Risk of Bowel Dysfunction with Diarrhea After Continent Urinary Diversion with Ileal and Ileocecal Segments

Hemi-Kock Continent Stoma With Augmentation Cystoplasty: Modifications and Outcomes

OBJECTIVE

To evaluate the long-term outcomes and impact of surgical modifications on the need for secondary surgery of the Hemi-Kock continent catheterizable stoma, comprising a detubularized ileal segment with an attached stapled ileoileal intussusception of the catheterizable channel, in patients with complex lower urinary tract disorders. The technique may be used for augmentation in patients with reduced bladder capacity who require a continent catheterizable channel. Compared to the flap and ileocecal valve procedures, the hemi-Kock technique has not been widely adopted.

MATERIALS AND METHODS

This is a retrospective case series including all patients who underwent a hemi-Kock catheterizable channel with cystoplasty from a single institution. Surgical technique and modifications in valve construction and tapering of the catheterizable limb are described.

RESULTS

A total of 109 patients, with a median age of 38 years (range 18-72), underwent the procedure. At a mean of 10.4 years, 98 patients (90%) reported that they were managing with clean intermittent catheterization ± pads; 11 (10%) were failures. A total of 70 (64.2%) patients underwent secondary interventions with >60% performed endoscopically or under local anesthesia, mainly for bladder stones. Fourteen patients (12.8%) required valve revisions. However, the rate decreased from 18.2% (8/44) to 9.3% (6/65) following incorporation of the surgical modifications.

CONCLUSION

We present the largest cohort to date of patients managed with a Hemi-Kock catheterizable channel and cystoplasty. Valve revision rate improved with surgical modifications. We demonstrate long-term durability and maintenance of stomal catheterization in the vast majority of patients.

Evaluation of Bowel Function Following Radical Cystectomy and Urinary Diversion Using Two Validated Questionnaires: What Are the Effects on Quality of Life?

OBJECTIVE

To assess both short- and long-term constipation symptoms and their impact on quality of life in patients who underwent radical cystectomy (RC) with three different types of urinary diversion: orthotopic neobladder (ONB), continent cutaneous diversion (CCD), and ileal conduit (IC).

MATERIALS AND METHODS

The validated Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires were administered to all patients at follow-up greater than 30 days from surgery. Clinical and pathological characteristics were prospectively recorded in an institutional review board approved bladder cancer database. Using multivariable linear regression analyses, we determined significant predictors of improved constipation symptoms and quality of life scores.

RESULTS

A total of 198 patients completed 255 PAC-SYM and PAC-QOL questionnaires with a median follow-up time of 1.7 years (IQR: 0.7 - 3.0 years). ONB, CCD, and IC were performed in 78%, 5.5%, and 16.5% of patients, respectively. Higher bowel function scores (i.e. worse symptoms) were noted at 3 months post-operatively, while these scores significantly improved over time for PAC-SYM total score (P = .004), abdominal subscore (P = .001), and rectal subscore (P = .018). On multivariable analysis, we found that patients <70 years old (B -2.1, P = .004), with follow-up >1 year (B -4.8, P = .001), and who received an IC (B -2.4, P = .02) had significantly lower PAC-SYM scores.

CONCLUSION

Patients have few constipation symptoms and are overall satisfied with their bowel function at long-term follow-up after RC. While patients with IC have significantly fewer constipation symptoms compared to those with ONB or CCD, all patients had significant improvement one year after the surgery.

Functional outcomes after robot-assisted radical cystectomy: A review of literature

Robot-assisted radical cystectomy has steadily gained wider acceptance among urologists compared with open and laparoscopic approaches. Robot-assisted radical cystectomy has shown comparable perioperative and oncologic outcomes compared with open radical cystectomy. Nevertheless, data about the functional outcomes and quality of life after robot-assisted radical cystectomy remain limited. We sought to review the literature and describe urinary, sexual and bowel functions after robot-assisted radical cystectomy in addition to mental health and health-related quality of life. Despite limitations of the available literature, data suggests that functional outcomes after robot-assisted radical cystectomy are comparable to open radical cystectomy. However, more studies utilizing standardized definitions are required.

Bowel function in patients with urinary diversion: a gender-matched comparison of continent urinary diversion with the ileocecal pouch and ileal conduit

PURPOSE

To evaluate stool habits and associated quality of life (QoL) in a matched pair analysis of patients who underwent continent cutaneous diversion using the ileocecal segment [Mainz pouch I (MzPI)] with an intussuscepted ileal nipple as efferent segment with those receiving an ileal conduit (IC) after radical cystectomy.

METHODS

We identified 250 patients who underwent radical cystectomy and urinary diversion (UD) with either MzPI with an ileal nipple or IC in our database. A detailed history of stool habits using the modified Wexner score was obtained, and questions addressing general lifestyle, comparison of symptom differences before and after surgery considering bowel function as well as bowel-associated QoL were assessed.

RESULTS

Forty-five age- and sex-matched pairs could be compared. Overall, stool incontinence (p = 0.481) and the Wexner score (p = 0.464) revealed no differences between both groups. However, patients with MzPI as compared to those with IC had significant higher rates of stool frequency (53 vs 31 %), softer stool consistencies (60 vs 13 %), diarrhea (62 vs 20 %) and a lower rate of constipation (4 vs 22 %). Patients with MzPI had a trend toward lower bowel-associated QoL compared with patients with IC. Similarly, the MzPI group reported a significantly impaired overall postoperative QoL (51 %) compared to the IC group (29 %) (p = 0.024).

CONCLUSIONS

Patients following UD by MzPI have an increased stool frequency and softer stool consistency. However, there is no difference between both groups in terms of de novo stool incontinence. Change in bowel habits should be part of preoperative informed consent in any kind of UD. Careful patient selection is of paramount importance.

Long-term results of a prospective randomized trial assessing the impact of re-adaptation of the dorsolateral peritoneal layer after extended pelvic lymph node dissection and cystectomy

OBJECTIVE

To evaluate the long-term oncological and functional outcomes of re-adaptation of the dorsolateral peritoneal layer after pelvic lymph node dissection (PLND) and cystectomy.

PATIENTS AND METHODS

A randomized, single-centre, single-blinded, two-arm trial was conducted on 200 consecutive patients who underwent PLND and cystectomy for bladder cancer (<cT4, cN0, cM0) between April 2006 and September 2009. Patients were randomized into two groups: group A with re-adaptation of the dorsolateral peritoneal layer (n = 100; 73 male, 27 female; median [range] age 68 [35-86] years) and group B without re-adapation (n = 100; 66 male, 34 female; median [range] age 65 [30-86] years). Regular postoperative follow-up was performed at our outpatient clinic. The median follow-up was 59 (3-100) months. Five patients were lost to follow-up in group A and seven in group B. Bowel function was evaluated using the validated Gastrointestinal Quality of Life Index questionnaire and an institutional questionnaire regarding post-cystectomy outcome. Local recurrences and distal metastases were evaluated using computed tomography and bone scan at the regular follow-up visits.

RESULTS

There was no significant difference between the two groups in terms of the rate of local (pelvic) recurrence (5/95 [5.3%] in group A; 7/93 [7.5%] in group B; P = 0.53), the rate of distant metastases (21/95 [22.1%] in group A; 23/93 [24.7%] in group B; P = 0.67), cancer-specific survival (P = 0.37) or overall survival (P = 0.59). Group A had significantly better bowel function at 3 (P < 0.001), 6 (P < 0.006), 12 (P < 0.006) and 24 months (P = 0.04), and significantly less postoperative abdominal pain and bloating at 3 (P = 0.002) and 6 months (P = 0.01).

CONCLUSION

Re-adaptation of the dorsolateral peritoneal layer after PLND and cystectomy has a beneficial long-term impact on bowel function and postoperative pain without compromising oncological radicality.

Long-term bowel disorders following radial cystectomy: an underestimated issue?

PURPOSE

Patients after radical cystectomy (RC) frequently complain about bowel disorders (BDs). Reports addressing related long-term complications are sparse. This cross-sectional study assessed changes in bowel habits (BH) after RC.

METHODS

A total of 89 patients with a minimum follow-up ≥1 year after surgery were evaluated with a questionnaire. Patients with BD prior to surgery were excluded. Symptoms such as diarrhea, constipation, bloating/flatulence, incomplete defecation, uncontrolled stool loss, and impact on quality of life (QoL) were assessed.

RESULTS

A total of 46.1 % of patients reported changes in BH; however, only 25.8 % reported experiencing related dissatisfaction. Primary causes of dissatisfaction were diarrhea and uncontrolled stool loss. The most common complaints were bloating/flatulence and the feeling of incomplete defecation, but these symptoms did not necessarily lead to dissatisfaction or impairment in quality of life. No difference was identified between an orthotopic neobladder and ileal conduit, and even patients without bowel surgery were affected. QoL, health status, and energy level were significantly decreased in unsatisfied patients.

CONCLUSIONS

About 25 % of patients complain about BDs after RC. More prospective studies assessing symptoms, comorbidities, and dietary habits are necessary to address this issue and to identify strategies for follow-up recommendations.

[Avoidance and management of complications in open surgical ureter reconstruction]

Open surgical reconstruction of the ureter is a urological procedure with a potentially high risk of complications. The correct selection of patients and time of operation are important aspects regarding the treatment strategy. Position and length of the affected ureter segment to be reconstructed determine the surgical intervention possibilities. The psoas hitch procedure is a well-established technique for distal reconstruction of the ureter where most iatrogenic injuries occur. In more proximal or complex defects, several procedures are available. Partial or complete replacement of the ureter with bowel is still considered the standard for bridging long ureteral defects but is accompanied with higher intra- and postoperative complication rates. In specific patients and situations, autotransplantation of the kidney and subcutaneous pyelovesical bypasses are clinical options. Using mucosal grafts or tissue engineering may be new therapeutic prospects to cover ureteral defects but the clinical impact still needs to be clarified. All therapeutic strategies share the fact that great surgical expertise and experience are necessary as the operative technique must be mastered to avoid severe complications.

Metabolic consequences after urinary diversion

Metabolic disturbances are well-known, but sometimes neglected immediate consequences or late sequelae following urinary diversion (UD) using bowel segments. Whereas subclinical disturbances appear to be quite common, clinically relevant metabolic complications, however, are rare. Exclusion of bowel segments for UD results in loss of absorptive surface for its physiological function. Previous studies demonstrated that at least some of the absorptive and secreting properties of the bowel are preserved when exposed to urine. For each bowel segment typical consequences and complications have been reported. The use of ileal and/or colonic segments may result in hyperchloremic metabolic acidosis, which can be prevented if prophylactic treatment with alkali supplementation is started early. The resection of ileal segments may be responsible for malabsorption of vitamin B12 and bile acids with subsequent neurological and hematological late sequelae as well as potential worsening of the patient's bowel habits. Hence, careful patient and procedure selection, meticulous long-term follow-up, and prophylactic treatment of subclinical acidosis is of paramount importance in the prevention of true metabolic complications.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: non-surgical considerations

Segments from almost all parts of the bowel have been used for urinary diversion. As a result, the available absorptive surface area of the bowel is reduced, and the incorporation of bowel segments into the urinary tract may have metabolic consequences. This is an area somewhat neglected in the literature. Metabolic complications are rare, but sub-clinical metabolic disturbances are quite common. Several studies have demonstrated that some of the absorbent and secreting properties of the bowel tissue are preserved after incorporation into the urinary tract. Hyperchloraemic metabolic acidosis can occur if ileal and/or colon segments are used, as well as malabsorption of vitamin B(12) and bile acid after the use of ileal segments. These metabolic effects are not as severe as may be suspected and can be prevented by prophylactic substitution. Secondary malignancies can develop as a long-term consequence of bladder augmentation. Using colonic segments, tumours are most likely to occur at the ureteral implantation site. To prevent metabolic complications, careful patient selection and meticulous and lifelong follow up, as well as prophylactic treatment, are mandatory. Endoscopy for early detection has been recommended, starting 10 years postoperatively for patients who underwent surgery for a benign condition.

Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience. Part II: Continent cutaneous diversion using the Mainz pouch I

After failure of conservative treatment of neurogenic bladders (deterioration of the upper urinary tract/incontinence) continent cutaneous diversion has to be considered in those patients with irreparable urethral sphincter defects or those who are unable to perform trans-urethral self-catheterization. In this second part of the study we investigated the long-term safety of using the Mainz pouch I with regard to protecting the upper urinary tracts and to provide urine continence. Between 1985 and 2002, operations to form an ileocaecal pouch with umbilical stoma (Mainz pouch I) were performed on 70 children and adolescents of median age 15.3 years (range 5.7-20 years). During the follow-up period five patients died 2.4-14 years postoperatively of causes not related to urinary diversion. A follow-up period of 8.7 years (0.9-18) was achieved in 65 patients with 118 renal units (RUs). As compared to preoperatively, the upper urinary tracts had remained stable or improved in 113/118 RUs (95.8%) at the latest follow-up. Complete continence was achieved in 97% of patients with a continent cutaneous diversion. Surgical revisions were required for: incontinence of the outlet mechanism in 9%, stoma prolapse in 2%, stoma stenosis in 23%, pouch calculi in 15%, symptomatic reflux in 1%, ureter stenosis in 16% of the RUs with submucosal tunnel and in 3% of the RUs with an extramural tunnel. We conclude that, in patients with irreparable sphincter defect and those who are unable to perform urethral self-catheterization, continent cutaneous urinary diversion with the Mainz pouch I provides a high continence rate with preservation of the upper urinary tracts in the long run. In patients with dilated ureters, the extramural tunnel technique results in a lower complication rate.

Bowel function after urinary diversion

Removal of bowel segments for the purposes of urinary diversion may have a significant effect on bowel function. The remaining bowel may not be able to fulfill its normal role, resulting in not only malabsorption syndromes, but also dysfunctional defecation. Provided, however, care is taken in selecting patients and the bowel segments for such procedures and follow-up is vigilant, complications should be minimal. There appears to be a significant risk of developing symptoms of increased bowel frequency following urinary diversion and reconstruction. Patients need to be counselled regarding this prior to surgery, however, further data needs to be collected to accurately quantify the risk and the effect it has on quality of life.

The “B-Bladder”—an Ileocolonic Neobladder with a Chimney: Surgical Technique and Long-Term Results

OBJECTIVES

A modified version of the "Le Bag" ileocolonic neobladder with a "Studer"-like ileal chimney (B-bladder) is presented. The surgical technique, perioperative complications, and long-term results, including cancer control and continence, are described.

METHODS

Twenty-nine patients underwent radical cystectomy and urinary diversion to an orthotopic ileocolonic neobladder with an ileal chimney. All operations were done by a single surgeon. Preoperative, perioperative and postoperative data were recorded. Median duration of follow-up was 3.4 years.

RESULTS

The operation was technically successful in all cases. Late complications included recurrent urinary tract infection (17%) and uretero-neobladder anastomotic stricture (3%), both at acceptable rates. Postoperative daytime continence was excellent. Cancer control was satisfactory during follow-up; 11 patients (38%) died of disease progression with distant metastases. Median survival was 71.1 months.

CONCLUSIONS

The B-bladder maintains the simplicity of preparation of the original "Le-Bag" neobladder while gaining the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications is low and long-term results with regard to cancer control, continence, and complications are excellent.

Skeletal growth and long-term bone turnover after enterocystoplasty in a chronic rat model

OBJECTIVE

To investigate skeletal growth and bone metabolism in a chronic animal model of urinary diversion.

MATERIALS AND METHODS

Young male Wistar rats (120) were allocated randomly to four groups undergoing: ileocystoplasty, ileocystoplasty and resection of the ileocaecal segment, colocystoplasty, and controls. All animals received antibiotics for 1 week after surgery; half of each group remained on oral antibiotics. Bone-related biochemistry was measured in serum and urine. Dual-energy X-ray absorptiometry and peripheral quantitative computed tomography (pQCT) were used to determine bone mass ex vivo.

RESULTS

Most (90%) of the rats survived the study period (8 months); six rats died from bowel obstruction at the level of the entero-anastomosis and four had to be killed because of persistent severe diarrhoea. Vital intestinal mucosa was found in all augmented bladders. There were no differences in bone length and volume. Loss of bone mass was almost exclusively in rats with ileocystoplasty and resection of the ileocaecal segment (-37.5%, pQCT, P < 0.01). There was no hyperchloraemic metabolic acidosis or gross impairment of renal function. Hypomagnesaemia, hypocalcaemia and decreased insulin-like growth factor-binding protein 3 were the only significant findings on blood analysis. Deoxypyridinoline crosslinks in urine were higher in rats with an enterocystoplasty than in controls.

CONCLUSIONS

Enterocystoplasty in rats neither impairs skeletal growth nor bone quantity, but leads to significant loss of bone mass when combined with resection of the ileocaecal segment. Rarefaction of the trabecular network is confined to the metabolically highly active cancellous compartment, most likely as a consequence of intestinal malabsorption.

Health-related quality of life after 5-12 years of continent ileal urostomy (Kock reservoir) in children and adolescents

OBJECTIVE

To assess quality of life after continent ileal reservoir diversion in children and adolescents.

MATERIAL AND METHODS

Nine boys and 9 girls (10.8-18 years old at surgery) were operated with a Kock reservoir and followed for 5-12 years. They participated in an interview using a questionnaire based on the Swedish self-esteem inventory, "I think I am". The questionnaire consisted of 76 questions that covered medical, physical, psychological, social, body image and sexual aspects.

RESULTS

Six of 18 patients had some difficulties on catheterization. Five complained of pain or bleeding during evacuation. Two patients had slight urinary leakage between evacuations and 6 had mucus secretion. Ten patients had diarrhea with different frequencies. Physical activities were not hampered by the operation in any patient. Instead, activities such as full day outside home, friend at home overnight, using all types of clothes, and participation in camps were increased in 8, 6, 5 and 5 patients, respectively. All patients but 2 had an excellent relation with friends and family members. More than half of patients had excellent positive self-esteem and body image and the rest had very good self-esteem. However, some patients were concerned about how they looked and felt that life was unfair to them.

CONCLUSIONS

The patients were satisfied with their operation. They were physically active and declared a positive perspective regarding self-esteem and body image. The medical problems related to the operation did not have any negative influence on the self-esteem or body image. The choice of the operation can only be determined on the basis of an attentive dialogue between surgeon, child and parents.

Orthotopic urinary diversion in women

Orthotopic urinary diversions can be performed safely with acceptable morbidity rates in women. Attention to detail during the surgical dissection of the bladder neck and vagina is critical to a good outcome. With improvements in orthotopic urinary diversions, earlier use of a cystectomy for the treatment of minimally invasive bladder cancer may improve the survival rate in these patients.

Bile acid malabsorption after continent urinary diversion with an ileal reservoir

PURPOSE

We determine the effect of urinary diversion with a Kock ileal reservoir on bile acid absorption and bowel habits.

MATERIALS AND METHODS

We asked 96 patients with a Kock ileal urinary reservoir to record bowel habits and abdominal symptoms for 1 week. Data on 75 patients were further analyzed. Bile acid absorption was determined in 29 healthy control subjects, in 17 before and 6 months after continent urinary diversion, and in 21, 2 to 14 years postoperatively. Bile acid absorption was considered pathological when retention of less than 10% of an oral capsule containing selenium-75 labeled tauroselcholic acid (SeHCAT) was noted after 1 week.

RESULTS

Mean number of defecations plus or minus standard deviation was 9.4 +/- 6.1 (75 cases). Of the patients 13% had 15 or more stools per week and 15% complained of always having loose stools. Mean value for the SeHCAT test was 32 +/- 19% preoperatively and 17 +/- 16% 6 months postoperatively (p = 0.0023). The corresponding value for healthy controls was 39 +/- 18%. Significant relationships were found between the results of the SeHCAT test postoperatively, and the number of stools per week and consistency of the feces. All patients with more than 10 defecations per week had a pathological SeHCAT test.

CONCLUSIONS

Most patients with an ileal urinary reservoir have fairly normal bowel habits. Bile acid absorption is significantly reduced postoperatively and approximately a third of the patients have a pathological SeHCAT test. Preoperative investigation of bowel habits is recommended and a SeHCAT test should be performed in patients with frequent, loose defecations. Other types of diversion should be offered when preoperative retention is below 10 to 20% especially in patients with impaired anal control.

Bile acid malabsorption after continent urinary diversion with an ileal reservoir

PURPOSE

We determine the effect of urinary diversion with a Kock ileal reservoir on bile acid absorption and bowel habits.

MATERIALS AND METHODS

We asked 96 patients with a Kock ileal urinary reservoir to record bowel habits and abdominal symptoms for 1 week. Data on 75 patients were further analyzed. Bile acid absorption was determined in 29 healthy control subjects, in 17 before and 6 months after continent urinary diversion, and in 21, 2 to 14 years postoperatively. Bile acid absorption was considered pathological when retention of less than 10% of an oral capsule containing selenium-75 labeled tauroselcholic acid (SeHCAT) was noted after 1 week.

RESULTS

Mean number of defecations plus or minus standard deviation was 9.4 +/- 6.1 (75 cases). Of the patients 13% had 15 or more stools per week and 15% complained of always having loose stools. Mean value for the SeHCAT test was 32 +/- 19% preoperatively and 17 +/- 16% 6 months postoperatively (p = 0.0023). The corresponding value for healthy controls was 39 +/- 18%. Significant relationships were found between the results of the SeHCAT test postoperatively, and the number of stools per week and consistency of the feces. All patients with more than 10 defecations per week had a pathological SeHCAT test.

CONCLUSIONS

Most patients with an ileal urinary reservoir have fairly normal bowel habits. Bile acid absorption is significantly reduced postoperatively and approximately a third of the patients have a pathological SeHCAT test. Preoperative investigation of bowel habits is recommended and a SeHCAT test should be performed in patients with frequent, loose defecations. Other types of diversion should be offered when preoperative retention is below 10 to 20% especially in patients with impaired anal control.

Bowel dysfunction after bladder reconstruction

PURPOSE

Bowel function may be disturbed after intestinal segments are used in urinary reconstruction. The etiology of this condition and its incidence in different patient groups is unclear. We studied the incidence of bowel disturbance in patients who underwent bladder replacement, continent diversion, enterocystoplasty for idiopathic detrusor instability and ileal conduit diversion.

MATERIALS AND METHODS

We evaluated 71 patients after ileal conduit diversion and 82 after bladder reconstruction, including clam enterocystoplasty for detrusor instability in 28, neurogenic bladder dysfunction in 26 and nonneuropathic conditions in 28. We noted the severity of symptoms, such as frequency of defecation, nocturnal diarrhea, flatus leakage, fecal urgency, fecal incontinence and explosive diarrhea, as well as quality of life.

RESULTS

Of the patients who underwent bladder reconstruction 24% had symptoms of bowel dysfunction preoperatively and 42% of those who were asymptomatic preoperatively described new bowel symptoms postoperatively. These symptoms were most common and severe in 54% of patients after clam enterocystoplasty for detrusor instability compared to 26% with neuropathy, 14% with a nonneuropathic condition and 15% with an ileal conduit. Compared to those in other groups patients who underwent enterocystoplasty for detrusor instability had a significantly higher incidence of nocturnal bowel movements (18 versus less than 4%, p <0.01), flatus leakage (29 versus less than 8%, p <0.01), fecal urgency (39 versus less than 12%, p <0.001) and fecal incontinence (32 versus less than 16%, p <0.001). The length of ileum used for clam enterocystoplasty was only slightly greater than that used for ileal conduit operations (25 versus 18 cm.). Of the patients who underwent enterocystoplasty for detrusor instability 29% regretted undergoing the procedure due to subsequent bowel symptoms.

CONCLUSIONS

After enterocystoplasty for detrusor instability patients are at risk of significant bowel symptoms. The development of new bowel symptoms was associated with poor patient satisfaction.

The Mitrofanoff principle in continent urinary reconstruction

Continent urinary diversion has increasingly become important for treating children and adults with urinary tract pathology that cannot be managed by direct reconstructive techniques. The Mitrofanoff principle, a term that has become synonymous with the flap valve mechanism for promoting the unidirectorial flow of a fluid medium, is a recapitulation of nature's design for the competent ureterovesical junction. Construction of a catheterizable channel using this principle can be performed with a variety of tissues and serves well as a continence mechanism for either the native bladder or intestinal reservoirs. In addition to its utility in managing urinary incontinence, implantation of a catheterizable channel into the cecum can be used to manage fecal incontinence in patients with neurogenic bowel dysfunction.

Continent urinary diversion: the Children's Hospital experience

PURPOSE

Continent urinary diversion has become increasingly important for treating childhood urinary tract pathology that cannot be managed by direct reconstructive techniques. We review our 9-year experience with continent diversion.

MATERIALS AND METHODS

Since 1986 continent diversions were created in 74 patients 3 to 38 years old (mean age 13.7). The underlying pathological condition was the exstrophy/epispadias complex in 34 patients, neurological disorders in 23, malignancy in 13 and other congenital anomalies in 4. Followup averaged 5.2 years after the last procedure. Nonbladder reservoirs in 39 patients (53%) were fashioned from ileocolic (17), colic (7), gastrocolic (6), sigmoid (3), gastrosigmoid (2), ileosigmoid (2), ileal (1) and gastroileac (1) segments. When possible, the native bladder was incorporated into the reconstructive strategy. A total of 26 patients underwent bladder augmentation with intestine or stomach, including ileal (11), gastric (8), sigmoid (3), gastroileac (2) and ileocolic (2) segments. Nine other patients did not require bladder augmentation. Continence mechanisms were a flap valve (Mitrofanoff principle) in 50 patients, nipple valve in 15 and ileal plication (Indiana pouch) in 9. When the Mitrofanoff principle was used with a native bladder reservoir in 30 cases, outlet resistance was altered by bladder neck division (15), fascial sling placement (6) or Young-Dees-Leadbetter bladder neck reconstruction (2). In the remaining 7 patients the bladder neck remained intact.

RESULTS

Excellent continence was obtained. The Mitrofanoff principle initially provided continence in 41 patients (82%). Six of the 9 incontinent patients were dry after a single revision. A total of 13 patients (87%) with nipple valves and 7 (78%) with Indiana pouches were dry, and the remaining 5 were cured after a single revision. Ultimately continence was achieved in 71 of the 74 patients (96%) after a maximum of 2 operations. Of the 48 complications in 29 patients the most common were difficulty in catheterizing (11), stones (11), infection (8) and upper tract deterioration (4).

CONCLUSIONS

Many options exist for reconstructing complex anomalies. Choices must be individualized based on patient anatomy. The dry state may be achieved in most cases without resorting to a bag on the abdomen.

Bladder replacement in women: a new experience

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.