Early clinical experience with the transverse colon-gastric tube continent urinary reservoir

The Double Dutch technique: A new way of creating an ileocystoplasty with a lengthy catheterizable ileal tube

INTRODUCTION

A tubularized conduit from an open 2-cm vascularized ileal segment is a frequently used technique to create a continent catheterizable channel in cases of an inappropriate or absent appendix. In the long term, many patients experience catheterization problems with the classic ileal segment tube, and even more with spiral or double-segment tubes.

OBJECTIVE

The objective of this paper was to introduce an ileocystoplasty modification combined with a long ileal segment tube that has better support by surrounding tissue than other lengthy ileal segment tubes. Briefly summarized, this newly introduced method begins with isolating approximately 30 cm of ileum and dividing it into two parts. Two strips are then created and closed as a double-length tube. The ileal segments are opened antimesenterically and closed over the tube in the middle. The lower part of the tube is implanted with a submucosal tunnel in the bladder wall, and the ileal patch is then anastomosed with the bladder. The tube is anastomosed to the umbilicus in an ordinary way without any traction (see Summary Fig.).

STUDY DESIGN

Between May 2005 and November 2012 the new technique was used at the current institution in nine children who needed an ileocystoplasty (mean age: 9 years and 3 months). Underlying etiology was neurogenic bladder in seven cases and epispadias in two.

RESULTS

All patients ultimately had stomas without leakage or strictures. During follow-up, three of nine tubes developed stenoses that were corrected; four stomas in total had some sort of surgical revision. Median follow-up was 93 months. Intermittent catheterization was uncomplicated in all at this time.

DISCUSSION

With this modification of the standard technique it seemed to be possible to create a more stable channel. The blood supply of the tube was secured by completely embedding the mesentery of the tube. Limitations included the small number of patients treated so far.

CONCLUSION

The lengthy tubes appeared to be straight and well supported by the surrounding tissues, which prevented kinking and sacculation. It is hoped that this technique will have better results and fewer complications at long-term follow-up.

Continent Catheterizable Vesicostomy: An Alternative Surgical Modality for Pediatric Patients With Large Bladder Capacity

OBJECTIVE

To present a modified technique and early outcomes of a continent catheterizable vesicostomy in pediatric patients with either flaccid neurogenic bladder or intractable voiding dysfunction and large capacity bladder.

METHODS

Six patients underwent the procedure from October 2014 to December 2015. A 4-cm Pfannenstiel incision was made, avoiding intraperitoneal dissection. After adequate mobilization, a 2-cm vertical flap at the dome of the bladder was identified and tubularized over a 12Fr catheter with 4-0 vicryl suture. The tubularized flap was then intussuscepted into the bladder with four 4-0 polydioxanone sutures, creating a continent mechanism. The catheterizable channel was then tunneled to the umbilicus, the channel ostomy matured, and the cystotomy closed in two layers.

RESULTS

The median patient age was 8 (interquartile range [IQR] 12) years. All patients had urinary dysfunction requiring drainage from etiologies that included Eagle-Barrett syndrome (n = 2), Noonan syndrome (n = 1), Lennox-Gastaut syndrome (n = 1), and Spina bifida (n = 2). Median hospital length of stay was 8 (IQR 3) days. One patient had a superficial wound infection treated with antibiotics, and 1 patient required balloon dilation of the catheterizable channel at 3 months postoperatively, secondary to difficulty self-catheterizing. Five patients were successfully self-catheterizing at last follow-up. Median follow-up was 6 (IQR 5) months and there were no intra- or perioperative complications.

CONCLUSION

Continent catheterizable vesicostomy is a novel technique for urinary drainage in patients with large bladder capacity that spares use of the appendix or ileum. Early results are encouraging, providing a catheterizable channel through the umbilicus without urinary leakage between catheterization.

First case of invasive squamous cell carcinoma in a stoma of a Monti ileovesicostomy

We report a very rare case of invasive squamous cell carcinoma (SCC) in the abdominal stoma of a Monti ileovesicostomy. Our patient underwent an uncomplicated Monti ileovesicostomy at age 16 for a neurogenic bladder. She presented 10 years later with difficulty catheterizing the stoma. A biopsy of peristomal tissue showed moderately differentiated SCC. A cystoscopy did not reveal any bladder tumours or suspicious lesions. A computed tomography (CT) scan of the abdomen and pelvis did not demonstrate metastasis. The patient underwent a complete en bloc resection of the stomal site, the Monti, a partial cuff of bladder, and 2 loops of bowel that were adherent to the Monti. Final pathology revealed pure invasive SCC arising around the stoma and negative surgical margins. Six months later, a follow-up CT scan showed no evidence of malignancy, while a cystoscopy revealed a small erythematous area in the posterior bladder wall. Urinary cytology was positive for SCC. Transurethral resection of the erythematous lesion with random bladder biopsies showed SCC in situ in the erythematous lesion and right lateral bladder wall. Staging workup was negative. The patient subsequently underwent a radical cystectomy and ileal conduit diversion with bilateral pelvic lymph node dissection. Final pathology on cystectomy specimen was SCC in situ without evidence of invasive carcinoma. The patient has remained in remission at the 3-year follow-up.

Yang-Monti's Catheterizable Stoma in Children

Background

In 1981, Mitrofanoff described a procedure to create a continent urinary stoma for clean intermittent catheterization. Since then several procedures have been described including Yang-Monti ileovesicostomy for effective catheterization.

Objectives

We report on our experience from the use of Monti’s procedure in children at our center.

Patients and Methods

Children < 18 years of age undergoing urinary diversion/reconstruction with Yang-Monti’s procedure for congenital conditions or neuropathic bladder formed the study group. All these children, post-operatively were taught clean intermittent catheterization (CIC) and put on a regime using a 14/16 Fr catheter every 3 hours. The children were followed regularly at 3, 6, 12, 18 and 24months post-operatively, with special attention paid to any problems with catheterization and incontinence.

Results

During the period from Jan 2000 to Dec 2011, at our center, 19 children less than eighteen years of age underwent urinary diversion with Yang-Monti’s catheterizable stoma. The indications for urinary diversion was neuropathic bladder in eight, exstrophy bladder in seven , valve bladder syndrome in three and persistent urethral stricture in one. None of the children found CIC difficult during the post-operative period and there was no hindrance to the passage of the catheter.

Conclusions

Although the appendix remains the tissue of choice for creation of catherterizable stoma, the Yang-Monti ileovesicostomy is effective, convenient conduit for children. Long-term complications are minimal and children find this comfortable to do CIC.

Continent urinary diversion in the epispadias-exstrophy complex

Despite improvements in modern surgical reconstructive techniques, many patients with epispadias-exstrophy continue to experience urinary incontinence. Continent diversion is commonly performed to achieve urinary continence and improve quality of life. In this work we describe the population that can be considered for continent urinary diversion, consider the benefits and implications of concurrent augmentation and bladder neck closure, and review recent literature regarding continence outcomes and common complications. Even in this complex patient population, urinary continence can be reliably achieved by bladder augmentation and the use of intermittent catheterization via a catheterizable cutaneous stoma with or without closure of the bladder neck.

Educational article: The Mitrofanoff procedure

The management of urinary incontinence has been revolutionized by the introduction of intermittent catheterization by Lapides in 1972, and later, by the description of the 'trans-appendicular continent cystostomy' by Mitrofanoff in 1980. Mitrofanoff launched a new concept whereby the bladder could be emptied by a route other than the urethra. This concept led to the publication of a plethora of alternatives to the appendix conduit, including the transverse ileal (Yang-Monti) tube, and conduits constructed from ureter, Fallopian tube, tubularized preputial transverse island flap, and longitudinally tubularized ileal and gastric segments. Further experience with the procedure, and the onset of complications such as stomal stenosis and leakage, instigated the description of various stomal options and conduit implantation techniques. More recently, laparoscopic and robotically assisted techniques have also been performed. We present a review of these techniques, and the outcomes reported over the last 30 years since the Mitrofanoff principle was first described.

Continent urinary reservoir formation with transverse colon for patients with pelvic irradiation

BACKGROUND

The creation of a continent transverse colon pouch for patients who had previously received radiation therapy for cervical cancer was attempted.

METHODS

Three patients underwent construction of a continent urinary reservoir. Approximately 30 cm of a transverse colon segment was isolated for constructing a pouch. A reconfigured colon segment was used in two cases as a continent valve and the appendix was used in one case. Both ureters were implanted submucosally into the pouch in two patients and a reconfigured colon was also used to reconstruct a defect of the ureter in one patient.

RESULTS

All patients could catheterize the pouch easily via the cutaneous stoma without incontinence. No complications were noted.

CONCLUSIONS

In the event that a urinary diversion is necessary for a patient who has previously had radiation therapy, the transverse colon pouch can be a useful method to improve the quality of life. In addition, versatility of the reconfigured colon segment enables the colon pouch to be adapted to adverse clinical situations.

Versatility of reconfigured-colon-segment technique for urinary reconstruction requiring use of tubular structures

INTRODUCTION

When a colon segment is used for urinary reconstruction and a tubular structure is necessary, the option for the tubular structures is limited. We prepared a short colon segment in advance for creating a reconfigured tube.

TECHNICAL CONSIDERATIONS

Short colon segments are separated beforehand from the edges of the main colon segment for a continent urinary reservoir or augmentation cystoplasty. The short segments are either reconfigured, if necessary, into tubular structures to produce a continent valve or to replace a ureteral defect or discarded if they prove not to be needed. The number of short segments can be predicted on the basis of the clinical situation before and during the operation.

CONCLUSION

Preparation of short colon segments is useful for urinary reconstruction using a colon segment that might require a number of tubular structures. The technique provides versatility and flexibility in difficult clinical conditions.

The Yang-Monti ileovesicostomy: a problematic channel?

OBJECTIVE

To compare the differences in the quality of Mitrofanoff channels created using appendix and re-tubularized small bowel (the Yang-Monti ileovesicostomy). Patients and methods The case-notes were reviewed retrospectively for all patients who underwent a Mitrofanoff procedure using either appendix or small bowel, over a 5-year period from June 1994 to July 1999.

RESULTS

In all, 92 patients underwent 94 Mitrofanoff procedures; the appendix was used in 69 and small bowel in 25. The underlying diagnoses were exstrophy-epispadias complex (38), neuropathic bladder (21), anorectal malformations and cloacal anomalies (15), posterior urethral valves (nine) and miscellaneous (nine). The mean (range) age at operation was 9.2 (1.1-18.3) years. The mean (range) follow-up for the appendix group was 37 (6.7-65) months and for the Monti group 25 (6-66) months. Catheterization problems occurred in 18 (27%) patients from the appendix group; two needed an adjustment of technique, six dilatation and 10 revision. Stomal stenosis occurred in 10 (15%) patients, bladder level stenosis in four (6%) and conduit necrosis in two. Catheterization problems were reported in 15 (60%) patients from the Monti group; five needed revision, three dilatation and seven are being managed conservatively. The incidences of stomal stenosis (four, 16%) and bladder level stenosis (two, 8%) were comparable with the appendix group. In addition, two patients had distal channel (sub-stomal) stenosis and two had mid-channel stenosis. The problem unique to the Yang-Monti channel was a pouch-like dilatation in seven patients (28%), all of whom presented with catheterization problems; five are being managed conservatively and two have needed pouch resection. Stomal prolapse occurred in five (7%) patients in the appendix group, but in none of the Monti group.

CONCLUSIONS

The appendix is the conduit of choice for a Mitrofanoff procedure. Re-tubularized small bowel conduits have a considerably higher incidence of catheterization problems. Anatomical factors may contribute to the unique incidence of pouch formation.

Colon pouch (Mainz pouch III) for continent urinary diversion after pelvic irradiation

OBJECTIVES

Urinary diversion after previous pelvic irradiation is challenging. The use of irradiated bowel in particular is associated with an increased rate of early and late complications. We therefore performed continent cutaneous urinary diversion using exclusively nonirradiated bowel segments in this group of patients.

METHODS

A continent colon pouch for urinary diversion was performed in 44 female patients after pelvic irradiation. The indications were irreparable vesical fistula in 20, local recurrence of gynecologic tumors in 22, and radical cystectomy for bladder cancer in 2 patients. Depending on the length of the nonirradiated bowel segment, a transverse-ascending colon pouch (n = 8) or transverse-descending colon pouch (n = 36) was performed. The efferent segment was created from a tapered bowel segment embedded in the pouch wall. The ureters were implanted using a submucosal (n = 67) or subserosal (n = 17) extramural tunnel.

RESULTS

No pouch-related complications were observed during the immediate postoperative period. In long-term follow-up (mean 52.2 months), upper urinary tract dilation was seen in five renal units. All five of these had been dilated preoperatively, and none required ureteral reimplantation. Incontinence occurred in 2 patients; both underwent reoperation with subsequent continence. Umbilical stoma stenosis was observed in 6 patients.

CONCLUSIONS

The technique of the colon pouch for continent urinary diversion in previously irradiated patients is safe and has a low complication rate. The use of nonirradiated bowel segments should be the method of choice in this group of patients.

The transverse colonic reservoir: the Unicamp technique

OBJECTIVE

To present the results of a continent and nonrefluxing transverse colonic urinary reservoir technique.

PATIENTS AND METHODS

Twenty patients who had received high doses of irradiation underwent construction of transverse colonic reservoir as a primary form of urinary diversion. Fourteen patients had a vesicovaginal fistula after definitive radiation therapy for gynaecological tumours and six had radiation therapy for invasive bladder cancer as a definitive treatment. They were followed for a median (range) of 4.5(1-8) years. Intravenous pyelography before diversion showed mild hydronephrosis in 10 patients.

RESULTS

After diversion, hydronephrosis improved in four patients and no upper tract deteriorated. All but one of the pouchograms showed no ureteric reflux. All the patients required clean intermittent self-catheterization every 3-4 h. Persistent asymptomatic bacteriuria was present in 14 patients, although clinical urinary tract infections were not reported. A moderate metabolic acidosis was present in 12 patients, but none required treatment. The urodynamic evaluation revealed a median (range) reservoir capacity of 450 (350-600) mL, with no contractions or contractions of <35 cm H2O.

CONCLUSION

These results suggest that the Unicamp technique for constructing a transverse colonic reservoir is a safe and effective diversion, and is recommended as an alternative method for patients treated by pelvic irradiation.

Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital

PURPOSE

We present our experience using the various Mitrofanoff techniques to create a continent catheterizable stoma as an adjunct to continent urinary tract reconstruction in children and young adults.

MATERIALS AND METHODS

Between 1990 and 1998 a Mitrofanoff procedure was performed at our institution in 55 male and 45 female patients with a mean age of 10.5 years. The etiology of incontinence was diverse but more than 90% of the patients had neurogenic bladder, the epispadias-exstrophy complex or a cloacal anomaly. Surgery included appendicovesicostomy in 57 cases, a Yang-Monti ileovesicostomy in 21, continent vesicostomy in 21 and formation of a tapered ileal segment as a catheterizable channel in 1. Simultaneously bladder augmentation was performed in 52 patients, bladder neck reconstruction was done in 48 and a Malone antegrade colonic enema stoma was constructed for fecal incontinence in 17.

RESULTS

The abdominal stoma is continent in 98 of our 100 patients. Mean followup is 2 years (range 2 months to 8 years) with the longer followup in the appendicovesicostomy group. One patient with stomal incontinence who underwent revision is now dry. Postoperative complications requiring an additional procedure developed in 20 patients, including stomal stenosis in 12. Continent vesicostomy was most prone to stomal problems (6 of 21 patients, 29%).

CONCLUSIONS

The Mitrofanoff procedure is a reliable technique for creating a continent catheterizable urinary stoma. Appendicovesicostomy continues to be our first option for this procedure, although we have also had good results with the Yang-Monti ileovesicostomy and continent vesicostomy. These newer options have allowed preservation of the appendix for the Malone antegrade colonic enema stoma procedure in patients with urinary and fecal incontinence.

Initial experience using a catheterizable ileovesicostomy (Monti procedure) in children

OBJECTIVES

To present a review of our experience using the recently described Monti ileovesicostomy as an alternative to appendicovesicostomy as a continent catheterizable stoma in children.

METHODS

Between January and December 1997, a Monti ileovesicostomy was performed as part of a reconstructive procedure in 13 children. Mean patient age was 1 1 years, and diagnosis included neurogenic bladder in 11 patients, cloacal exstrophy in 1, and cloacal anomaly in 1 patient. Simultaneous bladder augmentation was performed in 10 children, bladder neck reconstruction or closure in 7, and Malone antegrade continent enema (MACE) in 4.

RESULTS

All 13 patients have continent stomas (100%) and catheterize the Monti ileovesicostomy without difficulty. Mean follow-up was 7 months (range 1 to 14), and there have been no stomal problems or postoperative complications attributed to the ileal channel.

CONCLUSIONS

The Monti ileovesicostomy is a new technique for creation of a continent catheterizable stoma and has allowed preservation of the appendix for the MACE procedure, providing an additional option in patients with an absent or inadequate appendix. Early results of this technique for pediatric reconstruction have been excellent.

Transverse retubularized ileum: early clinical experience with a new second line Mitrofanoff tube

PURPOSE

Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique.

MATERIALS AND METHODS

From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube.

RESULTS

Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization.

CONCLUSIONS

With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.

Transversely tubularized ileal segments for the Mitrofanoff or Malone antegrade colonic enema procedures: the Monti principle

OBJECTIVE

To assess the use of a transverse tubularized segment(s) of ileum in the Mitrofanoff or Malone antegrade colonic enema (MACE) procedures.

PATIENTS AND METHODS

Eleven patients in three centres underwent the formation of a continent conduit to bowel (MACE, eight patients) and/or bladder (Mitrofanoff, four) using either a single segment of transverse tubularized ileum (10 patients) or two segments of ileum anastomosed and tubularized into a single conduit (two).

RESULTS

Within a follow-up of 8 weeks to 6 months, all conduits were continent and catheterized easily. One stomal stenosis required a revision procedure.

CONCLUSION

This method for forming a continent catheterizing conduit, based on the Mitrofanoff principle, appears to be effective and is recommended in cases where the appendix cannot be used or where a second conduit is required.

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.

New techniques for construction of efferent conduits based on the Mitrofanoff principle

Presently, urinary diversion with continence mechanisms based on the Mitrofanoff principle is frequently used. For its construction, the critical issue is related to the choice of efferent conduit; the most widely used are the appendix and the tapered ileum. Here, we present two alternative techniques for construction of tubes applicable to the same function. Ten dogs underwent operations with two different types of tubes constructed through transversal tubularization of small segments of ileum. These tubes were implanted in the bladder. The dogs were followed up for 30 days, during which all were continent. Their tubes were easily catheterized. The techniques described met the criteria defined for an efferent tube to be used according to the Mitrofanoff principle.

Continent gastric tube: new techniques and long-term followup

PURPOSE

The successful use of stomach for bladder augmentation and substitution is well documented. Gastric tissue has been used more recently to create continent catheterizable tubes. We describe 2 new techniques of gastric tube construction, and report our long-term followup of catheterizable gastric tubes in children and adults undergoing complex urinary tract reconstruction.

MATERIALS AND METHODS

A retrospective chart review of 6 male and 4 female patients 5 to 43 years old was done. Primary diagnoses included bladder exstrophy, cloacal exstrophy, rhabdomyosarcoma and neurogenic bladder. Five patients underwent gastrocystoplasty with simultaneous creation of a continent gastric tube from the anterior gastric flap. In 2 patients who had undergone previous gastrocystoplasty a continent gastric tube was created from an anterior flap raised from the existing gastric bladder. Isolated gastric tubes were constructed in 3 patients.

RESULTS

Followup ranged from 2 to 9 years (median 3.5). All patients demonstrated easy reliable catheterization. One patient required revision of the proximal end of the tube for incontinence. At followup all tubes were continent. Complications occurred only in flush or protuberant stomas, and resolved after stomal revision with recessed skin flaps.

CONCLUSIONS

Several techniques can be used to create a continent gastric tube. Long-term followup reveals reliable catheterization and good continence rates. Recession of the gastric tube stoma with a skin flap prevents peristomal complications.

The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results

Ten patients with a urethra that could not be catheterized and with absent appendixes underwent neobladder construction using an ileal segment fashioned to serve as the anti-incontinence mechanism. The latter was tapered and reimplanted following the guidelines of the Mitrofanoff procedure. Urinary reservoirs were constructed from detubularized segments of right colon, sigmoid colon and composite gastro-ileal combinations. Followup ranged from 9 to 21 months (mean 14.5). All patients presently catheterize the reservoir satisfactorily and are free of urinary leakage. Three patients (30%) experienced initial catheterization difficulties: 2 required endoscopic procedures and insertion of a stent, and 1 with stomal stenosis was successfully treated with a Y-V stoma plasty. One patient (10%) required a repeat ileal segment reimplantation due to urinary incontinence. The higher reoperation rate and the increased surgical complexity of this procedure compared with reconstructions using the ileocecal valve as part of the anti-incontinence mechanism make this operation a less attractive alternative in the creation of a continent urinary reservoir. However, with comprehension of the need for careful and detailed surgical technique in its creation, the tapered and reimplanted ileal segment is a successful choice as an alternative for the creation of an abdominal wall stoma when the appendix is unavailable.

Gastrocystoplasty without opening the stomach

We describe a modification of gastrocystoplasty using the GIA stapler to harvest the segment for augmentation without opening the stomach. This simplification reduces operative time and blood loss without introducing complication specific to it and has been successfully used in our first 5 patients.

Seromuscular trough modification in construction of continent urinary stomas

The creation of an effective flap-valve continent stoma requires use of supple, catheterizable conduit that is implanted in a submucosal bed having adequate backing. In some patients the backing that has been routinely used, colonic teniae or bladder detrusor for instance, is deficient or unavailable. As an alternative, the seromuscular layers of the recipient urinary reservoir can be simply reconfigured to provide the support required of a continent stoma. The technique has been effective in 4 patients and offers additional flexibility with challenging cases of continent urinary reconstruction.

Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder

Appendicovesicostomy is a useful adjunct to continent reconstruction of the bladder. During the last 3 years we have used this procedure in 14 children with difficult incontinence due to spina bifida (7), exstrophy/epispadias (5), imperforate anus (1) and urethral agenesis (1). In 4 patients in whom previous operations had failed to achieve continence the bladder neck was closed. In the remaining 10 children, all of whom had difficulty or discomfort catheterizing the native urethra, the bladder neck/urethra was preserved or reconstructed to serve as a vent for elevated bladder pressures. Continence was achieved in all 14 children with no complications related to the appendix. All children in whom the bladder neck/urethra was salvaged preferentially empty via the appendix and remain dry, except when the bladder is overly full.