Long-term metabolic consequences of continent ileal diversion

Reoperative ureteral reimplantation: strategies for management

Ureteral reimplantation is a procedure commonly performed by both urologists and pediatric surgeons. Although the vast majority are successful, there are some patients in whom technical considerations or bladder/ureteral abnormalities militate against success. We review our experience in 19 patients with multiple failed reimplants. The reasons for their failure, the investigations required to document such, and the management of these difficult problems will be discussed. In our hands, 95% of these patients ultimately became reflux-free and nonobstructed.

Continent urinary reservoirs in pediatric urological practice

During the last 3 years 20 patients (median age 8 years) have undergone construction of a continent urinary reservoir at our pediatric urology service. Of the patients 12 had failed exstrophy reconstruction, 7 had myelodysplasia with a neurogenic bladder and 1 had extensive bladder damage as a result of a previous operation. In 5 patients a continent reservoir was constructed after cystectomy performed in early childhood. Techniques of reconstruction included the Mitrofanoff procedure (4 patients), a modification of the Indiana pouch (12), a modification of the Benchekroun procedure (2), the use of the appendix in situ as a continence mechanism (2) and a modified Kropp procedure using a duplicate vagina for catheterization (1). The morbidity from these procedures was acceptable and consisted primarily of chronic diarrhea (4 patients), stone formation within the pouch (5) and the need to revise the continence mechanism (7). All but 1 patient maintained stable or improved upper tracts after diversion. Over-all, 85% of the patients experienced diurnal continence on an intermittent catheterization regimen, while 75% were dry at night. The plicated/intussuscepted ileal nipples required revision because of difficulty with catheterization (7 patients) and urinary leakage. We currently favor the use of the Benchekroun or Mitrofanoff techniques for the ease of construction and minimal requirements for revision.