SIGMOID CONDUIT URINARY DIVERSION PETER
T. SCARDINO,
DEMETRIUS
M.D.
H. BAGLEY,
NASSER JAVADPOUR, ALFRED
M.D.
M.D.
S. KETCHAM,
M.D.
From the Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
ABSTRACT - The courses of 11 patients with sigmoid conduit urinary diversionfollowing total pelvic exenteration were reviewed in detail and the results presented. The sigmoid conduit appears to be- a safe alternative to the ileal conduit fw urinary diversion, and offers in addition the possible advantage of an effective antirefluxing ureterocolic anastomosis.
Although the ileal conduit is currently the most widely used method of supravesical urinary diversion, reports continue to accumulate indicating the frequency of long-term complications. l-5 Progressive renal failure after ileal conduit diversion appears related to the coincidence of frequent infection and free reflux, leading to acute and chronic pyelonephritis. ‘9’ Efforts to avoid these complications have included attempts to create a nonrefluxing ureteroileal anastomosis and have met with varying success. WI However, experience with ureterosigmoidostomy has established the efficacy of the submucosal tunnel combined with direct suture of ureteral mucosa to colonic mucosa in preventing coloureteral reflux (Fig. lA).‘O Nevertheless, pyelonephritis and electrolyte imbalance led to a decline in the use of ureterosigmoidostomy. These complications might be minimized by a sigmoid conduit in that the sigmoid segment is removed from the fecal stream. Consequently, interest has become focused on the colon as an antirefluxing urinary conduit. Mogg’l has reported success with a sigmoid conduit for urinary diversion in patients with neurogenic bladder. He used a direct mucosa-tomucosa ureterosigmoid anastomosis and attempted to decrease reflux by creating an internal “nipple” of ureter in the colonic lumen (Fig. 1B). Complications were no greater than in
UROLOGY
/ AUGUST1975
/ VOLUMEVI,
NUMBER2
reported series of patients with ileal conduit diversions. Recently others have reported success with the sigmoid conduit in small series of patients. 12,13
FIGURE 1. Techniques of ureterosigmoid anastomosis. (A) Combined submucosal tunnel and mucosa-tomucosa anastomosis described by Leadbetter and Clark. (B) Mogg’s nippled direct mucosa-to-mucosa anastomosis. (C) Direct anastomosis of Nesbit.
167
TABLE
I.
Colonic conduits
Case
Age
Number
(Years)
Tumor*
72 60 29 53 40 37 57 33 60 44 52
NB sccc sccc TCCB sccc sccc sccc sccc sccc sccc sccc
1
2 3 4 5 6 7 8 9 10 11
Follow-up (Months) 4 5 6 7 16 19 21 22 32 38 225
*Key: NB = neurogenic bladder; SCCC = squamous cell carcinoma, uterine cervix; TCCB = transitional cell carcinoma, bladder.
This report concerns a group of patients treated in the Surgery Branch of the National Cancer Institute who underwent sigmoid conduit urinary diversion during pelvic exenteration for malignant disease. Case Review In a review of patients who had undergone urinary diversion at the National Cancer Institute, 11 patients were found to have sigmoid conduits. In 8 of these a direct mucosa-tomucosa anastomosis of the Nesbit type was used (Fig. 1C). In 3 patients an antirefluxing anastomosis was constructed (Fig. 1A). A detailed review of each chart was carried out with information gathered from up to seven different periods: on admission, at discharge, six months after operation, one to five years, six to ten years, eleven to fifteen years after operation, and at the last recorded visit. At each period gastrointestinal and urinary complications were noted. Renal function was reflected by serum urea nitrogen and creatinine, creatinine clearance, excretory urography, retrograde conduit studies, radioisotope renograms, serum electrolytes and mineral levels, and urinary pH. Infection was monitored by recording urinalysis, quantitative urine culture, antibiotic or suppressive medications, and clinical episodes of urinary infection, pyelonephritis, or septicemia. Results Nine of the 11 patients with sigmoid conduits were followed six months or longer (Table I). There were 9 female and 2 male patients ranging in age from twenty-nine to seventy-two (average
168
of forty-nine) years at the time of diversion. All underwent total pelvic exenteration except 2. Five of the 11 had pelvic radiotherapy preoperatively. Nine were alive four months to 18.75 years after operation. Two died of recurrent cancer at six and seven months after diversion. Urinary
tract complications
Urinary tract, tions are listed stoma1 dermatitis was transferred incision during
conduit, and stoma1 complicain Table II. In 1 patient perideveloped when the conduit to the center of an abdominal a later operation, making a
Complications following sigmoid conduit urinary diversion in 11 patients*
TABLE II.
Complications
Colonict
Urinary Leakage Anastomosis Conduit Obstruction Anastomosis Conduit Necrosis Redundancy Stoma Stenosis Hemorrhage Retraction Hernia Skin disorder Gastrointestinal Small bowel obstruction Fistula Enteric Fecal Enteroconduit Renal Azotemia Progressive renal failure Chronic pyelonephritis Metabolic Hyperchloremia Chemical acidosis Hypokalemia Alkaline urine Infectious Stoma1 abscess Acute pyelonephritis Treated urinary infections Urine culture >105 organisms per milliliter
0 0 0 0 1 1 0 0 1 1 3 I 0 0 0 0 1
1 2 2 2 0 2 5 8
*Total number of patients. iNumber of patients with each complication.
UROLOGY /
AUGUST 1975 /
VOLUME VI, NUMBER 2
TABLE IV. Excretory Urogram
TABLE III. RenaZfunction*
Clinical Data
Number of Patients
Admission Discharge 6 Months 1 to 5 Years 6 to 10 Years
11 11 11
11 to 15 Years > 15 Years
Blood Urea Creatinine Nitrogen 10.2 10.8 12.5 10.4 9.5 23.0 16.3
7 1 1 1
0.8 0.7 0.8 0.9 0.8
Latest Visit
Renal Units
Normal
Unchanged Deteriorated
3 10
Abnormal
Improved Unchanged Deteriorated
5 3 0
1.1 1.0
*Serum value in milligrams per 100 ml.; mean of all patients evaluated at each period.
secure fit of the appliance difficult. In another patient, heavily irradiated preoperatively, stoma1 stenosis developed requiring revision of both colostomy and ileostomy stomas. Gastrointestinal
On Admission
complications
Gastrointestinal complications were a major source of morbidity, as expected after total pelvic exenteration which leaves the pelvic floor denuded of peritoneum, covered only by small bowel (Table II). Renal jhaction
None of these patients showed a tendency to progressive renal failure (Table II), although 1 did have radiologic evidence of chronic pyelonephritis. Average serum urea nitrogen and creatinine values as well as creatinine clearances did not demonstrate any significant change over one to five years after diversion (Table III). Pre- and postoperative excretory urograms were assessed for the presence of dilatation of the collecting system or renal scars (Table IV). The colonic conduit without an antirefluxing
3
anastomosis did not protect against hydronephrosis or pyelonephritis. However, all 3 patients with an antirefluxing anastomosis showed no change or substantial improvement in degree of hydronephrosis postoperatively. Obstruction at the ureterocolic anastomosis was not apparent in this small group of patients. Metabolic
abnormalities
Hyperchloremia (Cl- > 110 mEq./L.), acidosis (CO2 < 24 mEq./L.), hypokalemia (K+ < 3.5 mEq./L.), and alkaline urine (pH > 7) were considered significant when found during at least two consecutive periods of observation. These persistent metabolic abnormalities resulted in no clinical symptoms in these patients. Hyperchloremic acidosis occurred in only 1 patient (Table II).
Znfections
Urinary tract infection was the most common complication, despite a standard program of vigorous antibiotic treatment of infections and continuous urinary suppressants at all other times. Catheterized specimens of conduit urine consistently contained greater than lo5 organisms per milliliter from 89 per cent of these patients (Table II).
1
2
stomy
FIGURE 2. Construction of sigmoid colonic conduit fxurinary diversion during total pelvic exenteration.
@ 0
UROLOGY
I AUGUST1975 / VOLUME VI, NUMBER2
169
FIGURE 3. (A) Preoperative excretory urogram showing mild bilateral ureterectasis and pyeloureteritis cystica. (B) Excretory urogram fourteen weeks after sigmoid conduit diversion by antirejluxing technique. (C) Retrograde conduitogram showing no r-eflux of contrast medium into ureters or renal pelvis fourteen weeks after antirejluxing sigmoid conduit.
Comment These results and those reported by Mogg,llJ4 Alpert and Tanagho, l5 Hendren,16 and others’7-1g have led us to believe that the sigmoid conduit is an acceptable technique for urinary diversion after pelvic exenteration and have encouraged us to explore the use of the sigmoid conduit further. The operation of total pelvic exenteration is shortened and simplified by the use of the sigmoid colon rather than ileum for urinary diversion. The sigmoid colon must be divided during removal of the operative specimen, and the conduit can be constructed by amputation from the distal end of the remaining sigmoid, avoiding isolation of a segment of ileum and construction of an ileoileal anastomosis (Fig. 2). The complications following ileal conduit diversion in our own institution, as well as those reported in other series,lm5 appear comparable to our results with sigmoid conduits. However, a possibly significant benefit of the colonic conduit is that an antirefluxing ureterocolic anastomosis can be constructed. We have used the antirefluxing technique in 3 patients undergoing urinary diversion. One of these (Case 1, Table I) was found to have a neurogenic bladder due to an arteriovenous malformation of the spinal cord. A permanent in-
170
dwelling catheter was required. Urinary incontinence with persistent urinary tract infections and recurrent pyelonephritis led to a decision to perform supravesicle urinary diversion. Preoperative excretory urogram showed mild bilateral hydronephrosis with pyeloureteritis cystica (Fig. 3A). An antirefluxing sigmoid conduit urinary diversion was performed. The excretory urogram three months after diversion showed persistent pyeloureteritis cystica and no dilatation of the collecting system (Fig. 3B). No reflux could be demonstrated on the retrograde conduit study performed at the same time (Fig. 3C). Of course, the ultimate criterion on which to judge the efficacy of the antireflux conduit must be its success in reducing urinary infection and pyelonephritis and in preventing chronic renal failure, demonstrated by careful long-term evaluation of these patients. National Cancer Institute Bethesda, Maryland 20014 (DR. SCARDINO) References 1. CFWEVY, C. D.: Renal complications after ileac diversion of the urine in non-neoplastic disorders, J. Urol. 83: 394 (1960). 2. SCHMIDT, J. D., HAWTREY, C. E., FLOCKS, R. H.,
UROLOGY /
AUGUST 1975 /
VOLUME VI, NUMBER 2
3.
4.
5.
6.
7.
8.
9.
and CULP, D. A.: Complications, results, and problems of ileal conduit diversions, ibid. 109: 210 (1973). RAY, P., and DEDOMENICO, I.: Intestinal conduit urinary diversion in children, Br. J. Urol. 44: 345 (1972). SUSSET, J. G.. TAGUCHI, Y., DEDOMENICO, I., and MACKINNON, K. J.: Hydronephrosis and hydroureter in ileal conduit urinary diversion, Canad. J. Surg. 9: 141 (1966). MURPHY, J. J.. and SCHOENBERG, H. W.: Survey of long-term results of total urinary diversion, Br. J. Ural. 39: 700 (1967). GUINAN, P. I)., et al.: The bacteriology of ileal conduit urine in man, Surg. Gynec. Obstet. 134: 78 (1972). MINTON, J. P., KISER, W. S., and KETCHAM, A. S.: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection, ibid. 119: 541 (1964). SCHELLHAMMER, P. F., and TEXTER, J. H.: An experimental ureteroileal anastomosis to prevent reflux, Invest. Urol. 11: 319 (1974). SMALL, M. P., BOYARSKY, S., and GLENN, J. F.: Clinical and experimental evaluation of ileal segment urinary diversion, Am. J. Surg. 115: 782 (1968).
10. LEADBETTER, W. F.: Consideration of problems incident to performance of uretero-enterostomy: report of a technique, J. Urol. 65: 818 (1951). 11. MOGG, R. A.: The results of urinary diversion using the colonic conduit, Br. J. Urol. 41: 434 (1969). 12. KELALIS, P. P.: Urinary diversion in children by the sigmoid conduit: its advantages and limitations, J. Urol. 112: 666 (1974). 13. ALTWEIN, J. E., and HOHENFELLNER, R.: Use of the colon as a conduit for urinary diversion, Surg. Gynec. Obstet. 140: 33 (1975). 14. MOGG, R. A.: The treatment of urinary incontinence using the colonic conduit, J. Urol. 97: 684 (1967). 15. ALPERT, P. R., and TANAGHO, E. A.: Colonic conduits: experimental and clinical studies of reflux and ascending infection, Invest. Urol. 11: 336 (1974). 16. HENDREN, W. H.: Personal communication, 1974. 17. BISGARD, J. D., and KERR, H. H.: Substitution ofthe urinary bladder with an isolated segment of sigmoid colon, Arch. Surg. 59: 588 (1949). 18. DYBNER, R., JETER, K., and LATTIMER, J. K.: Comparison of intraluminal pressures in ileal and colonic conduits in children, J. Urol. 108: 477 (1972). 19. RICHIE, J. P., and SKINNER, D. G.: Urinary diversion: the physiological rationale for nonrefluxing colonic conduits, Br. J. Urol., in press.
/ AUGUST 1975 / VOLUME VI, NUMBER 2
171
UROLOGY
T. SCARDINO,
DEMETRIUS
M.D.
H. BAGLEY,
NASSER JAVADPOUR, ALFRED
M.D.
M.D.
S. KETCHAM,
M.D.
From the Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
ABSTRACT - The courses of 11 patients with sigmoid conduit urinary diversionfollowing total pelvic exenteration were reviewed in detail and the results presented. The sigmoid conduit appears to be- a safe alternative to the ileal conduit fw urinary diversion, and offers in addition the possible advantage of an effective antirefluxing ureterocolic anastomosis.
Although the ileal conduit is currently the most widely used method of supravesical urinary diversion, reports continue to accumulate indicating the frequency of long-term complications. l-5 Progressive renal failure after ileal conduit diversion appears related to the coincidence of frequent infection and free reflux, leading to acute and chronic pyelonephritis. ‘9’ Efforts to avoid these complications have included attempts to create a nonrefluxing ureteroileal anastomosis and have met with varying success. WI However, experience with ureterosigmoidostomy has established the efficacy of the submucosal tunnel combined with direct suture of ureteral mucosa to colonic mucosa in preventing coloureteral reflux (Fig. lA).‘O Nevertheless, pyelonephritis and electrolyte imbalance led to a decline in the use of ureterosigmoidostomy. These complications might be minimized by a sigmoid conduit in that the sigmoid segment is removed from the fecal stream. Consequently, interest has become focused on the colon as an antirefluxing urinary conduit. Mogg’l has reported success with a sigmoid conduit for urinary diversion in patients with neurogenic bladder. He used a direct mucosa-tomucosa ureterosigmoid anastomosis and attempted to decrease reflux by creating an internal “nipple” of ureter in the colonic lumen (Fig. 1B). Complications were no greater than in
UROLOGY
/ AUGUST1975
/ VOLUMEVI,
NUMBER2
reported series of patients with ileal conduit diversions. Recently others have reported success with the sigmoid conduit in small series of patients. 12,13
FIGURE 1. Techniques of ureterosigmoid anastomosis. (A) Combined submucosal tunnel and mucosa-tomucosa anastomosis described by Leadbetter and Clark. (B) Mogg’s nippled direct mucosa-to-mucosa anastomosis. (C) Direct anastomosis of Nesbit.
167
TABLE
I.
Colonic conduits
Case
Age
Number
(Years)
Tumor*
72 60 29 53 40 37 57 33 60 44 52
NB sccc sccc TCCB sccc sccc sccc sccc sccc sccc sccc
1
2 3 4 5 6 7 8 9 10 11
Follow-up (Months) 4 5 6 7 16 19 21 22 32 38 225
*Key: NB = neurogenic bladder; SCCC = squamous cell carcinoma, uterine cervix; TCCB = transitional cell carcinoma, bladder.
This report concerns a group of patients treated in the Surgery Branch of the National Cancer Institute who underwent sigmoid conduit urinary diversion during pelvic exenteration for malignant disease. Case Review In a review of patients who had undergone urinary diversion at the National Cancer Institute, 11 patients were found to have sigmoid conduits. In 8 of these a direct mucosa-tomucosa anastomosis of the Nesbit type was used (Fig. 1C). In 3 patients an antirefluxing anastomosis was constructed (Fig. 1A). A detailed review of each chart was carried out with information gathered from up to seven different periods: on admission, at discharge, six months after operation, one to five years, six to ten years, eleven to fifteen years after operation, and at the last recorded visit. At each period gastrointestinal and urinary complications were noted. Renal function was reflected by serum urea nitrogen and creatinine, creatinine clearance, excretory urography, retrograde conduit studies, radioisotope renograms, serum electrolytes and mineral levels, and urinary pH. Infection was monitored by recording urinalysis, quantitative urine culture, antibiotic or suppressive medications, and clinical episodes of urinary infection, pyelonephritis, or septicemia. Results Nine of the 11 patients with sigmoid conduits were followed six months or longer (Table I). There were 9 female and 2 male patients ranging in age from twenty-nine to seventy-two (average
168
of forty-nine) years at the time of diversion. All underwent total pelvic exenteration except 2. Five of the 11 had pelvic radiotherapy preoperatively. Nine were alive four months to 18.75 years after operation. Two died of recurrent cancer at six and seven months after diversion. Urinary
tract complications
Urinary tract, tions are listed stoma1 dermatitis was transferred incision during
conduit, and stoma1 complicain Table II. In 1 patient perideveloped when the conduit to the center of an abdominal a later operation, making a
Complications following sigmoid conduit urinary diversion in 11 patients*
TABLE II.
Complications
Colonict
Urinary Leakage Anastomosis Conduit Obstruction Anastomosis Conduit Necrosis Redundancy Stoma Stenosis Hemorrhage Retraction Hernia Skin disorder Gastrointestinal Small bowel obstruction Fistula Enteric Fecal Enteroconduit Renal Azotemia Progressive renal failure Chronic pyelonephritis Metabolic Hyperchloremia Chemical acidosis Hypokalemia Alkaline urine Infectious Stoma1 abscess Acute pyelonephritis Treated urinary infections Urine culture >105 organisms per milliliter
0 0 0 0 1 1 0 0 1 1 3 I 0 0 0 0 1
1 2 2 2 0 2 5 8
*Total number of patients. iNumber of patients with each complication.
UROLOGY /
AUGUST 1975 /
VOLUME VI, NUMBER 2
TABLE IV. Excretory Urogram
TABLE III. RenaZfunction*
Clinical Data
Number of Patients
Admission Discharge 6 Months 1 to 5 Years 6 to 10 Years
11 11 11
11 to 15 Years > 15 Years
Blood Urea Creatinine Nitrogen 10.2 10.8 12.5 10.4 9.5 23.0 16.3
7 1 1 1
0.8 0.7 0.8 0.9 0.8
Latest Visit
Renal Units
Normal
Unchanged Deteriorated
3 10
Abnormal
Improved Unchanged Deteriorated
5 3 0
1.1 1.0
*Serum value in milligrams per 100 ml.; mean of all patients evaluated at each period.
secure fit of the appliance difficult. In another patient, heavily irradiated preoperatively, stoma1 stenosis developed requiring revision of both colostomy and ileostomy stomas. Gastrointestinal
On Admission
complications
Gastrointestinal complications were a major source of morbidity, as expected after total pelvic exenteration which leaves the pelvic floor denuded of peritoneum, covered only by small bowel (Table II). Renal jhaction
None of these patients showed a tendency to progressive renal failure (Table II), although 1 did have radiologic evidence of chronic pyelonephritis. Average serum urea nitrogen and creatinine values as well as creatinine clearances did not demonstrate any significant change over one to five years after diversion (Table III). Pre- and postoperative excretory urograms were assessed for the presence of dilatation of the collecting system or renal scars (Table IV). The colonic conduit without an antirefluxing
3
anastomosis did not protect against hydronephrosis or pyelonephritis. However, all 3 patients with an antirefluxing anastomosis showed no change or substantial improvement in degree of hydronephrosis postoperatively. Obstruction at the ureterocolic anastomosis was not apparent in this small group of patients. Metabolic
abnormalities
Hyperchloremia (Cl- > 110 mEq./L.), acidosis (CO2 < 24 mEq./L.), hypokalemia (K+ < 3.5 mEq./L.), and alkaline urine (pH > 7) were considered significant when found during at least two consecutive periods of observation. These persistent metabolic abnormalities resulted in no clinical symptoms in these patients. Hyperchloremic acidosis occurred in only 1 patient (Table II).
Znfections
Urinary tract infection was the most common complication, despite a standard program of vigorous antibiotic treatment of infections and continuous urinary suppressants at all other times. Catheterized specimens of conduit urine consistently contained greater than lo5 organisms per milliliter from 89 per cent of these patients (Table II).
1
2
stomy
FIGURE 2. Construction of sigmoid colonic conduit fxurinary diversion during total pelvic exenteration.
@ 0
UROLOGY
I AUGUST1975 / VOLUME VI, NUMBER2
169
FIGURE 3. (A) Preoperative excretory urogram showing mild bilateral ureterectasis and pyeloureteritis cystica. (B) Excretory urogram fourteen weeks after sigmoid conduit diversion by antirejluxing technique. (C) Retrograde conduitogram showing no r-eflux of contrast medium into ureters or renal pelvis fourteen weeks after antirejluxing sigmoid conduit.
Comment These results and those reported by Mogg,llJ4 Alpert and Tanagho, l5 Hendren,16 and others’7-1g have led us to believe that the sigmoid conduit is an acceptable technique for urinary diversion after pelvic exenteration and have encouraged us to explore the use of the sigmoid conduit further. The operation of total pelvic exenteration is shortened and simplified by the use of the sigmoid colon rather than ileum for urinary diversion. The sigmoid colon must be divided during removal of the operative specimen, and the conduit can be constructed by amputation from the distal end of the remaining sigmoid, avoiding isolation of a segment of ileum and construction of an ileoileal anastomosis (Fig. 2). The complications following ileal conduit diversion in our own institution, as well as those reported in other series,lm5 appear comparable to our results with sigmoid conduits. However, a possibly significant benefit of the colonic conduit is that an antirefluxing ureterocolic anastomosis can be constructed. We have used the antirefluxing technique in 3 patients undergoing urinary diversion. One of these (Case 1, Table I) was found to have a neurogenic bladder due to an arteriovenous malformation of the spinal cord. A permanent in-
170
dwelling catheter was required. Urinary incontinence with persistent urinary tract infections and recurrent pyelonephritis led to a decision to perform supravesicle urinary diversion. Preoperative excretory urogram showed mild bilateral hydronephrosis with pyeloureteritis cystica (Fig. 3A). An antirefluxing sigmoid conduit urinary diversion was performed. The excretory urogram three months after diversion showed persistent pyeloureteritis cystica and no dilatation of the collecting system (Fig. 3B). No reflux could be demonstrated on the retrograde conduit study performed at the same time (Fig. 3C). Of course, the ultimate criterion on which to judge the efficacy of the antireflux conduit must be its success in reducing urinary infection and pyelonephritis and in preventing chronic renal failure, demonstrated by careful long-term evaluation of these patients. National Cancer Institute Bethesda, Maryland 20014 (DR. SCARDINO) References 1. CFWEVY, C. D.: Renal complications after ileac diversion of the urine in non-neoplastic disorders, J. Urol. 83: 394 (1960). 2. SCHMIDT, J. D., HAWTREY, C. E., FLOCKS, R. H.,
UROLOGY /
AUGUST 1975 /
VOLUME VI, NUMBER 2
3.
4.
5.
6.
7.
8.
9.
and CULP, D. A.: Complications, results, and problems of ileal conduit diversions, ibid. 109: 210 (1973). RAY, P., and DEDOMENICO, I.: Intestinal conduit urinary diversion in children, Br. J. Urol. 44: 345 (1972). SUSSET, J. G.. TAGUCHI, Y., DEDOMENICO, I., and MACKINNON, K. J.: Hydronephrosis and hydroureter in ileal conduit urinary diversion, Canad. J. Surg. 9: 141 (1966). MURPHY, J. J.. and SCHOENBERG, H. W.: Survey of long-term results of total urinary diversion, Br. J. Ural. 39: 700 (1967). GUINAN, P. I)., et al.: The bacteriology of ileal conduit urine in man, Surg. Gynec. Obstet. 134: 78 (1972). MINTON, J. P., KISER, W. S., and KETCHAM, A. S.: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection, ibid. 119: 541 (1964). SCHELLHAMMER, P. F., and TEXTER, J. H.: An experimental ureteroileal anastomosis to prevent reflux, Invest. Urol. 11: 319 (1974). SMALL, M. P., BOYARSKY, S., and GLENN, J. F.: Clinical and experimental evaluation of ileal segment urinary diversion, Am. J. Surg. 115: 782 (1968).
10. LEADBETTER, W. F.: Consideration of problems incident to performance of uretero-enterostomy: report of a technique, J. Urol. 65: 818 (1951). 11. MOGG, R. A.: The results of urinary diversion using the colonic conduit, Br. J. Urol. 41: 434 (1969). 12. KELALIS, P. P.: Urinary diversion in children by the sigmoid conduit: its advantages and limitations, J. Urol. 112: 666 (1974). 13. ALTWEIN, J. E., and HOHENFELLNER, R.: Use of the colon as a conduit for urinary diversion, Surg. Gynec. Obstet. 140: 33 (1975). 14. MOGG, R. A.: The treatment of urinary incontinence using the colonic conduit, J. Urol. 97: 684 (1967). 15. ALPERT, P. R., and TANAGHO, E. A.: Colonic conduits: experimental and clinical studies of reflux and ascending infection, Invest. Urol. 11: 336 (1974). 16. HENDREN, W. H.: Personal communication, 1974. 17. BISGARD, J. D., and KERR, H. H.: Substitution ofthe urinary bladder with an isolated segment of sigmoid colon, Arch. Surg. 59: 588 (1949). 18. DYBNER, R., JETER, K., and LATTIMER, J. K.: Comparison of intraluminal pressures in ileal and colonic conduits in children, J. Urol. 108: 477 (1972). 19. RICHIE, J. P., and SKINNER, D. G.: Urinary diversion: the physiological rationale for nonrefluxing colonic conduits, Br. J. Urol., in press.
/ AUGUST 1975 / VOLUME VI, NUMBER 2
171
UROLOGY
