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Oh um ok, greetings uh to everybody from warm and sunny East London. Um and thank you for joining us. Uh Today, we are really uh privileged to have um our I can say a good old friend uh Professor John Lazarus, uh who will give us a talk on incontinent and continent urinary diversions in Children. And uh Professor Jones, uh he is the head of Division of Urology in the University of Cape Town which covers the hospital and the Red Cross Children's Hospital. And he's also the pediatric urologist and in charge of pediatric urology at the Red Cross Children's Hospital. And uh John, as we, most of us, we call him because we know him for so long. And he also has strong family connections to our department and worked in our department like 25 years ago. Um He is highly respected in the pediatric urology field, not only in the country but out so outside the country. So John, we are really pleased to have you. Thank you for spending time and you can start your talk. Uh Milo, thank you very much for those kind words of introduction. And uh thank you very much to your team for uh hosting. Uh Last uh Tuesday, we had a very productive meeting uh talking about some complicated uh cases in East London. Uh So, Professor Chit has asked me to talk about urinary diversion in Children. It's quite a broad topic and I hope uh without going too much into too much detail and we're just gonna hopefully give an overview that I think will be useful to the trainees to have some perspective about this big topic. I thought by way of starting, we've got three clinical cases which are quite um interesting and I think they will give food for thought and hopefully, uh talk about some of the practicalities of uh urine diversion in Children. The first case is certainly quite a startling case. And um, I don't know if there are any senior registrars who would like to have to get their teeth into what they might do at various points in this case. Uh I don't know if you could recommend perhaps there is one of the trainees who might want to answer some questions here. Um ok. Um I can see, I can see all the participants I could see. Uh Doctor Hilger in the house. Uh is Doctor Neha Gautam around Neha, if not, uh then Doctor HGA can, can try and answer. Ok, sorry to put some pressure, but it's uh we'll just have a bit of discussion. So the first case is very straightforward in some ways it was thought to be an uncomplicated, uh, inguinal hernia repair in a five month old male. However, he was very much not, well, the following day and required a laparotomy and believe it or not at the time, the laparotomy, right, ureteric injury and bladder injury was noted. So, Doctor Hilbert, what would you think has happened here, um, during the herniotomy, possibly an injury to the or uh, yeah, we were at the wrong space and injured the bladder and possibly the ureter, which I've seen have almost happened once good. And under what circumstances can that happen? Um, especially if it's a, um, a thick sac, big ureteric opening or very swollen, um, tissues that the dissection is more difficult and more difficult to differentiate what tissue we are actually dealing with. Uh, so I recall, Professor Chit teaching me how to do an in hernia repair and I've always had a great deal of respect. It's uh an operation that you need to be shown uh, properly how to do. You need to understand the anatomy very carefully and uh, not the simplest operation that we have to do as, as pediatric surgeons. Um, so it's probably a sliding hernia, isn't it? I suppose that's the word that we're looking for here to describe what this is. But the doctors were asked in retrospect, they had described a big sac. So they certainly hadn't appreciated that they were not simply dealing with, uh, simply inflamed hernial sac and didn't appreciate that. Perhaps that might have some contents anyway. So what should be done? What would you have done in, under these circumstances? Doctor Gan, you had laparotomy. Now you find a transected ureter and bladder injury. Um, well, certainly the bladder repair at, at that setting. I'm not entirely sure how, but the ureteric injury is, um, whether it can be repaired over a stent or not, not sure you need more information to properly assess what you need to do. Anyway, we the surgeons performed a cutaneous ureterostomy, uh was fasciated and the bladder was under son with that laparotomy. Unfortunately, the child was called back the very next day and it was when I was called, you know, sore laparotomy on day two, the right ureter was found to be non viable. And I think there's a message there that ureter is a very delicate organ and needs lots of respect. Lots of governs need to be left on the ureter. And in addition to the left was now found to be also transected. And so bilateral cutaneous reclast is performed and the surgeons noted that there was no real apparent bladder lift with this boy. Uh a week later, a third laparotomy was required by for adhesive bile obstruction. The right ureter was again found to be not viable and was refashioned for a second time. So, doctor, what would you do? Now, this child finally is recovering from the laparotomy or bilateral cutaneous ureterostomy and there's some suspicion that there's not much bladder left. What would you do? Um, is there not much bladder left because it's been resected or because it's just underused? Yeah. Good. So, I think we, we need a bit more information about the bladder, certainly. And, um, an investigation that could help determine that would be what is demonstrated here. I hope you can see that. So, this is a cystogram and you can get a sense all the tiny nub the bladder that is proving what we feared here was that this child had, in fact, had most of the bladder excise, complete cystectomy roughly at the level of a trigone. So bladder neck should be intact and external and sphincter critically should also be intact. So what options could we have to create a uh what would you advise the mother? There was obviously medical legal issues here and to dwell on that. But um what would be the next step for this child? Any anybody from the audience want to offer some suggestions, any of other trainees can just unmute yourself and, and onset? I think if nobody's coming forward, let's give them the answer off. All right. OK. Yes. So, so at the present time, this child is uh I think eight or nine years of age now. Uh So we've let a significant amount of time go by and you could ask the question, well, why have we waited so long? To do something definitive. He, he is a busy fellow. He's got AD HD and um one of our plans involves intermittent catheterization. And I think you can create a, a dangerous situation if you haven't got full cooperation from the uh child or what soon going to be young adult teenager. So I think this kid is up for um, for surgery this coming year and we can perhaps discuss a little bit later what our options are. Let's move on to uh the second case that we've got. Uh this is a child who came from Namibia. If I remember correctly, it's a nine month old female and she presented with a mass of the vagina. It's quite useful to have a differential for what that could be. Doctor. What, what's one of the causes for massive enteritis? I think John doctor got me joins. So let us give her preference. She's senior. So now yes. Can you see the slide? And can you answer from John's question? So what's your differential for a uh a mass at the enteritis in a, in a girl? Now, are you here? OK. If now uh is not able to answer, then I can continue. Eye, bro. No, no. How is that now? Yes, pro I can hear you. I was just trying to unmute the um OK. OK. So um the differential um so the one differential uh top is uh a rhabdomyosarcoma from the vagina. It looks like a mass to me. Very good. So that's certainly the sinister thing. In addition to that you prolapsed urethra prolapse and even benign things like um uh prolapse of urethra can perhaps cause a massive. So we went on to perform an ultrasound scan. And I think this shows a picture of the typical botryoid appearance of a uh rhabdomyosarcoma of the bladder. And uh the histology was confirmed through a cystoscopy and biopsy and this child received uh three cycles of VAC. And here's a nice operative picture which tells a rather disappointing story that unfortunately, many of these tumors are in an unfavorable site. So dry go and bladder neck area, such an elegant area of the body so critical to our bladder function. And unfortunately, in this child, despite all the chemo that had been given, there was still a mass there. Uh We did a frozen section in an attempt to uh determine how aggressive we would be. We would love to have been able to save the bladder neck, the urethra trigone. But uh our frozen sections in fact came positive, the perivesicle tissue was positive. And so we were required to do a excision of urethra and uh trigger, there's an operative picture and then you don't know who saw pediatric um histopathologist and she helped us in the frozen section. And uh just to say that this child um ended up with reasonable bladder capacity. That was the sort of disappointing thing. We unfortunately had to cut away urethra trigo, but we were left with a reasonable bladder. In her case, we performed an append vesicostomy uh onto the bladder so that she had a continent uh urinary diversion. So that's what we performed for her. The third case, uh not too dissimilar, 21 year old girl and presenting with some visible hematuria and cystoscopy revealed a bladder tumor. The tumor, unfortunately, yet again is, is commonly the case from the literature arose from the trigone, the wall appeared to be infiltrated. The lower urethra was uninvolved. Initially, we thought uh cervix and uterus were butting but clear. Uh sorry John, what, what uh operative procedure did you do for the first child? I just missed it. I beg your pardon. Uh That case is still coming for surgery and you can practice us at the end. What options we think would be useful for that child because it's clearly a an index case in many ways. Uh So we gave some chemo to this third child and uh didn't get much reduction in size. And so we elected to give radiotherapy and um at post chemo rad, we did a repeat cystoscopy and found that there was now no mass but there was still active tumor noted there was also mature rhabdomyoblast. And so this was the point for a definitive surgery. And then this child uh we did a genital sparing cystourethrectomy. And in this case, we did an incontinent uh aal conduit. And I think that I can't remember all of our thinking at the time, but II certainly have some regrets about this particular decision. We perform incontinent urinary diversions in adults for cancer of the bladder um frequently, but in Children, this is expected to last uh 90 years. And um you often get infected material from the conduit, refluxing up into the uh kidneys. And so this my child has had recurrent urinary tract infections, also had some stricturing of the urethra aal anastomosis and acquired a revision of that had at various times been discussed for a continent pouch. Uh But the family I think have moved away from that as an option. So she's left lifelong now with a an incontinent diversion. So just while we're on uh rhabdosarcoma, I feel always a little bit sad because I think the the cases that we end up with dealing with are um um quite distressing in uh rhabdo uh with Richard Wood, we reviewed our 50 cases over a 47 year period and I found that the overall survival was reasonable, 65%. Um But many of the tumors, the third had positive lymph nodes and uh 40% were greater than 10 centimeters in diameter. And I think that's the uh take home message for our developing world experience is that these rhabdodes tend to be more locally advanced, bulky nodal disease, et cetera compared with the developed world. It's a more challenging cohort to try and get urologically um uh continent and protecting of the kidneys. I must say one of my uh um I love going into the history of uh urinary diversion and it clearly is something that has plagued us as reconstructive surgeons. I think, as pediatric surgeons and urologists, we're fortunate to often have to think on our feet or unfortunate at times. Uh These aren't always reproducible operations. Each of the Children that we encounter for reconstruction requires a slightly different plan. And um the first attempts uh were from the pediatric uh community in the 19th century Thomas's Hospital in London. This paper was published and it's worth reading here. Mr Simon did indeed succeed in implanting the orifices of the ureters into the rectum and the communication soon so far established that the urine was voided for anus. And isn't that a fascinating uh description of um what we can now nowadays to know as a urethra sigmoidostomy. And I've drawn a picture here or copied a picture from the internet where we take the uh tia of the colon into that we lie the uh ureter and we close the tia over the reason we do that is to create an antireflux mechanism because these Children are obviously highly prone to uh fecal material being uh refluxed up into the kidney. So if you're able to create a nonrefluxing ureteric tunnel, then you might prevent that. And this operation has to some extent, fallen out of favor. Uh Doctor Gautam, do you know why it has fallen out of favor? It's obviously a very elegant solution. A rectal bladder, uh they void per rectum without the need for prosthesis, like uh in intermittent catheterization or bags if you put a conduit. Hello there. Doctor. Yeah, unmute yourself and answer. OK. I won't dwell too much then, but just to say that it uh is associated with colonic carcinoma. So that was the reason that it's one of the reasons that it's fallen out of favor. I do want to point out that uh the Germans have reinvented this procedure to an extent. And you'll know some of the difficult challenges that we face with our extra few patients. And in uh cologne particularly, they immediately abandon any attempts to get urethral continence in the XP community and simply take the bladder patch with its two ureters and create a um effectively a rectal bladder with that patch. And you can see the picture for that at the bottom right hand corner here. And what's important with the procedure is that the cancer is said to be where urine and feces mix, you get nitrosamines, which is said to be carcinogenic, that's the mechanism. And so by creating effectively two paths, one for feces and one for urine. In theory, you should reduce the chance of rectal polyps. There is a complication. Um Bricker is a, is a famous name in the urology community and, uh, he was the first person in 1950 to describe the ileal conduit here in a patient who had, uh, bladder cancer. And, uh, his name is still attached to one of the ureteral anastomosis. Uh We, in fact, don't use, we use something called the Wallace, but the BRCA is another option for ureteral iasis for the, um, and for the con and much of reconstructive, uh, pediatric urology wouldn't have made much progress without Jack The Piss from Ann Arbor in Michigan. This is his reprint of his 1972 paper. Uh And I think it's worth reading is seldom in medicine that things are so elegantly put and uh take us so much further. He says, intimate catheterization of the bladder should be an innocuous procedure provided the bladder is not permitted over the stent and is performed in an atraumatic fashion. Furthermore, a clean and not an aseptic technique should suffice since any bacteria introduced by the catheter will be neutralized by the resistance of the host. Uh That's just for me, one wonderful paragraph. That's uh kind of captures a big leap forward in terms of managing these patients with continent uh reservoirs. A big friend of uh South African urology is ST he comes from Bern in Switzerland and uh he's famous for the uh orthotopic neobladder and it's the uh David operation that we would use and someone who is, for example, having a rhor of the bladder and in fact, let me add that the first case, we will want to know what we were going to do. And this is probably what we're going to offer is we believe for that child, but there's no bladder left. We've got two cutaneous ureterostomy in the groin. And what we're effectively going to do is we're gonna take some ilium, we're gonna detubularise it. It's a key part of, of uh reconstruction to reduce the pressures and to create a sphere. And uh we got then ability to implant the ureter into that afferent limb, which is said to be anti-reflux. And we're gonna connect part of that uh spherical neobladder onto the uh remaining bladder neck area of this child. He may well learn to avoid uh volition by relaxing his pelvic floor and by performing a B salva. But he will also need to be able to perform catheterization to wash the mucus out of the pouch and also uh to potentially do C IC if he's carrying a residual. So that's probably what we got planned for this child this year. So we're inter to be deep waters in terms of the patient selection. And uh clearly anyone who's got renal failure would be an a contraindication to reconstruction where including bowel and the urinary tract. The obvious reason there is that you get absorption and you can get uh uremia and potentially electrolyte disturbances. You've got a short gut inflammatory bowel disease that's obviously gonna be a contraindication to using bowel in the urinary tract. And obviously, some of these cases where the urethra is no longer possible to use, that's obviously going to be a contraindication uh to a standard neobladder. We do augments and so on. In Children. You need to consider their social circumstances, their mental abilities to manage C IC, et cetera. So this is quite helpful, I think for uh trainees to have a, a little bit of a um classification for diversions in, in Children. And the first would be to say, well, you can divide it into either uh incontinent or continent. And if you think we have incontinent, you've got temporary things such as uh uh suprapubic percutaneous nephrostomy and you've got permanent, which would be ileal or colonic conduit. The chimney is where you take an ileal conduit, but you simply plug it onto the top of the bladder. So you've got the native, the psychiater junction to prevent reflux and that would be preferred to an ileal conduit because of that reason. Uh you've also got incontinent things like this boy had earlier. We discussed cutaneous ureterostomy with or without uh transureteroureterostomy. And this is something that I've become interested in for our bladder cancer patients. And we've uh about to publish now, a retrospective review of about 40 cases of uh 20 who had a conduit versus simply bringing the ureters to the skin and you speak to any urological surgeon and they're very cautious about bringing the ureter to the skin because long term they do tend to ST nose and um and it's not the preferred method, but I've done a fair bit of reading literature wise and uh with various technical modifications, I think it is an option which uh can be safe long term. And uh I won't go into the details of this, but just to say that our uh cutaneous group had higher stage, more renal impairment, so more elderly cohort uh but they had shorter hospital stay with less complications than the conduit group. And that amounted to a saving of, I remember thousands of rand. One needs to know about how you're going to implant the ureter into the uh augmented or neobladder segment. And there are various um methods for that. None of which make particularly much difference according to the meta analysis here. So the other classification it would be for continent diversion. And you need to think in terms of what sphincter you've got here. Are you going to use the native external urethral sphincter such as the stud and neobladder. We have planned for the child who has had a cystectomy through the hernia or would you use a rectal bladder using the rectal sphincter or continent such as a uh urethra? See, what else do you mean? Or would you use a micro off uh channel to use your continent and mechanism? So let's go through all three of those. There's the student and the young bladder, there are obviously other options. Um if you're using a rectal bladder and the most commonly used one is the minus two pouch. And if you're planning uh to do the appendix, the appendix is a cost toy. And uh that can either be into the bladder or it can be even if you're taking the right colon and to make what's called an Indiana, I've written Indian, it's actually Indiana pouch, um which takes the right colon, detubularise it and brings the appendix out as the continent, catheterisable stoma and use the ileocecal valve and it's where you put the ureters on to, you know, to potentially prevent reflux. So there was a famous pediatric uh adolescent urologist who said at the end of his career, he probably created enough work for several people with the complications related to reconstruction. And certainly these patients need very close follow up and obviously, things to watch out for are uh hydronephrosis, renal failure. You can get uh um fistula between bowel and the bladder infections are obviously a problem. And late you can get stones in these pouches. You can get uh stomal stenosis, herniation. So, lesion of different problems that can occur. Um And here's a relatively a big series and you can see the most common things here that are occurring are things like uh um metabolic acidosis, uh pyonephritis, et cetera. So, these are the common problems. One needs to consider different parts of, of uh bowel to have different impacts on uh renal function. So, the, the classic one would be to use uh or ilium. And here you get a hyperchloremic. So the chloride, those are metabolic acidosis. And that's a classic um a complication that you can have, particularly in a patient who is uh dehydrated. Uh he's had some gastro and who has um called margin or renal function in including bowel and urinary tract. That's what you're gonna end up with. And um it certainly has effect on, on the child's growth and of course, the growth, vitamin deficiencies, et cetera, et cetera. But uh colleagues, it's been a privilege to uh talk to you this afternoon and uh perhaps I can take some questions about um uh continent and incontinent diversions in Children. Uh John, there was one question asked by Doctor Patankar. Uh what chemotherapy regimen was used for the rhabdomyosarcoma patient. I think he's talking about that vaginal rhabdomyosarcoma. Yes. Uh So let's go back to those slides. I think we saw it was back. So, what's that? Uh I I'm slightly off my uh area of expertise here but um it's uh vinCRIStine was used here. Yeah, Dactinomycin, which is the A I think the cyclophos that's probably the three that we used. But uh I'm not the right person to ask that question to. Yeah, it's, that is the regimen I think uh let us give chance to the registers to ask any questions. So I see Doctor Gautam. Yeah. Uh just unmute yourself and ask any questions to probe John. You need to unmute yourself there. You haven't unmute it. Yeah. No. Yeah, I um don't really have a question right now. Ok. Um II was just, I actually walked into, into my house when you, I'm really sorry about that. That's fine but I don't have right now. It's fine. Um a any questions for me? No questions, the questions I had were answered already? Ok, I see. Doctor ZB. Is there Z any questions? Uh No, none from me. Thank you. It was a very good talk. Thank you. Ok. Um I see abi know she has passed her exams but she can still ask a question. Acona, I have no questions. Thank you. Prof ok. So there is one more question from Doctor Patankar in Mino procedure. Is it preferable to close the bladder neck or keep it open? Yes. Uh That's a good question. So I think we just need to set the scene a little bit there uh, for the Mitrofanoff. Um So he was the, uh French gentleman who first thought of this and uh we were pleased that uh Red Cross now it's becoming more um procedure that we're talking a little bit more about. Now. We have um uh Mary Arnold and he's got an interest in using the appendix as a, an ace. So it was a mace the Malone integra continence, EMA So we always arguing with a little bit about who deserves the appendix, the colon or the bladder. So that's one of the debates we've been having recently Red Cross. But um obviously, um there are various options and the Mitrofanoff doesn't imply a pen Vesico, it simply implies uh a uh catheterizable channel. And a variety of things have been used. You can use uh ilium, you can detubularise it and roll it up like a cigar, the opposite way that's called the uh the Yang Monti. I think the procedure uh we've used uh the ureter. So you can simply bring the proximal ureter, the nonfunctioning renal unit uh to the skin. And that has the advantage of having the native psychiater junction as a confluence mechanism, I believe. Um Fallopian tube has been used, obviously, the most commonly described thing would be the, the appendix there. And uh there's quite a lot of small print here because you're trying to mitigate against complications with um with the appendix. And so you've got to be having a strategy uh at the skin level uh to prevent. Uh and we tend to just use a ab flap which is then spatulated into the uh appendix. Um I moved away from being too cosmetic. In other words, I don't like putting it in the umbilicus uh because it defies the critical rule about performing a metro off, which is that you want it to be straight and short in other words, you're going to be too fancy by putting it cosmetically in the umbilicus. And you're going to end up with a, uh, with difficulty to catheterize because it may bow and difficult to get into the bladder. So keep it short and keep it straight. And, uh, obviously you want to decide where you're gonna put the channel because if you put it just on top of the bladder, there is a tendency for them simply to c and get the top few 100 miles off and leave a sump. And so there is evidence that if you put the um Atro off channel behind the bladder, you get better drainage. Although I haven't found that easy, technically, to always achieve. Uh So there's quite a lot of a small print. The other thing is obviously, how are you going to get it to be content? Are you going to tunnel it under the mucosa of the bladder or the augment? Are you going to do a, um cros or wrap around the appendix or you going to attempt to bring it through in a fancy way through the rectus abdominis? Some people would um take the rectus and bring it around the appendix in a fashion that, that promotes contents. Uh We use something called the Ace Ma stopper, which is a plastic at shaped piece of plastic which fits in the uh in the appendix and it promotes the continence and reduces stenosis. I'm very fond of giving that to the parents. Of course, they tend to use it within the first month and it's difficult to get hold of from America, but that's what we would do. But I rabbited on a bit. What I was trying to get to is to answer the question, which is to say, do you close the bladder neck? And I suppose we've got to think about the setting in which we, we, we're asking that question. Um And clearly, if you've got a unconstructive urethra, that's not really a discussion, isn't it? Because you've got a complete uh outlet um no outlet effectively. And, and that was the case with one of our Children where we had to remove the urethra and the bladder neck. So we're gonna close that area anyway. Um So, so in that situation, there's nothing to discuss. However, we also face this issue with Children who have low leak point pressure incontinence. So here you've got a child who may be having spina bifida and who has sphincteric incontinence. And so you're gonna be doing a bladder neck reconstruction. And um uh what I would advise there is to do your bladder neck reconstruction pretty tight because you, the last thing you want after that operation is that they continue to leak. And then you can in addition, give a covering um append of vasostomy and a covering trophon off. So you wouldn't close the bladder neck um because closing the bladder neck really creates a significant problem because if there's any um failure to do the catheterization, you've got a very dangerous uh clinical situation there. Um So you'd always rather keep the bladder neck open uh but tight, but uh still possible to instrument from below to put a catheter. If there's a problem with the Metro, I hope that answers the question a bit. I think that you have made a very important point, John. And uh, and uh, it wasn't uh emphasized on my mind. I always thought that you close the bladder neck. But uh, if there is noncompliance and uh the, the, the bladder is not catheterized in time when it is full, then there is a real danger of bladder perforating intraperitoneal, isn't it agreed? And the, the rate of, of uh perforation or rupture of an augmented bladder is seem to be close to 10%. Uh, so these often the Children who got spina bifida, they may have a century level. So they may not appreciate the uh, infected peritonitis that they've got before it is too late. So, certainly avoiding that scenario because you can imagine these are uh, intellectually challenged Children. They've got carers maybe in a home or whatever. So, if, for whatever reason, people are not properly able to catheterize the, um, uh metro and you've got a closed bladder, it, you've got a very dangerous medical situation there. Yeah. It's like a potential time bomb, in fact. Sure. Sure. Exactly. Um, I think there is another nice question from doctor, er, is Metro in Metro, is the appendix implanted Antegrade or retrograde? And the preference? Yes. Uh I think the answer is, it doesn't matter. I've not seen any uh, instruction in the literature that it has to be isoperistaltic or retroperistaltic. I don't think that is critical. My own uh practice has been that I'm petrified of stomal stenosis because who wants to have to go back there again? So I tend to uh leave a nice cuff of cecum on the, on the uh on the uh stump and bring that side out to the skin because then you've got a reasonable um thing that isn't going to stim down. So that's been my preference. Having said that I don't know if that's the right answer because, you know, sometimes those, they certainly don't stenos but they can bleed a little bit and a little bit unsightly. So sometimes a dressing has to be worn over them. So I'm not saying that is the right answer. I, I've done that with some Children and it has certainly prevented stomal stenosis and it's great uh by other problems. Um Hello. I have a question. Yes. Yes. Just identify yourself, please. Yes. Doctor S and from Nairobi Guinea. Very nice place. We know each other. Nice to hear your voice. Yeah. Thank you. Uh That's very interesting. My coho um very nice presentation. I just want to share our experience here in Kenya for the bladder xray, severe cases after failed uh repair once and twice and after also doing bladder neck reconstruction, which failed. We have actually done um mind pouch two. We have experience over now. We have people over 18 years who are really alive and well. And uh we have almost 30 cases between Hijabi Hospital and the COPTIC Hospital in Nairobi after we have done a lot of trials. And uh it's really working very well. Some of them or most of them are in the remote areas and they, they really don't actually need bicarbonate supply. We check the even uh electrolytes, we check, you know, the carbo uh bicarbonate level and they are really doing well. And uh and, and actually also we tried metro off in few cases, they usually very hard to get a clean water. They don't get supply of catheters, they can, they really suffer and the repeated ascending infection and the repeated, you know, uh or deterioration of the kidney function. And uh we really uh support and uh really encourage that this should be one of the, you know, methods of treating difficult bladder exstrophy or failed repair. Uh So I think that's that point is very well taken. And um I think that you are, uh you know, I think the rectal bladders have got a bad reputation internationally. It's felt to be a third world operation, excuse that phrase, a developing world operation. Um And the reason for that has been that, for example, uh obstetric fistula, a terrible spurge in various parts of our continent. And uh the option has been that since you cannot get appliances, you can't get bags that an A or conduit is a disaster for those patients. So therefore, the mandatory pouch has been recommended. But actually, it's coming back from the sense that you can see here. Uh This is a journal from a journal article from Cologne where they are reinvigorating this idea and from um Richard Woods Institution in the United States, it's not uh is it Cincinnati in Ohio? Uh They are now recommending this as a reasonable option as opposed to uh other option for uh continents in the Extrophy group. So the United States, the Europeans are following your lead. Uh somewhat. Actually, I was I presented in the Society of Pediatric Urology SPU our results of the mind pouch and even Doctor John Duckett, the pioneer from John Hopkins of Bladder Troy. And he really congratulated me and he said that there is always a space to do this operation and there is always an indication for it the way people, you know, we can't afford doing surgeries many stages, 34 stages, each hours and hours, we can't even afford for them to come back. Even our follow up of the cases we did from 18 years, we started doing that from 2003. They don't come and say Oh, we have no transport. We are doing well, we don't need you. We are happy and so on. So, uh it is coming back as you said, II agree and thank you for a very nice presentation. I think, I think I must thank Doctor Safa. Uh uh he had just uh eliminated the reality of life uh uh for patients in Africa. And uh I think, uh as I always think and say that we Africans must find out African solutions for our problems and our patients can't, don't read Western books. So I really congratulate you for your like pioneering work and, and I think this is, this is very good. I'm so glad that you are present for this talk and you have shared your experience. Um John, there is a question from Karen. It's about that uh bladder injury, child. Uh what sort of capacity do you think you can expect in your ideal bladder? Sorry, there's a typo there. It's meant to be the bladder, I bladder. Ok. It's very nice to hear from you. Uh just just explain what you're asking. I was just wondering um you know, when you make your ideal bladder, um it's obviously a question just based on some of my own experience um of what kind of capacity that you'll think it will give you kind of long term. Um Yeah, we just had some recent experience of kind of creating uh sort of neobladder and I in slightly older Children and um, although it goes well, I'm not sure that the reservoir actually, like suits them long term and we still struggle with actually quite a lot of leaking and incontinence. Um, despite sort of fairly good um catheterization. Um And I was just wondering, you know, we always talk about how much extra capacity you can actually expect, for example, from an augment. Um and how much you think you'll get for this boy? Yes. Uh So certainly in the adult population, it's, it's a very tried and tested thing. We take 56 centimeters. Uh We create an afferent limit of about 10 to 15 and the rest we uh detubularise and make it into a sphere. Um Obviously in kids, it's a little bit more of uh working it out as we go along in terms of how much power we would need to take. But I don't think that that would be so much of an issue here. Um You know, these are relatively standard procedures which should give you adequate capacity. I've used colon for uh augments before and they are prone to um retaining some of the pressure in inside there, so that can and cause problems with the upper tract. So we moved away from doing colonic augments. Um You've obviously got to make sure that you properly uh buy valve the bladder because you can get a, a setting where you've got an hourglass deformity with your augment in other words, the augment sits like a, an augment on top of this tiny bladder. And every time you catheterize, you're not actually catheterizing the, the po so you got to properly clam the bladder in order to put the, the augment on. Um I've certainly moved away from doing auto augmentation or uh uh the Reza Myomectomy because that didn't give me any reproducible, adequate um capacity. Um So perhaps I'm not understanding these particular cases you're referring to why they are still giving a problem. Uh Usually bow gives you a wonderfully apa um reservoir. Yeah, I think um part of it is also perhaps just related to uh how they're actually managing their um the catheterizable channel and how frequently they're actually doing the catheterizations and so on. Um Like I thought we had, you know, we sort of created a neobladder out of a but yeah, II thought we had really good capacity in that. Um our patient who was actually an extra, who had had a complete cystectomy at another institution. Um Like from my side, we sort of really thought that she should be uh continent. Uh but we struggled a bit, but it's actually still early days and I think maybe she just needs a bit more time and teaching. Sure. I mean, I think a sister grand can be your friend here to um actually the capacity of the bladder. And uh secondly, you can get her then to empty and uh work out how much is, has come out and see whether sometimes a syringe can help them to empty a bit better. Yeah, I think the problem is that she's leaving, she prefers to leave an indwelling catheter in and that she leaves it in too long and it gets occluded and then she leaks around it. Um, but we are trying to work on that with her. Mm. Um, Karen, can I ask you to comment briefly? Uh you relatively recently trained in Toronto for two years and now you've probably been working at Middle Hospital for just over two years. So any lessons or contrast from Canada and Joburg? Um Yeah, I think um yeah, I've only been in Joburg for two years. So um I still have a um I was sort of laughing about the joke about how previous urologists leave um or older urologists leave so much work for um incoming neurologists because a lot of my work is um patients who have had many previous surgeries. Um Yeah, I think um uh in Toronto. Um Yeah, it was interesting for me in that they were quite adverse to. So we had a, a large spinal defects um population and um the preference there was really for quite long term Botox management. Uh There was quite a lot of anxiety. So we did Metro um and we would often and we often did ac we split the appendix. Hm. Um But there was quite a lot of anxiety about augments. Um And they really used to try and sort of save it for older adolescents. And um the main anxiety I think was actually around the perforation. So there were a couple of patients who um who had perforations. And I think also once you've had a single perforation, your risk for further perforation really increases. And we, we saw that, that they would come back over and over. Um So they have quite a robust um Botox program there. Um But I do the Botox does give good results. Um But I do think you also have to draw a line. So there were some kids who are sort of being repeatedly Botox but not actually seeing the benefit of that and then you need to, you know, reinvestigate and um and then kind of seriously think about augment and Metro off. Um Yeah. Um I hope that answers your question. No, I think, I think it does. Um I think you have just sort of given uh one more point for the registrars to know and understand. But uh you have also emphasized that um I don't know how it is for you. In, in, in uh Nelson Mandela Hospital, we have recently got authority to get Botox case by case basis. And I don't think for one single patient, we can keep injecting Botox every three or six months. So I think we that is our reality. But yeah, but thank you for. Yeah. Yeah. So interestingly, actually our neurologist got um, the hospital to get the Botox in, but she's never managed to get herself a theater list. So, um, I use all the Botox that she's managed to order for us. Um, I saw an article um, recently actually trying to compare the cost of, but it was a very theoretical article that actually sort of came to the conclusion that long term Botox was probably more expensive than early augment. Um Yeah, it is very expensive. It it makes sense. Ok, Karen, thank you. Um I see. Doctor Rasi Shah is is attending, he is a senior pediatric surgeon, endoscopic surgeon, pediatric urologist, and a very close friend for very long time from Mumbai India. So Rasi please unmute yourself and and give your comments or share your experience. Uh Bye. Are you still here? And then maybe he just went out? Ok. Um uh any any other consultant specialist from the country before I ask our junior specialist uh Doctor NCO to ask questions. Uh John, I have a s simple question for you for permanent diversion, whether it is incontinent or continent. What are the commonest procedures you do? Uh 123. And what are the indications in in your practice in Cape Town for Children or a adult Children and adolescents? Yes. Um I think uh it's not an easy question to answer simply because it is about individualizing and tailoring uh to each individual problem. And I think those three cases illustrated yes, uh, Children that needed different options. One had a drop off onto a partial bladder, one's going to need a stud neobladder and the other ended up with an conduit. So each of them had different, um, requirements and I suppose the reconstructive surgeon needs to have all of those options to manage. Um, I think that, uh, um, no, I think that answers my question. Uh So it's basically an answer to that question is individualized, see what is available. Um Obviously, what can be done and obviously what are you comfortable in doing? And then you can do that and, and what will be the future availability of like doctors said, bags and, and catheters and all those things, isn't it? Sure. Exactly. Ok. Ok. Um I think, can I have small comment? Pro professor. Yes. Yes, please, please, please. Yeah. Also, uh you, you talked about, you know, uh closing the, the bladder neck. So the, the way we do it after we do the diversion, we also second stage or the same stage, we do mucosectomy and we close the bladder next. So the child does not have an internal ejaculation. And then uh after that, the second stage, we do the epi epispadia repair. Uh So they have uh you know, not much worry because there's no urine leakage because already the urine is passing through the rectum and then they are also. So the chances of fistula is less and because we don't do it before the age of 67 years. So already the the penis have grown and developed. So the reconstruction is easier and usually they are very happy and the uh uh continent and uh it it really prevent also the long term, you know, squamous metaplasia in the in the bladder, uh mucosa from staying long time due to, you know, leakage of urine and so on. So it is just worth it to, to comment on that. But that, that you are talking about bladder exstrophy. Is that correct? Yes. Yes. Mainly bladder. Ok. There is one question from our junior medical officer, Doctor Rau. Uh what is the preferred gold standard imaging for planning for reconstruction John? Uh Again, I think you, you need to focus individually on each case. Uh The important thing before going into these cases is to take a holistic approach. You've got to understand the anatomy. You've got to understand the impact on the physiology of including bowel and the urinary tract. You got to see the patient uh in, in their setting. Are they going to be able to cope with uh uh intermittent catheterization and the age of the patient. Um I've learned once by a bit of experience never to do a metro off too early. And uh you know, if the patient is in a home, et cetera, so I think it's uh really an opportunity to sit down and take a more careful look and uh try and, and um and properly. So there isn't really one test. I think you can't really be doing this work without uh having a a urodynamics um uh component of some description because that often dictates a lot of your thinking about the case and having good radiologist colleagues who can assist you to answer the questions, you need to, you know, to make your decisions. Um uh I see uh Professor Samad, she could join late but he's still here. So sad. Uh I know you could hear only the last part of the talk. Uh But you have heard the discussion. So any comments from you? Thanks. Uh like you said, I just came, hopefully I'll get a chance to listen to the rest of the recording because I really want to listen to, to John. But uh the comments, the last few comments that John and Karen and you have made uh basically summarize the problems for the people who have been involved in this kind of uh surgery. And uh I don't think I have too much more to add uh for this except for um emphasizing kin's comment that old urologists leave a lot of work for neurologists and pediatric surgeons are exactly the same because it's, I mean, we all have work from our colleagues which keep us going and we'll probably do that for our colleagues coming uh after us as well. Thanks. Uh Valen. Ok, thank you so much. I don't think Doctor Nikou is here. This could be due to load shedding. So I think I'm going to ask Professor John to uh sorry, there's one more. Ok. Uh to give his concluding remarks and then we can conclude the meeting. Yes, thank you. So I hope I've given the trainees um a nice classification of thinking about uh incontinent and uh continent urinary diversions. I think these are um procedures we don't do every day. And uh certainly a team approach to um offering these complex Children uh the best possible. And I think what's being hinted at here is that certainly in the private sector uh procedures may be done but may not always be the most sensible thing. And I think we as surgeons looking after Children need to advocate for um appropriately uh specialized services that can, can lead to better decision making to care for these uh complex cases. Ok. Now, I think uh thank you everybody. Um uh it it was a very nice uh meeting to start at the beginning of beginning of the year and there were minimum 50 attendees at all times and at one time there were 70. So this is very, very satisfying and fulfilling. So, thank you John again for your time. And are you sharing uh your expertise and knowledge with us? And I think for all including SFA who um have contributed to the discussion and, and uh that, that's also very useful for all of us in Africa, especially the trainees and the young pediatric surgeons and pediatric urologist. I can't often remember what topic uh will be uh discussed on the second Tuesday of February. But uh I will convert this meeting, load it on the youtube and then share the, the youtube link widely. And a week before the 14th of that is on the seventh of February. I will uh circulate the invitation for the February 14th meeting and we will also share the recording of the uh link to the recording of this meeting. So thank you everybody. Nicely. We are on the dot We are finishing in one hour. That's also good. Thanks. Ok, bye John. Goodbye. Thank you. Bye bye doctor.