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PURPOSE:Stomal stenosis has been reported to occur in 12% to 45% of patients following Malone antegrade continence enema and Mitrofanoff appendicostomy. The standard stoma technique entails excision of the distal appendix. We evaluated a novel technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would be decreased. MATERIALS AND METHODS:Medical records of patients who underwent appendicostomy for Malone antegrade continence enema or urinary diversion were retrospectively evaluated. We included cases with a minimum of 1 year of followup and those in which the distal portion of a complete appendix was oriented for use as the stomal end in the umbilicus. Variables such as age, gender, body mass index, antegrade continence enema or urinary diversion, open or laparoscopic approach, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique and stenosis were recorded. Cox proportional hazards analyses were performed to determine association of covariates. RESULTS:A total of 123 patients met inclusion criteria. The incidence of stenosis following standard stoma technique was 13% (12 of 93 patients) with a median followup of 9.4 years. Of these cases 75% occurred within 1 year of surgery. Stomal stenosis did not occur after the new stoma technique in 30 patients with a median followup of 3.3 years. Only technique cohort (standard vs new) was associated with stenosis (p=0.04). CONCLUSIONS:Stomal stenosis of appendicostomy may be lessened by preservation of the distal appendiceal vasculature and tip, and opening the lumen in a more proximal location.

We describe a technique of bladder neck detachment and augmented closure incorporating total prostatectomy and urinary diversion in men with complex bladder and urethral pathology due to fistula, radiation and neurogenic dysfunction.We retrospectively reviewed the records of 5 men 38 to 61 years old who presented with unsalvageable urethral pathology, including prostate cancer in 2. All 5 patients underwent radical prostatectomy and augmented bladder neck closure with creation of a continent catheterizable stoma in 4 and chimney diversion in 1.Bladder neck closure was performed with interposition of an ileocecal patch in 4 cases and sigmoid colon in 1. At a mean followup of 6 months no fistula, recanalization or urinoma developed. Delayed complications included stomal stenosis, stomal incontinence requiring collagen injection and rupture of the augmented bladder in 1 case each. The 2 men with prostate cancer had undetectable prostate specific antigen.Prostatectomy facilitated mobilization of the bladder neck away from the urethral pathology and interposition of an intestinal segment at the bladder neck allowed healing. In addition to cases of complicated urethrovesical pathology, this technique may have applications in salvage prostatectomy after pelvic irradiation for carcinoma.

The technique of forming a concealed umbilical stoma has been described previously and includes a posterior umbilical flap for improved cosmesis and stenosis prevention. We assessed long-term stomal stenosis.We reviewed retrospectively the charts of 46 patients (mean age at surgery 14 years) of whom 35 had undergone concealed umbilical stoma creation and 11 the Malone antegrade continence enema procedure for continent urinary diversion. Urinary stomas were created from appendix in 20 cases, ileum in 8, sigmoid colon in 5, bladder in 1 and stomach in 1. Malone antegrade continence enema stomas were constructed from appendix in 10 cases and sigmoid colon in 1. A total of 21 patients underwent urinary diversion and augmentation cystoplasty.At followup of 12 to 84 months (median 3.4 years) 93.5% of patients had an intact stoma with no need for surgical revision. Of the remaining patients 3 (6.5%) required revision of the stoma at skin level for stomal stenosis at 1, 4 and 38 months after initial surgery and 2 had a brief period of indwelling catheterization for correction of stenosis.The concealed umbilical stoma technique provides an excellent cosmetic result with a low rate of stomal stenosis in patients requiring intermittent bladder or bowel catheterization.

The "button" enteral feeding systems are widely used as a gastrostomy. We describe our use of this device to facilitate bladder drainage in children.We prospectively reviewed all patients who underwent insertion of a cystostomy button between 2002 and 2005. Indications and complications were analyzed.A total of 17 children (8 female, 9 male) with a mean age of 7.1 years underwent insertion of a cystostomy button during the 4-year period. Mean followup was 16 months (range 2 to 40). Cases selected included those with a neuropathic bladder, prune belly syndrome, previous major bladder neck surgery and those unsuitable for Mitrofanoff stoma formation. Complications included 1 wound infection treated with antibiotics. Four children had leakage from the cystostomy site that was successfully treated with a change in button size, and 14 buttons remain in situ.Button cystostomy is a safe and effective form of bladder drainage in children. It is a good alternative to standard suprapubic drainage and it gives children an improved quality of life.

We analyzed stoma related complications and continence rates in patients who underwent continent urinary diversion with the cutaneous ileocecal pouch (Mainz pouch I). We compared the intussuscepted ileal nipple and in situ, submucosally embedded appendix as continence mechanisms.A total of 401 patients were included in a retrospective followup study. Continence mechanisms were the intussuscepted ileal nipple in 205 patients and the in situ, submucosally embedded appendix in 196.A total of 144 patients (36%) required intervention for a stomal complication. Of patients who received an intussuscepted ileal nipple 34 (17%) had stomal stenosis at a mean time to first stenosis of 43.8 months, 41 (20%) had stones at a mean interval to the first stone of 62.8 months, 12 underwent reoperation for stomal incontinence, including 1 because of nipple necrosis, and 82% were completely continent. Of patients who received an in situ, submucosally embedded appendix 63 (32%) had stomal stenosis at a mean time to first stenosis of 31.4 months, 20 (10%) had stones at a mean interval to the first stone of 47.5 months, 3 underwent reoperation for stomal incontinence, 4 had appendiceal necrosis and 92% were completely continent.Of stomal complications 63% were treated endoscopically. The higher rate of stomal stenosis with the appendiceal stoma is most likely due to the smaller diameter of the appendix. The higher rate of stone formation in patients with the intussuscepted ileal nipple is related to metal staples. Continence rates of the 2 outlets are good with somewhat larger amounts of mucous secretion from the larger stoma of the intussuscepted ileal nipple.

Bladder neck closure (BNC) is an important component of reconstructive urological surgery, especially in the management of neurogenic bladder. To our knowledge we present the largest series of patients who have undergone this procedure.A total of 39 patients with lower urinary tract (LUT) dysfunction secondary to neurogenic bladder underwent transabdominal BNC and simultaneous LUT reconstruction between 1988 and 2002. Charts were reviewed and patients were retrospectively interviewed to ascertain demographics, previous urological surgeries, perioperative data, postoperative results and complications.Mean postoperative followup was 36.9 months (range 7 to 173). Concomitant procedures included ileovesicostomy in 19 patients (49%), augmentation enterocystoplasty with continent cutaneous stoma in 19 (49%) and revision of a previous Mitrofanoff appendicovesicostomy in 1. The overall complication rate was 31% with a vesicourethral fistula in 6 patients (15%), of whom 4 required eventual transabdominal or transvaginal surgical correction. No other problems directly related to BNC were identified. Patients were followed by serial renal ultrasound and abdominal x-ray with upper tract maintenance seen in all patients.Bladder neck closure with simultaneous urinary diversion is a highly effective, well tolerated treatment for many pathological processes of the LUT. Risks for prolonged urethral leakage include high pressure systems, prior bladder neck surgery and noncompliance with catheter/drain management. These data support our belief that a high degree of success with an acceptable complication rate is attainable with careful adherence to surgical technique, proper patient selection, appropriate early postoperative management and rigid surveillance.

We report on a man with bulky leiomyosarcoma occupying the entire pelvic cavity that was treated by pelvic exenteration. A urinary reservoir was constructed using a detubularized segment of sigmoid colon. The appendix was tunneled into the taenia to form a continent catheterizable stoma using the Mitrofanoff principle. Descending colostomy was also created. There is no evidence of recurrence 24 months after treatment and the patient has returned to full physical activity. Continence is complete with a capacity of up to 500 ml. and regular bowel movements. Because of the lack of intestinal anastomosis, this procedure may be recommended as an option for urinary diversion after pelvic exenteration.

We report 7 cases in which grafts of ureter were used as tube and patch segments in urethral reconstruction and formation of a continent catheterizable stoma. The ureteral grafts survived without long-term stricture in all cases. Meticulous preparation of the graft and recipient bed is required for success, as previously demonstrated experimentally. When available, ureter is an excellent source of tissue for urological reconstruction.

The use of continent urinary reservoirs has gained wide acceptance, particularly in urinary reconstruction in children with a small capacity or neuropathic bladder. When augmentation cystoplasty is combined with clean intermittent catheterization, patients are often able to achieve continence with low intravesical filling pressures and renal preservation. Often this approach requires fashioning a continent cutaneous stoma, which remains the most challenging aspect of continent urinary reservoirs. We analyzed our experience with continent diversion in patients with exstrophy-epispadias to determine complications and long-term results.We performed a retrospective database review of 704 cases of exstrophy-epispadias. Medical records were then used to identify those patients who had undergone creation of a continent urinary reservoir. Charts were reviewed to determine initial diagnosis, augmentation technique, continence mechanism, age, preoperative and postoperative bladder capacity, continence status and complications.Of the 91 patients identified (68 male, 23 female) who had undergone continent urinary diversion classic bladder exstrophy was present in 80, cloacal exstrophy in 8, complete male epispadias in 2 and female epispadias in 1. The most common techniques for augmentation and continent diversion were ileocystoplasty (41 patients [45%]) and sigmoid cystoplasty (30 [33%]), respectively. Appendix was used in 67 patients (74%) and variants of the Mitrofanoff procedure using segments of tapered ileum or ureter were used to create a continent stoma in 10 (11%). Bladder neck transection was performed in 59 patients (65%). Mean age at augmentation and continent diversion was 8 years (range 2 to 25), with a mean preoperative bladder capacity of 77 cc (15 to 220). Mean followup was 6 years (range 6 months to 12 years). Of the 91 patients 85 (93%) were continent with clean intermittent catheterization per stoma. Of these 85 patients 13 required anticholinergics and alpha-agonists to achieve continence. Six patients (7%) were incontinent after the procedure. Analysis of bladder capacity measurements after augmentation and continent diversion revealed that mean postoperative volume and mean volume increase were 404 cc (range 250 to 640) and 524%, respectively. The most common complications were bladder stone formation (24 patients [26%]) and stomal stenosis (21 [23%]). Bladder stones recurred in 9 patients and stomal stenosis in 3. Other less common complications were vesicourethral fistula (3 patients) and a small bladder perforation (2).Augmentation and continent diversion procedures can increase the functional capacity of the small contracted noncompliant exstrophic bladder, and allow the vast majority of patients to achieve continence and preserve renal function. Bladder calculi and stomal stenosis pose the most significant long-term complications in these patients.

Purpose: Creating a reliable continence mechanism for a continent reservoir is a great challenge. We describe an easily formed mechanism for allowing complete continence in such patients.Materials and Methods: The native appendix attached to a detubularized right colonic reservoir was used as the catheterizable efferent limb. The continence mechanism was created by crossing 2 nondetached right rectus muscle strips around the appendix.Results: At a mean followup of 32 months (range 4 to 52) in 17 patients complete continence was obtained between 2 to 4-hour self-catheterizations in all positions and even during straining.Conclusions: This continence mechanism is easy to construct and creates a reliable continent stoma in all patients who are not candidates for orthotopic bladder replacement and who retain the native appendix. In patients who have undergone appendectomy an alternate method is to create a small caliber efferent limb from a tailored terminal ileum and build the continence mechanism around it.

The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix.A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum.The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years.The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.

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.

Infection calculi are a frequent complication of continent urinary diversion. Percutaneous removal has become an accepted method for removing these stones. Unfortunately, this technique can be challenging due to mobility of the stones and because small fragments can easily be obscured in the mucosal folds. We describe a modification of the percutaneous technique in which a laparoscopic specimen retrieval bag is used to facilitate removal. CASE HISTORY A 54-year-old man with a history of invasive transitional cell carcinoma of the bladder underwent uncomplicated radical cystoprostatectomy with continent urinary diversion (Indiana pouch). Stones developed within the pouch 3 years postoperatively but the patient was asymptomatic and deferred treatment. The stone burden increased 7 years postoperatively (fig. 1, A) and the patient had recurrent symptomatic urinary tract infections. He was referred to our institution for surgical stone removal. With the patient supine a 16F flexible cystoscope was passed through the stoma of the pouch and 2 large stones were visualized. Under direct vision and ultrasound guidance a 10 mm. laparoscopic trocar was passed into the pouch through a 1 cm. incision (fig. 2). A specimen retrieval laparoscopic bag was deployed through the trocar (fig. 2) and the stones were captured under vision of the flexible cystoscope. The retrieval bag neck was brought through the skin incision, a standard 26F nephroscope was placed, and standard

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.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.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.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.

We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir.From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus.In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple.In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

Since 1990 we have used stomach for bladder augmentation and continent urinary diversions in 73 patients, of whom 15 received a gastric tube catheterizable stoma and are the subject of this report. The gastric tube receives its blood supply from the same vascular pedicle as the gastric patch and, therefore, it can be moved anywhere along with the patch. The tube is then reimplanted in the reservoir or bladder following the Mitrofanoff principle and brought to the skin as a catheterizable stoma. Patient age ranged from 12 to 60 years. Three patients underwent augmentation cystoplasty and 12 received a composite gastrointestinal continent reservoir (in 10 a prior bowel conduit was detubularized and used as part of the reservoir). The appendix was either previously removed (10 patients) or not suitable as a catheterizable limb (4). All patients are continent. Catheters used to empty the reservoir varied from 12F to 18F. Complications included an early traumatic perforation of the tube in 1 patient, distal stenosis in 1 and mucosal redundancy in 1. Of these patients 2 required revision. Two patients had mild peristomal skin irritation without ulceration. Anatomical and technical aspects of this procedure are presented. In summary, we believe the gastric augment single pedicle tube to be a useful tool for the reconstructive urologist, which in select cases may obviate the need for additional bowel anastomosis to create a tapered intestinal catheterizable limb.

Advanced rectal carcinoma sometimes invades the posterior bladder wall or the base of the prostate. Radical surgical treatment may involve resection of part or all of the bladder, prostate or ureters since it is essential to create clear margins if the procedure is to be curative. As a result, patients sometimes require 1 stoma for the urinary and another stoma for fecal stream diversion. Segmental resection is rarely performed, although it would significantly improve the quality of life for these patients by obviating the need for 2 stomas. To achieve this end, we performed en bloc removal of the rectum with the prostate in highly selected patients who had advanced rectal carcinoma with macroscopic invasion of the prostate but without invasion of the bladder or membranous urethra. This procedure could preclude urinary diversion and be useful for select patients.

The placement of a 1.5 cm. wide silicone sheath around a newly constructed urethra/bladder neck to ensure maintenance of repair length and to facilitate future placement of a sphincter cuff was reported by our institution in 1985. We present our long-term followup and new recommendations for use of the silicone sheath. A total of 15 silicone sheaths was placed between March 1981 and July 1984. Of the sheaths 14 were placed at the time of urinary reconstruction around the Young-Dees-Leadbetter bladder neck repair and 1 was placed after erosion of an artificial urinary sphincter cuff. Of the 15 sheaths 10 have eroded into the urethra and 4 sheaths remain in situ. Another sheath was replaced 2 years after its original insertion with an artificial urinary sphincter cuff. Mean time to erosion was 48.2 months, with a range of 2 to 108 months. Long-term followup of 10 patients revealed that 4 ultimately required ligation of the bladder neck and construction of continent stoma after erosion, 1 is dry after placement of a bulbar artificial urinary sphincter, 2 remain dry after removal of the eroded sheath alone, 2 required bladder neck revision to achieve continence after erosion and the most recent patient remains diverted with a suprapubic tube. All 4 patients with sheaths still remaining are dry without evidence of erosion (mean duration 116 months). These long-term results using a silicone wrap around a newly constructed bladder neck reveal an unacceptably high rate of erosion. Therefore, we no longer recommend or support the use of the silicone sheath in the manner we have described for bladder neck reconstruction.

With the current practice of continent urinary diversion the patient still has a cutaneous stoma and must perform intermittent catheterization. To circumvent these problems we devised the uretero-ileoceco-proctostomy (ileocecal rectal bladder), in which the intussuscepted ileocecal segment is interposed between the ureters and rectum, the rectal capacity is augmented by side-to-side anastomosis to the cecal limb of the segment and continence is controlled by the anal sphincter. The interposed segment prevents reflux of the urine-fecal mixture to the upper urinary tract and may decrease the risk of carcinoma at the ureteroileal anastomosis. The intussusception is stabilized without opening the recipient bowel (cecal limb), thus simplifying the subsequent ceco-proctostomy with automatic suture technique. Our preliminary experience in 18 patients with this new technique is encouraging with respect to voiding, preservation of renal function and quality of life.

In a rabbit model we describe and compare two continent catheterizable diversion techniques for which the bladder is intact and the stoma is situated in the lower abdomen. Both mechanisms are formed from a short segment of ileum; one utilizes the principles of the encircling loop technique as described by Koff and the second, the Kock principle (intravesical nipple). Both models were evaluated for the following parameters: ease of catheterization (87%, 79% respectively), continence (91%, 86% respectively), and ease of construction. We present evidence that both techniques are applicable to the clinical setting.

The indications for urinary and fecal diversion often mirror each other and at times overlap. Between 1980 and 1990 we encountered 14 patients with preexisting or newly diagnosed rectosigmoid disease who required diverting colostomy and urinary diversion. We describe a simple method for managing urinary diversion in these patients, which avoids a bowel anastomosis. The preexisting or newly created colostomy is used as the urinary stoma for a colon conduit, while a proximal colostomy is created for fecal diversion. This technique has proved to be beneficial and should be considered for high risk patients who require urinary and fecal diversion, and for whom an abbreviated operation would be desired.

The hemi-Kock system, constructed from approximately 40 cm. of terminal ileum, comprises a detubularized and remodeled ileal plate with a stapled ileoileal intussusception to form a 1-way valve. This system has been applied to reconstruct 30 varied cases in which the intussuscepted valve was used either for reflux prevention or as a continent stoma. The patients included 11 with intractable urinary incontinence and a devastated bladder outlet in whom the hemi-Kock pouch was anastomosed to the bladder after the bladder neck had been surgically closed, with the afferent limb of the nipple valve being routed through the abdominal wall as a continent stoma. In 9 patients who had previously undergone supravesical diversion, undiversion was accomplished with this system to augment the bladder, with the antireflux nipple being anastomosed to the prior ileal loop or ureters. In 5 patients in whom intractable bladder hyperactivity had led to devastated upper tracts with markedly dilated ureters this system was used for bladder augmentation, with the ureters being reimplanted into the afferent limb of the hemi-Kock system to prevent reflux. The final patients were those in whom the hemi-Kock pouch was converted into a complete reservoir and used for orthotopic bladder replacement. The hemi-Kock system proved to be successful in each of these roles. It created a capacious low pressure reservoir, protected the upper tracts from reflux and improved those that were previously dilated, and it proved to be a reliable continent stoma when applied to that use. The versatility of the hemi-Kock system in its application to a variety of reconstructive endeavors recommends it for use.

A technique is described by which a previously constructed ileal conduit is used as an efferent limb of a continent urinary reservoir. The ileal segment is tapered; 1 end is tunneled submucosally into a reconfigured colonic reservoir and the other end is brought to the skin as a catheterizable stoma. This modification of the Mitrofanoff principle provides a highly continent stoma that is easily catheterized, and allows for preservation of the terminal ileum and ileocecal valve within the gastrointestinal tract.

A simple continent colonic reservoir was constructed in its entirety with the aid of surgical stapling techniques in 17 men and 10 women. In 5 men an orthotopic pouch was created and in the rest a continent stoma was designed. Detubularization of the entire colonic segment assures a low pressure system with disruption of directional peristaltic activity. The ureters are implanted by simply burying them in a mucosal furrow. Operative time required for the creation of the reservoir (excluding time for cystectomy) has ranged between 70 and 140 minutes (mean 95.4 minutes). With a followup of 9 to 60 months (mean 22.8 months) continence has been achieved in all but 1 patient with no ureteral reflux or obstruction. Urodynamically the pouch has achieved a large capacity (mean 750 cc) with low filling pressures (8.1 cm. water) because of technical ease of construction together with a shortened operative time due to the stapling techniques. This form of bladder replacement offers an option for select patients in whom continent urinary diversion is contemplated.

Problems with continence and access for catheterization with previous continent stoma techniques have led us to search for an alternate method. We report our initial experience with the Benchekroun hydraulic valve in 9 patients. Five patients underwent creation of an ileocolic bladder: for myelodysplasia in 1, after cystectomy for bladder cancer in 2 and for exstrophy in 2. Two patients underwent conversion from an uncatheterizable Indiana pouch because of exstrophy (1) and interstitial cystitis (1). Two patients underwent small bowel augmentation of a small, poorly compliant bladder with an abdominal Benchekroun stoma: 1 had exstrophy and 1 had myelodysplasia. Patient age ranged from 7 to 63 years. Two patients had de novo creation of an ileocolic bladder, whereas 7 had bladder or previous bowel conduits incorporated in the continent reservoirs. At up to 20 months of followup all patients had diurnal and nocturnal continence, and none had experienced serious long-term complications. Problems were encountered in 5 patients. One patient had a valve fistula that was surgically revised. One patient experienced transient difficulty with catheterization when the reservoir was overdistended and a false passage developed. Three patients had stomal stenosis and require periodic dilation. We believe the Benchekroun hydraulic valve to be a useful adjunct in the construction of a continent urinary reservoir. It is easy to construct, provides reliable continence and is easy to catheterize. Furthermore, it may be applied to standard ileocolic bladders either de novo or as a salvage procedure for failed efferent limbs.

Creation of a circumferentially protruding urinary intestinal stoma is an important aspect to prevent stomal regression, stenosis and parastomal herniation. Furthermore, an improperly fashioned stoma may make fitting of an ostomy appliance difficult, resulting in urinary leakage with secondary dermatitis and incrustation. The major difficulty in fashioning the stoma is everting the mucosa over the intestinal mesentery. We describe our method of stoma formation that creates a circumferentially symmetrical protruding stoma free of tension that has been used successfully even in obese patients. This technique has made the use of a Turnbull stoma unnecessary in our recent experience. (J. Urol., 144: 1188–1191, 1990)

Construction of abdominal urinary reservoirs became routine for supravesical urinary diversion during the last decade. Fashioning a continence mechanism that is reliable and easy for catheterization is principally important for the successful functioning of intestinal reservoirs. We report a case of construction of an ileal reservoir with Meckel's diverticulum as a continence mechanism, which to our knowledge has not been described previously. CASE REPORT A 54-year-old man with the diagnosis of stage TBNOMX bladder cancer underwent radical cystoprostatectomy with simultaneous construction of a detubularized ileal reservoir at our center. During surgery Meckel's diverticulum was identified 80 cm. from the ileocecal valve on the antimesenteric side of the ileum. It was 7.5 cm. long and approximately 1 cm. in diameter. A detubularized ileal reservoir was fashioned using 50 cm. of ileum 55 cm. from the ileocecal valve. This part of the intestine was isolated and detubularized. After construction of the posterior wall the ureters were implanted into the reservoir using the Turner-Warwick technique1 with additional creation of seroserous tunnels. A valve mechanism was then fashioned from Meckel's diverticulum (see figure). Its tip was excised and a 10F catheter was placed through the diverticulum, which was plicated over the catheter. The anterior wall of the reserAccepted for publication April 3, 1998. voir was constructed and the reservoir was closed, leaving a 16F catheter indwelling. Approximately 3 cm. of mesentery were stripped off of the serosa of Meckel's diverticulum. Diverticulum was folded, placed on the anterior surface of the reservoir and embedded into the serous tunnel created by suturing the reservoir wall above it via seroserous interrupted stitches. An umbilical stoma was constructed using the distal end of Meckel's diverticulum. The reservoir was sutured to the anterior abdominal wall with 4 interrupted stitches placed circumferentially around the stoma. The 16F catheter was brought out through the anterior wall of the reservoir and anterior abdominal wall along with the ureteral stents. Two silicone drains were placed in the abdominal cavity. Convalescence was uneventful. The ureteral stents were removed on day 11, the reservoir catheters on day 13 and both abdominal drains on day 14 postoperatively. At followup 2 years postoperatively there are no signs of recurrent disease, the ileal reservoir holds between 400 and 450 ml., the continence mechanism is competent and the patient performs self-catheterization every 4 to 6 hours without difficulty.

A 56-year-old man with stage T2N0M0 grade III bladder cancer diagnosed by computerized tomography and transurethral biopsy underwent cystoprostatectomy. Glomerular filtration rate was 40 to 50 ml. per minute and serum creatinine level was less than 120 mol./l. The upper urinary tract was evaluated by excretory urography. Orthotopic ileal Studer neobladder was elected. At operation the peritoneal cavity was opened, and revealed short and fatty ileal mesentery and post-inflammatory bowel with mesenteric adhesions, which made the Studer neobladder impossible to perform. During surgery at 60 cm. from Bauhin’s valve an 8 cm. long Meckel’s diverticulum was identified on the antimesenteric side of the ileum (see figure). The Meckel’s diverticulum was examined, and the distal end was cut and histologically evaluated intraoperatively. The ileal loop with Meckel’s diverticulum was chosen as the Bricker loop because of its easy mobilization and convenient location in the near hood of the ureters. The right ureter was implanted to the sidewall of the distal end of the Bricker loop. The left ureter was anastomosed end-to-end using 3-zero running sutures, with the distal end of the Meckel’s diverticulum conveniently located on the antimesenteric side. The anastomosis was easily extraperitonized. The ureteroileal anastomosis was stented using polyethylene introduced through the abdominal stoma and removed on postoperative day 6. No wound infection, dehiscence or ileal obstruction was noted. The postoperative period was uneventful. The patient has been followed for 2 years with excretory urography performed every 6 months, plus urine culture sampling and creatinine level measurements. He tolerates the appliance well and has resumed almost normal activity. No sign of recurrent disease, stoma, anastomotic obstruction, stone formation or renal deterioration has been observed during 2 years of followup.

Purpose: In 1981 Mitrofanoff presented a procedure to create a continent urinary stoma for intermittent catheterization. Since then, several other methods have been introduced, including the Yang-Monti ileovesicostomy. The length of these ileovesicostomies is limited by the circumference of the bowel segment used, which is inadequate in some cases. We developed a procedure to double the length of the Yang-Monti ileovesicostomy using a single section of bowel. Materials and Methods: A 3.5 cm. section of ileum is isolated on its mesentery. The bowel is divided into 2 segments for 80% of its circumference, leaving the bowel intact over the mesentery. Each ring of bowel is then divided adjacent to the mesentery but on opposite sides, allowing the bowel to be unfolded and reconfigured in a single long strip that may then be tubularized. The blood supply to the tube is excellent and it is in the center of the reconfigured ileum. The ends may be trimmed or widely spatulated as necessary. Results: We have performed this procedure in 8 patients. The resulting ileovesicostomy created from a 3.5 cm. section of ileum is 10 to 14 cm. long and accepts a 12F catheter. A larger tube may be created from a longer piece of ileum. All patients are dry and they perform catheterization easily. Conclusions: This form of ileovesicostomy allows the creation of a long bowel tube that is easily catheterized. The longer length of the tube increases application of the continent stoma principle to more patients and enables reconstruction to be performed with optimal placement and without tension.

New procedures for tubeless cutaneous ureterostomy are described. The fundamental principles of the methods are 1) an everted ureteral nipple formation combined with a triangular skin flap as a permanent stoma and 2) a 2-stage operation to obtain a viable ureteral nipple against slough and retraction.

A new technique of using the in situ appendix to construct a continent catheterizable stoma is described in a patient who underwent continent urinary diversion, and the technical aspects of this procedure are illustrated in detail. The appendix is remodeled by invaginating its base into the cecum for 1cm., cecoplicating the middle portion for 2cm. and bringing the distal end to the skin as a cutaneous stoma. This new technique demonstrates that the in situ appendix can be constructed successfully to provide continence without the need for isolating it from the cecum and implanting the distal end into the urinary reservoir as described in the Mitrofanoff technique.

We compared the loop and end stoma techniques for ileal conduit urinary diversion in 54 and 27 adults, respectively, with serious bladder disease during a 3-year interval. Followup by trained enterostomal therapists averaged nearly 2 years for all patients. Stenosis occurred in 12 end stomas (44 per cent) but not in any loop stomas. We believe that this result reflects the inherently better blood supply of the loop stoma, which we recommend over the end ileostomy for patients undergoing ileal diversion.

A plicated ileocecal segment was used to construct an antirefluxing urinary conduit in 3 patients. Each patient had markedly dilated or shortened ureters that prevented conventional Leadbetter ureteral reimplantation into a colon conduit. Ascending colon was brought out as a cutaneous stoma, the ureters were anastomosed to ileum, and an antireflux mechanism was created from plicated terminal ileum and the native ileocecal valve. Significant reflux was prevented in all 3 patients. This technique provides a means to prevent urinary reflux into short or dilated ureters, and increases the versatility of the ileocecal segment for use in diversion and urinary tract reconstruction.

The principle of the continent urinary reservoir involves use of a variety of intestinal segments providing continence, a mechanism of antireflux and a catheterizable stoma in either an abdominal or pelvic location. This concept was used to create a continent urinary reservoir in a 3-year-old former ischiopagus tripus conjoined twin. The solitary renal unit had been drained into a hydrocolpos with an antirefluxing ureteral reimplantation at separation. The patient remained incontinent through the urogenital sinus. At subsequent reconstruction the posterior aspect of the hydrocolpos was tubularized as a vagina, while the remainder of the hydrocolpos was augmented with ileum to create a urinary reservoir. The conduit was constructed with imbricated ileum, in which myectomy had been performed to allow for easier imbrication and tubularization for a narrow neourethra. A second set of conjoined twins have been separated similarly. Of these twins 1 will undergo creation of a continent urinary reservoir in an identical fashion. This represents the first report of the use of hydrocolpos in the creation of a urinary reservoir.

All existing continent urinary reservoirs utilize cecum and/or varying lengths of ileum. In patients who have received prior pelvic radiation therapy, continent diversion has not been feasible because those segments of bowel lie within the field of irradiation. We describe a new technique of continent diversion utilizing only bowel outside the field of pelvic irradiation. A urinary reservoir is constructed from reconfigured transverse colon. A tubularized segment of stomach is implanted beneath the taenia of the reservoir to provide a continent, catheterizable stoma. We describe this technique in detail and report our results in five dogs followed for a mean of 59 days.

In 1980 Mitrofanoff described a continent urinary diversion, consisting of the bladder with a surgically closed bladder neck emptied by intermittent catheterization of the appendix, which had its distal end implanted in a submucosal nonrefluxing fashion in the bladder and its proximal end brought out as an inconspicuous stoma. Alternatively, Mitrofanoff described a high transureteroureterostomy in which the distal end of the ureter was brought out as a catheterizable stoma. The theme of this approach is the creation of an adequate capacity storage reservoir that is emptied intermittently by the catheterization of a small caliber conduit implanted in a nonrefluxing manner in the reservoir. In addition to the Mitrofanoff procedure, we have modified the principle in a variety of clinical situations and report 10 cases to demonstrate the value of this new concept in continent urinary diversion.

A new technique to achieve simultaneous diversion of the urinary and fecal streams using a single abdominal stoma is described. The procedure consists of the construction of a diverting loop colostomy with division of the colon approximately 10 to 15cm. distal to the stoma. The segment of colon distal to the stoma, the urine limb, acts as a urinary conduit. To date 3 patients have undergone the procedure with followup of 3, 13 and 18 months. Neither upper tract infection nor upper tract deterioration has occurred. The potential role of this procedure to treat a difficult group of patients is discussed.

Bacteriuria and intestinal loop urinary diversion with open (refluxing) ureterointestinal anastomoses did not prevent normal renal and body growth in 44 children, who were followed for 55.2 months. A comparison of the long-term use of sulfamethoxazole and nitrofurantoin with no treatment showed no statistically significant changes in the stoma, loop residual, renal function, serum electrolytes and treatment or prevention of bacteriuria.

Cutaneous ureterostomy is a simple procedure to perform but is attended by high morbidity owing to recurring abscesses, strictures and stenosis of the stoma. An improved technique applied to the diversion of 4 normal renal units and 3 dilated ureters is described. We have not experienced the complications mentioned in previous studies and none of the patients has required ureteral intubation in this small series with a 3-year followup.

A case is reported of persistent urinary leakage from the stoma of a Kock pouch owing to a pinhole fistula bypassing the efferent nipple.

While few myelomeningocele patients will undergo ileal conduit diversion, many who have been diverted in the past have renal deterioration related to stoma, infection and stone. In revising 7 of these patients we have used an ileal intussusception to prevent reflux and reduce renal contamination

Urinary diversion, as described by Bricker in 1950 was for use in adults who required pelvic exenteration for cancer. In this procedure, a 10 to 20 cm length of terminal ileum is isolated from the intestinal tract, and the continuity of the bowel re-established by open end-to-end anastomosis. The appendix is removed. The proximal end of the detached segment of ileum is closed. The ureters are divided from the bladder and anastomosed to the ileal segment, near its blind end through openings in the ileal wall cut to the exact size of each ureter. The distal end of the ileal segment is brought out to the surface of the abdomen in the right lower quadrant through a circular opening cut through skin, fascia, muscle and peritoneum and sutured to the skin to form a slightly protuberant ileal stoma. The various complications encountered with this procedure have prompted the introduction of several modifications. The Wallace method of ureteroileal anastomosis (1966) consists of splaying the distal ureters longitudinally. The medial edges are sutured together with a continuous 5-zero chromic catgut suture. The conjoined ureters are then sutured to the proximal ileal segment with a 4-zero chromic catgut suture at the apex of each ureter to the ileum and a continuous 5-zero chromic suture along the lateral edges. The entire anastomosis is retro- peritonealised. The ileal conduit is brought through the peritoneal cavity to the anterior abdominal wall where a stoma is constructed.

The Guzman continent ileal stoma is constructed by a modification of the Benchekroun technique, which is based on the principle of the inkwell and collapse of the inner tube through retrograde filling of the valve. We used this procedure in 7 patients, all of whom are continent. During a followup of 6 months to 2 years no major complications developed. The stoma is easy to construct, has a low risk of evagination because the inner tube is stabilized with sutures and is easy to catheterize. It does not require staples, which reduces the chance of stone or fistula formation. The terminal ileum in continuity with the cecum or an isolated ileal segment can be used.

Relocation of the ileal conduit stoma in cases of large peristomal hernia is simple and effective, and can be accomplished safely without formal laparotomy. Four difficult cases have been managed successfully in this manner. The technique also is applicable for other intransigent stomal problems.