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Botulin toxin has been used in various diseases of the urinary tract such as idiopathic or neurogenic detrusor hyperactivity, interstitial cystitis, painful bladder syndrome and benign prostatic hyperplasia 6.

Reports of the application of botulin toxin to children have shown good results. Hoebeke et al. However, they also reported side effects in all children studied 7. In a retrospective analysis of 10 children with detrusor hyperactivity of neurogenic cause treated with 3 to 5 applications of botulin toxin, Schulte-Baukloh et al. In a previous study, these investigators emphasized the need for periodical reapplications of botulin toxin to the detrusor 9.

Bladder augmentation is believed to improve the quality of life of children or adolescents with urinary incontinence The closure of the bladder neck performed during ileocystoplasty is effective for the control of urinary incontinence. This procedure involves low morbidity, at times requiring surgical revision, but its indication requires adhesion to the process of intermittent catheterization The tissue considered to be ideal for augmentation is the urinary tract itself, used in situations of unilateral renal exclusion with ureteral dilatation 12 , When it is not possible to use the ureter, intestinal segments of the colon or ileum are usually employed or, more rarely, a gastric segment is used.

However, due to the complications related to the use of intestinal tissue in the urinary tract, there is a need to search for alternative tissues for bladder augmentation.

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Bladder augmentation with an intestinal segment is not free of complications. These complications may be related to the procedure itself such as difficulty in conduit catheterization, urinary infections, intestinal obstruction or anastomosis dehiscence, lithiasis or perforation of the reservoir and neoplasias, as reported by DeFoor et al.

In addition, these patients present metabolic and electrolytic intercurrences after incorporation of the intestinal segment to the urinary tract, with metabolic acidosis being the most common 14 - Chronic acidosis can cause a reduction of bone mineral density and rickets or osteomalacia in children and osteoporosis in adults 5. However, even though some authors consider that children who require bladder augmentation are at a higher risk for osteopenia and compression fractures, the risk factors are often associated more with the base disease of the patient than with the surgical procedure Another possible complication is deficiency of vitamin B, which is absorbed through the ileum.

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In cases in which an ileal segment is used for bladder augmentation, the deficiency of this vitamin may cause megaloblastic anemia and Hunter glossitis. The intestinal changes that occur are mainly related to the enterohepatic circulation of bile salts and to colonization of the ileum by colonic bacteria in cases in which the ileocecal valve was removed. Increased concentrations of bile salts, water and sodium in the colon may cause diarrhea and steatorrhea. Colonization of the ileum by colonic bacteria alters the conjugation of bile salts, reducing fat absorption and also contributing to steatorrhea.

The absorption of insoluble vitamins A, D, K may be impaired. During the follow-up of the present patients, none of them presented clinical manifestations of water-electrolyte disorders and none required replacement of vitamin B12 or of liposoluble vitamins. This was probably due to the fact that the terminal ileum and the ileocecal valve were preserved, preventing diarrhea and preserving vitamin B12 absorption. No patient had osteomalacia or rickets. Regarding the complications related to the conduit for bladder catheterization, such as stenosis of the stoma, incontinence, difficulty in performing catheterization, prolapse, bleeding and perforation, reintervention is usually necessary for correction.

In the present study, only one patient had perforation of the conduit, which was corrected with surgery. In an attempt to reduce the incidence of lithiasis, which may require a surgical procedure for calculus removal and may be associated with urinary infection, periodic bladder washing with 50 ml of saline solution two to four times a day is recommended. The intestinal segment used for augmentation may produce large amounts of mucus which facilitate the obstruction of the bladder outlet and the formation of calculi 19 , A technical step that may be of help in reducing the incidence of lithiasis is the site of conduit implantation Mitrofanoff for catheterization.

Patients with an implant in the posterior bladder wall, which perhaps permits a more effective drainage of urine and mucus, develop fewer calculi than patients with an implant in the anterior bladder wall In the patients of the present series the incidence of bladder lithiasis was The management of VUR in bladder augmentation is a controversial point, with some authors suggesting ureteral reimplantation at the time of augmentation 22 while others believe in the reduction of VUR degree or in VUR disappearance with a reduction of intravesical pressure 23 , In a more recent review study, Misseri et al.

However, they stated that they did not detect a clear correlation between degree of reflux and successful reimplantation. Based on their review, they were unable to conclude whether ureteral reimplantation was more successful than observation, or vice versa. Ureteral reimplantation was not performed in any of the present patients with VUR.

Nine of the 19 kidneys with VUR showed improvement. However, since urethrocystography was not available for all patients, it is difficult to reach a definitive conclusion regarding our patients. Bladder augmentation with an ileal segment in children is a procedure that can provide good results in terms of preservation of the upper urinary tract and of renal function, permitting some previously incontinent patient to achieve continence.

Clinical and surgical complications can occur considering the complexity of the base disease, the clinical condition of the patient, the results of previous treatments, and the magnitude of the surgical procedure. Thus, these children require long-term follow-up and their attending physicians, pediatrician and urologist, must be able to recognize these complications and how to treat them.

J Pediatr Urol.

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PMID: Mitrofanoff P. Trans-appendicular continent cystostomy in the manangement of the neurogenic bladder. Chir Pediatr.

What topics will you cover?

Macedo A Jr, Srougi M. A continent catheterizable ileum-based reservoir. BJU Int. Start Here.

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Bowel regularity generally can be maintained by following a few simple suggestions: Drink adequate amounts of fluids — at least 48 ounces 6 to 8 glasses of fluids daily. Include plenty of fiber in your diet. Fiber can be obtained from fresh fruits and vegetables, whole grain breads and cereals, and dietary additives such as powdered psyllium preparations.

Get some physical activity. It helps keep things moving. Discuss remedies such as stool softeners, bulk forming supplements, enemas, suppositories or manual stimulation with your healthcare provider. It may take several weeks to know if these remedies are working. Continuous or regular use of laxatives is generally not recommended. Home Delivery Incontinence Supplies, Inc. Carries a variety of adult incontinence products including popular and specialty brands. February Ashford Always highly professional and empathetic. February Canterbury Very helpful with the issues we had.

February Dover Staff name is brilliant working with my son and understands his needs and issues. January Herne Bay Took the time to explain complicated doses - leaving me knowing what to do - in the long term solving the problem and if the problem is solved then my son won't need further care and therefore cost more NHS money. January Thanet Service has been extremely helpful and have felt like our concerns have been listened too and dealt with efficiently. January Sheppey The lady has been very helpful and went through everything and spoke to my daughter about her problem.

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