Frimberger Dominic, Lakshmanan Yegappan, Gearhart John P
Brady Urological Institute, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
J Urol. 2003 Oct;170(4 Pt 1):1338-42. doi: 10.1097/01.ju.0000082012.14663.7e.
Urinary continence is one of the primary goals in the surgical treatment of the patient with exstrophy. Children with inadequate bladder capacity, noncompliant or neuropathic bladder, or failed bladder neck reconstruction may require creation of a continent urinary reservoir to achieve continence. While initial success rates are excellent, some patients suffer persistent urinary incontinence, severely affecting their quality of life. The reasons for such failure and subsequent management were evaluated.
A retrospective database review was performed in 748 patients with the exstrophy complex. Patients with a history of failed continent urinary diversion with incontinence from the stoma or urethra were identified. Initial diagnosis, number of previous operations, reason for and time interval after surgery when failure occurred, and management strategies were evaluated.
Of 92 patients undergoing continent diversion procedures 19 (21%) had failure initially (15 with classic and 4 with cloacal exstrophy). Four of the 19 patients underwent primary surgery at our institution and 15 were referred. The procedure initially performed was an intussuscepted nipple valve in 8 patients, an intussuscepted ileocecal valve in 1 and an ileal or sigmoid reservoir with appendiceal flap valve (Mitrofanoff) in 10. Main reasons for failure included de-intussusception and bladder neck incompetence. Mean followup after continence was achieved was 2.9 years (range 3 months to 10 years). These patients underwent up to 8 operations to achieve continence (mean 5). Most patients (79%) were successfully treated with either 1 (47%) or 2 revisions (32%), while 1 required 3 reoperations. Overall, 89 of 92 patients (97%) are currently continent, including those requiring medications and further surgical procedures, while 3 are still wet.
Most patients with exstrophy with failure of continent urinary diversion have a long complicated surgical history. In this series incontinence from an intussuscepted nipple stoma was mostly due to de-intussusception. In patients with an initial Mitrofanoff stoma all incontinence occurred within the first few months postoperatively. Continence was achieved by either recreation of a Mitrofanoff stoma or bladder neck transection. Patients with a failed continent urinary diversion benefit from careful preoperative evaluation, meticulous surgical execution and persistent attempts to achieve continence.
尿失禁是膀胱外翻患者外科治疗的主要目标之一。膀胱容量不足、膀胱顺应性差或神经性膀胱，或膀胱颈重建失败的儿童可能需要创建可控性尿流改道贮尿囊以实现控尿。虽然初始成功率很高，但一些患者仍存在持续性尿失禁，严重影响其生活质量。我们评估了这种失败的原因及后续处理方法。
对748例膀胱外翻综合征患者进行回顾性数据库分析。确定有可控性尿流改道失败且造口或尿道存在尿失禁病史的患者。评估初始诊断、既往手术次数、失败发生时手术的原因及时间间隔，以及处理策略。
在92例行可控性尿流改道手术的患者中，19例（21%）最初失败（经典型膀胱外翻15例，泄殖腔外翻4例）。19例患者中有4例在我们机构接受了初次手术，15例为转诊患者。最初施行的手术中，8例采用套叠乳头瓣，1例采用套叠回盲瓣，10例采用带阑尾瓣（米氏瓣）的回肠或乙状结肠贮尿囊。失败的主要原因包括套叠解除和膀胱颈功能不全。实现控尿后的平均随访时间为2.9年（范围3个月至10年）。这些患者为实现控尿接受了多达8次手术（平均5次）。大多数患者（79%）通过1次（47%）或2次修复手术（32%）成功治愈，1例需要3次再次手术。总体而言，92例患者中有89例（97%）目前已实现控尿，包括那些需要药物治疗和进一步手术的患者，3例仍有尿失禁。
大多数可控性尿流改道失败的膀胱外翻患者有复杂的长程手术史。在本系列中，套叠乳头造口尿失禁主要是由于套叠解除。初始米氏瓣造口的患者，所有尿失禁均发生在术后最初几个月内。通过重建米氏瓣造口或膀胱颈横断术实现了控尿。可控性尿流改道失败的患者受益于仔细的术前评估、细致的手术操作以及为实现控尿而持续的努力。
