to 8-year followup is presented in 6 children in whom the abdominal neourethra afforded normal micturition through it or permitted intermittent catheterization. All children were dry between bladder emptyings as a result of a continence mechanism that combined a long elastic tube and a cephalad neourethral abdominal opening with a rectus striated muscle sphincter.
A
In 1966 Lapides presented a favorable clinical experience with a continent bladder tube or abdominal neourethra in adults. 1 The results suggested that a bladder tube possessed many of the characteristics of the normal urinary sphincter and could be used successfully as a sphincter substitute in selected cases. On the basis of these findings the abdominal neourethra was adapted for use in children. OPERATIVE TECHNIQUE
(\
With a urethral catheter in place, a suprapubic skin incision is made to expose the bladder (fig. 1, A). The bladder is filled with saline, and a 'flap is outlined and defined with its base near the bladder dome (fig. 1, B). The flap is made as long as possible (9 to 11 cm.). The width of the flap at its apex is 2 cm. and the base of the flap is 1 to 2 cm. wider than the apex to ensure good blood supply. To obtain a flap of sufficient length it may be necessary to angle the flap obliquely across the bladder and to direct it lateral to the urethrovesical junction. The lateral edges of the distal two-thirds of the flap are excised sufficiently to allow the remaining mucosa to be approximated over a lOF catheter (fig. 2, a). After the mucosa! edges are anastomosed together with 3-zero chromic catgut, the muscular wall is wrapped around the tube in an overlapping fashion to provide additional support (fig. 3, b ). The distal 1.5 cm. of the flap edges are not connected to provide a spatulated end for later incorporation into the skin flap. A complimentary skin flap is outlined as high as possible on the anterior abdominal wall but not so high as to cause tension on the completed anastomosis (fig. 1, A). The skin flap measures 1.5 x 1.5 cm. and overlies the mid portion of the rectus muscles, except in children with the prune belly syndrome in whom it must be placed more laterally in an attempt to obtain sufficient striated muscular support for the tube as it passes through the anterior abdominal wall. The stoma is created by cutting through the skin and subcutaneous tissues, and an opening is made in the rectus fascia by excising a portion of the rectus sheath. The bladder tube then is brought through the muscles of the anterior abdominal wall. The apex of the skin flap is attached to the most proximal point on the spatulated bladder· tube using 3-zero chromic catgut. The anastomosis between the skin flap and bladder tube then is completed (fig. 3). The bladder may be closed directly or it may be augmented with an intestinal segment if bladder capacity is reduced. At the conclusion of the procedure the bladder tube is stented with a fine catheter, the urine is diverted with a suprapubic cystostomy and a perivesical drain is placed. Accepted for publication September 28, 1984.
( \
B
~
\;J 1( 11
FIG: 1. A, position of abdominal incision and stoma placement for abdominal neourethra. B, flap that is wider at base than at apex is outlined on anterior surface of bladder. To obtain sufficient length it may be necessary to angle flap obliquely across bladder wall.
CLINICAL MATERIAL
An abdominal neourethra was created in 5 boys and 1 girl between 6 and 14 years old (mean age 8.8 years), and followup ranges from 5 to 8 years (see table). Intermittent catheterization through the abdominal neourethra was performed by 4 children, either on an intermittent basis to treat periodic bladder decompensation or continuously as the only method of bladder emptying. Two children were able to void through the abdominal neourethra and could direct the urinary stream into a paper cup or a urinal. With regular bladder emptying, patients were able to maintain urinary continence from 3 to 5 hours during the day and night. Perfect continence was maintained during coughing, straining, bending or laughing. In those children who voided through the urethra there was no leakage from the abdominal stoma during micturition. No child required a collecting device or pads over the stoma. Incontinence occurred only when the bladder was not emptied regularly and was allowed to overdistend. In this instance urine would occasionally trickle out the neourethra onto the abdominal wall. Urodynamic study of the neourethra demonstrated a flat urethral pressure curve of 10 to 25 cm. water in 2 children in the supine position. Upon standing or straining the corrected urethral pressure increased to 45 to 60 cm. water, with a peak pressure occurring at the level of the anterior abdominal wall muscles. During micturition through the abdominal neourethra
244
.ABDOl\1INAL :NEOURETI-IRA
the pressu:-ce {vvithout 48 cm. water.
betv,een 32 and
The excretory urograms (IVPs) and renal function studies were either normal or unchanged (hydronephrosis in the prune syndrome) in all but 1 patient (see table). Sterile urine was maintained in children on self-voiding, whereas transient asymptomatic bacilliuria occurred periodically in those on clean intermittent catheterization. CASE REPORTS
Case 1. T. T., a 9-year-old girl, was born with a mass in the vulva. After 6 operations she was referred with total urinary incontinence. The urethra and bladder neck were completely destroyed, and substituted by a large vesicovaginal fistula. The bladder capacity was less than 100 ml., and only a solitary normal kidney and ureter remained. An 11 cm. abdominal neourethra was created, which incorporated most of the remaining bladder. Bladder augmentation with sigmoid colon and closure of the vesical neck were done (fig. 4). The patient was taught clean intermittent catheterization through the abdominal neourethra. After 8 years of followup the solitary kidney remains normal and she is completely dry between catheterizations on no medication. Occasionally, asymptomatic bacilliuria develops. Case 2. G. S., a 7-year-old boy, was struck by a bus, and sustained pelvic fractures and a urethral disruption. He was managed with a suprapubic tube but immediately an extreme degree of tube intolerance with severe bladder spasms develDespite numerous tube changes and positional alterations patient would not tolerate this catheter. An abdominal neourethra was created 5 weeks after the injury (fig. 5). A month later the bladder spasms had resolved
:245
CHILDREN
and he was able to void through the neourethra into a paper had a good stream and was continent between cup. The voidings. A 1-stage transperineal membranous urethroplasty was performed 6 months later with satisfactory results. The patient began voiding freely and was entirely continent when he voided per urethram. A year after the urethroplasty the neourethra was taken down and reincorporated into the bladder. The patient has had no urinary obstruction, the urine has remained sterile and the latest IVP was normal except for minor postoperative deformity of the bladder. Case 3. J. M., a 10-year-old boy with the prune belly syndrome, had difficulty voiding and recurrent urinary infections. Evaluation revealed a large bladder, moderate left reflux and hydronephrosis typical of this syndrome. Cystoscopy showed no outflow obstruction. The bladder was decompensated and its capacity was 2,000 cc. The child strained to void and had a weak dribbling stream. Clean intermittent catheterization was attempted but was unsuccessful because of the peculiar shape of the dilated posterior urethra that kept the catheter from entering the bladder. An abdominal neourethra was created. The patient began clean intermittent catheterization through the neourethra and 2 months later he was able to resume normal voiding. During
LINE Of CROSS SECTION
\ FIG. 2. a, distal two-thirds of bladder flap edges are excised so that remaining mucosa can be approximated over lOF catheter. muscular to wall bladder flap is wrapped around tube in overlapping additional support.
Pt.
Age at Operation
TT (case 1)
9
GS (case 2)
7
JM (case 3)
10
FIG. 3. Stomal skin flap is attached to most proximal point on spatulated bladder tube and anastomosis to skin flap is completed.
Diagnosis
Followup (yrs.)
U rethrovesical destruction, total urinary incontinence, augmentation cystoplasty Traumatic membranous urethral stricture, urethroplasty Prune belly syndrome
8
Solitary kidney
Clean intermittent catheterization
8
Normal
Self-void
7
Stable hydroureteronephrosis
Self-void and clean intermittent catheterization Self-void and clean intermittent catheterization Self-void and clean intermittent catheterization Urinary diversion
IVP
NC
6
Prune belly syndrome
6
Stable hydroureteronephrosis
RC
8
Prune belly syndrome
5
Stable hydroureteronephrosis
PK
14
Traumatic avulsion of genitalia, retroperitoneal fibrosis, chronic renal insufficiency
7
Renal transplant
Bladder Emptying
246
KOFF
}mall bladder flap
I I
I
0 A
' ',section
',, Urethral destruction
of
sigmoid colon
B
neourethra
......__
C
-. ..... Vesical neck ligated
FIG. 4. Case I-urethral destruction and small bladder capacity. Operative sequence demonstrates compatibility of abdominal neourethra with sigmoid colon cystoplasty and intermittent catheterization.
I ,,Rectus muse.le /
A
.
\
C
sphincter
.\1;
- -~1i~-
~
I
'Membranous neourethra
---
I I \ \ \ \
..
\ \
Membranous urethral disruption:
\
urethroplasty
f
,
osteomye!itis and pelvic bone fragments............
' I
/
'- ..............................
',,,,
,J
B
~ -
FIG. 5. Case 2-membranous urethral disruption. Staged reconstruction using abdominal neourethra as temporary form of urinary diversion
the last 7 years he has had urinary retention approximately once a year and has required several weeks of clean intermittent catheterization. Between catheterizations the stoma is dry. Followup IVPs have been unchanged. DISCUSSION
The data obtained from these neurologically normal patients with an abdominal neourethra confirm Lapides' observation that a tube constructed from normally innervated bladder muscle and brought through the anterior abdominal muscle wall can function adequately as a urinary sphincter. 1• 2 The
mechanisms for continence are 3-fold. 1) The tube is long and elastic with wrapped smooth muscular support to create sufficient resting closure pressure. 3 2) The rectus or anterior abdominal wall muscles contract in response to increases in intraabdominal pressure to increase urethral resistance further and to enhance urethral closure pressure during stress. 3 3) The stoma is always superior to the bladder when the patient is in the supine, sitting and standing positions. To make the abdominal neourethra adaptable for a variety of uses in children certain modifications were required. Our neourethra is significantly longer than that designed by
247
ABDOMINAL r,;EOURETBRA IN CH,LDREN
Lapides, an.d incorporates the wrapped smooth muscular support technique described by Leadbetter. 4 These changes afford increased urethral resistance to a tube composed of normal bladder muscle and allow a tube made of attenuated muscular tissue, as in the prune belly syndrome, to maintain sufficient resistance for continence. Because of these modifications the abdominal neourethra was used successfully as a form of urinary diversion for temporary and reversible cases, and also in cases that required permanent diversion. In addition, it was perfectly compatible with clean intermittent catheterization either on a continuous or an occasional basis. This was particularly helpful in 3 children with the prune belly syndrome who had repeated episodes of bladder decompensation in the absence of obstruction and in whom intermittent urethral catheterization was anatomically impossible. With short courses of clean intermittent catheterization through the abdominal neourethra, easy recompensation of bladder function occurred in these children. When not needed the neourethral opening became functionless and did not leak. The neourethra also has application in children with relatively small bladder capacities in whom bladder augmentation in conjunction with intermittent catheterization is
:cequired. The neourethra may permit effective micturition through it when the bladder is otherwise normal, and upon correction of temporary bladder outlet obstruction the neourethra may be reincorporated into the bladder. With the introduction and wide application of clean intermittent catheterization and urinary undiversion techniques, it is apparent that the abdominal neourethra is not required for the majority of children with urinary incontinence or retention. However, it should be kept in mind for the occasional and unusual child with a significant anatomical deformity who may be rescued from a more major or complicated form of urinary diversion. REFERENCES 1. Lapides, J.: The abdominal neourethra. J. Urol., 95: 350, 1966. 2. Lapides, J.: Followup of abdominal neourethra. J. Urol., 119: 219, 1978.
3. Thuroff, J. W., Bazeed, M. A., Schmidt, R. A. and Tanagho, E. A.: Urodynamic evaluation of a bladder flap tube as urinary sphincter. Neurourol. Urodynam., 1: 113, 1982. 4. Leadbetter, G. W., Jr.: Surgical correction of total urinary incontinence. J. Urol., 91: 261, 1964.
Vol. 133, February
Copyright © 1985 by The Williams & Wilkins Co.
Printed in U.S.A.
THE ABDOMINAL NEOURETHRA IN CHILDREN: TECHNIQUE AND LONG-TERM RESULTS STEPHEN A. KOFF From the Department of Surgery, Division of Uro/,ogy, Ohio State University College of Medicine and Columbus Children's Hospita~ Columbus, Ohio
ABSTRACT
The abdominal neourethra is a continent bladder tube that is applicable to selected children with anatomical urinary incontinence or urinary retention and a nonnavigable urethra. A 5 to 8-year followup is presented in 6 children in whom the abdominal neourethra afforded normal micturition through it or permitted intermittent catheterization. All children were dry between bladder emptyings as a result of a continence mechanism that combined a long elastic tube and a cephalad neourethral abdominal opening with a rectus striated muscle sphincter.
A
In 1966 Lapides presented a favorable clinical experience with a continent bladder tube or abdominal neourethra in adults. 1 The results suggested that a bladder tube possessed many of the characteristics of the normal urinary sphincter and could be used successfully as a sphincter substitute in selected cases. On the basis of these findings the abdominal neourethra was adapted for use in children. OPERATIVE TECHNIQUE
(\
With a urethral catheter in place, a suprapubic skin incision is made to expose the bladder (fig. 1, A). The bladder is filled with saline, and a 'flap is outlined and defined with its base near the bladder dome (fig. 1, B). The flap is made as long as possible (9 to 11 cm.). The width of the flap at its apex is 2 cm. and the base of the flap is 1 to 2 cm. wider than the apex to ensure good blood supply. To obtain a flap of sufficient length it may be necessary to angle the flap obliquely across the bladder and to direct it lateral to the urethrovesical junction. The lateral edges of the distal two-thirds of the flap are excised sufficiently to allow the remaining mucosa to be approximated over a lOF catheter (fig. 2, a). After the mucosa! edges are anastomosed together with 3-zero chromic catgut, the muscular wall is wrapped around the tube in an overlapping fashion to provide additional support (fig. 3, b ). The distal 1.5 cm. of the flap edges are not connected to provide a spatulated end for later incorporation into the skin flap. A complimentary skin flap is outlined as high as possible on the anterior abdominal wall but not so high as to cause tension on the completed anastomosis (fig. 1, A). The skin flap measures 1.5 x 1.5 cm. and overlies the mid portion of the rectus muscles, except in children with the prune belly syndrome in whom it must be placed more laterally in an attempt to obtain sufficient striated muscular support for the tube as it passes through the anterior abdominal wall. The stoma is created by cutting through the skin and subcutaneous tissues, and an opening is made in the rectus fascia by excising a portion of the rectus sheath. The bladder tube then is brought through the muscles of the anterior abdominal wall. The apex of the skin flap is attached to the most proximal point on the spatulated bladder· tube using 3-zero chromic catgut. The anastomosis between the skin flap and bladder tube then is completed (fig. 3). The bladder may be closed directly or it may be augmented with an intestinal segment if bladder capacity is reduced. At the conclusion of the procedure the bladder tube is stented with a fine catheter, the urine is diverted with a suprapubic cystostomy and a perivesical drain is placed. Accepted for publication September 28, 1984.
( \
B
~
\;J 1( 11
FIG: 1. A, position of abdominal incision and stoma placement for abdominal neourethra. B, flap that is wider at base than at apex is outlined on anterior surface of bladder. To obtain sufficient length it may be necessary to angle flap obliquely across bladder wall.
CLINICAL MATERIAL
An abdominal neourethra was created in 5 boys and 1 girl between 6 and 14 years old (mean age 8.8 years), and followup ranges from 5 to 8 years (see table). Intermittent catheterization through the abdominal neourethra was performed by 4 children, either on an intermittent basis to treat periodic bladder decompensation or continuously as the only method of bladder emptying. Two children were able to void through the abdominal neourethra and could direct the urinary stream into a paper cup or a urinal. With regular bladder emptying, patients were able to maintain urinary continence from 3 to 5 hours during the day and night. Perfect continence was maintained during coughing, straining, bending or laughing. In those children who voided through the urethra there was no leakage from the abdominal stoma during micturition. No child required a collecting device or pads over the stoma. Incontinence occurred only when the bladder was not emptied regularly and was allowed to overdistend. In this instance urine would occasionally trickle out the neourethra onto the abdominal wall. Urodynamic study of the neourethra demonstrated a flat urethral pressure curve of 10 to 25 cm. water in 2 children in the supine position. Upon standing or straining the corrected urethral pressure increased to 45 to 60 cm. water, with a peak pressure occurring at the level of the anterior abdominal wall muscles. During micturition through the abdominal neourethra
244
.ABDOl\1INAL :NEOURETI-IRA
the pressu:-ce {vvithout 48 cm. water.
betv,een 32 and
The excretory urograms (IVPs) and renal function studies were either normal or unchanged (hydronephrosis in the prune syndrome) in all but 1 patient (see table). Sterile urine was maintained in children on self-voiding, whereas transient asymptomatic bacilliuria occurred periodically in those on clean intermittent catheterization. CASE REPORTS
Case 1. T. T., a 9-year-old girl, was born with a mass in the vulva. After 6 operations she was referred with total urinary incontinence. The urethra and bladder neck were completely destroyed, and substituted by a large vesicovaginal fistula. The bladder capacity was less than 100 ml., and only a solitary normal kidney and ureter remained. An 11 cm. abdominal neourethra was created, which incorporated most of the remaining bladder. Bladder augmentation with sigmoid colon and closure of the vesical neck were done (fig. 4). The patient was taught clean intermittent catheterization through the abdominal neourethra. After 8 years of followup the solitary kidney remains normal and she is completely dry between catheterizations on no medication. Occasionally, asymptomatic bacilliuria develops. Case 2. G. S., a 7-year-old boy, was struck by a bus, and sustained pelvic fractures and a urethral disruption. He was managed with a suprapubic tube but immediately an extreme degree of tube intolerance with severe bladder spasms develDespite numerous tube changes and positional alterations patient would not tolerate this catheter. An abdominal neourethra was created 5 weeks after the injury (fig. 5). A month later the bladder spasms had resolved
:245
CHILDREN
and he was able to void through the neourethra into a paper had a good stream and was continent between cup. The voidings. A 1-stage transperineal membranous urethroplasty was performed 6 months later with satisfactory results. The patient began voiding freely and was entirely continent when he voided per urethram. A year after the urethroplasty the neourethra was taken down and reincorporated into the bladder. The patient has had no urinary obstruction, the urine has remained sterile and the latest IVP was normal except for minor postoperative deformity of the bladder. Case 3. J. M., a 10-year-old boy with the prune belly syndrome, had difficulty voiding and recurrent urinary infections. Evaluation revealed a large bladder, moderate left reflux and hydronephrosis typical of this syndrome. Cystoscopy showed no outflow obstruction. The bladder was decompensated and its capacity was 2,000 cc. The child strained to void and had a weak dribbling stream. Clean intermittent catheterization was attempted but was unsuccessful because of the peculiar shape of the dilated posterior urethra that kept the catheter from entering the bladder. An abdominal neourethra was created. The patient began clean intermittent catheterization through the neourethra and 2 months later he was able to resume normal voiding. During
LINE Of CROSS SECTION
\ FIG. 2. a, distal two-thirds of bladder flap edges are excised so that remaining mucosa can be approximated over lOF catheter. muscular to wall bladder flap is wrapped around tube in overlapping additional support.
Pt.
Age at Operation
TT (case 1)
9
GS (case 2)
7
JM (case 3)
10
FIG. 3. Stomal skin flap is attached to most proximal point on spatulated bladder tube and anastomosis to skin flap is completed.
Diagnosis
Followup (yrs.)
U rethrovesical destruction, total urinary incontinence, augmentation cystoplasty Traumatic membranous urethral stricture, urethroplasty Prune belly syndrome
8
Solitary kidney
Clean intermittent catheterization
8
Normal
Self-void
7
Stable hydroureteronephrosis
Self-void and clean intermittent catheterization Self-void and clean intermittent catheterization Self-void and clean intermittent catheterization Urinary diversion
IVP
NC
6
Prune belly syndrome
6
Stable hydroureteronephrosis
RC
8
Prune belly syndrome
5
Stable hydroureteronephrosis
PK
14
Traumatic avulsion of genitalia, retroperitoneal fibrosis, chronic renal insufficiency
7
Renal transplant
Bladder Emptying
246
KOFF
}mall bladder flap
I I
I
0 A
' ',section
',, Urethral destruction
of
sigmoid colon
B
neourethra
......__
C
-. ..... Vesical neck ligated
FIG. 4. Case I-urethral destruction and small bladder capacity. Operative sequence demonstrates compatibility of abdominal neourethra with sigmoid colon cystoplasty and intermittent catheterization.
I ,,Rectus muse.le /
A
.
\
C
sphincter
.\1;
- -~1i~-
~
I
'Membranous neourethra
---
I I \ \ \ \
..
\ \
Membranous urethral disruption:
\
urethroplasty
f
,
osteomye!itis and pelvic bone fragments............
' I
/
'- ..............................
',,,,
,J
B
~ -
FIG. 5. Case 2-membranous urethral disruption. Staged reconstruction using abdominal neourethra as temporary form of urinary diversion
the last 7 years he has had urinary retention approximately once a year and has required several weeks of clean intermittent catheterization. Between catheterizations the stoma is dry. Followup IVPs have been unchanged. DISCUSSION
The data obtained from these neurologically normal patients with an abdominal neourethra confirm Lapides' observation that a tube constructed from normally innervated bladder muscle and brought through the anterior abdominal muscle wall can function adequately as a urinary sphincter. 1• 2 The
mechanisms for continence are 3-fold. 1) The tube is long and elastic with wrapped smooth muscular support to create sufficient resting closure pressure. 3 2) The rectus or anterior abdominal wall muscles contract in response to increases in intraabdominal pressure to increase urethral resistance further and to enhance urethral closure pressure during stress. 3 3) The stoma is always superior to the bladder when the patient is in the supine, sitting and standing positions. To make the abdominal neourethra adaptable for a variety of uses in children certain modifications were required. Our neourethra is significantly longer than that designed by
247
ABDOMINAL r,;EOURETBRA IN CH,LDREN
Lapides, an.d incorporates the wrapped smooth muscular support technique described by Leadbetter. 4 These changes afford increased urethral resistance to a tube composed of normal bladder muscle and allow a tube made of attenuated muscular tissue, as in the prune belly syndrome, to maintain sufficient resistance for continence. Because of these modifications the abdominal neourethra was used successfully as a form of urinary diversion for temporary and reversible cases, and also in cases that required permanent diversion. In addition, it was perfectly compatible with clean intermittent catheterization either on a continuous or an occasional basis. This was particularly helpful in 3 children with the prune belly syndrome who had repeated episodes of bladder decompensation in the absence of obstruction and in whom intermittent urethral catheterization was anatomically impossible. With short courses of clean intermittent catheterization through the abdominal neourethra, easy recompensation of bladder function occurred in these children. When not needed the neourethral opening became functionless and did not leak. The neourethra also has application in children with relatively small bladder capacities in whom bladder augmentation in conjunction with intermittent catheterization is
:cequired. The neourethra may permit effective micturition through it when the bladder is otherwise normal, and upon correction of temporary bladder outlet obstruction the neourethra may be reincorporated into the bladder. With the introduction and wide application of clean intermittent catheterization and urinary undiversion techniques, it is apparent that the abdominal neourethra is not required for the majority of children with urinary incontinence or retention. However, it should be kept in mind for the occasional and unusual child with a significant anatomical deformity who may be rescued from a more major or complicated form of urinary diversion. REFERENCES 1. Lapides, J.: The abdominal neourethra. J. Urol., 95: 350, 1966. 2. Lapides, J.: Followup of abdominal neourethra. J. Urol., 119: 219, 1978.
3. Thuroff, J. W., Bazeed, M. A., Schmidt, R. A. and Tanagho, E. A.: Urodynamic evaluation of a bladder flap tube as urinary sphincter. Neurourol. Urodynam., 1: 113, 1982. 4. Leadbetter, G. W., Jr.: Surgical correction of total urinary incontinence. J. Urol., 91: 261, 1964.