table urinary incontinence. J Urol 1995 ... center evaluation of urinary incontinence man- agement and ... umbilicus for continent abdominal stoma in chil- dren.
BLADDER NECK CLOSURE 10-YEAR FOLLOWUP
10. Misseri R, Casale AJ, Cain MP et al: Alternative uses of dextranomer/hyaluronic acid copolymer: the efficacy of bladder neck injection for urinary incontinence. J Urol 2005; 174: 1691. 11. Jayanthi VR, Churchill BM, McLorie GA et al: Concomitant bladder neck closure and Mitrofanoff diversion for the management of intractable urinary incontinence. J Urol 1995; 154: 886. 12. Khoury AE, Agarwal SK, Bägli D et al: Concomitant modified bladder neck closure and Mitrofanoff urinary diversion. J Urol 1999; 162: 1746.
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13. Hoebeke P, De Kuyper P, Goeminne H et al: Bladder neck closure for treating pediatric incontinence. Eur Urol 2000; 38: 453.
17. Hensle TW, Kirsch AJ, Kennedy WA 2nd et al: Bladder neck closure in association with continent urinary diversion. J Urol 1995; 154: 883.
14. Cervellione RM, Bianchi A, Fishwick J et al: Salvage procedures to achieve continence after failed bladder exstrophy repair. J Urol 2008; 179: 304.
18. Lemelle JL, Guillemin F, Aubert D et al: A multicenter evaluation of urinary incontinence management and outcome in spina bifida. J Urol 2006; 175: 208.
15. Nguyen HT and Baskin LS: The outcome of bladder neck closure in children with severe urinary incontinence. J Urol 2003; 169: 1114. 16. Mitrofanoff P: Cystotomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir Pediatr 1980; 21: 297.
19. Barroso U, Jednak R, Fleming P et al: Bladder calculi in children who perform clean intermittent catheterization. BJU Int 2000; 85: 879. 20. Landau EH, Gofrit ON, Cipele H et al: Superiority of the VQZ over the tabularized skin flap and the umbilicus for continent abdominal stoma in children. J Urol 2008; 180: 1761.
EDITORIAL COMMENT These authors report a retrospective BNC series with long followup (mean 12.4 years) in 5 patients with exstrophy, 3 with spinal dysraphism, 1 with sacral agenesis, 2 with trauma and 1 with a duplicated hindgut. Initial BNR was attempted in 11 patients but only 5 underwent concomitant bladder augmentation. Overall 11 of 12 patients underwent augmentation and 12 also received a Mitrofanoff channel in association with BNC. These values highlight the importance of bladder capacity at initial BNR and the fact that there are few candidates for BNR without simultaneous augmentation. My tendency is to augment cases that need a BN operation.1 On the other hand, an ideal
BNR technique is lacking, especially for exstrophy. In terms of the long-term risks of BNC periodic bladder irrigation, and aggressive CIC protocols are essential to avoid bladder stones and perforation, which are mostly seen in adolescents. Considering outlet channels, we recently incorporated a new approach after experimental and preliminary clinical experience, which may be used in association with BNC without gaining access to the peritoneal space.2 Antonio Macedo, Jr. Federal University of São Paulo São Paulo, Brazil
REFERENCES 1. Macedo A, Jr: Ileal reservoir with ileal catheterizable channel. In: Hinman’s Atlas of Pediatric Urologic Surgery. Edited by F Hinman Jr and L Baskin. Philadelphia: Saunders Elsevier 2009; pp 542–545. 2. Macedo A, Jr, Rosito T, Pires JAS et al: A new extra-abdominal channel alternative to the Mitrofanoff principle: experimental and preliminary clinical experience. Int Braz J Urol 2009; 35: 206.
REPLY BY AUTHORS Concomitant bladder augmentation in every patient who undergoes BNR might be correct practice for neuropathic bladders. However, it is not accepted practice for exstrophy, as BNR without augmentation is the standard of care in staged repair of these complex cases provided bladder capacity during an-
esthesia is not less than 85 ml.1 Bladder augmentation was discussed several times with the patient with duplicated hindgut. The final decision not to augment subsequently proved to be correct, as this patient has maintained continence and upper tract integrity for more than a decade.
REFERENCE 1. Baker LA and Gearhart JP: The staged approach to bladder exstrophy closure and the role of osteotomies. World J Urol 1998; 16: 205.
