Aims
of
Study
Urinary
incontinence
is
a
common
urological
problem,
especially
in
the
myelomeningocele
population.
Kropp
and
Angwafo
(1)
presented
a
urethral
lengthening
procedure
using
a
bladder
tube
for
neurogenic
incontinence
and
later
several
others
(2-4)
modified
this
procedure.
However,
bladder
wall
of
those
patients
is
often
too
thickened
and
rigid
to
be
used
as
a
neourethra
implanted
into
the
bladder
through
a
submucosal
tunnel.
Since
the
Mitrofanoff
principle
(5)
has
been
accepted
as
a
procedure
providing
an
excellent
flap
valve
mechanism,
we
applied
the
principle
to
urethral
lengthening
and
attempted
to
create
a
continent
neourethra
by
using
an
intestinal
tube.
In
the
present
study,
we
report
our
first
experience
with
this
new
procedure
and
its
urodynamic
effects.
Methods
Six
patients
(3
male
and
3
female,
8-24
year
old)
with
myelomeningocele
underwent
this
new
urethral
lengthening
procedure.
Preoperative
video-urodynamic
study
revealed
that
all
the
patients
had
intrinsic
sphincter
deficiency
(Fig.
2)
and
poor
compliant
acontractile
detrusor.
Augmentation
cystoplasty
using
sigmoid
colon
and
creation
of
a
continent
appendical
umbilical
stoma
were
performed
simultaneously
in
all
patients.
Two
patients
who
had
had
vesicoureteral
reflux
underwent
ureteral
reimplantation
at
the
same
time.
An
intestinal
tube
as
long
as
6
cm
was
created
using
a
tapered
ileal
segment
in
3
patients
and
a
transversely
reconfigured
sigmoid
colonic
segment
according
to
the
Monti
procedure
(6)
in
the
remaining
3
patients.
Serosal
and
muscle
layers
of
the
posterior
and
trigonal
bladder
wall
were
opened
longitudinally
along
the
mid-line
to
create
a
trough
for
submucosal
implantation
of
the
intestinal
tube
(Fig.
1A).
Anterior
bladder
wall
was
opened
longitudinally
to
the
bladder
neck
and
anterior
two
third
of
the
bladder
neck
was
divided.
One
end
of
the
intestinal
tube
was
introduced
into
the
trigone
through
a
mucosal
hole
created
at
the
distal
end
of
the
trough
and
anastomosed
to
the
urethra
in
an
end
to
end
manner
(Fig.
1B).
The
opposite
end
of
the
tube
was
fixed
at
the
proximal
end
of
the
trough
at
the
posterior
bladder
wall
as
a
new
internal
urethral
meatus
and
the
bladder
wall
was
reapproximated
over
the
intestinal
neourethra
to
embed
the
tube
submucosally.
All
patients
were
followed
up
and
reevaluated
by
video-uodynamic
investigations.
Results
The
postoperative
follow
up
raged
from
19
to
26
months.
Four
patients
(3
male
and
1
female)
became
dry
between
intermittent
catheterization
both
day
and
night.
The
remaining
two
experience
occasional
dribble
and
wear
a minipad. Neither vesicoureteral reflux or uretral stricture
was
observed
after
the
operation.
Valsalva
leak
point
pressure
was
increased
in
all
6
patients(Fig.
2).
Urethral
pressure
profile
revealed
that
the
functional
urethral
profile
length
was
significantly
increased
(Fig.
3),
but
the
maximum
urethral
closure
pressure
did
not
change
after
the
operation.
No
revisions
directly
related
to
the
operative
procedure
were
needed,
although
one
male
patients
had
difficult
catheterization
thruogh
the
urethra.
Conclusions
The
present
urethral
lengthening
procedure
using
an
intestinal
segment
based
on
the
Mitrofanoff
principle
provides
a
neouretha
acting
as
a
good
continent
flap
valve
and
minimal
complications
without
ureteral
reimplantation.
This
procedure
may
be
useful
especially
when
the
bladder
wall
is
too
thickened
and
poor
compliant
and
thus
augmentation
cystoplasty
is
required
simultaneously.
References
1.
J.Urol, 135: 533, 1986. 2. J. Urol, 143: 95, 1990. 3. J. Urol, 152: 799, 1994
4.
J. Urol, 158: 585, 1997. 5. Chir. Ped., 21: 287, 1980. 6. Urology, 49: 112, 1997.
