LONG TERM OUTCOME OF RECTAL BLADDER USING MODIFIED DUHAMEL TECHNIQUE IN THE MANAGEMENT OF BLADDER EXSTROPHY IN DUHOK CITY, IRAQ

Abstract

https://doi.org/10.31386/dmj.2025.19.2.2

Background: Urinary diversion is a great challenge in urological surgery, and it is also one of the hot spots in urology. Heitz-Boyer-Houvelac uretero-rectostomy was introduced in 1912. Shaw reported that he performed ureterorectal anastomosis in male and female corpses and demonstrated the feasibility of this procedure in 1937¹.one of the main indications for urinary diversion is Bladder exstrophy which is one of the most serious congenital malformations, is characterized by a spectrum of anomalies involving the ventral body wall, urinary tract, genitalia, bony pelvis  in which the bladder does not form into its normal round shape but instead is flattened and exposed on the abdominal wall and the pelvic bones are widely separated. This condition needs to be repaired surgically; the goal of treatment is to reform a considerable sized bladder, to optimize urinary control, to preserve normal renal function and to optimize the appearance and function of external genitalia, However nearly 10% of exstrophic bladders are of small capacity, and at least a further 30% of patients remain incontinent of urine even after a well performed staged reconstruction³.

Key words: Duhamel’s pull-through; Bladder exstrophy; Urinary diversion

Aim: To evaluate the efficacy and safety of the uretero-rectostomy using modified Duhamel’s technique for urinary diversion in treating urinary incontinence in patients with bladder exstrophy, preserving renal function and functional cosmetically acceptable genitalia following the repair of bladder exstrophy and to assess for the long-term complications metabolic, anatomical, risks of neoplasms and the physical quality of life.

Patients and Methods: Five years retrospective study conducted from March 2009 to July 2014 and seven years prospective Sept. 2014 to Nov. 2021. Twenty seven patients, nineteen male and eight female, age ranging 4 to 11 years  mean age 6.8 years, all patients underwent the same surgical technique by the same surgeon in two different hospitals, Paediatric Surgery Center at Heevi paediatric teaching hospital and Vazeen private hospital, anal sphincter function were studied in all patients by contrast enema and anal muscle electrical stimulator, average hospital stay was one week, intensive toilet training started one month postoperatively for two months, renal function test, serum electrolytes and PH were checked every two month for 1st six months and then every six months for two years after that every year during the follow up period, renal ultrasound every three months for first year then every six months during follow up period, rectal pouch capacity were assessed at three months and one year postoperatively using proctography, annual proctoscopy  with rectal biopsy was done,  at each visit frequency of urination and nocturnal bed wetting were assessed.

Results: Blood transfusion intraoperative in one patients, the mean operative time was four hours, in all patients the postoperative recovery were uneventful, during hospital stay Electrolytes, RFT, Blood gases, haemoglobin level and haematocrit values were checked daily all were within normal values and later according to follow up schedule, the rectal pouch capacity was significantly increased after one year with a mean of 330ml,  The ability of retaining motions was improving with time with a mean of 4 hrs. at one year, Bedwetting was significantly decreasing with time, from 8 times per month at 3 months to 4 times per month at 6 months and once monthly at one year follow up, two patients needed constipating agent for one month to assist rectal control,  Four patients had UTI, three of them without recurrence during follow up and one had recurrent UTI with febrile pyelonephritis and the cause was corrected surgically, Perianal skin excoriation were in 5 patients, most of them respond well to local emollients, none of patients had abnormal histopathology form the rectal pouch biopsy, regarding child satisfaction, girls more than boys.

Conclusion: Urinary divesion using modified Duhamel’s technique by creating rectal-bladder and uretero-rectostomy is good, easy to perform, successful in the immediate short term results with low complication rate in long term follow up.