Outcome of ureteral reimplantation in children with the urge syndrome.

PURPOSE: While bladder dysfunction, particularly detrusor-sphincter incoordination, appears to be associated with a higher ureteral reimplantation failure rate, the potential effect of the urge syndrome or detrusor instability alone on surgical outcome remains unclear. We assessed the effect of the underlying urge syndrome on the outcome of ureteral implantation in cases of primary vesicoureteral reflux. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent ureteral reimplantation for primary vesicoureteral reflux at our institution in an 11-year period. The urge syndrome was considered frequency, urgency or urge incontinence with absent urinary tract infection. Patients with and without the urge syndrome were compared with respect to the rate of urinary tract infection and renal scarring as well as postoperative outcome. RESULTS: We identified 25 patients (40 ureters) with and 67 (113 ureters) without the urge syndrome. Reimplantation was successful in all except 1 ureter in a patient without the urge syndrome. Postoperatively 2 patients without the syndrome had transient contralateral reflux and 1 in each group had transient ipsilateral reflux. No case required reoperation. Postoperatively patients with the syndrome had a significantly higher incidence of febrile (16% versus 1.5%, p <0.05) and afebrile (52% versus 12%, p <0.05) urinary tract infection. CONCLUSIONS: The results of ureteral reimplantation are excellent with 99.3% success irrespective of the presence or absence of the urge syndrome. Thus, when clinically indicated, reimplantation may be performed safely in such cases. The higher incidence of postoperative urinary tract infection in patients with the urge syndrome may require continuing antibiotic prophylaxis in addition to anticholinergics until voiding symptoms resolve.

Urethral atresia: long-term outcome in 6 children who survived the neonatal period.

PURPOSE: Urethral atresia is incompatible with life unless an alternative communication between the bladder and amniotic sac exists. Although antenatal intervention may improve perinatal mortality, clinical consequences remain. We outline the outcome after treatment of 6 patients born with urethral atresia. MATERIALS AND METHODS: We reviewed the charts of 6 patients with urethral atresia treated at the Children's Hospital of Michigan between 1982 and 1999. Patient age ranged from 3 to 17 years (mean 9). All patients were males (46 XY) and presented at birth or in early infancy. RESULTS: Oligohydramnios was demonstrated in 4 of the 6 patients (67%). A vesico-amniotic shunt had been placed in 2 patients (at more than 30 weeks of gestation and in 1 at 17 weeks of gestation). The remaining 3 patients presented at birth with either a vesicocutaneous fistula or patent urachus. Bilateral or unilateral hydronephrosis was identified in 4 patients while 2 had severe renal dysplasia. Cystography identified moderate to high grade vesicoureteral reflux in all patients, and 5 (83%) had the prune belly syndrome. Mean serum creatinine at age 1 year was 1.3 mg/dl (range 0.5 to 2.1). Renal failure occurred in 5 patients (83%) before age 10 years and 4 of them have received a renal transplant. An average of 7.8 (range 9 to 14) urological procedures were performed on each patient. Progressive urethral dilation was not successful in the majority of our cases and ultimately 67% required some form of supravesical diversion. CONCLUSIONS: Our study demonstrates that urethral atresia is not necessarily fatal. Prenatal decompression allows survival and in some cases may even lead to normal bladder and renal function. A complicated clinical course requiring extensive reconstruction is to be expected.

Further experience with seromuscular colocystoplasty lined with urothelium.

PURPOSE: We report our continuing experience with seromuscular colocystoplasty lined with urothelium. This procedure is designed to preserve the urothelium and potentially decrease the incidence of complications associated with standard bladder augmentation. MATERIALS AND METHODS: We retrospectively reviewed the charts of 32 patients who underwent seromuscular colocystoplasty lined with urothelium between April 1994 and July 1999. Data were collected on patient demographics, surgical indications, previous and adjunctive surgical procedures, preoperative and postoperative urinary continence, upper urinary tract changes, urodynamic parameters, surgical complications and histological findings. RESULTS: Mean patient age at surgery plus or minus standard deviation was 11.1 +/- 4.8 years. Mean followup was 1.6 +/- 1 years. A mean of 1.5 +/- 0.9 years postoperatively urodynamic studies available in 28 cases showed that total and safe bladder capacity increased by 1.8 and 2.4-fold, respectively. Continence was achieved in 71% of patients after the initial procedure, increasing to 81% after secondary procedures. Hourglass deformity developed in 7 cases (22%), augmentation failed in 4 (12.5%) and there were bladder calculi in 2 (6%). New onset or increased hydronephrosis and reflux were present in 6 of 62 (10%) and 9 of 60 (15%) evaluated renal units, respectively. Of the 7 interpretable biopsies 5 revealed various degrees of repeat colonic mucosal growth. There was no bladder perforation or metabolic abnormalities, and mucous production was not clinically significant. CONCLUSIONS: Seromuscular colocystoplasty lined with urothelium is a viable alternative to standard bladder augmentation. The 2 procedures have a similar overall complication rate. Comparatively there appears to be a low incidence of bladder calculi, mucous production has not been clinically significant, metabolic disturbances have not developed and perforation has not occurred during short-term followup. We are enthusiastic about this technique and continue to apply it in select patients.

A simplified technique of upper pole heminephrectomy for duplex kidney.

PURPOSE: We describe a simplified technique of upper pole heminephrectomy in cases of duplex kidney. MATERIALS AND METHODS: The upper pole collecting system is entered and the upper pole is excised. The vascular supply to the upper pole is then easily identified and divided. The upper pole ureter is dissected below the lower pole vessels and distal ureteral dissection is completed. We performed the technique in 11 girls and 3 boys with a mean age of 1. 8 years who had poor or nonfunctioning upper moieties of duplicated kidneys. The diagnosis was ectopic ureter in 11 cases and ureterocele with duplication in 3. RESULTS: Mean surgical time was 95 minutes. Blood loss was not clinically significant in any patient and mean hospitalization was 2.7 days. The only postoperative complication was atelectasis, which resolved promptly with medical treatment. There was no injury to the lower pole ureter or vascular pedicle. CONCLUSIONS: Our technique enables reliable and safe excision of upper pole renal tissue with the maximal preservation of functioning lower pole parenchyma. The chance of inadvertent entry into the lower pole collecting system is significantly decreased since the demarcation of the upper and lower moieties is clearly identifiable. In addition, the avoidance of initial, potentially cumbersome hilar dissection minimizes the risk of injury to the lower pole ureter and vascular supply. This technique may be performed rapidly and requires only brief hospitalization postoperatively.

Testicular position in the androgen insensitivity syndrome: implications for the role of androgens in testicular descent.

PURPOSE: We compared testicular position with genital phenotype in a clinical series and a literature review of androgen receptor mutations to assess the role of androgens in testicular descent. MATERIALS AND METHODS: Our clinical reports, the androgen receptor mutations database and selected literature were reviewed. Subjects with a proved androgen receptor mutation were included in our study when a female or ambiguous phenotype was present (Quigley grade 3 to 7) and testicular position was documented. Comparison among groups was done by Fisher's exact or chi-square test. RESULTS: Of the 7 patients with detailed clinical records 5 had abdominal (bilateral in 4) and 2 had bilateral inguinal testes. Four patients with abdominal testes also had aberrant pelvic ligaments extending medially from the gonads. Including an additional 102 cases identified in the literature, abdominal testes were present in 52% and 3% of those with complete and partial androgen insensitivity, respectively. The incidence of abdominal testes was highest (86%) in patients with a complete female phenotype and no pubic hair (grade 7). It decreased significantly with increasing masculinization and was higher in phenotypic females diagnosed at or after (67%) than in those identified before (22%) puberty. Hernia was associated with inguinal and abdominal testes. CONCLUSIONS: Testicular position correlates with genital phenotype in patients with androgen receptor mutations, supporting a major role for androgens in testicular descent. Inguinal hernia and abnormal pelvic ligaments in these individuals may partially determine testicular position but to our knowledge the role of androgen receptors, if any, in their development is unknown.

Bladder calculi in children who perform clean intermittent catheterization.

OBJECTIVE: To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients. PATIENTS AND METHODS: The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed. RESULTS: Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months. CONCLUSION: These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.

Surgical complications of bladder augmentation: comparison between various enterocystoplasties in 133 patients.

OBJECTIVES: Ileal and sigmoid augmentation are equally effective at increasing bladder capacity and compliance. Therefore, knowledge of the incidence of major complications, including perforation, small bowel obstruction (SBO), anastomotic complications, calculus formation, and indications for revision may be useful in choosing the ideal segment. We compared the complications of ileocystoplasty and two types of sigmoidocystoplasty that required reoperative surgery. METHODS: Between 1981 and 1997, 158 patients with a mean age of 11 years (range 2 to 25) underwent augmentation cystoplasty. Ileum or sigmoid colon was used in 133 patients, who were the subjects of this study. The mean follow-up was 64 months (range 6 to 185). Indications included neurogenic bladder (n = 100), bladder exstrophy (n = 12), cloacal exstrophy (n = 6), posterior urethral valves (n = 3), and miscellaneous (n = 12). Ileum was used in 65 patients and sigmoid colon in 68. Of these, 48 underwent conventional colocystoplasty and 20 seromuscular colocystoplasty lined with urothelium (SCLU). Seventy-nine percent required additional procedures to achieve continence or facilitate catheterization, which included bladder neck procedures in 56% or continent stomas alone in 23%. RESULTS: There were no deaths or complications of bowel anastomosis. Overall, continence was achieved in 95%. Spontaneous bladder perforation was highest in patients with neurogenic bladder. Calculi developed more frequently in patients with continent stomas (P = 0.04) and in patients with bladder/cloacal exstrophy (32%) than in patients with neurogenic bladder (P = 0.01). Additional procedures and route of catheterization did not increase the risk of perforation. One patient with SCLU with known hypercalciuria developed bladder calculi. CONCLUSIONS: Sigmoid colon showed a trend of a lower rate of SBO with no difference in perforation or stone formation compared with ileum. Primary diagnoses of bladder or cloacal exstrophy and continent stomas are risk factors for the development of calculi. SCLU has a low rate of surgical complications and no incidence of perforation or SBO thus far; therefore, we advocate the use of SCLU when feasible, and sigmoid as the preferred bowel segment for augmentation cystoplasty.

Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence.

PURPOSE: There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique. MATERIALS AND METHODS: A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate. RESULTS: Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional voiding and avoidance of bladder augmentation. Revision rates of various procedures were similar but the incidence of complications was highest with the Kropp procedure. Long-term published data were limited in regard to bladder neck sling, reconstruction, injection, suspension and urethral lengthening techniques. CONCLUSIONS: Long-term published data support artificial urinary sphincter creation as first line surgical management of neurogenic sphincteric incontinence. Girls who already depend on intermittent catheterization may benefit equally from a sling procedure if successful long-term continence is demonstrated in future studies.

Effects of an environmental endocrine disruptor on fetal development, estrogen receptor(alpha) and epidermal growth factor receptor expression in the porcine male genital tract.

PURPOSE: We studied the effect of a potent reproductive tract toxin, 2,3,7,8-tetrachlorodibenzo-rho-dioxin, on fetal development and expression of estrogen receptor alpha and epidermal growth factor receptor (EGFR) in male swine. MATERIALS AND METHODS: Fetal domestic swine and miniswine were injected with 1 microg./kg. dioxin on day 50 of gestation and removed near term (114 days). Germ cell counts were performed on sections of formalin fixed testes. Estrogen receptor a protein, and messenger ribonucleic acid (mRNA) and EGFR mRNA expression were analyzed in frozen tissue using Western blotting and semiquantitative reverse transcriptase polymerase chain reaction. RESULTS: Of 15 dioxin exposed male offspring 8 (53%) had genital anomalies, including cryptorchidism in 4, epididymal detachment in 1, epididymal atresia in 1 and vasal dilatation in 3, while 3 of 17 control male swine (18%) had incompletely descended testes (p = 0.06). High intra-abdominal testes were found in 3 of 4 cryptorchid dioxin exposed but no control male swine. Mean germ cell number per tubule was 4.0+/-1.1 and 2.7+/-0.7 in control and dioxin groups, respectively (p = 0.01). Estrogen receptor a protein and mRNA were identified in fetal uterus, testis, gubernaculum and epididymis. Protein levels were 2 to 3-fold higher in dioxin exposed testis, and mRNA levels were significantly lower in gubernaculum and epididymis. EGFR mRNA expression was similar in treated and control testis and epididymis. CONCLUSIONS: Preliminary data suggest that dioxin produces cryptorchidism and wolffian duct anomalies in male swine exposed just before mid gestation. Germ cell counts and estrogen receptor alpha mRNA expression in gubernaculum and epididymis were significantly reduced, and estrogen receptor a protein expression in testis appeared to be increased by dioxin exposure. Aberrant regulation of estrogen receptor a expression by dioxin may contribute to reproductive tract anomalies in male fetuses.

Long-term outcome based on the initial surgical approach to ureterocele.

PURPOSE: The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele. MATERIALS AND METHODS: We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery. RESULTS: Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months). CONCLUSIONS: Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.

Quantitative nuclear cystography does not predict outcome in patients with primary vesicoureteral reflux.

PURPOSE: Quantitative nuclear cystography has been advocated as a tool for determining the prognosis in children with primary vesicoureteral reflux. We reviewed our data on this technique to assess its usefulness for predicting the outcome in this population. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients with primary reflux in whom findings were positive on at least 2 nuclear cystograms at our institution between 1992 and 1997. Patients followed at least 3 years were stratified according to outcome. Unfavorable prognostic criteria included bladder volume at reflux onset 60% or less of total bladder capacity and calculated volume of reflux 2% or greater of bladder capacity. RESULTS: Of the 107 patients in our study 63 were followed for 3 years or longer, and reflux resolved in 17, was repaired in 24 and persisted in 22. Mean patient age at latest followup, duration of followup and number of cystograms did not significantly differ among groups. Intermittent reflux in 33% of the patients followed 3 years or longer was not associated with outcome or detrusor instability. Bladder and reflux volume varied and was nonpredictive in individuals. CONCLUSIONS: Quantitative nuclear cystography did not predict the outcome in patients followed for primary vesicoureteral reflux at a single institution for 3 years or longer. Intermittent reflux was common. These data suggest that nuclear cystography cannot be used to assess reliably the prognosis in individuals. Strong consideration should be given to using negative findings on 2 cystograms to confirm reflux resolution in patients at high risk.

Ureteral reimplantation in infancy: evaluation of long-term voiding function.

PURPOSE: The advisability of early ureteral reimplantation in neonates and infants is controversial and to our knowledge long-term results are not available. We evaluated long-term voiding function after ureteral reimplantation in infancy. MATERIALS AND METHODS: Between 1984 and 1993, 32 children underwent ureteral reimplantation in year 1 of life at our institution. Long-term results were evaluated in regard to surgical outcome, voiding function, urinary tract infection and the need for prophylaxis. Analysis of voiding function included family interviews, uroflowmetry and post-void residual urine measurement. RESULTS: Complete long-term data were available in 14 girls and 7 boys. The diagnosis was primary bilateral and unilateral vesicoureteral reflux, and ureterovesical junction obstruction in 11, 4 and 6 cases, respectively. Of the 26 refluxing renal units overall disease was grade II in 3, III in 6 and IV to V in 17. Patient age at surgery was 0.6 to 12 months (mean 5.4) and followup was 5 to 13 years (mean 9.5). Tapered reimplantation was performed in 8 renal units using excisional or infolding in 5 and 3, respectively. There were no complications in 19 patients (94%), while 2 had postoperative reflux for which 1 underwent reoperation. In 13 patients voiding habits were normal, while 8 reported infrequent voiding (3 or fewer voids daily). In 19 of the 20 patients tested voided volume was appropriate, and the flow rate of 10.8 to 52.7 cc per second (mean 20.9) and post-void residual urine volume of 0 to 40 cc (mean 11) were considered normal. One patient with normal uroflowmetry had incomplete vesical emptying. CONCLUSIONS: Early reimplantation may result in a high technical success rate and low postoperative morbidity in infants. After long-term followup infrequent voiding was common but noninvasive assessment of bladder function revealed no significant abnormality in the majority of patients.

Lack of morbidity from urodynamic studies in children with asymptomatic bacteriuria.

OBJECTIVES: Patients on clean intermittent catheterization (CIC) have a high rate of asymptomatic bacteriuria. Although prophylactic antibiotics for routine surgical procedures in patients with bacteriuria is common practice, the role of prophylaxis for invasive diagnostic procedures remains unclear. The aim of this study was to investigate the morbidity associated with urodynamic evaluation in patients with asymptomatic bacteriuria. METHODS: Routine urodynamic evaluation was performed in 69 pediatric patients (mean age 10 years). Ninety-six percent had a neurogenic bladder, and most were on CIC. Routine urine cultures were obtained at the time of the cystometrogram. Forty-six patients had positive urine cultures, and 23 patients with sterile urine served as a comparison. Patients were evaluated subjectively for symptoms of a urinary tract infection (UTI) within 1 week of the procedure. The results of the cystometrograms were compared between the patients with and without bacteriuria. RESULTS: No patient developed symptomatic UTI after the urodynamic studies. Overall, 65% of the patients with and 52% of the patients without bacteriuria had adequate capacity and compliance, and there was no difference in the urodynamic findings between the patients with and without bacteriuria (P = 0.4). CONCLUSIONS: Urodynamic studies were performed safely in the presence of asymptomatic bacteriuria in the present study. Therefore, routine use of urine cultures or prophylactic antibiotics before urodynamic studies in pediatric patients with a neurogenic bladder does not appear to be indicated.

Antegrade pyelography before pyeloplasty via dorsal lumbar incision.

PURPOSE: The need for contrast imaging of the ureter before routine pediatric pyeloplasty is controversial. We evaluated the use of antegrade pyelography for upper tract imaging before pyeloplasty via dorsal lumbar incision. MATERIALS AND METHODS: The records of all patients who underwent pyeloplasty from April 1994 through April 1998 at our institution were reviewed. The findings and outcome of patients with presumed ureteropelvic junction obstruction in whom antegrade pyelography was performed under the same anesthetic were assessed, and those in whom this procedure changed the planned operative approach were identified. RESULTS: Antegrade pyelography was performed without complication in 72 patients before planned pyeloplasty and 2 attempts were unsuccessful. In 10 cases (14%) plans for dorsal lumbar incision were abandoned based on findings of renal malrotation in 3, ureteral stricture in 2, ureterovesical junction obstruction in 2, unusually low or high position of the ureteropelvic junction in 1 each, and concurrent ureteropelvic and ureterovesical junction obstruction in 1. The study was misinterpreted in 1 case of renal malrotation and 1 case of horseshoe kidney, and the dorsal approach was used. In 1 of these cases conversion to an anterior approach was required. A nonobstructing ureterovesical junction was seen in 2 other patients who had ureteropelvic junction obstruction with mild ureteral dilatation on ultrasound. CONCLUSIONS: The dorsal lumbar incision may provide inadequate exposure in certain patients with upper tract obstruction. Antegrade pyelography is a simple, safe and useful technique to visualize the collecting system before planned pyeloplasty via dorsal lumbar incision, allowing the surgeon to choose a more suitable operative approach or procedure when warranted.

Functional, social and psychosexual adjustment after vaginal reconstruction.

PURPOSE: We assessed the long-term functional, social and psychosexual outcome in children who underwent vaginal reconstruction. MATERIALS AND METHODS: We interviewed and assessed the psychological development of 16 women 17 to 28 years old (mean age 22) who underwent vaginal reconstruction only or in combination with other urogenital reconstructive procedures at ages 11 months to 18 years (mean 8.8). Psychological measures included the Beck Depression Inventory, Draw-a-Person test and Linkowski acceptance of disability scale as well as a standard questionnaire evaluating the sexual adjustment, social adjustment and ability for self-support of these women. RESULTS: Mean Beck Depression Inventory was 8.5 with less than 9 defined as minimal depression. Mean acceptance of disability score was 83.9 (range 54 to 94), indicating that patients were well adjusted with respect to the disability. Functionally 10 women were satisfied with the appearance of the vagina, 4 were neutral and 2 were dissatisfied. A total of 12 patients had no doubts about their female identity but 2 had occasional, 1 had significant and 1 had chronic doubts. Of the 16 patients 12 have completed high school, 3 are still in high school and 1 has withdrawn from high school. Of the 12 women who have completed high school 9 are currently in college and 3 have completed college. Socially all 16 participants rated family relationships as good and 13 were at least satisfied with their social life. Of the 16 women 12 have had a sexual encounter, including 1 who did not achieve orgasm. Six women are involved in long-term relationships, of whom 1 is married. In regard to the future all patients believe that they will be independent and financially stable with a fulfilling career. CONCLUSIONS: While women who have undergone vaginal reconstruction may be at risk for avoiding interpersonal relationships and sexual intimacy, we did not note this finding in our series. The majority of these patients were well adjusted to their physical condition, and had a high level of education and a stable family life.

Orthotopic urethral substitution in female patients using the mitrofanoff principle.

PURPOSE: We present our experience with orthotopic urethral substitution in female patients using the Mitrofanoff principle. MATERIALS AND METHODS: We performed orthotopic urethral substitution using the Mitrofanoff principle in 18 female patients 1 to 29 years old (mean age 10). The conduit was constructed with appendix in 13 cases, tapered ileum in 4 and fallopian tube in 1. The etiology of incontinence included exstrophy in 8 patients, neurogenic bladder in 3, urogenital sinus in 3, and bilateral ectopic ureter, ectopic ureterocele, the prune-belly syndrome and post-cystectomy undiversion in 1 each. RESULTS: Mean followup was 29 months (range 9 to 72). A total of 16 patients achieved continence following a program of clean intermittent catheterization. There were 2 unsuccessful operations. In 1 case the appendix become ischemic and in 1 a vesicoperineal fistula developed. One patient catheterizes every 2 hours to avoid leakage. Catheterization was temporarily difficult in 5 patients, of whom 2 had an appendiceal and 3 had a tapered ileal conduit. Two patients with an ileal conduit have had chronic difficult catheterization. CONCLUSIONS: Orthotopic replacement of the urethra using the Mitrofanoff principle is suitable in highly select female patients who need continent diversion or a catheterizable conduit but who will not accept an abdominal stoma. It is particularly suited to patients in whom exstrophy reconstruction has failed.

Results of the rectus fascial sling and wrap procedures for the treatment of neurogenic sphincteric incontinence.

PURPOSE: We assessed the early results of the rectus fascial sling and modified rectus fascial wrap for treating neurogenic sphincteric incontinence in a pediatric population. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent a rectus fascial sling or wrap procedure for neurogenic incontinence at our institution. Most recent status was confirmed by telephone interview as successful-complete day and night dryness, partially successful-occasional daytime wetting and/or nocturnal enuresis and failed-frequent daytime incontinence. Results were analyzed with regard to patient sex, associated bladder augmentation and previous or subsequent anti-incontinence surgery. RESULTS: A total of 27 patients underwent 10 sling and 18 wrap procedures. Five patients in each group were dry after 1 to 4.5 years of followup. Six of the 7 boys were wet and 1 was partially dry postoperatively, while 10 of the 20 girls became dry (p = 0.026 Fisher's exact test), resulting in an overall 36% success rate. In failed cases continence was achieved after periurethral collagen injection and artificial urinary sphincter placement in 0 of 5 and 5 of 6, respectively. CONCLUSIONS: Total continence was achieved even after a brief followup in a minority of patients in whom rectus fascia was used to correct neurogenic incontinence. However, our early data suggest that cases in which these procedures fail may be salvaged by artificial urinary sphincter implantation but not by periurethral collagen injection.