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Published on: January 7, 2019
Efficacy and safety of continent anal urinary diversion for complicated bladder exstrophy in children by using
Mohamed A Baky Fahmy1, Alae A Al Shenawy2, Sameh M Shehata3
1Al Azher University, Department of Pediatric Surgery, Cairo, Egypt.
Insights
This study demonstrates a modified Duhamel rectal pouch procedure for bladder exstrophy patients, achieving urinary continence and improving quality of life. The technique shows promising short-term safety and efficacy, with no neoplastic changes observed.
Area of Science:
- Pediatric Urology
- Surgical Reconstruction
- Continence Management
Background:
- Urinary incontinence is a significant challenge for children with bladder exstrophy, impacting quality of life even after surgical reconstruction.
- Many patients retain normal anal sphincter function, enabling rectal-based neobladder construction for improved continence and body image.
Purpose of the Study:
- To evaluate the efficacy and safety of a modified Duhamel's rectal pouch procedure in pediatric patients with bladder exstrophy.
- To assess the potential for avoiding urine-feces mixing and to monitor for renal complications and rectal neoplastic changes.
Main Methods:
- A modified Duhamel's rectal pouch technique was performed on 19 children, incorporating a stapler for rectal bladder construction and non-refluxing ureterorectostomy.
- Patients were followed for up to 6 years, with regular assessments of renal function, electrolytes, and acid-base balance.
- Proctoscopy was conducted regularly to surveil for rectal neoplastic changes.
Main Results:
- The procedure resulted in no observed neoplastic changes, renal function deterioration, or major electrolyte disturbances.
- Patients achieved good urine-holding capacity (350-550 mL) and daytime continence, with infrequent voiding.
- Three patients experienced nocturnal enuresis, and four developed manageable pyelonephritis.
Conclusions:
- The continent rectal bladder created using the modified Duhamel pull-through technique is a feasible and successful short-term option for bladder exstrophy.
- The procedure offers improved quality of life regarding continence with low complication rates.
- Longer-term follow-up is necessary to confirm the absence of rectal neoplastic changes, and comparative studies with other procedures are recommended.
Background:
A high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence and a miserable life even after a well-performed staged reconstruction in specialized centers. Most of those children usually have a normal anal sphincter allowing construction of a neobladder from the rectum, so they are continent without an abdominal stoma, and do not require frequent catheterization, which greatly contribute to a favorable body image.
Objective:
In this study a modified Duhamel's rectal pouch done for 19 children, with implication of suitable stapler adopted to construct a rectal bladder with a non-refluxing urterorectostomy, there is a theoretical advantage in our procedure of avoiding a mix of urine and feces. All patients were followed for up to 6 years (2-8 years) for efficacy, safety, subsequent renal complications, and surveillance for any rectal neoplastic changes in this new diversion.
Study Design:
Assessment of electrolytes, acid base balance, and renal function were carried out regularly and all data were analyzed using the SPSS 9.0.1 statistical package and compared using a paired t test; data were considered significant if p < 0.05. Proctoscopy was performed 6 monthly in the first year then annually thereafter, and at any time if there was any rectal bleeding.
Results:
In this group of patients, follow-up revealed no neoplastic changes in the rectal bladder, deterioration in renal function, or major electrolytes disturbance. They can hold up to 400 mL (350-550 mL) of urine and all are continent during the daytime with an emptying frequency of 3-5 h; three patients had infrequent (4 episodes/month) nocturnal enuresis; and four cases developed pyelonephritis controlled with medical treatment.
Conclusion:
The continent rectal bladder created by using the principles of the Duhamel pull-through is feasible, easy to perform, successful in the immediate short term with low complications after 6 years of follow-up and appropriately accepted by the children and their families with marked improvement in quality of life regarding continence; longer-term follow-up is requested to rule out rectal neoplastic changes. A comparative review of the complications, patient's acceptance, and longer-term follow-up with other well-known procedures, such as Mainz II, is required.
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