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PEDIATRIC
UROLOGY
doi: 10.1590/S1677-553820090006000030
Mitrofanoff
continent catheterizable conduits: top down or bottom up?
Berkowitz J, North AC, Tripp R, Gearhart JP, Lakshmanan Y
Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins
Medical Institutions, Baltimore, MD, USA
J Pediatr Urol. 2009; 5: 122-5
- Objective:
During augmentation and Mitrofanoff procedures, conduits are usually
implanted into the posterior bladder wall. Anatomical considerations
may necessitate an anterior conduit. To compare the relative drainage
efficiency in patients with posterior and anterior conduits, we studied
their rates of bladder stone formation and urinary tract infection (UTI).
Materials and Methods: A retrospective chart review identified exstrophy
patients who underwent augmentation and Mitrofanoff between 1991 and
2003. Patients with 3 years or greater follow-up were included. Fifty-four
patients fit this criterion, with a conduit implanted anteriorly (33)
or posteriorly (21). We compared rates of bladder stone formation and
UTI. Stomal revisions and the status of the bladder neck were also noted.
Results: Stone formation and UTI rates were higher in the anterior conduits,
although only UTI showed a statistically significant difference. Patient
demographics were similar between the two groups, including age and
sex. The rates of stomal complications and the bladder neck status were
also similar.
Conclusions: Patients with anterior conduits had an increased risk of
UTI and bladder stone formation compared to those with posterior conduits,
although this was not significant in the case of bladder stone rate.
This may indicate sub-optimal bladder drainage and should be addressed
with careful preoperative counseling and close follow-up.
- Editorial
Comment
A 12-year period from 1991-2003 was chosen and Mitrofanoff conduits
were reviewed. All patients had greater than 3 years of continuous follow
up. Fifty-four patients fit the criterion and 33 had the conduit anastomose
to the augmented bladder anteriorly and 21 had their Mitrofanoff conduit
placed posteriorly. Patients with cloacal exstrophy and spina bifida
were excluded from this data base because it was felt that they had
a higher risk of stone formation, which was one of the study criteria.
Stomas were placed at the umbilicus. Patients were told to irrigate
their augmented bladders daily with saline and had renal and bladder
ultrasounds every three months for the first year and every six months
thereafter.
Results showed that urinary tract infections were 36.3% in the anterior
placed stomas and 9.5% in the posterior group and that was statistically
significant. Bladder stones were also higher in the anterior placed
conduit group at 48.4%, but this did not reach statistical significance.
Stomal complications were not statistically different and most of these
were at the skin level. Stomal complications were common happening in
over 42% of the patients, with an average of over 3 years of waiting
for the stomal complications. The authors felt that the bladder was
drained more poorly with the anterior placement of the conduits increasing
the infection risk and the risk of stone disease. Many times placement
of the conduit was dictated by the disease of the patient and the type
of bowel utilized and prior scar tissue.
Augmentations in conduit placements are still fraught with complications.
They solve many problems and bring on new problems. This is quite a
high stone complication rate in these patients and stomal complications,
although they are becoming more commonly noted. It seems that placing
the catheterizable stoma in the most dependent portion in the augmented
bladder has the best advantage and should be considered by urologic
surgeons.
Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu
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