Colonic volvulus detected by CT scan in a case with mental retardat...
- PubMed - NCBI
The NCBI web site requires JavaScript to function.
FormatSummarySummary (text)AbstractAbstract (text)MEDLINEXMLPMID ListChoose DestinationFileClipboardCollectionsE-mailOrderMy BibliographyCitation managerFormatSummary (text)Abstract (text)MEDLINEXMLPMID ListCSVCreate File1 selected item: FormatSummarySummary (text)AbstractAbstract (text)MEDLINEXMLPMID ListMeSH and Other DataE-mailSubjectAdditional textE-mailAdd to ClipboardAdd to CollectionsOrder articlesAdd to My BibliographyGenerate a file for use with external citation management software.Create File
):185-8. doi: 10.1016/j.asjsur.. Epub
2012 Feb 18.Colonic volvulus detected by CT scan in a case with mental retardation and prune belly syndrome.1, , , .1Department of Thoracic, Endocrine and Pediatric Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan. oka-y@cis.fukuoka-u.ac.jpAbstractColonic volvulus is a rare disease in children. Delayed diagnosis of the condition can often be fatal, especially in pediatric patients with mental retardation. We herein present the case of a female pediatric patient with colonic volvulus, prune belly syndrome, and mental retardation. Preoperative CT scans showed the characteristic signs of this disease. The volvulus occurred in the proximal colon of the colostomy. The release of the colonic volvulus and reconstruction of the colostomy were performed without the resection of the ischemic colon. The postoperative clinical course was uneventful.Copyright (C) 2012. Published by Elsevier B.V.PMID:
[PubMed - indexed for MEDLINE]
Publication TypesMeSH TermsFull Text SourcesMedical
Supplemental Content
External link. Please review our .Services on DemandArticleIndicatorsCited by SciELO Related linksSharePrint version ISSN Int. braz j urol. vol.32 no.6 Rio de Janeiro Nov./Dec. 2006 http://dx.doi.org/10.-00010
PEDIATRIC UROLOGY
appendicovesicostomy in association with monfort abdominoplasty in the treatment
of prune belly syndrome
Ubirajara Barroso Jr; Joao T. M Sergio L. O Gilmar G Guilherme
T. D Valdemar O Antonio Macedo Jr
Division of Urology,
Federal University of Sao Paulo (UNIFESP), Sao Paulo, and Division of Urology,
Federal University of Bahia (UFBA), Bahia, Brazil
OBJECTIVE:
To evaluate the role of elective appendicovesicostomy in association with Monfort
abdominoplasty to avoid urinary tract infection (UTI) and renal damage in the
post-operative follow-up of patients with prune belly syndrome.
MATERIALS AND METHODS: We followed 4 patients operated in our institution
(UNIFESP) (Monfort, orchidopexy and Mitrofanoff) and compared them to 2 patients
treated similarly, but without an appendicovesicostomy, in a second institution
(UFBA). We evaluated postoperative clinical complications, UTI and preservation
of renal parenchyma. Patients were followed as outpatients with urinalysis,
ultrasonography (US) and occasionally with renal scintigraphy.
RESULTS: Mean follow-up was 23.5 months. Immediate post-operative course
was uneventful. We observed that only one patient with the Mitrofanoff channel
persisted with UTI, while the 2 patients used as controls persisted with recurrent
pyelonephritis (& 2 UTI year).
CONCLUSION: Our data suggest that no morbidity was added by the appendicovesicostomy
to immediate postoperative surgical recovery and that this procedure may have
a beneficial effect in reducing postoperative UTI events and their consequences
by reducing the postvoid residuals in the early abdominoplasty follow-up. However,
we recognize that the series is small and only a longer follow-up with a larger
number of patients will allow us to confirm our suppositions. We could not make
any statistically significant assumptions regarding differences in renal preservation
due to the same limitations.
Key words:
surgical procedures, urinary tract
infections
INTRODUCTION
Prune belly syndrome
occurs once in 35,000 live births and consists of a triad of deficient abdominal
wall musculature, intra-abdominal testes and dilated urinary tract. Extensive
urinary tract reconstruction (cystoplasty, ureteroplasty and reimplantation)
has moved up to more conservative approaches such as clean intermittent catheterization
(CIC) aiming to avoid residual volumes. Abdominoplasty plays a role not only
in improving cosmetics but also in ameliorating bladder and intestinal emptying.
We adopted in
our institution the concept of performing elective appendicovesicostomies in
association with the Monfort abdominoplasty and orchidopexy. We believe that
providing an outlet channel adds little morbidity to the surgical procedure
itself and brings a very beneficial mechanism of residual volume control. We
hypothesized that by doing so we could be able to reduce the number of UTI and
new scars per year in comparison to the classical strategy of watchful waiting.
We believed as well that, in some case, we would be able to avoid the secondary
need of urethral CIC, which can be a difficult issue due to the high sensitivity
of the urethra.
We evaluated our
concept of elective appendicovesicostomy in association with the Monfort abdominoplasty
and orchidopexy with the classical strategy of abdominoplasty and orchidopexy
only, by means of a retrospective comparative study involving 2 Brazilian institutions
to answer this question.
MATERIALS AND METHODS
We reviewed the
medical records of boys with prune belly syndrome treated in 2 centers from
1999 to 2004. We performed 6 Monfort abdominoplasties with patients ranging
from 1 to 7 years (mean 3.5 years) at surgery. Antenatal diagnoses were possible
in three patients and a fetal obstetric procedure was attempted in two cases
(1 bladder punction and 1 vesicoamniotic shunt). One patient developed initial
respiratory distress while the others were born without other complications.
Urological investigation
at the time of treatment identified bladders with increased capacity and hypotonic
detrusor function. Half of the patients had massive vesicoureteral reflux (VUR).
All patients presented recurrent symptomatic UTI. Bowel constipation was a rule
except for one patient.
The standard surgical
procedure consisted of classical Monfort abdominoplasty and open orchidopexy
and was conducted in 4 cases in our institution and in two cases in the associated
university (). Patients operated in
our center additionally received the appendix implanted in the bladder dome
after removal of the urachal diverticulum (). A
cystostomy tube was left for 3 weeks and after that the patient, and family,
was trained by an urotherapist nurse to perform intermittent catheterization
4 times a day ().
Patients were followed as
outpatients. They were monitored with urinalysis to
check for UTI and with US for upper urinary tract evaluation. Once a year the
patients underwent a voiding cystogram, renal scintigraphy and, occasionally,
an urodynamic study.
Early postoperative
course was uneventful. Patients with the Mitrofanoff channel performed CIC initially
4 times a day but subsequently were oriented to catheterize their bladder only
after a spontaneous micturition. Residual volume reduction was seen in three
of four patients and CIC frequency could be reduced. Two patients had documented
residual volume and therefore maintained regular catheterization over 2 times
a day. One patient did not perform any CIC and another one did it only once
a day. The clinical follow-up for this group of patients was satisfactory and
3 of them did not have any more clinical UTI. The patient who persisted with
mild clinical UTI remained with VUR and was referred to an anti-reflux surgery.
The two patients
of the other group initially maintained high residual volumes but one recovered
progressively as he started voiding better. Clinically both these patients had
recurrent pyelonephritis (more than 2 UTI a year).
All patients felt
an improvement in constipation and were very satisfied with the final cosmetic
appearance of the abdominal wall.
We could not correlate
renal damage with the surgical procedure. Concerning the vesicoureteral reflux,
one patient is still waiting for surgery, one has been previously operated and
the other has reflux into a nonfunctional kidney and nephrectomy is being considered.
Present follow-up is 23.5 months ().
The overall prognosis
of prune belly syndrome is poor, with more than 20% of extreme cases being stillborn.
Renal failure will develop in approximately 30% of survivors during childhood
and adolescence. Early detection of urinary infection or renal deterioration
can be done by close surveillance enabling early recognition of bladder drainage
abnormalities, which are the main source of complications.
Reduction cystoplasty
and extensive tailoring of the ureters and reimplantation have been advocated
in an attempt to improve drainage but adequate emptying can in fact be obtained
with clean intermittent catheterization. The abdominal wall defect has long
been regarded as a purely cosmetic disability and managed by elasticized corset-like
body stocking undergarments, but clinical results with the Monfort wall plasty
emphasized improvements in self-esteem, bowel function and marked reduction
in post-void residual urine (1). Smith et al. reported a decrease in post-void
residual volumes in 7 patients treated by the Monfort abdominoplasty without
concomitant urinary tract reconstruction from 40% of bladder capacity preoperatively
to 14.3% postoperatively.
Another argument
in favor of reconstructing the abdominal wall is the beneficial effect on spinal
stability. The prevalence of spinal deformities, particularly those related
to scoliosis, in prune belly syndrome might be secondary to a chronic imbalance
in spinal musculature and there is evidence that abdominal wall strengthening
constitutes an important aspect in the restoration of overall trunk muscle function
and stability (2).
The Monfort abdominoplasty
enables an effective increase in the thickness of the anterior wall and rapidly
gained popularity after its introduction to the medical community (3,4).
Other techniques
have been proposed as alternatives to the Monfort abdominoplasty. Furness et
al. reported on an extra peritoneal plication technique which obviated the need
for a fascial incision and/or entrance into the peritoneal cavity and presented
adequate cosmetic results in 13 patients (5). Although this method consists
of an extra peritoneal approach, only 5 patients from the series were treated
without celiotomy, since most patients required at least an open orchidopexy
at the time of the abdominoplasty.
We believe that
the Monfort procedure is “the gold standard” technique to reconstruct
the abdomen. We perform the Monfort procedure routinely for full-blown syndrome
at the time of transabdominal orchidopexy in early infancy. The appendicovesicostomy
procedure is a straight-forward procedure once the abdominal wall is open and
the bladder prepared after removal of the urachal diverticulum. We admit, however,
that controversy exists regarding the true advantage of early post-operative
intermittent catheterization as defended in our study.
In our series,
we were able to compare 4 patients who started urinary catheterization immediately
after abdominoplasty 4 times/day through a Mitrofanoff channel with 2 patients
who were not provided with an outlet channel. All patients presented recurrent
UTI and bowel constipation pre-operatively. We recognize that due to the small
number of patients, no definitive conclusion can be taken but we were able to
identify some trends in the clinical evolution of these patients. Considering
UTI as a clinical parameter, we observed that patients in the first group had
significantly less UTI than patients in the second group, which had persistence
of recurrent pyelonephritis (more than 2 a year). However the presence of vesicoureteral
reflux is a second factor that also contributes to UTI occurrence besides post-void
residuals and in cases in which both factors occur we recognize is not possible
to attribute the influence of each separately. The beneficial aspects of abdominoplasty
were visible in both groups, consisting of improvement in bowel habits and reduction
of the residual volume. Patients with elective Mitrofanoff showed progressive
reduction of residual volume and at the last follow-up only two of them needed
objectively post-void catheterization (more than 40% of the capacity). In the
other group, one of the two also did not present residual volume. This result
suggests that abdominal wall reconstruction itself is responsible for improvement
in bladder emptying and that an elective Mitrofanoff is advantageous, only during
the accommodation period, for 50% of the patients and essential, for much longer
periods, for the other 50%.
If one considers
that pyelonephritis is an important risk factor for renal scars in children
less than 5 years of age, it seems logical to consider ways to minimize such
risk. The popularization of CIC and catheterizable stomas in pediatric urology
helped us to learn about the advantages and special cares and needs of patients
and families and also about the complications of appendicovesicostomy. One could
argue that when we provide a Mitrofanoff channel for every patient with prune
belly we are probably overtreating many of them. This is probably true and our
series suggests that this might have happened in half of the cases. On the other
hand, the aggressive treatment of residual volume may have a role in renal function
preservation although this could not be proved in this short series. We agree
that the persistence of vesicoureteral reflux also might have been an important
factor contributing to postoperative pyelonephritis and this should be considered
when evaluating overall response to the treatment we are proposing (6).
We should note
that an appendicovesicostomy is a simple surgical step when one is already reconstructing
the abdominal wall but it is certainly more complicated if performed later on.
Another beneficial
aspect of routine early abdominoplasty is the possibility of performing concomitant
orchidopexy. Recent advances in the treatment of fertility support the idea
that many patients with the prune belly syndrome may ultimately be fertile and
therefore treated. Repair in infancy generally allows successful placement of
the testes into the scrotum without division of the spermatic vessels which
is obviously facilitated by the abdominal incision. In our series, all testes
were easily brought to the scrotum and showed no evidence of retraction or shrinkage
in the present follow-up.
CONCLUSION
In conclusion
we believe that treatment of the prune belly syndrome is evolving and if one
is interested in the functional aspects of the urinary tract our concept of
early abdominal bladder emptying is appealing. As seen in this short series,
no morbidity was added to the first group compared to the classical approach
of abdominal wall reconstruction and orchidopexy. Our data suggests beneficial
effects in reducing post-operative UTI events in the elective Mitrofanoff group
of patients. We recognize, however, that the series is small and only a longer
follow-up with larger number of patients will allow us to confirm our suppositions.
We admit that this approach is novel and it is still in investigation in our
Department and we recognize the opinion of others regarding the standard approach
which is still abdominoplasty alone and a Mitrofanoff channel in more selected
cases. However this “no risk at all strategy” with little increase
of morbidity during the Monfort abdominoplasty is definitely an argument to
propose this different approach.
OF INTEREST
None declared.
REFERENCES
1. Smith CA, Smith
EA, Parrott TS, Broecker BH, Woodard JR: Voiding function in patients with the
prune-belly syndrome after Monfort abdominoplasty. J Urol. : 1675-9.&&&&&&&&[  ]2. Lam KS, Mehdian
H: The importance of an intact abdominal musculature mechanism in maintaining
spinal sagittal balance. Case illustration in prune-belly syndrome. Spine. 1999;
24: 719-22.&&&&&&&&[  ]3. Monfort G, Guys
JM, Bocciardi A, Coquet M, Chevallier D: A novel technique for reconstruction
of the abdominal wall in the prune belly syndrome. J Urol. : 639-40.&&&&&&&&[  ]4. Woodard JR:
Prune-belly syndrome: a personal learning experience. BJU Int. 2003; 92 Suppl
1: 10-1.&&&&&&&&[  ]5. Furness PD 3rd,
Cheng EY, Franco I, Firlit CF: The prune-belly syndrome: a new and simplified
technique of abdominal wall reconstruction. J Urol. : 1195-7; discussion
1216.&&&&&&&&[  ]6. Liguori R, Macedo
A Jr, Gon&alves I, Nobre Y, Garrone G, Hachul M, Ortiz V, Srougi M. The
Monfort technique for abdominal wall reconstruction, orchidopexy and elective
appendicovesicostomy in the management of the prune belly syndrome. J Urol 2005:
173; 204 (Abst 750).&&&&&&&&[  ]&
Correspondence address:
Dr. Antonio Macedo Jr
Federal University of S&o Paulo
Rua Maestro Cardim, 560 / 215
S&o Paulo, SP, , Brazil
Accepted after
September 1, 2006
EDITORIAL COMMENT
Parallel to its
main characteristics, the Prune Belly Syndrome (PBS) is also known for a variable
presentation among the patients, as well as the lack of correlation between
the degree of abdominal laxity and urinary tract involvement. Also, the intensity
of dilatation and dysplasia of one kidney and its ureter is not the same as
that of the contralateral unit. The presence of vesicoureteric reflux (VUR),
and the capacity of the bladder to empty itself adequately are other variables
that have to be considered when planning the treatment of these patients.
In this work, the
authors present their experience with 5 patients in whom a Mitrofanoff channel
was added as a means for easy catheterization, when abdominoplasty and orchiopexy
were performed. The concept of intermittent bladder catheterization in PBS patients
is interesting, since several, but surely not all of them, have significantly
enlarged and hypotonic bladders, with post-void residuals, that are associated
to urinary tract infection (UTI). Nevertheless, the presence of VUR to a dilated
ureter, sometimes associated to a kidney with already limited function, is probably
more important in the cause and recurrence of pyelonephritis. In the group of
patients described, it seems that persistence of VUR was more important for
the recurrence of UTI and pyelonephritis than the lack of the Mitrofanoff channel.
Not mentioned by
the authors, the comprehensive surgical treatment, proposed by Woodard almost
30 years ago, includes the simultaneous orchiopexy and abdominoplasty with the
reconstruction of the urinary tract, according to individual needs: the non-functioning
kidneys and its ureters are removed, the very dilated and/or refluxing ureters
are tailored and reimplanted and the very enlarged bladders are partially reduced
in size, with removal of their non-contractile domes and urachal diverticulum
(1). With this procedure, the anatomical conditions of the urinary tract that
predispose further renal injury due to pyelonephritis are significantly reduced.
In our experience of 32 patients treated comprehensively without primary diversion,
20 (including 4 without bladder reduction) had normal postoperative voiding,
without residuals, and 9 presented a hypocontractile bladder, but had adequate
emptying achieved with scheduled voiding associated to Cred&’s
and Valsalva’s maneuvers. Only 3 patients had significant postvoid residuals,
requiring either intermittent catheterization or secondary vesicostomy. Furthermore,
recurrent asymptomatic bacteriuria was observed in only 4 children, including
2 undergoing intermittent catheterization, while renal function deteriorated
in only 2 patients (2).
It is our opinion
that the comprehensive surgery efficiently prevents UTI and pyelonephritis in
PBS patients not only by reducing urinary stasis in the bladder and ureter,
but also by eliminating the VUR. The addition of a Mitrofanoff channel to the
procedure, on an individual basis, may help on the long run the reduced number
of patients whose bladders have significant and irreversible voiding malfunction.
However, the correct preoperative identification of such patients is still matter
of debate.
REFERENCES
FT: Surgical Treatment of Prune Belly Syndrome. In: Hohenfellner R, Fitzpatrick
JM, McAninch JW (eds.), Advanced Urologic Surgery. Malden, Blackwell Publishing.
2005, pp. 458-464.
FT, Arap MA, Giron AM, Silva FA, Arap S: Comprehensive surgical treatment of
prune belly syndrome: 17 years experience with 32 patients. Urology. 2004; 64:
Francisco T. Denes
Division of Urology
University of Sao Paulo, USP
Sao Paulo, Brazil
EDITORIAL COMMENT
of the most important problems related to the Prune Belly syndrome is regarding
the urinary stasis and incomplete bladder emptying, both predisposing to repeating
conditions of acute pyelonephritis and loss of renal function. The reduction
of postvoid residuals can be obtained with reduction cystoplasty at the bladder
dome, sphincterectomy, and ureteral tailoring with reimplantation, besides abdominoplasty.
Clinical measures can be added such as the Valsava and Cred& maneuvers
and, finally, intermittent catheterization (made difficult due to the normal
sensibility of the urethra). As an additional preventive measure the authors
propose a systematic construction of abdominal stoma in association with the
Monfort abdominoplasty and present a comparative study in 6 cases, insufficient
for significant conclusions, but justifiable due to the low incidence of the
syndrome. A lower incidence of pyelonephritis was obtained in the diverted group
and a routine incorporation of the abdominoplasty procedure was suggested.
On reference 1 in the manuscript, the voiding function was studied in 12 patients before
and after abdominoplasty. The questionnaires answered showed a subjective increase
in voiding, continence, vesical plenitude sensation and urinary flow parameters.
However, the urodynamic parameters, bladder capacity and maximum detrusor pressure
did not change. Even though the mean residual volume dropped from 40.3% to 13%,
no patient required intermittent catheterization and the incidence of UTI dropped
approximately 80% in all patients. Such data show a direct cause implication
of abdominoplasty over the micturition quality. D&nes et al. (1) reported
longitudinal abdominoplasty and urinary reconstruction in 32 patients with a
mean postoperative follow up of 5 years. Twenty patients progressed with normal
voiding without residual urine, 9 were compensated with Cred& and Valsava
maneuvers, 2 were submitted to catheterization and 1 to a vesicostomy. Renal
function worsened in only 2 patients. The mentioned works included heterogeneous
samples, both in relation to the severity of the cases and to the urinary reconstruction
performed, making it difficult adequate comparisons. However, they suggest cutaneous
derivation routinely associated to abdominoplasty, as proposed in the present
work, even though with little change in morbidity, seems to mean overtreating
for the majority of the patients. In the lack of a well defined criteria, the
preoperative selection of cases with compromised renal functions and high residual
volumes, may contribute for a more rational and precise indication of the Mitrofanoff
principle. Another pertinent consideration would be the convenience of the treatment
of high degree reflux together with abdominoplasty aiming at avoiding future
re-intervention besides contributing to urinary infections control.
1. Denes FT, Arap
MA, Giron AM, Silva FAQ, Arap S: Comprehensive surgical treatment of prune-belly
syndrome: 17 years’ experience with 32 patients. Urology. 9-94.
Paulo R. Monti
Head, Section of Urology
School of Medicine,
Triangulo Mineiro Federal University
Uberaba, Minas Gerais, Brazil