Extravesical detrusor tunneling: a variant of antireflux procedure.

Detrusor tunneling procedure is an extravesical technique, which provides antireflux implantation of different tube systems (ureter, appendix, tubularized preputial flap, tapered ileum). The main characteristic of the technique is the formation of extravesical submucosal tunnel by creating a bridge from the unresected bladder muscle under which the tube is passed. During the period from January 1987 to July 1995, the technique was performed on 442 different tube systems: 402 ureters, 12 appendices, 26 tubularized preputial flaps and 2 tapered ileums. Patients were aged from 15 days to 42 years (mean 39 months). Follow-up was from 2 months to 8 years (mean 2.9 years). Postoperative complications occurred in 11 cases. There were 3 stenoses and 5 refluxes in ureteroneocystostomies, and one stenosis and 2 urine leakages in continent cutaneous vesicostomies. The extravesical detrusor tunneling procedure could be a very useful method for antireflux implantation of various tube systems.

[Surgical treatment of vesicoureteral reflux by tunnelling of the detrusor muscles]. / Hirursko lecenje vezikureterskog refluksa metodom tunelisanja misica detruzora.

Detrusor tunnelling is an extravesical surgical procedure of ureteral reimplantation. It is surely the least traumatic method of surgical correction of vesico-ureteral reflux because antireflux mechanism is achieved with minimal detrusor muscle dissection. This procedure simplifies implantation of dilated ureters, double ureters as well as the ureters shortened by previous antireflux surgical procedures. Ureteral tapering is unnecessary. One hundred and forty detrusor tunnelling uretero-cysto-neostomies in 102 patients have been performed in the University Children's Hospital between January 1990 and September 1994. The youngest patient was 1 month old and the eldest was 15 years (mean age 6.8 years). Indications for surgical treatment were primary (45.0%) and secondary (26.4%) megaureter as well as grade IV & V (international classification) vesico-ureteral reflux (28.6%). Follow up was 1-40 months (mean 26 months). Excellent postoperative results were achieved in 130 detrusor tunnelling uretero-cysto-neostomies, i.e. more than 90% of patients. Complication rate was 7.1% (6 patients-10 ureteral units) and about one third were classified as major-postoperative relapses or stenosis or minor-intraoperative mucosal perforation, hematuria, parahiatal diverticulum, spontaneous proximal migration of ureteral double J stent-about two thirds.

Epispadias surgery--Belgrade experience.

From 1987 to 1991, 46 patients underwent surgical treatment for epispadias. Of these, 14 had isolated epispadias and 22 had epispadias within the exstrophy/epispadias complex. The patients ranged in age from 6 months to 20 years. To correct the genital aspect of the anomaly the basic principles of Ransley's technique were used. In addition, the island flap technique was used for the most severe, so-called "cripple" form. In patients with exstrophy/epispadias complex, only elongation of the penis was performed during primary reconstruction, while the correction of epispadias, using the above techniques, was performed in the second-stage operation. Complications occurred in 6 patients.

[Surgery in recurrence of undescended testes]. / Hirurgija recidiva nesputenog testisa.

In the period from Jan. '80 to Dec. '87 at the Pediatric Surgical Clinic in Belgrade 119 patients were operated upon or 147 recurrencies of undescended testes; in 28 cases (23.52%) there were bilateral recurrences. 4 patients were twice unsuccessfully operated on at the same side. The authors analyse the causes of failures of orchiopexy; the proved mistakes were divided into four groups: a) Mistakes due to the undiscovering of the testis, b) unpreparation, or insufficiently preparated the testis from surrounding tissues, c) insufficiently shortening of the testis' way toward the scrotum, and d) mistakes being occasionally arised during the fixation of the testis into the scrotum. During the first unsuccessful operation 20 testes have atrophied, so that a reintervention consisted only in the exploration. In other cases the testis was placed into the scrotum regardless whether it was normal or hypotrophic. In two cases a Fowler-Stephens procedure was carried out, and in one case an autotransplantation of the testis was done. An improvement was found in 89 testes (60.57%), while 38 cases (25.85%) remained with the same characteristics, as they were in the course of our surgical interventions.

[Stenosis of the external urethral opening as one of the causes of recurrent urinary infections in girls--surgical treatment]. / Stenoza spoljasnjeg otvora uretre kao jedan od uzroka recidivantnih urinarnih infekcija u zenske dece--hirurska leenje.

105 middleaged girls (8.4 years) were operated upon at this Clinic because of distal meatal stenosis (DMS) as one of the causes of recurrent urinary infections and/or tenacious dysuria. Meatoplasty, one small surgical intervention, does treat about 78.1% infections of the urinary tract, as well as about 36.8% vesicoureteral reflux (VUR) of the I and II grade. The fibrous ring which is an anatomical alteration of DMS, is primarily obstructive lesion, which is appearing most frequently associated with urinary infection. In one quarter of cases in which a meatoplasty did not show a clinical improvement, one should think over the more radical surgery either at the urinary neck or at the vesico-ureteral junction. Spontaneous improvement or/and regression of VUR, in one third of cases following meatoplasty is an encouraging datum; but this intervention by itself is not a method for its treatment. A small number of complications, one stress incontinence only, demonstrate a reliability of this procedure in selected cases. Meatoplasty and dilatation of stenosed urethral meatus are alternative methods, which give similar results and their use mainly depends on the urologist's affinity to this method.