Minimally Invasive Approach for Treatment of Urinary and Fecal Incontinence in Selected Patients with Spina Bifida
ABSTRACT At our institution, the use of cecostomy tubes has provided a successful method for managing severe constipation in patients with spina bifida, with good patient and caretaker satisfaction and minimal morbidity. We have developed a modified technique to allow placement of the cecostomy tube under direct vision during laparoscopic appendicovesicostomy. We present our initial experience and technique.
Patients with a normal bladder capacity and compliance who were scheduled for creation of an appendicovesicostomy and who also had refractory constipation were offered concurrent cecostomy tube placement. At the laparoscopic procedure, we performed percutaneous placement of the cecostomy tube through the abdominal wall under direct visualization. Subsequently, dissection of the appendix with its mesentery was performed. The detrusor muscle was dissected and a trough for the appendix created. Laparoscopic anastomosis of the appendix to the bladder mucosa and approximation of the detrusor over the appendix created a nonrefluxing channel.
Three patients have undergone concurrent cecostomy tube placement at appendicovesicostomy. No complications have been encountered thus far. On follow-up, the cecostomy tube scar has been well concealed and appears no different from the ones placed under radiologic guidance. The patients have been using the catheterizable channel to access the bladder and dry performing intermittent catheterization without difficulties.
In patients with a neurogenic bladder who do not qualify for major bladder reconstructive procedures, such as augmentation cystoplasty or bladder neck repair, social continence and independence can be achieved with minimally invasive surgery. Concomitant laparoscopic appendicovesicostomy and cecostomy tube placement may be a suitable surgical option.
- SourceAvailable from: Francesco Molinaro
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- "Taking care of disabled children often leads to repeated surgical attempts to improve comfort and lifestyle. Developing minimally invasive procedures  and using new devices can allow us to help in a much better way than was previously possible. Appendix can be kept aside to ensure, if required, a continent vesicostomy according to Mitrofanoff. "
ABSTRACT: This study evaluated the Trap-door button use (Cook Medical, Bloomington, IL) for antegrade enemas in children. Since 2002, patients with fecal incontinence or encopresis and constipation underwent percutaneous cecostomy under laparoscopy using a button. Technical details are described. Age at surgery, operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the button for less than 1 month were excluded from this evaluation. The survey concerned volume and frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment of the antegrade enemas in continence. Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11 syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and 3 sigmoidostomy button placements were successful with no intraoperative complication. The mean operative time was 25 minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-two parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL (mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes (mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6 needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery, only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder exstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were asked to give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt there had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good result, and 12 a very good result. The mean grade was 3.44 (17.2/20). A total of 3 patients had hypertrophic granulation tissue formation around the cecostomy button, and 12 had tiny leakage. Percutaneous placement of a cecostomy button under laparoscopic control is an easy and major complication-free procedure. The use of the Trap-door device by the patients or with the help of the parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.Journal of Pediatric Surgery 11/2008; 43(10):1853-7. DOI:10.1016/j.jpedsurg.2008.03.043 · 1.31 Impact Factor
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ABSTRACT: Most children born with spina bifida, the most common disabling congenital abnormality, have normal renal function. If left untreated, more than half of these children will have serious renal deterioration by age 5. This deterioration is secondary to hostile neurogenic changes of the bladder. Renal development should follow a normal course when close evaluation and intervention are undertaken during the newborn period and toddler years. As children age, attention is directed to quality-of-life issues, such as the establishment of urinary and bowel continence. Teenagers face the responsibility of understanding their medical condition and should begin to assume responsibility for their own care with eventual transition to the adult health care system. This article describes the foundations of management, beginning at birth, for caring for children with spina bifida.Current Urology Reports 04/2008; 9(2):151-7. DOI:10.1007/s11934-008-0027-y · 1.51 Impact Factor
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ABSTRACT: Continent urinary diversion has a central role in treating various urinary tract conditions and traditionally has been performed as an open procedure. We report on 10 patients who underwent a robotic assisted laparoscopic Mitrofanoff procedure using the da Vinci surgical system. Patients had bladder dysfunction of various etiologies, including posterior urethral valves and neurogenic bladder. Preoperatively all patients unsuccessfully attempted clean intermittent catheterization via the urethra. Mean operative time was 323 minutes (range 181 to 507). One case was converted to open surgery secondary to an inadequate appendix discovered intraoperatively. Mean estimated blood loss was 48.4 cc (range 5 to 200). Median hospitalization was 5 days. Median followup was 14.2 months. Urinary leakage developed postoperatively in 1 patient, requiring an open revision. Minor incontinence developed in 2 cases, of which 1 was corrected with dextranomer/hyaluronic acid injection and 1 resolved without intervention. The robotic assisted laparoscopic Mitrofanoff procedure is feasible to perform, is associated with satisfactory outcomes and minimal complications, and has the benefits of a minimally invasive approach.The Journal of urology 09/2009; 182(4):1528-34. DOI:10.1016/j.juro.2009.06.055 · 3.75 Impact Factor