A new extra-abdominal channel alternative to the mitrofanoff principle: experimental and preliminary clinical experience

A New Extra-Abdominal Channel Alternative to the Mitrofanoff

Principle: Experimental and Preliminary Clinical Experience

Antonio Macedo Jr., Tiago Rosito, Jesus A. S. Pires, Riberto Liguori, Valdemar Ortiz

Department of Urology, Federal University of Sao Paulo, Unifesp, Sao Paulo, SP, Brazil

ABSTRACT

Introduction: The appendix is the gold-standard channel for the Mitrofanoff principle in pediatric urology, but the search

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Material and Methods::HFRQ¿JXUHGDWXEHIURPWZRUHFWDQJXODUVNLQÀDSV[FPRSSRVLWHHDFKRWKHULQWKHPLGGOH

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Result:7KHWHFKQLTXHSURYHGIHDVLEOHLQDOODQLPDOVRIFRXOGEHHDVLO\FDWKHWHUL]HGDQGXQGHUZHQWXURG\QDPLFVWXG\

1RVWRPDOHDNDJHZDVREVHUYHGLQDQLPDOVDWKLJKEODGGHUSUHVVXUHV!FP+DQGRQO\DQLPDOVKDGVRPHOHDNDJH DWFP+8URG\QDPLFVSHUIRUPHGWKURXJKWKHVWRPDVKRZHGXUHWKUDOOHDNDJHDWFP+WKHUHIRUHGHPRQVWUDWLQJ WKHHI¿FDF\RIWKHYDOYXODUPHFKDQLVP+LVWRORJLFDODQDO\VLVFRQ¿UPHGJRRGLQWHJUDWLRQEHWZHHQWKHWXEHDQGWKHEODGGHU 0HDQIROORZXSRIWKHFOLQLFDOVHULHVSDWLHQWVZDVPRQWKV7ZRSDWLHQWVUHPDLQHGFRQWLQHQWXSWRKRXUVZKHUHDV SDWLHQWKDGVRPHOHDNDJHDIWHUKRXUV

Conclusion::HZHUHDEOHWRFRQ¿UPIHDVLELOLW\RIDQHZH[WUDDEGRPLQDOFKDQQHOEDVHGRQWKH0LWURIDQRIISULQFLSOHDQG

VXFFHVVIXOO\UHSURGXFHGWKHPHWKRGLQDFOLQLFDOVHWWLQJ)ROORZXSZDVVKRUWDQGORQJWHUPUHVXOWVDUHUHTXLUHGEHIRUH DQ\FRQFOXVLYHMXGJPHQWFDQEHPDGH

Key words: bladder; children; urinary diversion; Mitrofanoff principle; surgery Int Braz J Urol. 2009; 35: 205-16

INTRODUCTION

7KHLQWURGXFWLRQRIFOHDQLQWHUPLWWHQWFDWK-HWHUL]DWLRQ&,&DWWKHVLPSURYHGFRQVLGHUDEO\ WKHTXDOLW\RIOLIHLQSDWLHQWVZLWKQHXURJHQLFEODG-GHU DQG RWKHU HQGVWDJH EODGWKHTXDOLW\RIOLIHLQSDWLHQWVZLWKQHXURJHQLFEODG-GHU GLVHDVH 7KH DSSHQGLFRYHVLFRVWRP\JDYHSDWLHQWVPRUHFRPIRUW DQG DXWRQRP\ HVSHFLDOO\ IRU WKRVH FRQ¿QHG WR D

LQWHVWLQDOVHJPHQWVZKLFKFRXOGEHDYRLGHGZKHQ WKHUHLVQRQHHGIRUEODGGHUDXJPHQWDWLRQEXWRQO\D 0LWURIDQRIIFKDQQHOLQWKHQDWLYHEODGGHU $VHFRQGSRLQWRIFRQFHUQLQXULQDU\DQGFRORQLF FRQWLQHQWVWRPDVLVWKHKLJKLQFLGHQFHRIVWRPDVWULFWXUH ZKLFKPLJKWEHUHODWHGWRYDULDEOHVOLNHWKHWHFKQLTXH LWVHOIIUHTXHQF\RIFDWKHWHUL]DWLRQDQGSUHVHQFHRIIHFHV although this latter condition has not yet been proved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

MATERIALS AND METHODS

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operated on under sterile conditions and under opti-FDOPDJQL¿FDWLRQ;:HPDGHWZRUHFWDQJXODU ÀDSV[FPERWKRSSRVLWHHDFKRWKHULQWKHPLGGOH OLQHRIWKHORZHULQIHULRUDEGRPHQ)LJXUH$7KH YDVFXODUVWUXFWXUHRIERWKÀDSVZDVNHSWLQWDFWE\ LQIHULRUVXSHU¿FLDOHSLJDVWULFYHVVHOVDQGVXSHU¿FLDO LOLDFFLUFXPÀH[ 7KHFUDQLDODQGODWHUDOVXUIDFHRIWKHÀDSVZDV VHFWLRQHGJLYLQJLWHQRXJKPRELOLW\WRDOORZD GHJUHHURWDWLRQ7KHKRUL]RQWDOVXSHULRUERUGHUZDV PRYHGWRWKHYHUWLFDOSRVLWLRQFORVHWRHDFKRWKHU$ SRO\JOLFROLFDFLGUXQQLQJVXWXUHZDVSHUIRUPHG FRQ¿JXULQJDVNLQSODWH)LJXUH%7KHQH[WVWHS FRQVLVWHGRIDQDQDVWRPRVLVRIWKHODWHUDOPDUJLQVRI WKHÀDSVXVLQJD)SODVWLFWXEHDVDPROGLQRUGHU WRFUHDWHDWXEH)LJXUH&

Figure 1 –7ZRUHFWDQJXODUVNLQÀDSV[FPRSSRVLWHHDFKRWKHULQWKHPLGGOHOLQHRIWKHORZHULQIHULRUDEGRPHQDUHDQDVWRPRVHGDV

an “onlay” to create a tube to be connected to the bladder dome.

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$IWHULQLWLDOH[SHULHQFHZLWKWKHH[SHULPHQWDO PRGHOZHGHVLJQHGDFOLQLFDOSURWRFRODQGLQIRUPHG parents about potential advantages of the technique, PDLQO\ WR DYRLG RSHQLQJ WKH SHULWRQHDO VSDFH DQG SRVVLEOH FRPSOLFDWLRQV ZHUH DOVR PHQWLRQHG7KH SURWRFRO ZDV DOVR DSSURYHG E\ ORFDO (WKLFV &RP-PLWWHH:HWKHQLQWURGXFHGWKHPHWKRGLQFOLQLFDO SUDFWLFH:HRSHUDWHGRQWKUHHFKLOGUHQSUHVHQWLQJ ZLWKQRQQHXURJHQLFFRQJHQLWDOEODGGHUDEQRUPDOL- WLHVSUHVHQWLQJZLWKPDVVLYHUHVLGXDOYROXPHVZLWK-RXWVWRUDJHGH¿FLHQF\2QHSDWLHQWKDGSUHVXPDEO\ SULPDU\EODGGHUQHFNREVWUXFWLRQ)LJXUHVDQG one had posterior urethral valve and a third boy had

SUXQHEHOO\ V\QGURPH )LJXUH$JH DW VXUJHU\ and additional surgical procedures are described in 7DEOH$VWRPDFDWKHWHU)VLOLFRQH7XEHZDVOHIW LQGZHOOLQJIRUWKUHHZHHNVZKHQDQXUVHXURWKHUDSLVW WUDLQHGSDWLHQWVKRZWRSHUIRUP&,&3DWLHQWVZHUH IROORZHGDVRXWSDWLHQWVHYHU\PRQWKIRUDWOHDVW PRQWKVIRUFRQWLQHQFHXULQDU\WUDFWLQIHFWLRQRFFXU-UHQFHDQGVWRPDFRPSOLFDWLRQV

RESULTS

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Table 1 –8URG\QDPLFUHFRUGVRISRVWRSHUDWLYHHYDOXDWLRQDWWKSRVWRSHUDWLYHGD\H[FHSWDQLPDOVJURXS

Animal UD per Urethra UD per stoma

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COMMENTS

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The ureter has also been used to construct a 0LWURIDQRIIFKDQQHO+RZHYHULQWKHVWXGLHVRI9DQ 6DYDJHHWDOWKHUHZDVDKLJKHUULVNRIFRPSOLFD-Figure 4 –$QDVWRPRVLVRIWKHWXEHWRWKHEODGGHUGRPHDQG¿QDODVSHFWRIWKHVWRPDDWWKSRVWRSHUDWLYHGD\)LJXUH'

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tions due to the need for associated ureteral recon-VWUXFWLRQUHLPSODQWDWLRQRUWUDQVXUHWHURXUHWHURVWRP\ DVZHOODVDJUHDWHUULVNRIVWRPDVWHQRVLV

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Additional Procedure Present Status

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389 &RKHQUHÀX[UHSDLU &RQWLQHQW!KRXUV

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Figure 6 – Histological analysis of the specimen showed good integration of the skin tube with the bladder, in some areas with loss of epithelium however without ulceration.

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CONFLICT OF INTEREST

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REFERENCES

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