Continent diversion using the Mainz Pouch II procedure for Bladder Exstrophy - a 15-year experience
Safwat Andrawes, MD1, Dan Poenaro, MD2.
1Nairobi Hospital, Nairobi, Kenya, 2McGill, Monterial, QC, Canada.
BACKGROUND: Bladder exstrophy patients represent a significant challenge in East Africa. They typically present late at ages up to 25 years, have limited access to basic medical care, are unable to return for multiple surgeries, and cannot financially afford neither surgical care nor even transport to specialized facilities. The most disturbing problem is urinary incontinence, considered similar to a curse in resource-constrained communities. Bladder capacity is typically inadequate, both in fresh cases and in the many with failed attempts at urinary reconstruction. The Mainz Pouch II (MP) continent uretero-sigmoidostomy uses the anal sphincter for urinary continence in a single surgery, and reduces ascending urinary infections as well as hyperchloremic acidosis.
METHODS: Criteria for performing the MP were: two previous failed bladder closure attempts, one failed bladder neck reconstruction, a bladder capacity under 100 cc 3 years after bladder closure, age over 6 years, and patients coming from remote areas with limited access to follow-up appointments and to further procedures. A detailed explanation of the procedure to the parents and patients was critical, and a continent anal sphincter essential.
RESULTS: Between 2003 and 2017 MP was used in 30 patients at two charitable private hospitals in Kenya. Patient age ranged from 6 years to 25 years (mean 10.5 years). All 30 patients experienced 100% day continence and 90% night continence at last follow-up, and were returned to school and normal life. One patient died early in the series one year after surgery from stenosis of ureteric re-implantation and progressive renal failure. The longest follow-up was 15 years (3 patients). Only one patient underwent routine colonoscopy after 10 years - the rest could not afford the procedure. Renal function and renal Ultra Sound scan was followed for up to one year and remained normal; one patient required bicarbonate supplement. Twenty patients were unfortunately lost to follow-up beyond 2 years.
CONCLUSIONS: The MP is life-changing for late-presenting patients with Bladder Exstrophy and is a good alternative to failed classic staged repairs. It is better accepted culturally than stomas, and avoids catheterization which is often not possible in remote areas for lacking of running water and catheters , has a lower complication rate and lower number of re-do interventions than other diversion procedures,. We recommend this operation for selected bladder exstrophy patients in such settings as a simple, reliable and viable answer to a great urological problem.
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