title: Total continence reconstruction using the artificial urinary sphincter and the Malone antegrade continence enema.
abstract: OBJECTIVE
  Surgical management of children with myelomeningocele addresses 2 aspects of the disease, neurogenic bladder and neurogenic bowel. Results of total continence reconstruction using an artificial urinary sphincter and Malone antegrade continence enema are presented.
  
  
  METHODS
  We performed a retrospective chart review of patients who underwent simultaneous artificial urinary sphincter placement and a Malone antegrade continence enema procedure. From 1997 to 2007 a total of 21 patients with myelomeningocele underwent total continence reconstruction using the artificial urinary sphincter. Mean patient age was 10.4 years (range 6 to 22) and mean followup was 4.7 years (range 0.66 to 11.7). Artificial urinary sphincter cuff was placed around the bladder neck. A Malone antegrade continence enema was performed using appendix in 19 patients and cecal based flaps in 2. Two patients underwent concomitant augmentation cystoplasty. Six patients had concomitant Mitrofanoff vesicostomy using split appendix in 4 and Monti tube in 2.
  
  
  RESULTS
  Immediate postoperative complications were observed in 5 patients, including prolonged ileus (2), urinary tract infection (2) and superficial wound dehiscence (1). Seventeen patients (81%) achieved complete urinary continence and 5 were voiding with sphincter cycling. Improvement in urinary continence with dry intervals greater than 3 hours was reported in 2 patients. There were 19 patients (90%) who reported fecal continence, with 2 reporting soiling 1 to 2 times a week. Malone antegrade continence enema stoma stenosis occurred in 3 patients and 2 required revisions. Sixteen patients (76%) achieved complete continence of stool and urine. During followup 2 artificial urinary sphincters were explanted and 8 patients (38%) underwent bladder augmentation.
  
  
  CONCLUSIONS
  Urinary and fecal continence in patients with myelomeningocele is achievable with a single total continence reconstruction procedure using the artificial urinary sphincter and the Malone antegrade continence enema with durable results.
authors.affiliation: Division of Pediatric Urology, Miami Children's Hospital and Department of Urology, University of Miami, Miami, Florida 33133, USA. yuvalbary@hotmail.com
authors.forename: Yuval
authors.initials: Y
authors.lastname: Bar-Yosef
authors.forename: Miguel
authors.initials: M
authors.lastname: Castellan
authors.forename: Devandra
authors.initials: D
authors.lastname: Joshi
authors.forename: Andrew
authors.initials: A
authors.lastname: Labbie
authors.forename: Rafael
authors.initials: R
authors.lastname: Gosalbez
mesh_terms: D000293:Adolescent; D002648:Child; D013505:Digestive System Surgical Procedures / Q000379:methods; D004733:Enema; D006801:Humans; D008591:Meningomyelocele / Q000150:complications; D055496:Neurogenic Bowel / Q000150:complications / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D001750:Urinary Bladder, Neurogenic / Q000150:complications / Q000209:etiology / Q000601:surgery*; D016741:Urinary Sphincter, Artificial; D055815:Young Adult