459
Continent Urinary Diversion in Children under 5 Years
International Braz J Urol Vol. 35 (4): 459-466, July - August, 2009
Is Continent Urinary Diversion Feasible in Children under Five
Years of Age?
Luiz L. Barbosa, Riberto Liguori, Sergio L. Ottoni, Ubirajara Barroso Jr, Valdemar Ortiz, Antonio Macedo Junior
Division of Urology, Federal University of Sao Paulo, Sao Paulo, Brazil
ABSTRACT
Purpose:7RUHYLHZRXUFOLQLFDOH[SHULHQFHZLWKXULQDU\FRQWLQHQWFDWKHWHUL]DEOHUHVHUYRLULQFKLOGUHQXQGHU¿YH\HDUVRI age.
Materials and Methods: $WRWDORISDWLHQWVPDOHVIHPDOHVZLWKDPHGLDQDJHRI\HDUVZHUHHYDOXDWHG $PRQJWKHVHKDGDSRVWHULRUXUHWKUDOYDOYHP\HORPHQLQJRFHOHEODGGHUH[VWURSK\ JHQLWRXULQDU\UDEGRP\RVDUFRPDKDGVSLQDOWXPRUDQGDQDQRUHFWDODQRPDO\
Results:3HULRSHUDWLYHFRPSOLFDWLRQVZHUHREVHUYHGLQIRXUSDWLHQWVFRQVLVWLQJRIRQHIHEULOHXULQDU\WUDFWLQIHFWLRQRQH SDUWLDORSHUDWLYHZRXQGGHKLVFHQFHRQHSDUWLDOVWRPDOGHKLVFHQFHDQGRQHYHVLFRFXWDQHRXV¿VWXODDIWHUDVHFRQGDU\H[ VWURSK\UHSDLU7KHRYHUDOOORQJWHUPFRPSOLFDWLRQVUDWHZDVDQGFRQVLVWHGRIWZRVWRPDOVWHQRVHVRQH QHREODGGHUPXFRVDOH[WUXVLRQWKUHHQHREODGGHUFDOFXOLDQGSHUVLVWHQFHRIXULQDU\LQFRQWLQHQFHLQWKUHH SDWLHQWV7KHRYHUDOOVXUJLFDOUHYLVLRQZDVDQG¿QDOFRQWLQHQFHUDWHZDVZLWKPHDQIROORZXS RIPRQWKV
Conclusion:&RQWLQHQWXULQDU\GLYHUVLRQLVWHFKQLFDOO\IHDVLEOHHYHQLQVPDOOFKLOGUHQZLWKDFFHSWDEOHUDWHVRIFRPSOLFD tions.
Key words: children; congenital anomalies; urinary diversion; continence Int Braz J Urol. 2009; 35: 459-66
INTRODUCTION
7KH DELOLW\ WR YRLG VSRQWDQHRXVO\ PD\ EH FRPSURPLVHG LQ FKLOGUHQ ZLWK YDULRXV FRQJHQLWDO XURORJLFDEQRUPDOLWLHVQHXURJHQLFEODGGHUSRVWHULRU XUHWKUDOYDOYHDQGEODGGHUH[VWURSK\$OWKRXJKFOHDQ LQWHUPLWWHQWFDWKHWHUL]DWLRQ&,&SKDUPDFRORJLFDO WUHDWPHQWDQGRYHUQLJKWFDWKHWHUGUDLQDJHKDVFKDQJHG WKHQDWXUDOKLVWRU\RIPRVWRIWKHVHXURSDWKLHVLWLVQRW always possible to avoid renal deterioration in these SDWLHQWVRZLQJWRDFRPELQDWLRQRIKLJKGHWUXVRUSUHV VXUHLQIHFWLRQDQGYHVLFRXUHWHUDOUHÀX[PRUHRYHU XUHWKUDOFDWKHWHUL]DWLRQFDQEHSDLQIXORUQRWSRVVLEOH LQIHPDOHSDWLHQWVERXQGWRDZKHHOFKDLU
Pediatric Urology
7KHXVHRIFRQWLQHQWXULQDU\UHVHUYRLUVKDV JDLQHGZLGHDFFHSWDQFHEHFDXVHZKHQWKLVSURFH GXUHLVFRPELQHGZLWK&,&SDWLHQWVDUHRIWHQDEOHWR DFKLHYHFRQWLQHQFHZLWKORZLQWUDYHVLFDOSUHVVXUH,I QHFHVVDU\DFRQWLQHQWFDWKHWHUL]DEOHXULQDU\UHVHUYRLU DQGDFRQFRPLWDQWEODGGHUQHFNSURFHGXUHFDQEH KHOSIXOWRUHVWRUHFRQWLQHQFH
regards patients’ initial age when this procedure can EHVDIHO\SHUIRUPHG7KHPDMRULW\RIWKHVHULHVUHSRUW EODGGHUDXJPHQWDWLRQLQSDWLHQWVDERYH\HDUVRIDJH !\HDUV
We retrospectively present our experience with orthotopic continent urinary diversion in children XQGHU¿YH\HDUVRIDJH:HHYDOXDWHGDOOFRQWLQHQW FDWKHWHUL]DEOHSURFHGXUHVWKDWZHUHSHUIRUPHGLQRXU LQVWLWXWLRQWRLQYHVWLJDWHLIFRQWLQHQWXULQDU\GLYHU VLRQLVWHFKQLFDOO\IHDVLEOHDQGVDIHHYHQLQ\RXQJHU children.
MATERIALS AND METHODS
7KH UHFRUGV RI FKLOGUHQ ZKR XQGHUZHQW D Macedo’s continent catheterizable reservoir below ¿YH\HDUVRIDJHZHUHUHWURVSHFWLYHO\UHYLHZHG$ WRWDORISDWLHQWVPDOHVIHPDOHVPHWWKHLQFOX VLRQFULWHULDLQRXUSUHVHQWVHULHVRISURFHGXUHV 3DWLHQWDJHDWVXUJHU\YDULHGIURPWR\HDUVZLWK PHGLDQDJHRI\HDUV$OOFKLOGUHQKDGSUHYLRXVO\ XQGHUJRQHXURG\QDPLFHYDOXDWLRQH[FHSWWKRVHZLWK UDEGRP\RVDUFRPDDQGEODGGHUH[VWURSK\
7KHWHFKQLTXHFRQVLVWVRIDFRQWLQHQWFDWK HWHUL]DEOHLOHXPEDVHGUHVHUYRLU$FPVHJPHQW RIWKHGLVWDOLOHXPLVLVRODWHGDQGERZHOFRQWLQXLW\ UHVWRUHGE\HQGWRHQGDQDVWRPRVLV7KHGHWXEXODUL]D WLRQRIWKHLOHDOVHJPHQWIROORZVWKHDQWLPHVHQWHULF ERUGHURIWKHLQWHVWLQHXSWRWKHPLGGOHRIWKHVHJPHQW Here the incision line continues transversally to the DQWHULRUVXUIDFHRIWKHLOHXPUHDFKLQJWKHPHVHQWHULF ERUGHU$FPKRUL]RQWDOLQFLVLRQDORQJWKHPHVHQWHULF VLGHLVFRQWLQXHGEHIRUHUHWXUQLQJWRLWVXVXDOGLUHFWLRQ DWWKHDQWLPHVHQWHULFERUGHU7KHUHPDLQGHURIWKH LOHXPLVWKHQRSHQHGORQJLWXGLQDOO\)LJXUH$7KH FPÀDSIURPWKHDQWHULRUVXUIDFHRIWKHPLGGOHSDUW RIWKHLOHXPLVPRELOL]HGFUDQLDOO\DQGWXEXODUL]HG DURXQGD)VLOLFRQH)ROH\FDWKHWHU)LJXUH%7KH FRQWLQHQFHYDOYHPHFKDQLVPLVSURGXFHGE\HPEHG GLQJWKHWXEHRYHUDVHURXVOLQHGH[WUDPXUDOWXQQHO FUHDWHGE\SRO\SURS\OHQHVXWXUHV)LJXUH&7KH GLVWDOHQGRIWKHWXEHLVDQDVWRPRVHGLQWRD9VKDSHG WRWKHVNLQÀDSWRDYRLGVWRPDOVWHQRVLV7KHUHVHUYRLU LVDQDVWRPRVHGWRWKHEODGGHURUXVHGDVDVXEVWLWXWH
Surgical indications included patients with ORZEODGGHUFRPSOLDQFHDQGFDSDFLW\¿OOLQJGHWUXVRU
SUHVVXUHDERYHFP+2DQGRUXULQDU\LQFRQWL QHQFHWKDWKDGIDLOHGWRFRQVHUYDWLYHPDQDJHPHQW &,&DQGDQWLFROLQHUJLFV
$PRQJWKHSDWLHQWVKDGSRVWHULRU
XUHWKUDOYDOYH389P\HORPHQLQJRFHOH EODGGHUH[VWURSK\JHQLWRXUL QDU\UDEGRP\RVDUFRPDVSLQDOWXPRUDQG KDGDQDQRUHFWDODQRPDO\7DEOH)RXU SDWLHQWVKDGXQGHUJRQHHLWKHUDYHVLFRVWRP\ RUQHSKURVWRP\SULRUWREODGGHUDXJPHQWDWLRQ2QH SDWLHQWKDGEODGGHUDXJPHQWDWLRQPRQWKVEHIRUH NLGQH\WUDQVSODQWDWLRQ7DEOH
7KHSURFHGXUHZDVSHUIRUPHGZLWKWKHLOHXP LQSDWLHQWVDQGWUDQVYHUVHFRORQLQ SDWLHQWV7KHFRORQZDVXVHGLQWZRFDVHV RIJHQLWRXULQDU\UKDEGRP\RVDUFRPDGXHWRWKHULVN RIXVLQJDSUHYLRXVLUUDGLDWHGLOHXPWRSHUIRUPEODG GHUVXEVWLWXWLRQ,QRQO\WKHVHWZRSDWLHQWVWKH technique was used as a pouch whereas in the others LWZDVXVHGDVDEODGGHUDXJPHQWDWLRQ
,QRQHSDWLHQWDQDQWHJUDGHOHIWFRORQ HQHPDSURFHGXUHZDVSHUIRUPHGLQFRPELQDWLRQZLWK EODGGHUDXJPHQWDWLRQGXHWRIHFDOLQFRQWLQHQFH
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EODGGHUQHFNSURFHGXUHGXHWRSHUVLVWHQWOHDNDJHDQG ORZGHWUXVRUOHDNSRLQWSUHVVXUH
The patients’PHGLFDOUHFRUGVZHUHUHYLHZHG LQ RUGHU WR GH¿QH FRPSOLFDWLRQ UDWHV DFXWH DQG FKURQLF VXUJLFDO UHYLVLRQ UDWH DQG ILQDO FRQWL nence.
RESULTS
$SHULRSHUDWLYHFRPSOLFDWLRQZDVREVHUYHG LQIRXUSDWLHQWVFRQVLVWLQJRIRQHIHEULOHXULQDU\WUDFW LQIHFWLRQRQHSDUWLDORSHUDWLYHZRXQGGHKLVFHQFHRQH SDUWLDOVWRPDOGHKLVFHQFHDQGRQHYHVLFRFXWDQHRXV ¿VWXODDIWHUDVHFRQGDU\H[VWURSK\UHSDLU7KLVODVW SDWLHQWGHYHORSHGVHSVLVGXHWRIXQJDOLQIHFWLRQDQG did not survive.
461
Continent Urinary Diversion in Children under 5 Years
Figure 1 – Macedo’s continent catheterizable reservoir - surgical technique. Reproduced from Macedo A. Jr., Srougi M.: A continent catheterizable ileum-based reservoir. BJU Int. 2000; 85: 160-2.
1A
1B
462
Continent Urinary Diversion in Children under 5
Y
ears
PRQWKV Peri-operative Chronics
AAS Exstrophy MP Aug No No No Yes
ACG 6SLQDOWXPRU MP Aug No No No Yes
%90/ MMC MP Aug No No No Yes
%66 RMS MP Subs No /LWKLDVLV 2SHQF\VWROLWRWRP\ Yes
&(/ 389 MP Aug No /LWKLDVLV 2SHQF\VWROLWRWRP\ Yes
'%6 389 MP Aug No No No Yes
ESS Exstrophy MP Aug No No No Yes
EHM Exstrophy MP Aug Wound
Dehiscence /HDNDJHWKURXJKurethra Waiting No
)7) $QRUHFWDO
$QRPDO\ MP Aug No 6WRPDOVWHQRVLV Monti Yes
)% MMC MP Aug No No No Yes
*&$% RMS MP Subs No /LWKLDVLV 2SHQF\VWROLWRWRP\ Yes
GGG Exstrophy MP Aug )LVWXOD6HSVLV
'HDWK32 Death
HMS MMC MP Aug 87, No No Yes
JPNS 389 MP Aug No No No Yes
-9)$& MMC MP Aug No No No Yes
-)' MMC MP Aug No 6WRPDOVWHQRVLV 0LWURIDQRII Yes
/0'0 MMC 03$XJ00 No No No Yes
MACS 389 MP Aug No No No Yes
NCR MMC MP Aug No No No Yes
PMPN MMC MP Aug Distal dehiscence
conduit 8ULQDU\VWRPDOOHDNDJH Monti Yes
TMNS 389 MP Aug No 8ULQDU\UHWHQWLRQ Neobladder
drainage Yes
TTR 389 MP Aug No Mucosal Extru
sion ZLWK0LWURIDQRIIUHextrusion Yes
WDM MMC MP Aug No 8ULQDU\6WRPD
/HDNDJH 5HDXJPHQWDWLRQ Yes
463
Continent Urinary Diversion in Children under 5 Years
,QWKHWZRFDVHVRIVWRPDOVWHQRVLVVXUJLFDO revision was necessary in both cases because progres VLYHVWRPDOGLODWDWLRQIDLOHG
7KHSDWLHQWZLWKQHREODGGHUPXFRVDOH[WUX VLRQ XQGHUZHQW UHGR FORVXUH DQG DSHQGL FRYHVLFRVWRP\
Three patients presented with persistence RIXULQDU\OHDNDJHWZROHDNLQJWKURXJK WKHVWRPDDQGRQHSDWLHQWWKURXJKWKHXUHWKUDDIWHU IDLOHGEODGGHUQHFNVXUJHU\7KHSDWLHQWVZLWKVWRPDO XULQDU\OHDNDJHZHUHUHRSHUDWHGRQHSDWLHQW XQGHUZHQWD0RQWLSURFHGXUHDQGWKHRWKHUDUHDXJ PHQWDWLRQDQGWKH\DUHFXUUHQWO\FRQWLQHQW
Three patients developed reservoir calculi DQGXQGHUZHQWRSHQF\VWROLWRWRP\DIWHU IDLOHGHQGRVFRSLFDWWHPSW$OOFDVHVZHUHIRXQGWR KDYHWKHFDOFXOLJURZQRQDVXWXUHOLQHSUHVXPDEO\ DVVRFLDWHGWRRQHRIWKHVHURPXVFXODU3UROHQHVXWXUHV RIWKHWXEHYDOYXODUPHFKDQLVP
One patient presented with late urinary reten WLRQGXHWRRYHUGLVWHQWLRQRIWKHUHVHUYRLUDQGWXEH RXWOHWDQGDF\VWRVFRS\ZDVQHFHVVDU\WRKHOSFDWKHWHU SDVVDJHWKURXJKWKHVWRPD
7KHRYHUDOOVXUJLFDOUHYLVLRQZDVDQG ¿QDOFRQWLQHQFHUDWHZDVZLWKPHDQIROORZ XSRIWRPRQWKV7KHRQO\LQFRQWLQHQW
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COMMENTS
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7KHFKRLFHRIWKHLQWHVWLQDOVHJPHQWWRFRQ VWUXFWWKHUHVHUYRLULVPDGHDFFRUGLQJWRVXUJHRQV¶ H[SHULHQFHEXWIDFWRUVOLNHLQFLGHQFHRIHOHFWURO\WH UHDEVRUSWLRQDQGORVVDFLGRVLVDQGDOFDORVLVFHUWDLQO\ play a role in this procedure.
7KH FUHDWLRQ RI D FRQWLQHQW FDWKHWHUL]DEOH FRQGXLWZDVLQLWLDOO\GHVFULEHGE\0LWURIDQRIIXV LQJWKHDSSHQGL[DVDFDWKHWHUL]DEOHVWRPD$OWKRXJK WKHDSSHQGL[LVWKHPRVWSRSXODUFKDQQHOQXPHURXV RWKHURSWLRQVKDYHEHHQUHSRUWHGXUHWHUIDOORSLDQ WXEHVDQGWXEXODUL]HGFRORQLFRUEODGGHUÀDSV ,QFDVHVZKHQWKHDSSHQGL[LVDEVHQWWRRVKRUWRU KDVHYLGHQFHRIOXPLQDOVWHQRVLVWKHVHDUFKIRUDQ DOWHUQDWLYHLVLPSHUDWLYH7KH<DQJ0RQWLSURFHGXUH FRQVLVWVRIXVLQJDVPDOOVHJPHQWRIERZHOXVXDOO\ LOHXPWRFUHDWHDQHIIHUHQWWXEH$FPVHJ PHQWRIERZHOLVGHWXEXODUL]HGLQWKHDQWLPHVHQWHULF ERUGHUUHVXOWLQJLQDWXEHRIFPLQOHQJWKZKHQ WUDQVYHUVHO\UHWXEXODUL]HG7RGDWHWKH<DQJ0RQWL WHFKQLTXHLVFRQVLGHUHGWKHVXEVWLWXWHRIFKRLFHRIWKH DSSHQGL[IRUWKH0LWURIDQRIISULQFLSOH
,Q0LWURIDQRIIDQG<DQJ0RQWLSURFHGXUHV ZKHQFRQFRPLWDQWEODGGHUDXJPHQWDWLRQRUVXEVWL WXWLRQ LV QHHGHG WZR VHJPHQWV RI ERZHO PXVW EH SUHSDUHGIRUFUHDWLRQRIDQHREODGGHUDQGDQHIIHUHQW WXEH$IWHUWKDWERWKVWUXFWXUHVKDYHWREHMRLQHG together. The Macedo’s continent catheterizable res HUYRLUDOORZVERWKSURFHGXUHVXVLQJWKHVDPHVHJPHQW RIWKHERZHO:HUHFHQWO\SHUIRUPHGDQH[SHULPHQWDO VWXG\WRGH¿QHWKHHI¿FDF\RIWKHWHFKQLTXHLQDGGL WLRQWRRWKHUIDFWRUVWKDWPD\LQÀXHQFHFRQWLQHQFHRI FDWKHWHUL]DEOHFKDQQHOVXVLQJWKHSULQFLSOHRIHPEHG GLQJWKHRXWOHWWXEH)URPSLJVFRORQVSHFLPHQV ZLWKFPOHQJWKZHUHREWDLQHGDQGDWUDQVYHUVH ÀDSLQWKHDYHUDJHSRLQWRIWKHLQWHVWLQHZDVLQFLVHG WRFUHDWHDQHIIHUHQWWXEH$SUHVVXUHVWXG\RIERWK Table 2 – Overall complication rate, surgical revision and
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General Complication Rate Absolute Number/ %
Acute
Chronic
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Neobladder extrusion
Surgical Revision
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/HVOLHHWDOUHFHQWO\UHYLHZHGWKHLUVHULHV RI0RQWLXULQDU\FKDQQHOVSHUIRUPHGIURPWR 7KHVHDXWKRUVLGHQWL¿HGSDWLHQWVZLWKDJH RIPRQWKVWR\HDUVDWVXUJHU\0HDQIROORZXS ZDV\HDUV,QSDWLHQWVWKHLOHXPZDVXVHG WRFUHDWHWKHFKDQQHOLQZKLOHVLJPRLG FRORQZDVXVHGLQWKHRWKHU$VLQJOH0RQWLFKDQQHO ZDVFUHDWHGLQDQGDVSLUDO0RQWLLQ $WRWDORIRSHQUHYLVLRQVZHUHUHTXLUHG 2IWKHVHSDWLHQWVUHTXLUHGRQO\RSHQ UHYLVLRQUHTXLUHGUHYLVLRQVDQGSDWLHQWUHTXLUHG UHYLVLRQV2IWKHSDWLHQWVZHUHFRPSOHWHO\ FRQWLQHQWRIRUKDGUDUHOHDNDJH KDGRFFDVLRQDORULQWHUPLWWHQWOHDNDJHDQGFRQ WLQXHVWRKDYHIUDQNOHDNDJH
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7KH¿QDORYHUDOOFRQWLQHQFHUDWHZDV WKHUHIRUHVLPLODUWRRWKHUVHULHV6WRPDOOHDNDJHZDV IRXQGLQWZRSDWLHQWVUHTXLULQJDVXUJLFDOUH YLVLRQUHGRSURFHGXUHLQRQHSDWLHQWDQGRXWOHWFKDQ QHOUHYLVLRQ0RQWLWXEHLQWKHRWKHU%RWKSDWLHQWV DUHSUHVHQWO\FRQWLQHQW7KHRWKHUFDVHRIXUHWKUDO incontinence was an exstrophy patient who is cur UHQWO\DZDLWLQJDVHFRQGEODGGHUQHFNSURFHGXUH
3HUVLVWHQWOHDNDJHDQGVWRPDOFRPSOLFDWLRQV PDLQO\ VWHQRVLV DUH WKH PRVW FRPPRQO\ UHSRUWHG SLWIDOOVRIFRQWLQHQWXULQDU\GLYHUVLRQ3UHYLRXVVWXG LHVKDYHH[DPLQHGWKHUHODWLRQVKLSEHWZHHQVWRPDO FRPSOLFDWLRQVDQGW\SHRIFRQGXLWW\SHRIUHVHUYRLU DQGW\SHDQGVLWHRIVWRPD6WRPDOVWHQRVLVDSSHDUV WREHLQGHSHQGHQWIURPDOORIWKHVHYDULDEOHV ,WLVZHOONQRZQWKDWEODGGHUDXJPHQWDWLRQ and catheterizable urinary diversion lead to an in FUHDVHGULVNRIXUROLWKLDVLV5HDVRQVIRUWKLVLQFOXGH XULQDU\VWDVLVPXFXVSURGXFWLRQDQGFKURQLFEDFWH ULXULD2XULQFLGHQFHRIOLWKLDVLVZDVORZHU WKDQRWKHUVHULHV$WRXULQVWLWXWLRQDOOSDUHQWVDUH LQVWUXFWHGWRSURPRWHDJJUHVVLYHLUULJDWLRQRIWKHLU FKLOGUHQ¶VUHVHUYRLUDWOHDVWRQFHHYHU\KRXUVZLWK WRP/RIZDWHU$QXUVHVSHFLDOL]HGLQSHGL DWULFXURORJ\DQGVWRPDOFDUHPRQLWRUVRXUSDWLHQWV UHJXODUO\WRPDNHVXUHWKDWSDUHQWVIROORZHVWDEOLVKHG guidelines.
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Malignancy and enterocystoplasty is also a JURZLQJFRQFHUQDQGUHSRUWVIURPSHGLDWULFEODGGHU DXJPHQWDWLRQDUHLQFUHDVLQJLQIUHTXHQF\,WLVEH OLHYHGWKDWWKHLQFLGHQFHRIPDOLJQDQF\ZLOOLQFUHDVH ZLWKORQJHUIROORZXS3DWKRJHQHVLVOLNHO\LQYROYHV QLWURVDPLQHVSURGXFHGE\EDFWHULDLQXULQH 8QWLO WKH SDWKRJHQHVLV DQG WKH HWLRORJ\ DUH EHWWHU XQGHUVWRRG WKH PDLQVWD\ RI SUHYHQWLRQ LV UHJXODU HQGRVFRSLFVXUYHLOODQFH,QWKHKRSHRISUHYHQWLQJWKLV GLVWXUELQJHYHQWVRPHDXWKRUVKDYHEHFRPHPRUHDJ JUHVVLYHLQPDQDJLQJUHFXUUHQWXULQDU\WUDFWLQIHFWLRQV and advocate annual surveillance cystoscopy to begin DWOHDVWWR\HDUVDIWHUDXJPHQWDWLRQ7KHUROHRI screening urinary cytology has not been explored but LWKDVPHULWDQGZDUUDQWVIXUWKHUVWXG\
465
Continent Urinary Diversion in Children under 5 Years
FRPSOLFDWLRQVOLNHPDOLJQDQF\RUQXWULWLRQDOGH¿FLWV EXWWKLVZDVQRWWKHVFRSHRIWKLVDUWLFOH2QWKHRWKHU KDQGZHEHOLHYHWKDWRQFHDSUHFLVHLQGLFDWLRQIRU DXJPHQWDWLRQLVHVWDEOLVKHGLWZRXOGPDNHQRGLI IHUHQFHLQRSHUDWLQJWKHFKLOGDIWHU\HDUVRIZLWKLQ \HDUVPHDQDJHDWSUHVHQWVWXG\,WLVLPSRUWDQW to stress that we are not advocating earlier surgery than necessary but only reporting on clinical data UHWURVSHFWLYHO\:HDGPLWKRZHYHUWKDWWKLVLVVXH LVFRQWURYHUVLDODQGPDQ\DXWKRUVZRXOGDUJXHWKDW WKH\ZRXOGOHDYHSDWLHQWVZLWKLQFRQWLQHQWVWRPDV RUXUHWHURVWRPLHVXQWLOODWHURQ:HUHVSHFWWKLVDU JXPHQWEXWZHUHJXODUO\RIIHUSDWLHQWVERWKRSWLRQV DQGWKH\LQIDFWKHOSXVWRGHFLGHZKLFKSURFHGXUH WRIROORZ
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urethral sensitivity.
:HZRXOGOLNHWRPDNHFOHDUWKDWWKHVFRSH RIWKLVUHWURVSHFWLYHVWXG\ZDVWRORRNEDFNLQRXU EODGGHUDXJPHQWDWLRQGDWDEDVHDQGHYDOXDWHLIWKH UDWHRIFRPSOLFDWLRQVZDVKLJKHULQWKLVSHULRGRIOLIH We are not advocating early surgery but this series FRPSULVHVDYHU\FRPSOH[SRSXODWLRQDQGPRVW389 DQGP\HORPHQLQJRFHOHSDWLHQWVKDGXSSHUXULQDU\ WUDFWGHWHULRUDWLRQDQGUHFXUUHQWXULQDU\WUDFWLQIHFWLRQ DQGUHTXLUHGWUHDWPHQW
CONCLUSION
Our experience shows that continent catheter L]DEOHXULQDU\GLYHUVLRQSHUIRUPHGE\0DFHGR¶VWHFK QLTXHLVDVDIHSURFHGXUHHYHQLQVPDOOSDWLHQWVEHORZ ¿YH\HDUVJXDUDQWHHLQJUHQDOIXQFWLRQSUHVHUYDWLRQ
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CONFLICT OF INTEREST
None declared.
REFERENCES
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plasty on linear growth in children with exstrophy. J 8UROGLVFXVVLRQ
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EDITORIAL COMMENT
7KLVUHWURVSHFWLYHVHULHVRIFKLOGUHQXQGHU DJH\HDUVXQGHUJRLQJFRQWLQHQWXULQDU\GLYHUVLRQ SURYLGHVIRRGIRUWKRXJKWWRUHDGHUV7KHVKRUWDQG ORQJWHUPFRPSOLFDWLRQUDWHVLQFOXGLQJVWRQHIRUPD WLRQRQJRLQJOHDNDJHVWRPDOVWHQRVLVDQGWKHQHHG IRUIXUWKHUVXUJHU\DUHVLPLODUWRWKRVHSUHYLRXVO\ SXEOLVKHGIURPRWKHUFHQWHUVUHJDUGLQJROGHUSDWLHQWV The surgical technique described is another novel YDULDWLRQRIWKH0LWURIDQRIISULQFLSOH&OHDUO\WKH WHFKQLFDO IHDVLELOLW\ RI SHUIRUPLQJ WKLV VXUJHU\ LQ \RXQJSDWLHQWVKDVEHHQHVWDEOLVKHGE\WKHDXWKRUVEXW
DVWKH\ULJKWO\SRLQWRXWWKHQHFHVVLW\IRUVXFKVXUJHU\ DWD\RXQJDJHUHPDLQVGHEDWDEOH7KHRQHGHDWKLQ WKHLUVHULHVDOWKRXJKSHUKDSVDVWDWLVWLFDODEHUUDWLRQ VSHDNVWRWKHJUDYLW\RISHUIRUPLQJWKHVHSURFHGXUHV LQ\RXQJSDWLHQWVZLWKRIWHQFRPSURPLVHGUHVHUYHV &DXWLRQVKRXOGEHDGYLVHGEHIRUHFRQVLGHULQJFRQ tinent urinary diversion as the standard approach to the young incontinent patient. These patients and WKHLUIDPLOLHVDUHRIWHQZHOOVHUYHGZLWKLQFRQWLQHQW VWRPDVDQGSXOOXSVRUSDGVXQWLOVL]HPDWXULW\DQG VRFLDOL]DWLRQPDQGDWHDVXUJLFDOVROXWLRQ
Dr. Andrew E. MacNeily
BC Children’s Hospital Vancouver, British Columbia Canada E-mail: amacneily@cw.bc.ca
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Accepted after revision: March 10, 2009
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