Female Pelvic Medicine & Reconstructive Surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 2: management of urinary incontinence in a neurogenic patient.

Discussion and management of incontinence in a patient with spina bifida by four international experts followed by a literature review.

The vagaries of proper imaging in diagnosing single-system ectopic ureter in children with continuous incontinence and outcomes of simple nephrectomy.

PURPOSE: To investigate the proper diagnostic modalities and failure cases of treatment in patients with single-system ectopic ureter (SSEU) who underwent nephrectomy for incontinence. METHODS: SSEU combined with dysplastic kidney is a rare cause of female incontinence. We retrospectively analyzed 45 pediatric SSEU patients that underwent simple nephrectomy at our institution during 1996-2013 for incontinence. We reviewed imaging studies to detect dysplastic kidney and ectopic ureter insertion, postoperative results, and urodynamic findings for remaining incontinence after nephrectomy. RESULTS: Median operative age was 59.3months. Both ultrasonography and magnetic resonance imaging (MRI) showed 50.0% dysplastic kidney detection rates respectively. Dimercaptosuccinic acid (DMSA) scanning and computerized tomography (CT) showed equal detection rates of 95.5%. Ectopic ureter insertion sites were determined by ultrasonography, CT, and MRI in 17.5%, 13.6%, and 33.3% of patients, respectively. Renal vascular structures were identified in 3/22 patients (13.6%) with CT. Post-nephrectomy, incontinence disappeared in 41 patients (91.1%), but remained in 4 patients (8.9%); urodynamics suggested bladder neck incompetence in these patients. CONCLUSIONS: DMSA is a highly sensitive diagnostic modality for detecting dysplastic kidney in SSEU patients with more than 95% detection rates. Once detected by DMSA, additional CT or MRI studies do not provide further information about ectopic ureter insertion or renal vascular structure. Although nephrectomy is successful in nearly 90% of SSEU patients with dysplastic kidneys, postoperative incontinence occasionally remains and requires additional treatment.

Evaluation of transcutaneous electrical posterior tibial nerve stimulation for the treatment of fecal and urinary leaks in children: preliminary results.

OBJECTIVE: To examine the effectiveness of posterior tibial nerve stimulation (PTNS) for the treatment of fecal and urinary incontinence in children with malformations of the bowel or neurological pathologies. INTRODUCTION: Treatment of fecal and urinary leaks, in cases of congenital malformations remains a challenge. Recent studies in adults have shown the effectiveness of PTNS. METHOD: Eight children: 4 with anorectal malformations, 3 with neurological causes (1 medullary lipoma, 1 Arnold Chiari malformation, 1 sacrococcygeal teratoma) and 1 with Hirschsprung's disease presenting with serious anal incontinence, despite extensive bowel management during at least 2 years, were treated with PTNS. Six children had associated urinary leaks. Jorge-Wexner score for defecation and Schurch score for urine were used before treatment and after the second and sixth months of stimulation. RESULTS: After six months, five patients had no more fecal leakage, two patients were improved and one did not respond. Five out of the 6 patients with urinary leaks were continent at 6 months. CONCLUSION: PTNS is a noninvasive technique and painless modality which seems to be effective for the treatment of fecal and urinary leaks in children even with congenital digestive pathologies or neurological malformations. These results will be confirmed in a prospective study.

The Manchester-Fothergill and the Elevate Posterior technique for the correction of a cervical elongation and large enterocele in a patient with bladder exstrophy and multiple surgeries.

INTRODUCTION AND HYPOTHESIS: A 60-year-old woman presented with congenital bladder exstrophy, urinary incontinence since birth, and pelvic organ prolapse since the menopause at the age of 46 years. METHODS: The patient (gravida 2, para 2 by cesarean sections and tubal ligation) described an extensive past surgical history that included epispadias and neourethral procedures, anti-reflux surgery using the Lich-Grégoir technique, bilateral ureterosigmoidostomy achieving continence, uterine fixation after the Doléris operation, and neovaginal reconstruction. The physical examination revealed a fourth-degree enterocele with cervical elongation (POP-Q: Aa-2, Ba-2, C + 3, D + 4, gh:5, pb:2.5, Tvl:6, Ap + 3, Bp +6). Gynecological ultrasound and uro-CT were performed to ensure that the ureterosigmoidostomy had been successful, and CT-based 3D bone reconstructions were obtained to calculate the distance between the pubic rami and the ischial spines. Based on a literature review of the management options for these patients and the specific characteristics of our patient, a decision was made to perform trachelectomy (the Manchester technique with Fothergill stitches) and a polypropylene mesh placement with sacrospinous ligament anchor (Elevate Posterior® PC, AMS). RESULTS: Six months after the surgery, we observed good anatomical and functional results with significant improvement in the patient's quality-of-life scale score. CONCLUSION: We believed that the vaginal approach was minimally invasive with a low risk of morbidity in our patient, who had a very altered anatomy, but produced a satisfactory functional result.

International Children's Continence Society's recommendations for initial diagnostic evaluation and follow-up in congenital neuropathic bladder and bowel dysfunction in children.

PURPOSE: The objective of this ICCS standardization document is to report the initial diagnostic evaluation and subsequent work-up of children with neuropathic bladder dysfunction. MATERIALS AND METHODS: Due to a paucity of level I or level II, "levels of evidence" publications, these recommendations are actually a compilation of best practices because they seem to be effective and reliable, although not with any control. RESULTS: Throughout the document, the emphasis is on promoting early, comprehensive evaluation of lower urinary tract function that is thorough but with a minimum of unnecessary testing. This includes what tests to order, when to order them and what to do with the results. Some of the recommendations may not be practical in various worldwide locations but the suggested testing should be considered the ideal approach to completely diagnosing and then promulgating treatments based on the full knowledge of the condition and its effect on urinary tract function. Once the findings are delineated, those lower urinary tract patterns of dysfunction that put the kidneys at risk for deterioration, that are barriers to attaining eventual continence, and that have long-term consequence to the lower urinary track can be obviated by specific management recommendations. The indications and timing of investigations to achieve these objectives are clearly defined in each diagnostic category and during follow-up. RECOMMENDATIONS: This document should be used as a basis for appropriate evaluation and timely surveillance of the various neuro-urologic conditions that affect children.

International Children's Continence Society's recommendations for therapeutic intervention in congenital neuropathic bladder and bowel dysfunction in children.

PURPOSE: We present a consensus view of members of the International Children's Continence Society on the therapeutic intervention in congenital neuropatic bladder and bowel dysfunction in children. MATERIAL AND METHODS: Discussions were held by a group of pediatric urologists and gastroenterologists appointed by the board. The following draft review document was open to all the ICCS members via the ICCS web site. Feedback was considered by the core authors and by agreement, amendments were made as necessary. The final document is not a systematic literature review. It includes relevant research when available as well as expert opinion on the current understanding of therapeutic intervention in congenital neuropatic bladder and bowel dysfunction in children. RESULTS: Guidelines on pharmalogical and surgical intervention are presented. First the multiple modalities for intervention that do not involve surgical reconstruction are summarized concerning pharmacological agents, medical devices, and neuromodulation. The non-surgical intervention is promoted before undertaking major surgery. Indicators for non-surgical treatments depend on issues related to intravesical pressure, upper urinary tract status, prevalence of urinary tract infections, and the degree of incontinence. The optimal age for treatment of incontinence is also addressed. This is followed by a survey of specific treatments such as anticholinergics, botulinum-A toxin, antibiotics, and catheters. Neuromodulation of the bladder via intravesical electrical stimulation, sacral nerve stimulation, transcutaneous stimulation, and biofeedback is scrutinized. Then follows surgical intervention, which should be tailored to each individual, based on careful consideration of urodynamic findings, medical history, age, and presence of other disability. Treatments mentioned are: urethral dilation, vesicostomy, bladder, augmentation, fascial sling, artificial urinary sphincters, and bladder neck reconstruction and are summarized with regards to success rates and complications. Finally, the treatment on neuropathic bowel dysfunction with rectal suppositories irrigation and transrectal stimulation are scrutinized.

Boys with posterior urethral valves: outcome concerning renal function, bladder function and paternity at ages 31 to 44 years.

PURPOSE: The short-term prognosis for boys with posterior urethral valves (PUV) has improved in recent decades, but the long-term prognosis in terms of renal and bladder function and fertility is still a matter of great concern. This study is a followup of boys with PUV and dilated upper urinary tract treated in 1956 to 1970 at the Children's Hospital in Göteborg, Sweden. MATERIALS AND METHODS: The records of 54 boys treated for PUV were reviewed. Of 27 boys with PUV and upper urinary tract dilation, 5 boys (18%) died at an early age and 3 boys were lost to followup during adolescence, leaving 19 to be included in the followup. They all answered a questionnaire about renal and bladder function and paternity. RESULTS: Of the 19 men 32% were uremic, 21% had moderate renal failure and 47% had not been checked since adolescence. There were signs of bladder dysfunction in 40% and all these subjects had bladder symptoms suggesting detrusor weakness as the cause. All the men were continent. The ability to father children was dependent on whether or not the man was uremic. CONCLUSIONS: This long-term followup study emphasizes the importance of checking renal and bladder function throughout life in men born with PUV. Increasing attention to bladder dysfunction and its early treatment could probably improve the long-term prognosis.

Lower urinary tract reconstruction is safe and effective in children with end stage renal disease.

PURPOSE: Congenital urinary tract anomalies with bladder dysfunction pose a formidable management challenge in children with end stage renal disease (ESRD). We report a series of patients with ESRD who underwent lower urinary tract reconstruction to assess the results and surgical complications. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients with ESRD who underwent urinary reconstruction. The etiology for renal failure included posterior urethral valves, cloacal anomalies, VATER syndrome and reflux nephropathy. RESULTS: From 1989 to 2000, 20 patients were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 7.3 years. Pre-transplant augmentation cystoplasty was performed in 14 patients (70%) and continent reconstruction without bladder augmentation was performed in 6 patients. Subsequent renal transplant was performed in 19 patients (15 with a living related donor). Overall patient survival was 95%. There was 1 death in the immediate post-transplant period secondary to cerebral edema thought to be due to a precipitous decrease in blood urea nitrogen. The overall graft survival rate is 82%. No patients lost grafts due to infection or technical complications. All patients have stable upper tracts, and mean creatinine is 1.2 mg/dl. Three patients required major surgery due to complications of the reconstruction and 2 treated with gastrocystoplasty had severe hematuria while anuric before transplantation. All patients are continent of urine. CONCLUSIONS: Our long-term data confirm that severe bladder dysfunction can be managed safely and effectively with continent urinary reconstruction in children with ESRD.

Bladder neck cinch for pediatric neurogenic outlet deficiency.

PURPOSE: The fascial bladder neck sling achieves continence in 50% to 90% of children with neurogenic outlet deficiency. Most slings apply only partial pressure around the bladder neck. We evaluated the effectiveness of a rectus fascia bladder neck cinch which applies circumferential pressure around the bladder neck and elevation as a means of increasing outlet resistance. MATERIALS AND METHODS: Fifteen children with spina bifida underwent a fascial bladder neck cinch procedure at the time of augmentation cystoplasty. A 1 to 1.5 cm width of variable length rectus fascia was harvested and a vertical slit was made in 1 end. The fascia was "cinched" tightly around the bladder neck and secured to the symphysis or rectus fascia. RESULTS: The 14 girls and 1 boy ranged in age range from 4 to 17 years. All children had neurogenic intrinsic sphincter deficiency and a poorly compliant and/or small capacity bladder. Followup ranged from 10 to 36 months (followup in 12 greater than 1 year). Postoperatively, all children perform clean intermittent catheterization. At the last followup 8 girls and the boy (60%) were dry (no leak and no pads at 4 hours from the last catheterization and dry throughout the night). CONCLUSIONS: Rectus fascia used as a bladder neck cinch is effective but no better than other bladder neck slings for decreasing urinary incontinence. The bladder neck cinch appears to be an acceptable addition to the technique of fascial slings. However, we have subsequently changed our technique because these results did not meet our expectations.

Pelvic floor magnetic resonance imaging after neonatal single stage reconstruction in male patients with classic bladder exstrophy.

PURPOSE: We evaluate a magnetic resonance imaging (MRI) protocol used to study the pelvic floor anatomy in male patients following neonatal single stage complete bladder exstrophy and epispadias repair with osteotomies. MATERIALS AND METHODS: From 1996 to 2002, 9 males underwent surgical correction of bladder exstrophy and epispadias with osteotomies within 1 to 12 days of birth. Pelvic floor MRI was conducted comparing this group to 5 aged matched male patients with no pelvic anatomical abnormality who underwent MRI for other illness. We compared various measurement of pelvic musculature by unpaired Wilcoxon test. RESULTS: Median followup was 3 years (range 0.5 to 5.3). All surgical procedures succeeded in closure of abdominal wall and genitalia defects. MRI data showed that in the exstrophy group symphyseal distance was significantly wider than that in controls (median 3.8 vs 1.1 cm). In addition, the levator ani fibers diverted more laterally (42 vs 22 degrees), the pelvic floor in coronal view was more flat (103 vs 80 degrees) and the anus was more anteriorly displaced (2.8 vs 4.4 cm). We also documented shorter anterior corporeal bodies in the exstrophy group (1 vs 2 cm). No statistical difference between the 2 groups was found in the dimensions of the levator and obturator muscles, sagittal angle of the pelvic floor, and the dimensions and angle of the posterior corporal bodies. Two patients achieved some degree of continence around the age of 4 years. They had the shortest symphyseal distance and sharpest angle of levator ani fiber divergence, and the bladder neck was more deeply located in the pelvic. CONCLUSIONS: We applied novel MRI parameters to the pelvic floor anatomy providing a new quantifiable approach. Our protocol is feasible and reproducible, allowing for future comparison of the impact of different surgical modalities, and correlation between anatomical findings and continence.

Alpha blocker therapy for children with dysfunctional voiding and urinary retention.

PURPOSE: Alpha blocker therapy has been successfully used to decrease residual urine in children with complex neuropathic and nonneuropathic voiding dysfunction. We evaluated the safety and efficacy of using selective alpha blocker therapy for children with uncomplicated voiding dysfunction and underlying poor bladder emptying. MATERIALS AND METHODS: A total of 55 patients with a mean age of 7.9 years presented with symptoms of urinary incontinence, urgency and urinary tract infection. All patients had increased post-void residual (PVR) on bladder ultrasound, with a mean residual volume of 65 ml (22% of age expected capacity). All patients were treated with doxazosin, a selective alpha-1 adrenergic antagonist, at dosages of 0.5 mg to 2.0 mg daily. Of the patients 38 were treated at presentation with a regimen of anticholinergics, timed voiding and antibiotic prophylaxis before initiating alpha blocker therapy. Patients were reevaluated with post-void ultrasound of the bladder 6 weeks after initiating alpha blocker therapy. RESULTS: After starting doxazosin average PVR decreased to 8 ml (p <0.0001), representing an 88% reduction in residual urine (or reduction to only 2.7% of age expected bladder capacity). Medication was discontinued in 2 patients due to minor side effects. CONCLUSIONS: Selective alpha blocker therapy appears to be effective for improving bladder emptying in children with an overactive bladder, wetting, recurrent infection and increased PVR urine. This therapy may be used as either a replacement or in addition to biofeedback in patients with urinary retention. Further investigation, including a prospective randomized trial of alpha blocker therapy in children with urinary tract dysfunction, is warranted based on the findings of our study.

The effect of endoscopic injections of dextranomer based implants on continence and bladder capacity: a prospective study of 31 patients.

PURPOSE: A prospective study was conducted to assess the efficacy of dextranomer based implants as a new bulking agent for endoscopic treatment of pediatric structural incontinence. MATERIALS AND METHODS: A total of 33 children and adolescents 5 to 18 years old with severe incontinence due to sphincteric incompetence (exstrophy-epispadias in 13, neuropathic bladder in 16, bilateral ectopic ureters in 4) were enrolled in the study. All but 1 patient wore diapers. Preoperative evaluation consisted of medical history, pad test, urine culture, urinary tract ultrasound and videourodynamics. This evaluation was repeated 6 months and 1 year after treatment and then on a yearly basis. Of the patients 14 had 2 and 1 had 3 treatment sessions to achieve a definitive result. At each evaluation the patient was considered cured-dryness interval of 4 hours confirmed by pad test, significantly improved-minimal incontinence requiring no more than 1 pad a day with less than 10 gm. leakage during pad test; and no further treatment required, and treatment failure-no significant improvement. Videourodynamics were mainly useful to study the evolution of the bladder capacity, activity and compliance. Followup after the last injection ranged from 6 to 36 months (mean 18). RESULTS: The mean injected volume was 3.9 ml. (range 1.6 to 12) and the procedure lasted a mean of 30 minutes (10 to 60). In the postoperative period 2 patients had temporary dysuria and 10 had a nonfebrile urinary tract infection. At 1 month 24 of the 33 patients (73%) were dry or improved. Two patients were subsequently excluded from study for noncompliance with followup. At 6 months 17 of 31 patients (55%), at 1 year 13 of 28 (46%), at 2 years 10 of 23 (43%) and at 3 years 10 of 20 (50%) were dry or improved. Similar success occurred in cases of neuropathic bladder (57%) and exstrophy-epispadias complex (46%). Success rate of re-treated patients was 35%. Of 13 patients with a normal initial bladder capacity 3 had a bladder decompensation requiring augmentation after 6 months. Also an increase of at least 50% in capacity was observed in 12 of 18 patients with an initial small bladder. No side effect related to the substance was observed. CONCLUSIONS: Endoscopic treatment of pediatric structural urinary incontinence with dextranomer implant, a nontoxic, nonimmunogenic, nonmigrant synthétic substance, was effective after 3 years in half of our patients. It may also be beneficial for patients with small bladder functional capacity. As the success rate decreased during the first year of followup, the result observed at 1 year seems to remain stable subsequently.

Endoscopic treatment of urinary incontinence in pediatric patients: 2-year experience with dextranomer/hyaluronic acid copolymer.

PURPOSE: We investigated the effectiveness of dextranomer/hyaluronic acid copolymer (dextranomer microspheres in sodium hyaluronan solution) as a treatment for urinary incontinence due to sphincter incompetence in children and adolescents. MATERIALS AND METHODS: Patients with urinary incontinence due to neurogenic and structural causes were given a transurethral injection of dextranomer/hyaluronic acid copolymer to increase bladder outlet resistance. Patients were assessed at 1, 3, 6, 12 and 24 months after injection using a validated questionnaire, 1-hour pad test, ultrasonography, cystography and cystometry. Patients who remained incontinent were offered repeat injections of dextranomer/hyaluronic acid copolymer up to a maximum of 3 injections. RESULTS: A total of 16 patients 8 to 22 years old were treated with dextranomer/hyaluronic acid copolymer, including 3 with neurogenic bladder, 8 with bladder exstrophy after 3-stage reconstruction, 4 with penopubic epispadias and 1 with urogenital sinus. Mean volume injected was 2.8 ml. (range 1.8 to 4.0) and mean number of injections received was 2.3 per patient. Dry time interval increased by 43 minutes (p <0.05) and functional bladder capacity increased by 34 ml. (p <0.05) at 6 months after treatment compared with pretreatment values. Improvement in both parameters was maintained at 12 months. At 6 and 12 months of followup 12 (75%) and 8 (50%) patients reported improvements in daytime and nighttime dryness, respectively. A slight decrease in continence parameters was observed in the 13 patients who completed the 24-month followup. No adverse events were reported and no upper urinary tract deterioration was observed as a consequence of endoscopic treatment within the 2-year followup period. CONCLUSIONS: Use of dextranomer/hyaluronic acid copolymer as a bulking agent to increase bladder outlet resistance improves symptoms in children and adolescents with incontinence of neurogenic and nonneurogenic origin.

The use of small intestinal submucosa as an off-the-shelf urethral sling material for pediatric urinary incontinence.

PURPOSE: Use of autologous rectus fascia for urethral slings in the pediatric population has produced reliable and predictable results. However, the potential morbidity and complications associated with harvesting the autologous rectus fascia have driven efforts to find a reliable off-the-shelf material for urethral slings. Small intestinal submucosa is a collagen based material that has been shown to promote tissue specific regeneration in a variety of organs. We report the clinical experience at 4 institutions with small intestinal submucosa for urethral slings. MATERIALS AND METHODS: A total of 20 patients 3 to 18 years old (mean age 8.7) received urethral slings using the commercially available form of small intestinal submucosa (STRATASIS, Cook Urologic Spencer, Indiana) via a sling suspension procedure from a suprapubic approach. RESULTS: The material was consistently uniform to work with and user-friendly. All 20 patients tolerated the procedure well with no intraoperative complications. Postoperative followup has ranged from 9 to 26 months (mean 13), and 14 (70%) patients are completely dry (85% in females and 43% in males). Of the 14 dry patients 13 are on intermittent catheterization and 1 female with epispadias voids spontaneously. CONCLUSIONS: This report is the largest and longest followup series using small intestinal submucosa as an "off the shelf" urethral sling material in children. These continence rates are equal to autologous fascia without additional morbidity of graft harvest.

Is bladder dysfunction and incontinence associated with ureteroceles congenital or acquired?

PURPOSE: Bladder dysfunction (a disorder often characterized by incontinence, urgency, patterns of dysfunctional voiding, incomplete emptying and so forth) in association with ureteroceles has been attributed to surgical intervention. A previous study suggested that patients with ectopic ureteroceles may have bladder dysfunction as part of this disorder regardless of the type of surgical intervention. We reviewed all types of ureteroceles (ectopic versus intravesical, simple versus duplex) to characterize the patterns of bladder dysfunction and its association with prior surgical treatments. MATERIALS AND METHODS: A retrospective review of medical records was performed as part of a multi-institutional study. From 1986 to 2000, 616 patients were identified with ureteroceles. Bladder dysfunction was determined by detailed history (that is, voiding diary) plus urodynamic evaluation when deemed appropriate. RESULTS: Based on initial history, 39 of 616 (6.3%) patients had some form of bladder dysfunction and 34 of the 39 underwent urodynamics. All patients had ectopic ureteroceles of duplex systems. The most common symptoms of bladder dysfunction were urinary urgency and incontinence. Infrequent voiding, less than 4 voids daily, occurred in 13% (5 of 39) of the patients. Of the 33 incontinent patients 7% (2) had undergone endoscopic surgery, 12% (4) open lower tract surgery, 45% (15) a combination of upper and lower tract surgery and 36% (12) open upper tract surgery alone. Bilateral ureteroceles did not seem to increase the risk of bladder dysfunction. The majority (35 of 39) of patients with bladder dysfunction responded to behavioral modifications and medical therapy. CONCLUSIONS: Bladder dysfunction associated with ureteroceles occurs in approximately 6% of patients regardless of surgical therapy. The fact that patients treated with upper tract surgery alone have similar rates of incontinence suggests that bladder dysfunction is congenital as opposed to surgically acquired.

Modified Young-Dees-Leadbetter bladder neck reconstruction: new concepts about old ideas.

INTRODUCTION: The modern Young-Dees-Leadbetter bladder neck reconstruction is a procedure that has evolved during the past 82 years. During this time, the modifications and contributions of several urologic surgeons have improved the procedure and ultimate patient outcomes. We review the evolution and describe in detail our version of the Young-Dees-Leadbetter bladder neck reconstruction procedure. TECHNICAL CONSIDERATIONS: Optimally, patients should have a minimal bladder capacity of 85 mL and be mature enough to participate in a postoperative voiding program. Adequate radical exposure of the lateral aspects of the bladder and bladder neck are important. Cephalotrigonal or cross-trigonal ureteral reimplantation is typically performed to mobilize the ureters in relation to the proposed bladder neck and correct reflux. A mucosal template 15 mm wide by 30 mm long is created that will serve as the reconstituted posterior urethra and bladder neck. Triangular lateral bladder mucosal wedges are marked and demucosalized. The neourethra is closed over an 8F Firlit tube. The demucosalized flaps are brought over the urethra sequentially in a "vest-over-pants" fashion with the final layer consisting of suspension sutures. Finally, ureteral stents and a suprapubic tube are used, but no urethral catheter is left in place. CONCLUSIONS: The modern Young-Dees-Leadbetter bladder neck reconstruction is the result of the contributions of various urologic surgeons during 82 years. When patients are appropriately selected, it is an effective method of lower urinary tract reconstruction in cases of congenital urinary incontinence.

Kock urinary reservoir maturation in children and adolescents: consequences for kidney and upper urinary tract.

OBJECTIVE: To study Kock reservoir maturation in children and adolescents and its effects on the kidneys and upper urinary tract. METHODS: Ten boys and 10 girls, aged 10.8-18 years, had Kock reservoir surgery for congenital urinary incontinence. They were followed for 3-10 years, divided into 3 different periods, and assessed with urography and enterocystography, the findings of which were correlated to renal function as measured by (51)Cr EDTA clearance, reservoir endoscopy and patient's history. RESULTS: The reservoir was located in the pelvis and remained in this position throughout the whole follow-up in 75% of patients and in the lower or midabdomen in 25%. Angled efferent nipple seen on enterocystoscopy or enterocystography coincided with nipple dysfunction, reservoir malposition or infrequent reservoir emptying. Upper urinary tract dilatation was detected in 84% of patients 3 months after surgery, 25% at 1 year and 30% at 2-10 years. The dilatation was improved in 56% of patients and unchanged in 25% after 1 year. The situation continued to improve at late follow-up. New focal renal scars were radiologically detected in 1 of 19 at early and in another 1 of 17 patients at late follow-up. Progression of old scars was detected in 1 of 19 at early and in 4 of 17 at late follow-up. Eight of 19 cases had deterioration of renal function with a change in the split renal function. Of these 8 patients, 7 reported infrequent reservoir evacuation. CONCLUSIONS: Kock reservoir is a useful form of urinary diversion in children and adolescents with congenital urinary incontinence. Radiological examinations are good methods of follow-up of the maturation of the pouch and its effects on the urinary tract and for detection of complications. Urinary tract dilatation is a frequent finding early after surgery but it subsides in most cases 3-12 months after surgery. Long-term efferent nipple dysfunction may be the result of angulation, reservoir stones, malposition and/or overdistension. Permanent renal damage may be due to pyelonephritis, stones, infrequent reservoir emptying or urinary obstruction. A strict regime of reservoir evacuation to avoid overdistension and nipple dysfunction and to decrease the possibility of renal function deterioration is strongly advisable in these patients. It is imperative that their own management of the reservoir is continuously supervised.

Evaluation of Kock urinary reservoir function in children and adolescents at 3-10 years' follow-up.

The aim of this study was to evaluate Kock reservoir function in children and adolescents operated for congenital urinary incontinence and to determine the complication rate. Reservoir function was investigated in 13 children (age range 10.8-16 years) and 7 adolescents (age range 16-18 years) through enterocystometry, enterocystoscopy and patient history. Patients were followed up for 3-10 years. The follow-up was reported as early (3 months-2 years) and late (2-10 years) postoperative periods. At early follow-up reservoir capacity was high in four patients and normal in the remaining patients. A low reservoir pressure was accompanied by high capacity and compliance. On enterocystometry first sensation for emptying was experienced in 82% of patients at early follow-up and 92% at late follow-up. Reservoir contractions were recorded in 60% of patients at early follow-up and 65% at late follow-up. The contractions were recorded at an average reservoir capacity of 270 ml at early follow-up and 340 ml at late follow-up. The complication rate was high in the child group compared with that in adolescents. Of 13 patients with at least one reservoir complication 10 were from the child group. Nipple dysfunction (angled nipple, prolapsed or stenosed stoma) occurred in 35% of patients, stones in 40% and bleeding during catheterization in 15%. Revision was performed in 38% of the child group and 15% of the adolescents. Reservoir perforation was observed in two patients at 6 and 9 years postoperatively. At late follow-up continence was excellent in 17 of 19 patients and good in 2. We conclude that the Kock reservoir is a good modality for urinary diversion, but the complication incidence is high in the child group (<16 years). Stability of the reservoir in terms of volume and low internal pressures was achieved one year after operation, except in the patients with infrequent reservoir emptying. A time-related increase in the reservoir sensitivity and contractility was reported on enterocystometry. Nipple dysfunction is common during the first two years after surgery, particularly in the child group. Stones may form 3-4 years after surgery. Satisfactory continence was achieved in all patients, although a revisional operation was necessary in some patients in order to obtain permanent continence.