Fahmy Mohamed A Baky, Al Shenawy Alae A, Shehata Sameh M
Al Azher University, Department of Pediatric Surgery, Cairo, Egypt.
National Institute of Urology, Cairo, Egypt.
J Pediatr Urol. 2015 Oct;11(5):254.e1-6. doi: 10.1016/j.jpurol.2015.02.018. Epub 2015 Apr 24.
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.
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.
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.
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.
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.
即使在专业中心进行了良好的分期重建手术后，仍有很大比例的膀胱外翻患儿会持续遭受尿失禁之苦，生活悲惨。这些患儿中的大多数通常肛门括约肌正常，可利用直肠构建新膀胱，因此他们无需腹壁造口即可自主排尿，也无需频繁导尿，这极大地有助于塑造良好的身体形象。
在本研究中，为19名儿童实施了改良的杜哈梅尔直肠囊袋术，采用合适的吻合器构建直肠膀胱并进行抗反流输尿管直肠吻合术，我们的手术在理论上具有避免尿液和粪便混合的优势。对所有患者进行了长达6年（2 - 8年）的随访，以评估疗效、安全性、后续肾脏并发症以及监测这种新改道方式中直肠是否发生肿瘤性变化。
定期评估电解质、酸碱平衡和肾功能，所有数据使用SPSS 9.0.1统计软件包进行分析，并采用配对t检验进行比较；若p < 0.05，则数据被视为具有显著性差异。术后第一年每6个月进行一次直肠镜检查，此后每年进行一次，若出现直肠出血则随时检查。
在这组患者中，随访发现直肠膀胱未发生肿瘤性变化，肾功能未恶化，也未出现主要电解质紊乱。他们能够容纳多达400毫升（350 - 550毫升）的尿液，白天均能自主排尿，排尿间隔时间为3 - 5小时；3例患者夜间偶尔（每月4次）遗尿；4例患者发生肾盂肾炎，经药物治疗得到控制。
运用杜哈梅尔拖出术原理构建的可控直肠膀胱是可行的，操作简便，近期效果良好，随访6年后并发症发生率低，患儿及其家庭对其接受程度较高，在控尿方面生活质量有显著改善；需要进行更长时间的随访以排除直肠肿瘤性变化。还需要与其他知名手术，如美因茨II术，在并发症、患者接受度以及更长时间随访方面进行比较性综述。
