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Total Continence Reconstruction: A Comparison to Staged Reconstruction of Neuropathic Bowel and Bladder
Total Continence Reconstruction: A Comparison to Staged Reconstruction of Neuropathic Bowel and Bladder A. J. Casale,* P. D. Metcalfe, M. A. Kaefer,† A. M. Dussinger, K. K. Meldrum, M. P. Cain and R. C. Rink From the Department of Pediatric Urology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine
Purpose: Surgical treatment for neuropathic bowel and bladder has become an essential tool in maximizing the quality of life in patients with myelomeningocele. We present our results comparing results in patients who underwent total continence reconstruction of the urinary and gastrointestinal tracts to patients who underwent a separate or single operation. Materials and Methods: We performed a retrospective chart review of all patients with myelomeningocele at our institution who underwent reconstruction with a cutaneous catheterizable urinary channel or Malone antegrade continence enema. We compared outcomes with regard to surgical revisions of the channel between patients who underwent the construction of each simultaneously, that is total continence reconstruction, to outcomes in those with a single channel or who underwent reconstruction at 2 or more operations. Results: Most of our patients underwent genitourinary and gastrointestinal reconstruction, and few desired surgical intervention for only a single system. We were unable to find any differences in the continence rate or stomal complications. However, patients who underwent staged reconstruction usually had significant secondary reasons for repeat surgery. Conclusions: Surgical success for urinary and fecal continence can be safely and effectively achieved through single or multiple procedures. However, because of shared pathophysiology, we believe that most patients benefit from intervention in the gastrointestinal and the genitourinary tract. Therefore, a major advantage of total continence reconstruction is avoidance of the morbidity of a second major surgical procedure. Key Words: reconstructive surgical procedures; bladder, neurogenic; fecal incontinence; spinal dysraphism; urinary diversion
ntroduction of the Mitrofanoff catheterizable channel and MACE revolutionized treatment for neuropathic bowel and bladder.1– 6 The pathogenesis of myelodysplasia usually affects bowel and bladder control, so that a patient who has incontinence of 1 system severe enough to benefit from surgical management almost always has a similar degree of dysfunction in the other system. Therefore, if medical management for incontinence fails and the patient desires surgical intervention, this surgery can be performed to correct the bowel and/or bladder. If surgery addresses each form of incontinence it may be performed separately or simultaneously. To examine the outcomes of urinary and bowel reconstruction in patients with myelomeningocele we reviewed the records of patients who underwent neurogenic bowel and bladder correction simultaneously or as separate procedures, or who only required 1 of the operations. We defined TCR as simultaneous surgical treatment for bowel and bladder incontinence with a MACE and Mitrofanoff or Monti catheterizable channel. Many patients underwent other elements of reconstructive surgery, such as ileocystoplasty or a bladder neck procedure, as indicated, but they were not addressed in this study. The comparison group was patients with a urinary catheterizable channel or MACE. These patients were divided into those in whom 1 or 2 channels were
I
* Correspondence and current address: Department of Urology, University of Louisville, Louisville, Kentucky 40292.
0022-5347/06/1764-1712/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
created at separate staged operations. We believe that the ability to perform these complex surgeries simultaneously offers distinct advantages to the patient. It is an exceptional patient who requires and desires only 1 form of continence reconstruction. MATERIALS AND METHODS We performed a retrospective chart review from 1978 to 2003. The first bladder augmentation was performed at our institution in 1978 and many patients underwent subsequent urinary channel creation. The first MACE was performed at our institution in 1996 and the first TCR was done in 1997. Continent catheterizable channels created with appendix or small intestine (the Monti catheterizable channel) have been performed since 1990. Data were analyzed for general demographic information, number and type of surgeries performed, and complications. We examined only the myelodysplasia population since they would be expected to experience equal bowel and bladder difficulties. These patients are followed at our multidisciplinary clinic and they are well documented. Only channel complications requiring surgical intervention were included because we believed that this was the most dependent and quantifiable. We compared continence rates and channel complications. Channel complications were divided into superficial problems, which required surgery at the skin stoma only, and deep complications, which required laparotomy.
1712
Vol. 176, 1712-1715, October 2006 Printed in U.S.A. DOI:10.1016/j.juro.2006.04.086
TOTAL CONTINENCE RECONSTRUCTION
1713
TABLE 2. Continence rate % Continence Urinary
Fecal
93 94 96
95 94
TCR Staged reconstruction 1 Urinary channel 1 MACE
100
No difference in continence rates in patients with TCR vs staged or single reconstruction.
Most patients in our cohort underwent TCR, significant number underwent staged reconstruction and few underwent reconstruction of single system only.
RESULTS A total of 275 patients were identified, of whom 158 (57%) underwent TCR and 45 (16%) underwent staged reconstruction. A total of 60 patients (22%) had a single catheterizable urinary channel and 12 (4%) had a single MACE (see figure). Therefore, 73% of the entire cohort underwent surgical intervention for neurogenic bowel and bladder. All surgery was performed only after prolonged efforts with medical management had failed. The 31 patients (15%) with single system bowel or bladder reconstruction had achieved adequate urinary and fecal control, and they were content with current treatment. In patients who chose TCR we did not attempt to discern which system was the primary determinant for surgery. Average patient age at reconstruction in the TCR group was 121 months, which was significantly younger than those with a single urinary channel (194 months, p ⬍0.05). Mean age at single MACE was 148 months. Mean age at first surgery in the 12 patients who underwent primary urinary channel placement was 128 months with a mean time to MACE of 74 months. Mean age at MACE was 118 months with an average of 31 months to catheterizable channel surgery. All patients in our cohort performed clean intermittent catheterization. There was no statistical difference in age among any of the other groups. Mean followup in the TCR, staged reconstruction and single system reconstruction groups was 46, 113 and 124 months, respectively.
TABLE 1. Secondary indication for surgery with staged reconstruction Primary Urinary Channel, Secondary MACE
Primary MACE, Secondary Urinary Channel
No. Pts
Surgery Co-Indication
No. Pts
Surgery Co-Indication
4 3 2 1 6
Re-augmentation Bladder neck surgery Bladder stones Mitrofanoff revision None
2 2 1
Secondary augmentation Bladder neck surgery None
Of 17 patients 14 (82%) had a secondary indication.
Of the 45 staged reconstructions 20 were performed in patients with bladder augmentation who underwent a MACE or Monti procedure at subsequent surgery. The remaining 25 patients underwent MACE or urinary channel construction as separate surgical procedures. The urinary channel was the first procedure in 19 patients, while 6 underwent a MACE procedure first and then a Monti procedure. Five of the 6 patients who originally underwent a MACE procedure with the urinary channel created secondarily had separate surgical indications for a return to the operating room. Three cases were due to the necessity of repeat bladder augmentation because of newly increased bladder pressures and 2 required coexistent bladder neck surgery for continence. The final patient had MACE done elsewhere and had not previously been offered a urinary channel (table 1). Of the 19 patients who underwent MACE as a second operation 13 had significant other indications for surgery, including 6 who required repeat augmentation, 4 with urethral incontinence who desired bladder neck procedures, 2 with bladder stones and 1 who required Mitrofanoff stomal revision. Only 6 patients underwent MACE without another surgical procedure (table 1). In the TCR group 138 of 158 patients (87.3%) received tubularized ileum for the urinary channel. The remainder received appendix (17 or 10.8%), sigmoid (2 or 1.3%) and tubularized detrusor (1 or 0.6%). All patients in whom appendix was used for the urinary channel were deemed to have sufficient length (greater than 10 to 12 cm) and appropriate vascularity to split the appendix for a MACE and a Mitrofanoff procedure. The sigmoid channels were used in the presence of a significant amount of redundant sigmoid colon. Fecal and urinary continence was excellent in all groups and no statistical difference was detected among the groups (table 2). In the entire study group channel revision was required in 74 patients overall (27%) for a total of 108 surgeries (table 3). In the TCR cohort 69% of channel revisions were superficial stomal revision, while in the staged
TABLE 3. Channel complication rate % Complications (No./total No.) TCR channel: Urinary MACE Urinary ⫹ MACE Staged reconstruction 1 Urinary channel 1 MACE Total No statistical difference among the groups.
24 (38/160) 12 (19/160) 6 (9/160) 6 (10/160) 29 (13/45) 17 (10/60) 25 (3/12) 27
1714
TOTAL CONTINENCE RECONSTRUCTION TABLE 4. Superficial vs deep channel revisions % Complications
TCR Staged reconstruction 1 Urinary channel 1 MACE Total
Superficial
Deep
69 30 43 100 57
31 70 57 43
No statistically significant differences among groups but a trend toward a decreased number of deep revisions was noted for TCR.
and single MACE, and the Monti groups 30%, 43% and 100%, respectively, were superficial stomal revision only. There were no significant differences among any of the 4 categories (table 4). DISCUSSION In the myelodysplasia population urinary tract reconstruction may be required to protect the upper urinary tract and the physical health of the child. However, quality of life has become an increasingly important outcome and continence has been shown to be fundamentally important.7,8 Most patients with myelodysplasia have coexistent bowel and bladder dysfunction, and the pediatric urologist usually manages each entity. Medical management is often effective for achieving urinary and fecal continence but, if this fails, appropriate surgical intervention has great potential to improve quality of life3,9 –11 despite the increased commitment required by caregivers.12 Reconstruction in these patients is complex with the potential to require bladder augmentation, a catheterizable channel, a bladder neck procedure and a MACE, so that each patient requires thorough and individualized preoperative evaluation and planning. Achievement of continence has been shown to be a major factor in patient and caregiver well-being and self-esteem.7,8 Furthermore, the facility of catheterizing through an abdominal stoma promotes patient independence and increased self-care.13,14 This effect only increases with aging in the child as progressive physical impairments make urethral access more difficult. Successful treatment for urinary or fecal continence is well documented1– 6,9,13,15 but the simultaneous treatment of both has been less well examined. In 1997 the Great Ormond experience was published with 18 patients and 5 simultaneous reconstructions.16 However, only 5 patients had myelodysplasia and followup was 37 months. In 2001 Wedderburn et al reported the experience at 2 institution with a total of 30 TCRs.17 They emphasized the complexity and high revision rate (17%) but championed simultaneous reconstruction. Kajbafzadeh and Chubak reported that divided appendix could be used for the 2 channels and they noted successful simultaneous reconstruction.18 With our series we were unable to observe any difference in channel complication rates among all of our groups. This was somewhat surprising since were had hypothesized that the increased adhesions and more complicated dissection of the second surgery would result in more ischemia. Our overall rate of 27% agrees with that in other contemporary literature.12,17,19,20 We have not previously seen the classification between major and minor revisions but we believe that this is an
important differentiation. A revision at skin level only can normally be performed as an outpatient procedure and it requires a much lower commitment by the patient than deeper revisions requiring laparotomy. It appears that TCR is associated with an increased proportion of superficial vs deep revisions but our limited numbers in other groups limit our statistical power. Also, the age at which patients underwent surgery reflects a bias because patients who underwent bladder augmentation before 1990 did not have the option of a catheterizable stoma and they elected placement after it became available. We believe it is a significant finding that 18 of 25 patients (82%) with a staged procedure had significant other indications for surgery. We interpreted this to mean that many patients are interested in having the 2 systems reconstructed but they are reluctant to return to the operating room unless also motivated by a second indication. There are several intangible advantages to TCR. The second surgery is inevitably more difficult since it involves extensive adhesiolysis. More difficult dissection increases the risk of enterotomy and devascularization. Although we were not able to quantify this, we believe that it can be assumed that most patients would rather avoid a second major abdominal surgery, additional surgical bowel preparation, an additional week in the hospital, and the ensuing pain and recovery.
CONCLUSIONS We believe that this study provides valuable insight into the care and reconstruction of neuropathic bowel and bladder. The pathophysiology of myelodysplasia often results in equal degrees of dysfunction in the 2 systems and the failure in medical management affects the 2 systems. Our data demonstrate that TCR, staged or single system reconstruction is able to achieve equivocal outcomes and all are capable of improving quality of life in this difficult population. However, we believe that TCR has intangible benefits in providing the potential for total continence with a single surgery. It is our procedure of choice.
Abbreviations and Acronyms MACE ⫽ Malone antegrade continence enema TCR ⫽ total continence reconstruction
REFERENCES 1.
2.
3.
Liard, A., Seguier-Lipszyc, E., Mathiot, A. and Mitrofanoff, P.: The Mitrofanoff procedure: 20 years later. J Urol, 165: 2394, 2001 Cain, M. P., Casale, A. J., King, S. J. and Rink, R. C.: Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children’s Hospital. J Urol, 162: 1749, 1999 Yerkes, E. B., Cain, M. P., King, S., Brei, T., Kaefer, M., Casale, A. J. et al: The Malone antegrade continence enema procedure: quality of life and family perspective. J Urol, 169: 320, 2003
TOTAL CONTINENCE RECONSTRUCTION 4.
Cain, M. P., Casale, A. J. and Rink, R. C.: Initial experience using a catheterizable ileovesicostomy (Monti procedure) in children. Urology, 52: 870, 1998 5. Horowitz, M., Kuhr, C. S. and Mitchell, M. E.: The Mitrofanoff catheterizable channel: patient acceptance. J Urol, 153: 771, 1995 6. Malone, P. S., Ransley, P. G. and Kiely, E. M.: Preliminary report: the antegrade continence enema. Lancet, 336: 1217, 1990 7. Rendeli, C., Ausili, E., Tabacco, F., Caliandro, P., Aprile, I., Tonali, P. et al: Assessment of health status in children with spina bifida. Spinal Cord, 43: 230, 2005 8. Edwards, M., Borzyskowski, M., Cox, A. and Badcock, J.: Neuropathic bladder and intermittent catheterization: social and psychological impact on children and adolescents. Dev Med Child Neurol, 46: 168, 2004 9. Ellsworth, P. I., Webb, H. W., Crump, J. M., Barraza, M. A., Stevens, P. S. and Mesrobian, H. G.: The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures. J Urol, 155: 1416, 1996 10. Hagglof, B., Andren, O., Bergstrom, E., Marklund, L. and Wendelius, M.: Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol Suppl, 183: 79, 1997 11. Sheldon, C. A.: Urinary reconstruction (rather than diversion) for continence in difficult pediatric urologic disorders. Semin Pediatr Surg, 5: 8, 1996
12.
13. 14.
15. 16.
17.
18.
19. 20.
1715
Clark, T., Pope, J. C. T., Adams, C., Wells, N. and Brock, J. W., 3rd: Factors that influence outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive procedures in children. J Urol, 168: 1537, 2002 Skobejko-Wlodarska, L.: Treatment of neuropathic urinary and faecal incontinence. Eur J Pediatr Surg, 12: 318, 2002 Kurtz, M. J., Van Zandt, D. K. and Sapp, L. R.: A new technique in independent intermittent catheterization: the Mitrofanoff catheterizable channel. Rehabil Nurs, 21: 311, 1996 Griffiths, D. M. and Malone, P. S.: The Malone antegrade continence enema. J Pediatr Surg, 30: 68, 1995 Mor, Y., Quinn, F. M., Carr, B., Mouriquand, P. D., Duffy, P. G. and Ransley, P. G.: Combined Mitrofanoff and antegrade continence enema procedures for urinary and fecal incontinence. J Urol, 158: 192, 1997 Wedderburn, A., Lee, R. S., Denny, A., Steinbrecher, H. A., Koyle, M. A. and Malone, P. S.: Synchronous bladder reconstruction and antegrade continence enema. J Urol, 165: 2392, 2001 Kajbafzadeh, A. M. and Chubak, N.: Simultaneous Malone antegrade continent enema and Mitrofanoff principle using the divided appendix: report of a new technique for prevention of stoma complications. J Urol, 165: 2404, 2001 Malone, P. S.: The antegrade continence enema procedure. BJU Int, 93: 248, 2004 De Ganck, J., Everaert, K., Van Laecke, E., Oosterlinck, W. and Hoebeke, P.: A high easy-to-treat complication rate is the price for a continent stoma. BJU Int, 90: 240, 2002
Purpose: Surgical treatment for neuropathic bowel and bladder has become an essential tool in maximizing the quality of life in patients with myelomeningocele. We present our results comparing results in patients who underwent total continence reconstruction of the urinary and gastrointestinal tracts to patients who underwent a separate or single operation. Materials and Methods: We performed a retrospective chart review of all patients with myelomeningocele at our institution who underwent reconstruction with a cutaneous catheterizable urinary channel or Malone antegrade continence enema. We compared outcomes with regard to surgical revisions of the channel between patients who underwent the construction of each simultaneously, that is total continence reconstruction, to outcomes in those with a single channel or who underwent reconstruction at 2 or more operations. Results: Most of our patients underwent genitourinary and gastrointestinal reconstruction, and few desired surgical intervention for only a single system. We were unable to find any differences in the continence rate or stomal complications. However, patients who underwent staged reconstruction usually had significant secondary reasons for repeat surgery. Conclusions: Surgical success for urinary and fecal continence can be safely and effectively achieved through single or multiple procedures. However, because of shared pathophysiology, we believe that most patients benefit from intervention in the gastrointestinal and the genitourinary tract. Therefore, a major advantage of total continence reconstruction is avoidance of the morbidity of a second major surgical procedure. Key Words: reconstructive surgical procedures; bladder, neurogenic; fecal incontinence; spinal dysraphism; urinary diversion
ntroduction of the Mitrofanoff catheterizable channel and MACE revolutionized treatment for neuropathic bowel and bladder.1– 6 The pathogenesis of myelodysplasia usually affects bowel and bladder control, so that a patient who has incontinence of 1 system severe enough to benefit from surgical management almost always has a similar degree of dysfunction in the other system. Therefore, if medical management for incontinence fails and the patient desires surgical intervention, this surgery can be performed to correct the bowel and/or bladder. If surgery addresses each form of incontinence it may be performed separately or simultaneously. To examine the outcomes of urinary and bowel reconstruction in patients with myelomeningocele we reviewed the records of patients who underwent neurogenic bowel and bladder correction simultaneously or as separate procedures, or who only required 1 of the operations. We defined TCR as simultaneous surgical treatment for bowel and bladder incontinence with a MACE and Mitrofanoff or Monti catheterizable channel. Many patients underwent other elements of reconstructive surgery, such as ileocystoplasty or a bladder neck procedure, as indicated, but they were not addressed in this study. The comparison group was patients with a urinary catheterizable channel or MACE. These patients were divided into those in whom 1 or 2 channels were
I
* Correspondence and current address: Department of Urology, University of Louisville, Louisville, Kentucky 40292.
0022-5347/06/1764-1712/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
created at separate staged operations. We believe that the ability to perform these complex surgeries simultaneously offers distinct advantages to the patient. It is an exceptional patient who requires and desires only 1 form of continence reconstruction. MATERIALS AND METHODS We performed a retrospective chart review from 1978 to 2003. The first bladder augmentation was performed at our institution in 1978 and many patients underwent subsequent urinary channel creation. The first MACE was performed at our institution in 1996 and the first TCR was done in 1997. Continent catheterizable channels created with appendix or small intestine (the Monti catheterizable channel) have been performed since 1990. Data were analyzed for general demographic information, number and type of surgeries performed, and complications. We examined only the myelodysplasia population since they would be expected to experience equal bowel and bladder difficulties. These patients are followed at our multidisciplinary clinic and they are well documented. Only channel complications requiring surgical intervention were included because we believed that this was the most dependent and quantifiable. We compared continence rates and channel complications. Channel complications were divided into superficial problems, which required surgery at the skin stoma only, and deep complications, which required laparotomy.
1712
Vol. 176, 1712-1715, October 2006 Printed in U.S.A. DOI:10.1016/j.juro.2006.04.086
TOTAL CONTINENCE RECONSTRUCTION
1713
TABLE 2. Continence rate % Continence Urinary
Fecal
93 94 96
95 94
TCR Staged reconstruction 1 Urinary channel 1 MACE
100
No difference in continence rates in patients with TCR vs staged or single reconstruction.
Most patients in our cohort underwent TCR, significant number underwent staged reconstruction and few underwent reconstruction of single system only.
RESULTS A total of 275 patients were identified, of whom 158 (57%) underwent TCR and 45 (16%) underwent staged reconstruction. A total of 60 patients (22%) had a single catheterizable urinary channel and 12 (4%) had a single MACE (see figure). Therefore, 73% of the entire cohort underwent surgical intervention for neurogenic bowel and bladder. All surgery was performed only after prolonged efforts with medical management had failed. The 31 patients (15%) with single system bowel or bladder reconstruction had achieved adequate urinary and fecal control, and they were content with current treatment. In patients who chose TCR we did not attempt to discern which system was the primary determinant for surgery. Average patient age at reconstruction in the TCR group was 121 months, which was significantly younger than those with a single urinary channel (194 months, p ⬍0.05). Mean age at single MACE was 148 months. Mean age at first surgery in the 12 patients who underwent primary urinary channel placement was 128 months with a mean time to MACE of 74 months. Mean age at MACE was 118 months with an average of 31 months to catheterizable channel surgery. All patients in our cohort performed clean intermittent catheterization. There was no statistical difference in age among any of the other groups. Mean followup in the TCR, staged reconstruction and single system reconstruction groups was 46, 113 and 124 months, respectively.
TABLE 1. Secondary indication for surgery with staged reconstruction Primary Urinary Channel, Secondary MACE
Primary MACE, Secondary Urinary Channel
No. Pts
Surgery Co-Indication
No. Pts
Surgery Co-Indication
4 3 2 1 6
Re-augmentation Bladder neck surgery Bladder stones Mitrofanoff revision None
2 2 1
Secondary augmentation Bladder neck surgery None
Of 17 patients 14 (82%) had a secondary indication.
Of the 45 staged reconstructions 20 were performed in patients with bladder augmentation who underwent a MACE or Monti procedure at subsequent surgery. The remaining 25 patients underwent MACE or urinary channel construction as separate surgical procedures. The urinary channel was the first procedure in 19 patients, while 6 underwent a MACE procedure first and then a Monti procedure. Five of the 6 patients who originally underwent a MACE procedure with the urinary channel created secondarily had separate surgical indications for a return to the operating room. Three cases were due to the necessity of repeat bladder augmentation because of newly increased bladder pressures and 2 required coexistent bladder neck surgery for continence. The final patient had MACE done elsewhere and had not previously been offered a urinary channel (table 1). Of the 19 patients who underwent MACE as a second operation 13 had significant other indications for surgery, including 6 who required repeat augmentation, 4 with urethral incontinence who desired bladder neck procedures, 2 with bladder stones and 1 who required Mitrofanoff stomal revision. Only 6 patients underwent MACE without another surgical procedure (table 1). In the TCR group 138 of 158 patients (87.3%) received tubularized ileum for the urinary channel. The remainder received appendix (17 or 10.8%), sigmoid (2 or 1.3%) and tubularized detrusor (1 or 0.6%). All patients in whom appendix was used for the urinary channel were deemed to have sufficient length (greater than 10 to 12 cm) and appropriate vascularity to split the appendix for a MACE and a Mitrofanoff procedure. The sigmoid channels were used in the presence of a significant amount of redundant sigmoid colon. Fecal and urinary continence was excellent in all groups and no statistical difference was detected among the groups (table 2). In the entire study group channel revision was required in 74 patients overall (27%) for a total of 108 surgeries (table 3). In the TCR cohort 69% of channel revisions were superficial stomal revision, while in the staged
TABLE 3. Channel complication rate % Complications (No./total No.) TCR channel: Urinary MACE Urinary ⫹ MACE Staged reconstruction 1 Urinary channel 1 MACE Total No statistical difference among the groups.
24 (38/160) 12 (19/160) 6 (9/160) 6 (10/160) 29 (13/45) 17 (10/60) 25 (3/12) 27
1714
TOTAL CONTINENCE RECONSTRUCTION TABLE 4. Superficial vs deep channel revisions % Complications
TCR Staged reconstruction 1 Urinary channel 1 MACE Total
Superficial
Deep
69 30 43 100 57
31 70 57 43
No statistically significant differences among groups but a trend toward a decreased number of deep revisions was noted for TCR.
and single MACE, and the Monti groups 30%, 43% and 100%, respectively, were superficial stomal revision only. There were no significant differences among any of the 4 categories (table 4). DISCUSSION In the myelodysplasia population urinary tract reconstruction may be required to protect the upper urinary tract and the physical health of the child. However, quality of life has become an increasingly important outcome and continence has been shown to be fundamentally important.7,8 Most patients with myelodysplasia have coexistent bowel and bladder dysfunction, and the pediatric urologist usually manages each entity. Medical management is often effective for achieving urinary and fecal continence but, if this fails, appropriate surgical intervention has great potential to improve quality of life3,9 –11 despite the increased commitment required by caregivers.12 Reconstruction in these patients is complex with the potential to require bladder augmentation, a catheterizable channel, a bladder neck procedure and a MACE, so that each patient requires thorough and individualized preoperative evaluation and planning. Achievement of continence has been shown to be a major factor in patient and caregiver well-being and self-esteem.7,8 Furthermore, the facility of catheterizing through an abdominal stoma promotes patient independence and increased self-care.13,14 This effect only increases with aging in the child as progressive physical impairments make urethral access more difficult. Successful treatment for urinary or fecal continence is well documented1– 6,9,13,15 but the simultaneous treatment of both has been less well examined. In 1997 the Great Ormond experience was published with 18 patients and 5 simultaneous reconstructions.16 However, only 5 patients had myelodysplasia and followup was 37 months. In 2001 Wedderburn et al reported the experience at 2 institution with a total of 30 TCRs.17 They emphasized the complexity and high revision rate (17%) but championed simultaneous reconstruction. Kajbafzadeh and Chubak reported that divided appendix could be used for the 2 channels and they noted successful simultaneous reconstruction.18 With our series we were unable to observe any difference in channel complication rates among all of our groups. This was somewhat surprising since were had hypothesized that the increased adhesions and more complicated dissection of the second surgery would result in more ischemia. Our overall rate of 27% agrees with that in other contemporary literature.12,17,19,20 We have not previously seen the classification between major and minor revisions but we believe that this is an
important differentiation. A revision at skin level only can normally be performed as an outpatient procedure and it requires a much lower commitment by the patient than deeper revisions requiring laparotomy. It appears that TCR is associated with an increased proportion of superficial vs deep revisions but our limited numbers in other groups limit our statistical power. Also, the age at which patients underwent surgery reflects a bias because patients who underwent bladder augmentation before 1990 did not have the option of a catheterizable stoma and they elected placement after it became available. We believe it is a significant finding that 18 of 25 patients (82%) with a staged procedure had significant other indications for surgery. We interpreted this to mean that many patients are interested in having the 2 systems reconstructed but they are reluctant to return to the operating room unless also motivated by a second indication. There are several intangible advantages to TCR. The second surgery is inevitably more difficult since it involves extensive adhesiolysis. More difficult dissection increases the risk of enterotomy and devascularization. Although we were not able to quantify this, we believe that it can be assumed that most patients would rather avoid a second major abdominal surgery, additional surgical bowel preparation, an additional week in the hospital, and the ensuing pain and recovery.
CONCLUSIONS We believe that this study provides valuable insight into the care and reconstruction of neuropathic bowel and bladder. The pathophysiology of myelodysplasia often results in equal degrees of dysfunction in the 2 systems and the failure in medical management affects the 2 systems. Our data demonstrate that TCR, staged or single system reconstruction is able to achieve equivocal outcomes and all are capable of improving quality of life in this difficult population. However, we believe that TCR has intangible benefits in providing the potential for total continence with a single surgery. It is our procedure of choice.
Abbreviations and Acronyms MACE ⫽ Malone antegrade continence enema TCR ⫽ total continence reconstruction
REFERENCES 1.
2.
3.
Liard, A., Seguier-Lipszyc, E., Mathiot, A. and Mitrofanoff, P.: The Mitrofanoff procedure: 20 years later. J Urol, 165: 2394, 2001 Cain, M. P., Casale, A. J., King, S. J. and Rink, R. C.: Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children’s Hospital. J Urol, 162: 1749, 1999 Yerkes, E. B., Cain, M. P., King, S., Brei, T., Kaefer, M., Casale, A. J. et al: The Malone antegrade continence enema procedure: quality of life and family perspective. J Urol, 169: 320, 2003
TOTAL CONTINENCE RECONSTRUCTION 4.
Cain, M. P., Casale, A. J. and Rink, R. C.: Initial experience using a catheterizable ileovesicostomy (Monti procedure) in children. Urology, 52: 870, 1998 5. Horowitz, M., Kuhr, C. S. and Mitchell, M. E.: The Mitrofanoff catheterizable channel: patient acceptance. J Urol, 153: 771, 1995 6. Malone, P. S., Ransley, P. G. and Kiely, E. M.: Preliminary report: the antegrade continence enema. Lancet, 336: 1217, 1990 7. Rendeli, C., Ausili, E., Tabacco, F., Caliandro, P., Aprile, I., Tonali, P. et al: Assessment of health status in children with spina bifida. Spinal Cord, 43: 230, 2005 8. Edwards, M., Borzyskowski, M., Cox, A. and Badcock, J.: Neuropathic bladder and intermittent catheterization: social and psychological impact on children and adolescents. Dev Med Child Neurol, 46: 168, 2004 9. Ellsworth, P. I., Webb, H. W., Crump, J. M., Barraza, M. A., Stevens, P. S. and Mesrobian, H. G.: The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures. J Urol, 155: 1416, 1996 10. Hagglof, B., Andren, O., Bergstrom, E., Marklund, L. and Wendelius, M.: Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol Suppl, 183: 79, 1997 11. Sheldon, C. A.: Urinary reconstruction (rather than diversion) for continence in difficult pediatric urologic disorders. Semin Pediatr Surg, 5: 8, 1996
12.
13. 14.
15. 16.
17.
18.
19. 20.
1715
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