INVESTIGATIVE UROLOGY

The Macedo-Malone antegrade continence enema procedure: early experience
Calado AA, Macedo A Jr, Barroso U Jr, Netto JM, Liguori R, Hachul M, Garrone G, Ortiz V, Srougi M
From the Department of Urology, Division of Pediatric Urology, Federal University of Sao Paulo, Sao Paulo, Brazil
J Urol. 2005; 173: 1340-4

• Purpose: The successful treatment of fecal incontinence can dramatically improve the quality of life of affected children. The introduction of the Malone antegrade continence enema provides the opportunity to manage previously resistant cases. However, using the appendix to create this catheterizable channel is not always possible, and the duration of these antegrade enemas is a source of concern for the patients. We describe a new approach to create left continent colonic access to shorten the duration of these enemas, and report the experience gained from the first 9 cases managed at our institution.
• Materials and Methods: During a 5-year period 9 patients underwent a Macedo-Malone antegrade continence enema at our institution. Incontinence was associated with myelomeningocele in 7 patients and anorectal malformation in 2. The antegrade continence enema procedure is begun by isolating a 2 cm flap in a tenia on the left colon (spleen flexure). A 12Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow tubularization of the plate with interrupted polyglycolic acid 3-zero transverse sutures, creating an efferent tubular conduit. Antegrade colonic washouts were started 2 weeks after surgery with saline solution or tap water in all patients.
• Results: Followup of our 9 cases ranged from 8 to 33 months (average 20.7). Enema volume varied from 250 to 800 ml, with administration taking from 45 to 60 minutes, and colonic evacuation occurred within 30 to 60 minutes of enema administration. Of the 9 patients 8 were completely continent and 1 was partially continent. Four patients experienced difficulty with catheterization initially because of stenosis of the stomal track. The affected stomas were dilated, which was successful in 1 case. Three patients subsequently required stomal revision.
• Conclusions: The Macedo-Malone procedure is a relatively straightforward operative approach providing an effective washout technique that is acceptable to parents and children.
  
  
• Editorial Comment
  After extensive investigation in animals, the authors transposed to clinical setting their experience with a new approach to create left continent colonic access to shorten the duration of antegrade enemas for children who have not only urinary incontinence, but also have problems of fecal elimination. Macedo & Srougi (1) described a continent catheterizable ileum based reservoir in which a catheterizable conduit could be created in continuity with the augmented segment. The Macedo-Malone procedure incorporates some of the same principles that have proved reliable in urinary diversion. The authors initially demonstrated that this procedure in the left colon might significantly decrease the time required for enema administration and washout, thereby increasing patient satisfaction and compliance. The authors have to be congratulated on this new technique to antegrade enemas, based on a solid previous basic investigation in animals.

Reference
1. Macedo A Jr, Srougi M: A continent catheterizable ileum-based reservoir. BJU Int. 2000; 85: 160-2.

Dr. Francisco J.B. Sampaio
Full-Professor and Chair, Urogenital Research Unit
State University of Rio de Janeiro
Rio de Janeiro, Brazil