World J Urol (1992) 10:107-114

World Journal of

~r

Urology

© Springer-Verlag1992

Continent urinary diversion in childhood M. Fisch 1, R. Wammack 1,, ~3. Sert 2, S.C. M01ler 1, and R. Hohenfellner 1 1Department of Urology, University of Mainz, Medical School, W-6500 Mainz, Federal Republic of Germany 2Department of Urology, University Hospital, 42001 Konya, Turkey

Summary. Continence and a positive body image are important, especially to the adolescent patient. Since 1964 we have used ureterosigmoidostomy and have achieved a complete continence rate of 92.3%. The creation of a low-pressure reservoir by antimesenteric splitting of the recto-sigmoid eliminated many of the shortcomings of ureterosigmoidostomy. This procedure is termed the sigma-rectum pouch and has been applied in six children to date. Mainz-pouch bladder augmentation or substitution has been performed in 20 children, 17 of whom are completely continent. The results of the modified Young Dees procedure were disappointing. In three children, conversion into a continent diversion was necessary. All of the 41 children who underwent continent diversion using the Mainz pouch procedure are continent. The overall rate of late complications following the Mainz pouch procedure was 19.6%.

Continent diversion is the current method of choice for urinary diversion. It improves the body image by avoiding the need for an external collection device and serves to stabilise or even improve renal function. Many procedures for continent urinary diversion are available, each having their particular advantages and disadvantages [1-6]. All forms of continent diversion rival in their achievement of certain goals. The ideal technique would provide a large capacity, low-pressure reservoir, allow for antirefluxive ureteral implantation and enable voiding or easy catheterisation at convenient intervals. Ureterosigmoidostomy was a very popular form of permanent urinary diversion during the second quarter of this century, especially in children. However, due to the high postoperative complication rate and to deterioration of the upper urinary tract, the number of ureterosigmoidostomies carried out declined steadily. Renal insufficiency and uremia were not uncommonly encountered [7, 8]. Increasing reports of the development of colonic tumors * To whom correspondence should be addressed

many years after ureterosigmoidostomy (mean, 22 years) [9-11] further reduced the frequency of this operation. The widespread introduction of antibiotics and drugs for the treatment and prevention of hyperchloraemic acidosis as well as the possibility of creating a non-obstructive, non-refluxing ureterointestinal anastomosis rekindled the interest in this proven surgical technique. Due to our previous excellent results and to a continence rate exceeding 90%0, ureterosigmoidostomy remains the treatment of choice for bladder exstrophy at our institution [12]. On the basis of experience gained in urodynamic investigations of different forms of urinary diversion, we developed a modification of this classic technique of ureterosigmoidostomy termed the sigma-rectum pouch (Mainz pouch II) [13]. The sigma-rectum pouch provides many features that a continent form of urinary diversion should preferentially offer, as is shown and discussed in a subsequent section of this report. Children with neuropathic bladders represent the main group requiring bladder augmentation or continent urinary diversion. Nevertheless, the path leading to the indication for operative intervention has changed. The prognosis of the patients was drastically changed by the introduction of clean intermittent catheterisation (CIC). The broad implementation of selective and potent drugs such as anticholinergics supported this conservative treatment. In past decades, these patients usually died of renal insufficiency; in the present day and age, however, their prognosis can be considered to be good. Nevertheless, for patients bound to a wheelchair, intermittent transurethral catheterisation causes problems due to body disproportion and immobility. For these patients, continent urinary diversion in which the stoma is located in the area of the umbilicus is an ideal solution. For patients with a neuropathic bladder who are in good orthopaedic condition, bladder augmentation remains an excellent solution. Generally, any bowel segment can be used for bladder augmentation. Subtotal bladder resection is required in patients presenting with a pathological detrusor caused by inflammation or neurogenic disturbances. Subsequent neoimplantation of the ureters becomes necessary. For

108 this reason, we used the ileocecal segment for augmentation, enabling antirefluxive ureteral implantation into the cecal portion. This well-established surgical technique is termed the Mainz pouch procedure for bladder augmentation (Mixed A u g m e n t a t i o n / l e u m and Zecum). In the present report, we present and discuss our experience with these different operative techniques of continent urinary diversion in children.

Indications and operative techniques Ureterosigmoidostomy As mentioned above, ureterosigmoidostomy remains the method of choice for treating bladder exstrophy at our institution. After this procedure, complications almost exclusively occurred in patients who have undergone previous surgery such as failed attempts at bladder closure for bladder exstrophy. In practically all of these cases, the upper urinary tract was dilated preoperatively. On the basis of this experience, we believe that a dilated upper urinary tract or prior radiotherapy are contraindications for the classic technique of ureterosigmoidostomy. The prerequisites for ureterosigmoidostomy include a well-functioning anal sphincter, guaranteeing postoperative continence. If ureterosigmoidostomy is to be performed in infants or young children who arc not yet capable of voluntarily controlling their sphincter, an anorectal pressure profile is valuable. The operation should be performed at either the end of the 1st year or the beginning of the 2nd year of life. After longitudinal antimesenteric opening and excision of a buttonhole in the mucosal and muscular layer of the back wall of the sigmoid colon, the ureters are pulled through transmesenterically. Ureteral implantation using the Goodwin-Hohenfellner technique [14, 15] is performed. After the ureter has been embedded in a submucosal tunnel measuring 3 - 4 cm in length, the bowel mucosa is closed over the buttonhole with one or two interrupted sutures. The right ureter is implanted 2 cm distal of the left ureter via an identical technique. A single row of interrupted sutures is used to close the sigmoid. The sigmoid colon is subsequently fixed at the retroperitoneum to prevent ureteral kinking or strangulation at the implantation site.

nary-tract dilatation has previously been temporarily treated by a nephrostomy and creatinine levels have dropped below 2.0 mg/dl. After median laparatomy, the rectum and sigmoid colon are opened antimesenterically over a length of 1 0 - 1 2 cm both proximally and distally to the rectosigmoid junction. The medial margins are anastomosed by a seromuscular running suture (polyglyconate 4/0). The cranial end of this running suture represents the point at which the pouch is eventually fixed to the promontory. Ureteral implantation is performed parallel to the running suture using the Goodwin-Hohenfellner technique [14, 15]. In the presence of dilated ureters, the "openend" technique for ureteral implantation using a wide submucoscal tunnel proves to be most advantageous. The pouch is closed using a running suture or interrupted sutures (polyglyconate 4/0).

Bladder augmentation or substitution using the Mainz pouch procedure Indications for augmentation include bladder exstrophy and incontinent epispadia. A further indication for bladder augmentation is the neurogenic bladder after the failure of conservative treatment. The duration of survival and the quality of life in this patient group has been completely changed by the introduction of clean intermittent self-catheterisation. In the recent past, a neurogenic bladder dysfunction would have led to renal insufficiency, whereas the current prognosis is considered to be good.

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The sigma-rectum pouch: a modification of ureterosigmoidostomy Ureteral implantation into a mobile sigmoid segment is a common error in ureterosigmoidostomy, as subsequent ureteral kinking causes upper urinary tract dilatation. This prompted us to modify this proven surgical technique with the aim of creating a low-pressure reservoir and guaranteeing a straight ureteral path. This technique is not only indicated as an alternative to primary ureterosigmoidostomy but is also suitable when a revision of ureterosigmoidostomy becomes necessary. When this procedure is implemented, upper urinary-tract dilatation is no longer a contraindication. The sigma-rectum pouch (Mainz pouch II) can also be constructed when upper uri-

Fig. 1. Mainz pouch II: after side-to-side anastomosis of the posterior wall, the ureters are implantated using the Goodwin-Hohenfellnertechnique

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Fig. 4. Use of the appendix as a continence mechanism for the Mainz pouch I: after windows have been excised in the mesentery, the appendix is placed in the prepared bed and the seromuscular layer is closed over the embedded appendix

Fig. 2. Modified Young Dees procedure for bladder-neck reconstruction: the bladder remnant serves as the continence mechanism, whereas the Mainz pouch functions as the reservoir

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the other hand, individuals who are bound to a wheel chair may have severe difficulties; for this group, continent urinary diversion in which the stoma is attached to the umbilical funnel is more advantageous and facilitates CIC. The indication for bladder substitution in children is iatrogenic or traumatic bladder loss. For this procedure, a functioning urethral sphincter and an undamaged urethra are prerequisite. As only a very small number of the children in whom urinary diversion is indicated fulfill these requirements, bladder substitution in childhood is rare.

Bladder augmentation. Creation of the pouch requires

Fig. 3. Mainz pouch I: intussusception of the ileum is accomplished by means of two Allis clamps, followed by fixation of the intussusception by two rows of staples at the 3 and 9 o'clock positions. The mucosa is roughened. The intussusception is pulled through the ileocecal valve and subsequently fixed by a third row of staples at the 12 o'clock position

Bladder augmentation is superbly suited for patients presenting with a neurogenic bladder in the absence of diplegia. However, it must be kept in mind that even after augmentation, CIC might be necessary to avoid residual urine. For such patients who are in good orthopaedic condition, CIC generally does not present a problem. On

12 cm of the cecum and colon ascendens as well as two terminal ileal loops of identical length. Bowel continuity is restored by an ileoascendostomy. To create the pouch plate, the ascending colon, the cecum and both terminal ileal segments are opened at the antimesenteric aspect. The ileal loops are anastomosed side to side by a single row running suture. The posterior wall is completed by anastomosis of the ascending colon with the terminal ileal loop. After subtotal resection of the bladder, the pouch is connected to the bladder remnant by a single row of all-layer interrupted sutures (3/0 or 4/0 polyglyconate). The ureters are implanted using the open-end technique via a submucosal tunnel and are subsequently stented to secure the anastomosis. The anastomosis of the pouch to the anterior bladder wall is completed using a single row of all-layer interrupted sutures.

The modified Young Dees procedure. For patients with incontinent epispadia or exstrophy, this procedure uses the bladder to achieve continence, whereas the pouch serves as the actual reservoir. For the construction of the continence mechanism, the bladder mucosa is separated from the detrusor in the vicinity of the bladder neck and

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Fig. 5. Urogram obtained in a 4-year-oldchild after the construction of a sigma-rectumpouch (Mainz pouch II), showingmild upper-tract dilatation on the 17th postoperative day

Fig. 6. Postoperativeurogram obtained in a 7-year-oldchild following Mainz-pouch bladder augmentation

tubularised over a transurethrally inserted catheter. The detrusor is then laid over the mucosal pipe in an overlapping manner. This represents the actual continence mechanism. The pouch is then connected to the newly formed bladder.

sure has failed or continence could not be achieved by the modified Young Dees procedure - sinus urogenitalis and malignant tumors such as rhabdomyosarcomas. The reservoir is created using the same technique described above. Construction of the continence mechanism can be accomplished by using either an intussuscepted ileal nipple or the submucosally embedded appendix. We prefer to use the appendix for reasons that are discussed in detail below.

Bladder substitution. The reservoir is created in the same manner used for bladder augmentation. A buttonhole incision is made at the most inferior aspect of the cecal pole. If the appendix has a wide enough lumen, an appendectomy may be performed such that a stump measuring about 1.5 cm in length remains for end-to-end anastomosis to the membranous urethra. The anastomosis is carried out using five to six interrupted sutures, which are first placed and subsequently tied.

Continent urinary diversion using the Mainz pouch technique As discussed above, patients presenting with neurogenic bladders and diplegia meet the criteria indicative for continent urinary diversion. Further indications include bladder exstrophy - especially if primary bladder clo-

Intussuscepted ileal nipple. An additional ileal segment measuring 8 - 1 0 cm is necessary for the creation of the continence mechanism. The serosa of the mesentery o f this segment is incised and the mesentery is freed of fatty tissue on both sides to facilitate intussusception. The intussusception is performed by means of two Allis clamps and is stabilised by two rows of staples placed at the 3 and 9 o'clock positions. The mucosa of the nipple thus created is roughened to improve subsequent fixation into the ileocecal valve. Then, again using two Allis clamps, the nipple is pulled through the ileocecal valve and fixed at the 12 o'clock position by the placement of a third row

111 of staples. The space between the ileocecal valve and the intussuscepted ileal nipple is filled with fibrin adhesive. The mucosa of the inner tip of the ileal nipple and of the cecal opening of the ileocecal valve is resected and the borders are sutured circumferentially. For the creation of the stoma, the umbilicus is separated from the external rectus fascia and opened at its deepest point; then, the fascia and the peritoneum are incised. The incision is subsequently enlarged and the efferent loop of the pouch is pulled through the opening. Thereafter, five to seven single sutures are placed that grasp the skin o f the umbilicus from the interior, then from the fascia, and finally from the muscular layer of the efferent loop. Normally, the efferent loop is too long and must be resected to a length of 2 cm.

The appendix as a continence mechanism. Prerequisite is a 5- to 6-cm-long appendix, which can be dilatated up to 16 E Using this technique, it is sufficient to isolate only the cecum and ascending colon as well as two ileal loops of identical length. When the colon is split at the antimesenteric side, the caudal 4 - 5 cm of the cecal pole remain intact. The seromuscular layer of the intact cecal pole is split along the taenia libera down to the mucosa. By extensive dissection of the seromuscular tissue from the mucosa, a broad submucosal bed is created for the appendix, in analogy to the Lich-Gregoir procedure for treating vesicoureteral reflux. Windows are carefully excised in the appendicular mesentery, with care being taken not to compromise the blood supply. The appendix is laid back and the seromuscular layer is closed over the embedded appendix by the placement of interrupted sutures (polyglyconate 4/0). The ureters are implanted using the open-end or Goodwin-Hohenfellner technique, and the pouch is closed. Before the appendix is anastomosed to the umbilicus, a V-shaped incision is made in both; we have found that this reduces the incidence of stomal stenosis. The pouch is drained via a 16- or 18-F transappendicular catheter and a 10-F pouchostomy. Results

Ureterosigmoidostomy Since 1964, 58 children have undergone ureterosigmoidostomy. In all, 12 of these 58 individuals could not be followed. The indication for ureterosigmoidostomy was bladder exstrophy in 40 patients, incontinent epispadias in 5 subjects and neurogenic bladder dysfunction in i case. Of the 40 patients with bladder exstrophy, 8 underwent ureterosigmoidostomy after the failure of other reconstructive attempts and 6 had upper-tract dilatation prior to ureterosigmoidostomy. Three subjects with previously damaged upper urinary tracts required early postoperative conversion due to severely increasing dilatation. Three other patients required conversion to preserve renal function after a mean of 10 years. All but one of these patients are alive and show a functioning ureterosigmoidostomy (mean follow-up, 14.7 years). One subject died at 16 years post surgery due to circumstances that were not related to the procedure. The daytime continence rate

was 97.4% (38 of 39 patients) and the complete continence rate was 92.3% (36 of 39 cases). No bowel neoplasia has been observed except for one tubular adenoma, which was removed during routine colonoscopy. None of the 45 patients currently being followed has shown signs of renal insufficiency.

Sigma-rectum pouch. We started to use this procedure in November 1990. To date, it has been performed in a total of 27 patients, including 6 children. No postoperative complication has been observed. All of the children are completely continent and show normal renal function without dilatation of the upper urinary tract. Mainzpouch technique. Since 1983, we have constructed a Mainz pouch in a total of 28l patients, including 61 children. Among the latter, 20 children underwent bladder augmentation or substitution, whereas continent diversion was carried out in 41 children. In 2 cases (3.3%), relaparatomy became necessary. During a follow-up period of up to 80 months (mean 30 months) we observed late complications in 12 of the 61 children (19.7%; Table 1). Indications for bladder augmentation or replacement included bladder exstrophy or incontinent epispadias in 8 children, iatrogenic bladder loss in 7 children, and neurogenic bladder disturbances in 5 children. Continent diversion using the Mainz pouch technique was required due to neurogenic bladder in association with diplegia (n = 14), neurogenic bladder in the absence of diplegia (n = 7), bladder exstrophy (n = 14), urogenitalia (n = 2), rhabdomyosarcoma (n = 3) and trauma (n = 1). In the bladder substitution/augmentation group, 17 of the 20 children are now completely continent during both daytime and nighttime. One child is partially incontinent during the nighttime. The two children who remain incontinent are undergoing biofeedback training. Eight children were subjected to a modified Young Dees procedure in combination with bladder augmentation for the treatment of exstrophy. All had previously undergone failed attempts at primary bladder closure. Only one child now shows diurnal and nocturnal continence. Four are incontinent during the nighttime, and two of these children are those currently under biofeedback training. Three cases had to be converted into continent urinary diversion due to incontinence or complete obstruction. All of the children who underwent urinary diversion are presently completely continent. Reflux persists in two children despite antirefluxive implantation; both of them Table 1. Late complications following urinary diversion using the Mainz pouch technique in 61 children Complication

Patients (n)

Ureteroneoimplantation Nipple revision Stoma stenosis Pouch perforation Calculus formation Total

3 5 2 1 1 12/61 (19.7070)

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exhibited severely damaged and dilated ureters preoperatively. Discussion Primary bladder closure with subsequent bladder-neck reconstruction (Young Dees) is the method of choice for the treatment of bladder exstrophy at most institutions [16]. Presumably acceptable results for the establishment of continence have been reported [17, 18]. However, the term continence as it pertains to bladder closure seems to be defined differently [19]. Multiple procedures are required to achieve continence. Nocturnal continence remains the exception [20], although continence may improve by the time puberty is reached. Urodynamic investigations have revealed that an unstable detrusor of the closed bladder is most likely responsible for the nighttime incontinence. Even a combination of the Young Dees procedure with bladder augmentation cannot produce the continence rate that we customarily achieve using ureterosigmoidostomy or continent diversion (Mainz pouch I). The results we obtained using the Young Dees procedure were most disappointing (Table 1). Of the eight children treated, only one is now completely continent. Three cases had to be converted due to incontinence or obstruction and underwent urinary diversion with a continent stoma. The results reported by Hollowell and Ransley [19] are also disappointing (Table 2). Mesrobian et al. [21] have demonstrated that deterioration of renal function due to reflux is commonly encountered. The results obtained concerning the upper urinary tract using primary bladder closure did not fulfill our expectations. Can any form of incontinence, even nocturnal incontinence, be accepted nowadays? The first form of continent urinary diversion, ureterosigmoidostomy, enjoyed broad popularity during the first half of the twentieth century. The initial enthusiasm was followed by disappointment when such serious problems as electrolyte imbalance, urinary tract infection, pyelonephritis, loss of renal function, renal calculi and colonic carcinoma became evident. The modern era of ureterointestinal surgery began with Coffey's description of a tunnelled technique for ureteral implantation that simulated the natural ureteral-vesical implantation [22]. Having solved primary renal complications by antirefluxive ureteral implantation, life-threatening complications aris-

ing from hyperchloremic metabolic acidosis and electrolyte imbalance led in 1956 to the recommendation that ureterosigmoidostomy should be abandoned [23]. Alternative methods such as the ileal conduit described by Bricker in 1950 [24] were preferred until long-term follow-up also demonstrated a significant rate of complications [25, 26]. Refinements of the techniques used in bowel preparation, improved antibiotics and the development of newer, absorbable suture materials have rekindled the interest in ureterosigmoidostomy, which is an appliance-flee technique of continent urinary diversion. Considering the risk for the development of colonic tumors following ureterosigmoidostomy, one should bear in mind that the risk that adenocarcinoma will arise in an exstrophic bladder is no less [7]. Colonoscopy should be performed 5 years after ureterosigmoidostomy and should be repeated annually. Any form of continent urinary diversion generally involves a risk of secondary malignancy. The sigma-rectum pouch (Mainz pouch II) respects anatomical variations that can lead to failure of ureterosigmoidostomy. In patients with a deep pelvis and fatty mesentery, the exact location of the sigmoid segment for ureteral implantation is difficult. If ureteral implantation is carried out too high, it may cause obstruction due to abnormal tension acting upon the ureter. This might be further aggravated by generally asymptomatic anatomical variations such as an extremely elongated sigmoid colon. The promontory with the anterior longitudinal ligament represents an ideal point for fixation of the rectosigmoid junction. This, as well as the parallel implantation of the ureters, guarantees a straight ureteral path and avoids kinking and subsequent obstruction. Via antimesenteric opening of the bowel, a low-pressure reservoir is created - one of the most important principles of continent urinary diversion. This procedure is technically simpler [13] than enlargement of the rectum using an ileal patch [27]. The indications for bladder augmentation and bladder substitution are limited. An undamaged, functioning bladder neck and external sphincter are prerequisite. Iatrogenic bladder loss during hernia repair due to the instillation of Tris buffer or ether into the umbilical artery represented the indication for bladder substitution in our series. Bladder augmentation is a good method of increasing the bladder capacity o f patients with a neurogenie bladder. It should be kept in mind that even after bladder augmentation, CIC might be necessary; thus, pa-

Table 2. Bladder-neckreconstructionand augmentation: outcomein 68 patients a Outcome

Status

Patients (n)

Satisfactory

CIC/voiding Mitrofanoff AUS Awaiting CIC Awaiting AUS Awaiting Mitrofanoff Wet/unknown

43 5 3 80°?0 7 2 1 20°70 7

Unsatisfactory

a From Hollowell and Ransley [19] From Artificial urinary sphincter

Table 3. Results obtained using Mainz-pouch bladder augmentation and the modifiedYoung Dees procedure in 8 children aged 3 - 13 years Outcome

Patients (n) Remarks

Complete continence Daytime continence, partial nighttime continence Daytime continence, nighttime incontinence Complete incontinence No spontaneous voiding

1 2 2 2 1

Conversion Conversion

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tients with neurogenic bladders should be divided into two groups according to their orthopaedic condition. For those in good orthopaedic condition, especially women, CIC is easy to perform; nevertheless, the risk of prostatitis or epididymitis in men is increased. For the achievement of complete continence, sling procedures or the implantation of an artificial sphincter may be required. For patients bound to a wheelchair, CIC is a problem due to body disproportion and immobility. As catheterisation through the umbilical funnel is much easier, continent urinary diversion instead of bladder augmentation should be performed in this group. Residual urine is one of the major problems arising after bladder augmentation. Therefore, the cystostomy tube should remain in place postoperatively until the patients can empty their bladder; this can take weeks, because in the immediate postoperative period the feeling for bladder filling is lost. After removal of the cystostomy tube, regular ultrasound examinations are mandatory; if residual urine is found, CIC is indicated. Increasing residual urine can lead to overtension of the pouch, increasing the risk of subsequent perforation. Continent Mainz pouch I urinary diversion creates a low-pressure reservoir with a high capacity. The formula V = r2x ~×1, describes the volume of a cylindric object. Hinman [28] modified this equation to calculate the volume of urinary reservoirs. It follows that the use of a segment of large bowel with a large radius is most advantageous for the creation of a reservoir with a large capacity; thus, the length of ileum to be isolated can be reduced (maximum, 30 cm). Even soon after construction, the pouch shows a large capacity; this means that the patient is continent starting with the removal of the pouch catheter. As only a short section of the ileum is required, the risk of metabolic imbalances is reduced. A further advantage of using the ileocecal region is that antirefluxive ureteral implantation can be performed. Nevertheless, dilated ureters are prone to stenosis following this procedure. Under these conditions, the question arises as to how long the submucosal tunnel should be. Problems resulting from antirefluxive implantation include reflux on the one hand and secondary obstruction on the other. Pressure variations in obstructed or refluxive ureters, which are currently not accessible for measurements, may result in a secondary obstruction of the uretero-pelvic junction. This is further complicated in children and adolescents, as their organisms are in a continuing state of growth; therefore, for the revision of a stenosis at the ureteral implantation site, a direct implantation seems to be superior to an antirefluxive procedure. Stomal stenoses were frequently encountered after the connection of the efferent ileal loop or appendix to the umbilical funnel. However, in the vast majority of cases, a stomal stenosis can simply be treated endoscopically using local anaesthesia and on an out-patient basis. It seems that making a V-shaped incision in both the appendix and the umbilical funnel prevents this complication. In the technique described for the use of the ileal nipple or appendix, the efferent segment is extremely short and the continence mechanism is located inside the pouch; thus, the risk of perforation during catheterisation is re-

duced. Despite all of these advantages, it must be emphasised that the creation of this continence mechanism is more complicated than that of reservoirs described in other reports [3]. Of special interest is the question as to whether the loss of the ileocecal segment might possibly lead to gastrointestinal problems in the long run. A critical review of the literature suggests that vitamin B 12 malabsorption might occur in cases in which more than 6 0 - 80 cm ileum are resected. However, biliary acid malabsorption may be possible after the resection of as little as of 3 0 - 5 0 cm ileum. As the operative technique described herein necessitates the resection of 2 4 - 3 0 cm of terminal ileum, the question of late biliary acid malabsorption remains open. Our follow-up study in 24 children (mean follow-up period, 20 months) revealed that levels of vitamin B 12, folic acid and biliary acid lay within the physiological range. Nuclear medicine offers a very useful tool for the longterm evaluation of chronic calcium and vitamin D metabolic disturbances. Scintigraphical measurements of the osseous density in the lumbar spine as well as in the femur are carried out at 6-month intervals. The development as well as the weight and height of the children treated were within the normal range. The results achieved using the Mainz pouch technique are quite satisfying. Therefore, we see no need to modify this established technique. Gastric segments are not used for urinary diversion due to the risk of hemorrhagic urethritis and cystitis. Artificial sphincters should be avoided in children because of the high complication rate. Continence and a positive body image are physical aspects that are most important, especially to the adolescent patient. Incontinent diversions are not acceptable to these patients, and conversion to a continent form is frequently desired. In such cases, the bowel segment used in the previous incontinent diversion should ideally be incorporated into the continent reservoir, thereby reducing the amount of bowel that must be resected. The surgeon's decision as to which form of continent diversion might be preferable should be based on the individual aspects of the respective case rather than conforming to fixed strategies. The intermediate types of urinary diversion, especially colon conduits, are now much more important than in the past, as subsequent conversions to continent forms are easily accomplished. We obtain excellent results using colon conduits in children due to the combination of isoperistaltic construction and antirefluxive ureteral implantation. Unfortunately, many institutions wait too long to perform urinary diversion. All too often, upper urinarytract dilatation is extensive and ureteral fibrosis and pyelonephritic changes have occurred; in such cases of "late" diversion, the results are not so favourable. Against the current trend, we believe that urinary diversion is indicated "early"; this does not mean that conservative treatment should not be fully applied, but when functional or morphological deterioration is evident, urinary diversion should be performed quickly. Continent forms of urinary diversion generally result in complete daytime and nighttime continence. These are the standards that reconstructive techniques following bladder closure for exstrophy

114

must reach. Redefining the term continence for such operations is not valid.

15.

References 1. Kock NG, Nilson AE, Nilsson LO, Norlen L J, Philipson BM (1982) Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol 128:469 2. Carney M (1987) Bladder replacement by ileocystoplasty following radical cystectomy. Semin Urol 5:8 3. Rowland RG, Mitchell ME, Bihrle R, Kahnoski R J, Piser JE (1987) Indiana continent urinary reservoir. J Urol 137:1136 4. Tht~roff JW, Alken P, RiedmiUer H, Engelmann U, Jacobi GH, Hohenfellner R (1985) The Mainz pouch (mixed augmentation ileum and zecum) for bladder augmentation and continent urinary diversion. World J Urol 3:179 5. Duckett JW, Snyder HM III (1986) Continent urinary diversion: variations of the Mitrofanoff principle. J Urol 136:58 6. Mitrofanoff P (1980) Cystostomie continente transappendiculaire dans le traltement des vessies neurologiques. Chir Pediatr 21:297 7. Mesrobian HGJ, Kelalis PP, Kramer SA (1988) Long-term followup of 103 patients with bladder exstrophy. J Urol 139:719 8. Bennett AH (1973) Exstrophy of bladder treated by ureterosigmoidostomies: long-term evaluation. Urology 2:165 9. Spence HM, Hoffmann WW, Fosmire GP (1979) Tumor of the colon as a late complication of ureterosigmoidostomy for exstrophy of the bladder. Br J Urol 51:466 10. Warren RB, Warren TFCS, Hafez GR (1980) Late developments of colonic adenocarcinomas 49 years after ureterosigmoidostomy for exstrophy of the bladder. J Urol 124:550 11. Gittes RF (1986) Carcinogenesis in ureterosigmoidostomy. Urol Clin North Am 13:201 12. St6ckle M, Becht E, Voges G, Riedmiller H, Hohenfellner R (1990) Ureterosigmoidostomy: an outdated approach to bladder exstrophy? J Urol 143:770-775 13. Fisch M, Hohenfellner R (1991) Der Sigma Rektum Pouch: eine Modifikation der Harnleiterdarmimplantation. Aktuel Urol 22 14. Goodwin WE, Harris AP, Kaufman JJ, Beal JM (1953) Open,

16. 17.

18.

19. 20.

21. 22. 23.

24. 25.

26.

27.

28.

transcolonic ureterointestinal anastomosis: a new approach. Surg Gynecol Obset 97:295 Hohenfellner R, Planz C, Wulff H-D, Moormann G, Romahn A, Kunkel R, Oberhausen E, Burmeister W, Straub E (1967) Die transsigmoidale Ureterosimaoidostomie (Sigma-Rectum-Blase): Operationstechnik und Gesamtk6rperkaliumbestimmung. Urologe 6:275 Gerhart JP (1990) Editorial. J Urol 143:774 Husmann DA, McLorie GA, Churchill BM (1989) Closure of the exstrophic bladder: an evaluation of the factors leading to its success and its importance on urinary continence. J Uro] 142:522 Connor JP, Hensle TW, Lattimer JK, Burbidge KA (1989) Longterm follow-up of 207 patients with bladder exstrophy: an evolution in treatment. J Urol 142:793 Hollowell JG, Ransley PG (1991) Surgical management of incontinence in bladder exstrophy. Br J Urol 68:534 Marberger M, Straub E (1982) Ureterosigmoidostomy in children. In: Ashken MH (ed) Urinary diversion, ch. 3. Springer, New York Berlin Heidelberg, p 59 Mesrobian H-G, Kelalis PP, Kramer SA (1988) Long-term followup of 103 patients with bladder exstrophy. J Urol 139:719 Coffey RC (1929) Bilateral submucous transplantation of ureters into large intestine by the tube technique. JAMA 93:1929 StameyTA (1956) The pathogenesis and implications of the electrolyte imbalance in ureterosigmoidostomy. Surg Gynecol Obstet 103:736 Bricker EM (1950) Bladder substitution after pelvic evisceration. Surg Clin North Am 30:1511 Johnson DE, Lamy SM (1977) Complications of a single-stage radical cystectomy and ileal conduit diversion: review of 214 cases. J Urol 117:171 Sullivan JW, Grabstald H, Whitmore WF Jr (1980) Complications of ureteroileal conduit with radical cystectomy: review of 336 cases. J Urol 124:797 Gonheim MA, Shebab-E1-Din AB, Ashamallah AK, Gaballah MA (1981) Evolution of the rectal bladder as a method for urinary diversion. J Urol 126:737 Hinman F Jr (1988) Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J Urol 139:519

Continent urinary diversion in childhood: European experience.

World J Urol (1992) 10:107-114 World Journal of ~r Urology © Springer-Verlag1992 Continent urinary diversion in childhood M. Fisch 1, R. Wammack...
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