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OBJECTIVE Although tracheal stomal stenosis can be life-threatening, factors associated with the occurrence of stomal stenosis remain unknown. This study was performed to evaluate these factors in adult patients. METHODS We retrospectively identified adult patients who underwent tracheostomy from 2010 to 2016 using a Japanese national inpatient and outpatient database. We performed Cox proportional hazard regression analyses to evaluate factors associated with the occurrence of tracheal stomal stenosis. RESULTS We obtained data on 25,436 eligible patients. The proportion of tracheal stomal stenosis was 0.9%. Tracheal stomal stenosis was significantly less likely to occur in patients with regular use of oral steroids [hazard ratio (HR), 0.28; 95% confidence interval (CI), 0.09-0.88; P = 0.03] and in male patients (HR, 0.75; 95% CI, 0.57-0.97; P = 0.03). The occurrence of tracheal stomal stenosis was significantly associated with use of a mechanical ventilator at home (HR, 2.54; 95% CI, 1.55-4.15; P < 0.001) and a body mass index of

Objective To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method. Materials and Methods Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children—simple division of the appendix, 4 children—appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall. Results Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix). Conclusion The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Highlights • A case report of using a metal stent to manage ileal conduit stomal stenosis. • A stent can avoid the need for a refashion or reconstruction of the stoma. • Stent insertion is minimally invasive and does not require general anaesthesia. • The stoma regained full function after stent insertion. • There were no issues with stent migration, oxidation or calcification., Intoduction Ileal conduit stomal stenosis is a difficult complication to manage. Definitive treatment usually requires refashioning or a reconstruction of the conduit. There remains a need for minimally invasive procedures that can restore function to the stoma while avoiding the risks associated with a significant surgical procedure. This case illustrates a novel approach to the management of this complication. Presentation of case An 84 year old female with muscle-invasive bladder cancer underwent cystectomy with formation of an ileal conduit urinary diversion system. Her recovery was complicated by stomal stenosis leading to recurrent urinary tract infections. The Memokath Stent 045 is a thermo-expandable nickel–titanium stent designed for treatment of urethral strictures. The stent was inserted into the stoma under direct vision without the need for general anaesthesia or intraoperative radiography. The conduit remains patent 12 months after insertion and the metal stent showed no evidence of migration, calcification, oxidation or degradation. Discussion The use of a thermo-expandable nickel–titanium stent is able to provide the patency required to treat ileal conduit stomal stenosis. In this case, insertion of the stent was a simple procedure and no adverse events or degradation of the stent was identified at 12 months after insertion. The need for a significant surgical procedure such as a refashioning or reconstruction was avoided and general anaesthesia was not required to perform the procedure. Conclusion This case report highlights the possibility of using the thermo-expandable Memokath Stent 045 as an alternative to the long-term management of ileal conduit stomal stenosis.

Background/Purpose The Malone antegrade continence enema (MACE) channel is an effective means to manage patients with neurogenic bowel; however, complications may occur that may require surgical revision. Specific reports of the outcomes of these interventions are limited. We describe our clinical results following revision of MACE. Methods We retrospectively identified patients undergoing MACE revision for at our institution between 1997 and 2009. Type of MACE (in situ appendicocecostomy (AC=247), ileocecostomy (IC=25), cecal flap (CF=10)) performed was recorded, time from creation to revision, site of revision, and need for repeat surgical revision were recorded. Results Of a total of 282 patients that underwent creation of MACE during the study period, 49 patients (17%) required surgical revision. Of these 49 patients, 42 had undergone AC, four had IC and three had CF. Mean time from MACE creation to revision was 19months. Sixty-eight revision procedures were performed in the 49 patients. Skin level or endoscopic procedures accounted for 52/67 (78%) procedures. Sixteen patients (33%) required more than one revision and three patients (6%) required more than two procedures. Conclusions Skin level revisions accounted for over three-fourths of MACE revisions. In our series, two thirds of patients requiring revision required only a single procedure, but one third required more than one revision.

Summary Introduction The Malone antegrade continence enema (MACE) procedure is effective in management of fecal incontinence and intractable constipation. Stomal incontinence and stenosis are the most common issues reported, and a recent large study of imbricated MACE procedures reports a surgical revision rate of 17%. The laparoscopic approach is now widely used and precludes imbrication. To date, few studies have reported revision rates in these patients who have undergone non-imbricated MACE creation. Objective Our goal was to report the long-term outcomes of our non-imbricated patients focusing on complication rates and need for revision. Study design Records of patients younger than 18 years of age who underwent non-imbricated MACE between January 2000 and March 2016 at our institution were reviewed. Patients with less than 2 years of follow-up or non-compliance with MACE usage were excluded from analysis. Patient age, ambulatory status, surgical technique, stomal site, and complications including stomal leakage, stomal stenosis, and need for revision were evaluated. Stomal leakage was classified based on our previously reported system. Results A total of 81 patients met inclusion criteria. Mean age at time of surgery was 8.4 years. Mean and median follow-up were 6.7 and 6.7 years, respectively. Overall revision rate, for stenosis or incontinence, was 16% with a mean time to any revision of 2.1 years (range 28 days to 7.8 years). Four patients required revision for stomal incontinence while others improved spontaneously without intervention. At the last follow-up, stomal leakage was grade 0 in 93.8% of patients, grade 2 in 2.4%, and grade 3a in 3.7% ( summary Table ). Stomal stenosis was noted in 11 patients, eight of whom required revision. Discussion Our study is limited by its retrospective nature with some component of recall bias. A single surgeon experience is also not representative of others' experiences. However, our results indicate that incontinence improves spontaneously in a majority of patients without need for revision in this non-imbricated cohort. Conclusions Our series shows a similar long-term revision rate in line with that reported in the literature. While imbrication is still recommended during open surgery when the anatomy is suitable, equitable success without imbrication supports the laparoscopic approach and a more liberal approach during open surgery if the anatomy does not permit imbrication. Table . Stomal continence. Grade 0 Grade 1 Grade 2 Grade 3a Grade 3b Initial classification 55.6% 18.5% 6.2% 14.8% 4.9% Final classification 93.8% – 2.4% 3.7% –

Introduction Cutaneous ureterostomy is the simplest and safest method of all permanent urinary diversions. However, the procedure does carry a risk of stomal stenosis. We describe a simple technique for improving tubeless cutaneous ureterostomy. Technical Considerations Between June 1991 and June 2003, the Toyoda cutaneous ureterostomy was performed in 54 patients (102 renal units) with a minimum of 6 months of follow-up. Since 1998, we introduced a new technique, consisting of fixation between the anterior and posterior rectus sheath by four interrupted sutures to maintain the stability of the abdominal wall tunnel for the ureters. The ureteral patency rate was reviewed. Of the 79 renal units (77.5%) that achieved a tubeless condition, 70 (68.6%) had no hydronephrosis. The catheter-free rate improved from 60.5% (26 of 43 renal units) to 89.8% (53 of 59 renal units) with the introduction of the new surgical stabilization step for the abdominal wall tunnel. Conclusions This surgical modification is an effective and simple procedure that improves tubeless cutaneous ureterostomy performed with the Toyoda method.

To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs.Between November 1990 and June 1999 an ileocecal reservoir with appendico-umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9-82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol.There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow-up of 60 months all patients are continent day and night.Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

Objective The aim of our study was to review the management of stomal stenosis after the Malone antegrade continence enema (MACE) procedure at our center, and to describe and assess the early outcomes of 2 novel procedures used in the management of conduit stenosis: Maceoscopy and the rendez-vous . Subjects/patients and methods We retrospectively reviewed 45 consecutive MACE cases performed by 1 surgeon at St George's hospital over a 13-year period. Results Until April 2002, 5 cases presented with difficulty catheterizing their MACE. This was attributed to stenosis without further investigation, and the MACE revised surgically. Of 13 cases presenting with suspected stenosis since May 2002, 8 channels turned out to be patent when assessed and catheterized endoscopically via Maceoscopy. Two truly stenotic MACEs were revised; patency of the other 3 was reestablished by means of a new double-endoscopic procedure we have termed the rendez-vous.

Background Since the initial description of the antegrade colonic enema (ACE) procedure, stomal stenosis has been recognized as its most common complication. We previously reported that 44% of our patients required a dilatation for stomal stenosis, with 22% requiring surgical revision. We present our findings with the use of an ACE stopper (Medicina, Adlington, Lancashire, UK) as a means of avoiding this problem. Methods A retrospective review of the case notes of all patients who underwent an ACE procedure with a follow-up longer than 6 months was carried out over a 3-year period. Two weeks after the ACE procedure, an ACE stopper was sited in the conduit for at least 4 months and removed only for catheterization. Results Fourteen patients underwent an ACE procedure, 12 of whom received it laparoscopically. All patients received the ACE stopper. The patients' median age at surgery was 10 years (range, 5-16 years). Diagnoses included spinal dysraphism (n = 6) and anorectal malformation (n = 4), with soiling as the presenting complaint among all patients. The patients' median follow-up was 12 months (range, 6-39 months). There was no stomal complication, and 13 patients reported a marked improvement in soiling. Conclusions The use of an ACE stopper has abolished stomal stenosis on short-term follow-up. We recommend the stopper as an adjunct to the overall management of concerned patients. Longer follow-up is required to establish the true effectiveness of this simple device.

Eight patients with bowel incontinence underwent an open Malone Antegrade Continence Enema (MACE) procedure between May 1997 to May 2000. Indications for the procedure included high anorectal malformation in 3, bowel dysmotility in 1. spinal dysraphism in 3 and presacral teratoma in 1. Age at presentation varied between 06 to 12 years. All but one patient claimed excellent results. Complications of the procedure included stomal stenosis in 1, stomal leak in 2 and inadequate emptying of effluent in 1. Patient selection was the key to success. All patients except one, were children who were literate and had access to a western toilet Whereas, for the vast majority in the Indian rural setting, the procedure may not be beneficial but for a select group of bowel incontinence children, this procedure may bring a dawn of hope.

We describe a reliable and simple technique of parastomal hernia repair using primary fascial repair with synthetic mesh that minimizes the known complications of infection and stomal stenosis while eliminating the need for peritoneal exploration, lysis of adhesions, and relocation of the stoma. We applied this technique to 6 patients (aged 65 to 83 years) with symptomatic, first-time parastomal hernias. The results are discussed.

SUMMARY In our hands, the Benchekroun hydraulic ileal valve has proved to be a very reliable continence mechanism. The patient is provided with a cosmetically acceptable stoma that creates diurnal and nocturnal continence and ease of catheterization. Stomal stenosis has occurred in several patients in our series and has been managed successfully with dilatation or minor surgical revision. The efferent limbs are readily accessed by endoscopic equipment, permitting treatment of stones and surveillance for malignancy. The need for surgical revision is moderate, as only 5 of 15 patients have required such intervention, compared with the revision rate of 58% with plicated ileal efferent limbs in our hands.8 The in situ Benchekroun technique represents an economy of time and energy, especially as a salvage procedure for failed plicated ileal limbs. Currently, the Benchekroun hydraulic ileal valve is our continence mechanism of choice.

There is a need for operations by which the complications of ileal conduits can be prevented or corrected. The author details techniques to ensure the formation of a short conduit, to shorten a conduit through a peristomal incision, and to correct ileocutaneous stomal stenosis.

The Monti ileovesicostomy provides an excellent substitution for an appendicovesicostomy when the appendix is unavailable or suitable for use. The spiral Monti is a useful modification to the traditional Monti as it allows creation of a longer channel when needed. In 2007, the short-term outcomes were reported; they compared traditional and spiral Monti in 188 patients with an average follow-up of 43 months. In the present population, a total of 25 subfasical revisions were performed in 21 patients: nine (8.3%) subfascial revisions in the traditional Monti (TM) patients and 12 (15.2%) subfascial revisions in the spiral Monti (SM) patients. The study found an increased risk of subfascial revisions of either TM or SM when the stoma was located at the umbilicus versus right lower quadrant (16.8% vs 6.3%, P0.05). On subgroup analysis, this increased subfascial revision rate appeared to be driven by SM channels to the umbilicus rather than other stomal locations, but this trend was not statistically significant.It was hypothesized that with longer follow-up, the spiral Monti would require more subfascial revisions due to progressive lengthening of the channel.A retrospective chart review was performed for all patients undergoing a traditional Monti (TM) or spiral Monti (SM) procedure at the present institution (1997-2013). Patient demographics, bowel segment used, stomal location, channel or stomal revisions, number of anesthetic endoscopic procedures performed, and indications for revision were reviewed. Kaplan-Meier analysis and Cox proportional hazards modeling was used for analysis.Of the 296 patients identified, 146 had Monti procedures and 150 had spiral Monti procedures (median follow-up 7.7 years). Median age at surgery was 10.6 years. Myelomeningocele was the most common underlying cause of neuropathic bladder, totaling 169 (57.1%) patients. Stomas were located at the umbilicus (106, 35.8%), right lower quadrant (183, 61.8%) and left lower quadrant (seven, 2.4%). Median follow-up for the entire cohort was 7.7 years (range: 1 month-15.7 years). Stomal stenosis rate was 7.4%, and 96.6% of the channels were continent. A total of 87 revisions were performed in 74 patients (25.0%). Of these, 55 were subfascial revisions in 49 patients (16.6%). The umbilical spiral Monti on univariate and multivariate analysis was found to be over twice as likely to undergo subfascial revision.The majority of patients with a Monti channel had durable results and did not require further channel surgery with long-term follow-up. Spiral Monti channels to the umbilicus were more than twice as likely to undergo subfascial revision compared to all other Monti channels. Overall, one in three umbilical SM channels required a subfascial revision at 10 years after the initial surgery, compared to one in six of all other Monti channels. The study was limited by being a retrospective, single-center series; however, it does represent the largest series of pure SM and TM patients. It focused only on surgical interventions, thus was likely to underestimate the overall risk of complications, as some complications were managed conservatively. As in all studies, some patients were lost to follow-up and inevitably some of these may have had complications. Correction for this was attempted through survival analysis.The present study reported durable and reliable long-term results with Monti and spiral Monti procedures based on a large patient cohort. Spiral Monti to the umbilicus was more than twice as likely to require a subfascial revision.

Stomal stenosis is a frequent complication after creation of a Mitrofanoff stoma for urinary diversion. We describe a new technique for achieving a skin-lined stoma opening that is easy to construct and decreases the risk of stenosis in the long term.

The Mitrofanoff urinary diversion is fraught with the complication of cutaneous stomal stenosis, which prevents catheterization. The authors report another sequel of stomal stenosis-acute appendicitis, a complication not reported hitherto.

Purpose Clean intermittent catheterization (CIC) is a cornerstone in the management of VBS. Sometimes, there is difficulty or pain during performing CIC per urethra which might affect patient compliance. Using appendicovesicostomy might allow better patient compliance and have a positive impact in the management of VBS. Material and Methods Appendicovesicostomy was performed in 10 boys with VBS to allow better implementation of CIC (group I). Other 10 boys with VBS performing CIC per urethra were used as a control group (group II). Both groups were followed regarding complications of catheterization (pain, difficulty, and false passage), rate of UTI, compliance and effect on upper tract dilatation. Stomal complications in addition to continence status were recorded in group I. Results Age range in both groups was 3-9 years and the follow up period is 2 years. No complications of catheterization encountered in group I. Pain was present in 6, false passage in 2 and difficulty in 3 boys in group II. As regards UTI, documented upper tract infection was present in one case in group I and in 4 cases in group II. Lower tract infection was present in 2 cases in group I and in 7 cases in group II. Two cases in group II had recurrent epididymitis. Compliance to CIC was 100% in group I while in group II was 70 %. At the last follow up, there was improvement in upper tract dilatation in 4 cases in group I compared to its status before performing the appendicovesicostomy. Only one case in group I had stomal stenosis that needed surgical revision. All stomas were continent in between the period of CIC. Conclusions Continent appendicovesicostomy is a valid procedure in the management of VBS when compliance in CIC is equivocal. It is a safe and easy procedure with long term success that obviates problems of urethral catheterization.

Purpose To assess the long-term outcome of continent diversion in children with structural or neurogenic cause for incontinence with special interest in differences between closed or open bladder neck. Material and Methods A cohort of 63 children with intractable incontinence treated with continent diversion between january 1998 and january 2008 was reviewed for underlying disease, type of surgery, complications and outcome. Results 40 patients have had a continent diversion with bladder neck reconstruction (group 1), 23 patients have had their bladder neck closed (group 2: 11 primarily closed=2A, 12 secondarily closed =Group 2B). There was no difference in patient's characteristics, in surgical complications or reinterventions or in stone formation ( table 1 ). The continence rate however was significantly better in group 2 (95.7% vs 78.5%). Table 1 . Surgical interventions following continent diversion with and without BN closure. Closed BN (n=23) #procedures (#patients) Open BN (n=40) #procedures (#patients) p-value Cystotomy for stones 2 (2) 3 (3) Ns Endoscopic stone treatment 4 (3) 6 (4) Ns Bladder neck revision 4 (4) 3 (3) Ns Open revision for stomal stenosis 6 (4) 13 (8) Ns Endoscopic revision for stomal stenosis 1 (1) 7 (5) Ns External stomal orifice revision 6 (5) 11 (8) Ns Revision for stomal leakage 2 (1) 7 (6) Ns Other related surgery (augmentation, ureter reimplantation, bladder perforation, …) 7 (2) 11 (10) Ns Total 31 (14) 61 (16) P=0,04 Conclusions In children treated with a continent diversion for intractable incontinence, bladder neck closure as primary or as salvage procedure does not result in extra morbidity and has high success ratio. Good urodynamic evaluation of bladder function is an important key to success in therapy planning for these children and thus minimizing the need for reintervention.

PURPOSE Cecal/colonic flap (CCF) has been suggested as an alternative to the appendix or Monti reconfigured ileum (MRI) for the Malone antegrade continence enema (MACE) procedure in children. The literature regarding its efficiency is scant. We, therefore, analyzed our results of MACE, and compared these 3 alternative techniques, regarding stomal incontinence, and stenosis/obstruction. MATERIAL AND METHODS We conducted a retrospective chart search. All patients who underwent the MACE procedures at our institute were included in our study. RESULTS Seventeen patients with fecal incontinence (11 males, 6 females; mean age 12.8 years) underwent the MACE procedure between 1998 and 2008. Diagnoses included myelodysplasia (8 patients), anorectal malformations (6), sacral agenesis (2), and pelvic trauma (1). The MACE conduits were constructed using the appendix in 5 patients, MRI in 8, and CCF in 4. One patient with an appendix-MACE underwent dilation of a stenosed stoma. In two of the patients with MRI revision was necessary for obstruction/stenosis. No appendix or MRI conduits leaked. All 4 patients with CCF conduits became incontinent 6 to 24 months following surgery. One of these patients also required dilation for stomal stenosis. Attempts to cure incontinence by submucosal injection of dextronomer/hyaluronic acid at the conduit-colon junction failed in 2 patients. Two CCF conduits were successfully replaced by MRI, 1 was replaced by button cecostomy, and 1 is awaiting reconstruction. CONCLUSIONS Our initial results reveal that CCF has failed as a conduit for the MACE procedure because of 100% stomal incontinence. We, therefore, abandoned this procedure, and recommend the appendix or MRI for MACE procedures.

Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Endotherapy Using Sodium Morrhuate (SM) to Induce Stomal Stenosis May Prevent Need for Surgical Revision Marc F. Catalano, Thomas Y. Chua, Oscar A. Batista, Goran T. Rudic Obesity is a chronic medical condition associated with increased morbidity & mortality. Affects 250 million world-wide & 300 thousand deaths/yr. Surgery appears to be the best long-term Rx option, with high success. The most popular procedure is the Roux-Y gastric bypass (RYGB) which takes advantage of both restrictive (small pouch) & malabsorptive surgery. Complications following RYGB have been well described. Those which may be amenable to endotherapy include dilation of gastric stoma. These pts present with wt gain following initial wt loss. Aim: Determine efficacy of SM injection of large gastric stoma in pts with RYGB presenting with wt gain. Methods: Over 4-yrs, 31 pts (10 M, 21 F, age 27-58) with morbid obesity & recent RYGB presented with wt gain following initial wt loss, all with large gastric stoma (stoma size S15 mm) by EGD or x-ray. Rx included injection of SM circumferentially along the dilated stoma to induce tissue retraction and scarring. A total of 1-3 injection sessions were performed. Amount of SM injected per session ranged 8-20 cc (mean 14.5). Successful endotherapy was defined: stoma size S1.2 cm, loss of &75% of wt that was regained following initial wt loss. F/U range 6-25 mo (mean 18). F/U visits were at 4-8 wks. Wt was recorded and compared to historical wt. Results: A mean of 2.3 sessions were performed in 31 RYGB pts. Successful endotherapy as defined at entry, was seen in 19/31 (61%). Mean pre surg wt was 322 lbs, mean post surg wt of 179 lbs. In this group, wt gain was a mean 65 lbs. Following completion of SM endotherapy, wt loss was a mean of 49 lbs at 18 mo F/U. Estimated mean stoma diameter at study entry was 17 mm (range 14-20). Following Sclerotherapy, mean stoma diameter was 10 mm (range 5-16). Of the 12 pts with unsuccessful endotherapy, 5 had revision of their RYGB. Remaining 7 pts continued post bariatric diet & life modification. At subsequent endoscopy, 11 pts had shallow circumferential stomal ulcers & were treated with PPI. All ulcers healed at 8 wks. Presence of ulcer formation resulted in higher success of endotherapy 82% (9/11) compared to those w/o ulcer 50% (10/20). Conclusions: Endoscopic injection of SM surrounding a dilated gastric stoma complicating RYGB surgery appears to be a successful, less invasive therapeutic alternative to surgical revision. The presence of a stomal ulcer, following endotherapy, is a positive predictor for successful outcome.

We evaluated 77 consecutive patients who had undergone horizontal gastroplasty over a 2 year period. Mean follow-up was 26 months (88 percent of patients) and ranged from 15 to 45 months. There were no operative deaths. Early complications were common. Stomal dilatation resulting in cessation of weight loss or in weight regain occurred in 19 patients (25 percent). Stomal stenosis occurred in four patients. Among patients with an intact gastroplasty, the percentage excess weight decreased from a preoperative mean of 142 +/- 46 percent to 80 +/- 38 percent at 1 year, 68 +/- 30 percent at 2 years, and 83 +/- 45 percent at 3 years. Fewer than 25 percent of the patients weighed less than 50 percent above ideal body weight at 2 or 3 years. In our experience, horizontal gastroplasty was associated with an unacceptably high mechanical failure rate. Using strict criteria, weight loss was generally inadequate at 2 years and not sustained, even in patients with intact gastroplasty.

Urinary diversion plays an important role in the therapeutic repertoire of urologists. The stoma is often the weak link of any diversionary procedure. Some of the more common stomal problems include peristomal dermatitis, stomal stenosis, parastomal hernias, malposition, prolapse, and retraction. Depending on the nature and severity of the problem, it may be treated by local wound care, urinary appliance adjustment, dilatation, or surgical intervention. Careful site selection and stomal creation will keep stomal problems to a minimum.

Sixty patients with urethral strictures at the bulbous and membranous levels were treated with Turner-Warwick urethroplasty. Initially, there were significant difficulties with restenosis of either the proximal or distal st-ma following the first-stage urethroplasty. Use of nitrofurazone-hydrocortisone (Furacin-Hc) urethral suppositories practically eliminated recurrent stomal stenosis after the first stage. Several additional modifications were made in the original technique; these included placement of urethral sutures prior to scrotal mobilization and abandonment of the suprapublic cystotomy for frainage at the second stage of the procedure. These modifications increased the chances of achieving a successful result while facilitating the actual surgery and improving the patients' comfort. The over-all success rate was approximately 90 per cent. Patients with urethral stricture surgery subsequent to prostatectomy had problems with urinary control, but not so if prostatectomy was done after the first stage of urethroplasty. It appears that the Turner-Warwick urethroplasty is good one, and predictably good results can be expected on selected patients with urethral strictures.

An improved technique of tubeless cutaneous ureterostomy through a single stoma was devised by modifing the traditional cutaneous ureterostomy. Using this method, urinary diversions were performed on 12 cases with malignancies: 6 had radical cystectomy and the other 6 had pelvic exenteration. Normal bilateral ureters were observed in 11 cases in preoperative intravenous pyelography. Stomal stenosis was found in 1 case (8.3%) requiring operative stomal revision. Generally satisfactory results were obtained. This method could lower the incidence of complications. A long-term follow-up is needed, but 2 cases who have survived for more than 4 years since the operation have shown excellent results. It was thought that it would be difficult to perform tubeless cutaneous ureterostomy on normal-sized ureters, but our clinical results indicate that this method may be able to provide permanent urinary diversion.

The bioCarbon ureterostomy device is a stomal prosthesis for upper tract urinary diversion that has had preliminary successes in animal and human trials in Europe and Peru. Implantation of a pure carbon stomal prosthesis offers the potential advantages of high biocompatibility, lack of encrustation, and elimination of stomal stenosis which is frequently associated with cutaneous ureterostomy. Nine bioCarbon ureterostomy devices were implanted from August, 1984 through July, 1985. Although successful implantation was achieved in 2 patients, the complication rate was high. The bioCarbon ureterostomy device has potential as an alternative form of urinary diversion. However, significant problems need to be remedied before it can be recommended for routine clinical application.