SCIENTIFIC ARTICLE~
UTILIZATION OF ILEAL CONDUIT IN CONSTRUCTION OF CONTINENT URINARY RESERVOIR JOSEPH E. OESTERLING, M.D. JOHN E GEARHART, M.D. From the Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital; and the Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
ABSTRACT--Two patients with ileal conduits underwent planned urinary undiversion; in both oatients, the previously constructed ileal conduit was utilized to augment the continent urinary reservoir. Both patients are totally continent with stable upper urinary tracts; neither individual uffers from diarrhea or intestinal absorption abnormalities. This variation in the construction of ihe continent urinary reservoir allows for the usage of less terminal ileum, and as a result, the risk of htractable diarrhea as well as folate and vitamin BIe malabsorption should be diminished. The ~iteria that must be met to utilize the ileal conduit in the construction of the continent urinary ~eservoir include: (1) adequate remaining conduit length after mobilization, and (2) a normalappearing conduit with sufficient mesenteric length after mobilization.
the recent past, a wide variety of techniques ;for bladder augmentation and bladder substitui;tion have been developed. 1-6 Recent interest in ~avoiding cutaneous urinary collecting devices i!has resulted in further refinements of older pro!~dures and the development of new techniques ~6r bladder replaeementd ,8 Our initial expe:~lenee with the Indiana continent urinary reseryoir has been most favorable However, we l~liavebeen concerned about vitamin malabsorpitihn and the possibility of intractable diarrhea i!inthese patients, especially younger people and myelodysplasia. In an attempt of these potential side effects, the previously constructed ileal !ient and the ileotrigonal conr to construct the continent :; both patients were undergo[nary undiversion. The expew-up of these 2 patients is re-
i
I
:
~!,U~OLOGy /
JULY 1990
h
/
VOLUME XXXVI, NUMBER 1
Case Reports Case 1 A seventeen-year-old female presented for consideration of urinary undiversion. She was born with an L3-$2 myelomeningoeele that was closed shortly after birth. Because of persistent urinary incontinence, she underwent an ileotrigonal conduit at six years of age. Her clinical course was uneventful until age ten when she began having recurrent episodes of pyelonephritis and increasing bilateral hydronephrosis. At age fourteen, she began having severe stoma problems, and one year later she underwent a stoma revision. At age sixteen, she presented with inquiries about the possibility of urinary undiversion. However, she weighed 180 pounds and was 5 feet 2 inches in height. Dieting and psychologic counseling were instituted, and the patient lost 60 pounds over the next year. With this apparent desire to be free of a 15
FIGURE 1. (A) Intravenous pyelogram four weeks following construction of neobladder shows prompt function bilaterally with excellent drainage into reservoir, (B) Contrast study of neobladder four weeks following surgery shows 400-cc capacity with no reflux.
collecting device, urinary undiversion was considered. The patient underwent construction of a standard Indiana continent urinary reservoir with one exception. The patient's ileotrigonal conduit was taken down, and the trigone of the bladder was excised. The ureters were implanted into the cecum in an antirefluxing manner. After plieating the terminal ileum over a 14F red rubber catheter, the ileal segment remaining from the ileal trigonal conduit was used to augment the cecal segment, completing a composite urinary structure. The patient is totally continent thirty-six months following her surgery and catheterizes her neobladder at four-hour intervals during the day. A mild metabolic acidosis is corrected easily with oral bicarbonate therapy. The upper urinary tracts are stable, and her previous hydronephrosis has improved. Case 2
A twenty-five-year-old female was born with an L3-L5 myelomeningoeele and hydrocephalus. At three days of age, the spinal cord defect was closed, and a ventrieulo-peritoneal (VP) shunt was placed. By age five, a markedly trabeeulated, noneompliant, small-capacity bladder with bilateral grade III vesieoureteral reflux had developed. The patient underwent a eysteetomy and a Brieker ileal conduit urinary diversion2 Over the ensuing years, multiple renal calculi developed, and she had recurrent episodes of acute pyelonephritis bilaterally. On two separate occasions, marked stenosis of the abdominal stoma developed, necessitating surgical revision. In March 1988, the patient presented to the pediatric urology clinic at The Johns Hopkins
16
Hospital with intermittent left flank pain and eomplained that she could no longer keep an appliance on her stoma. An intravenous pyelogram demonstrated multiple left renal calculi and a left mid-ureteral stricture. The patient underwent a percutaneous nephrolithotomy to remove all calculi and balloon dilatation of the ureteral stricture. A subsequent Whitaker test confirmed no pressure gradient across the involved area. Because the patient desired to be appliancefree, a continent urinary reservoir utilizing a eatheterizable a b d o m i n a l stoma was constructed. The ileal conduit was mobilized carefully and opened on the antimesenterie border along its entire length. Both ureters were amputated at the level of the ureteroileal anastomosis, and the left ureter was retunneled beneath the mesentery of the sigmoid colon eephalad to the inferior mesentery artery. The continent urinary reservoir with a eatheterizable abdominal stoma was constructed. In this patient, however, a left-to-right transureteroureterostomy was performed because of the short length of the left ureter, and a right ureteroeolonie anastomosis was accomplished according to the technique described by Coffey 1° and later modified by Leadbetter. 1~ An intravenous pyelogram four weeks following the procedure demonstrated prompt function bilaterally and excellent drainage of the upper tracts (Fig. 1A). A contrast study of the neobladder ("neobladdergram") at the same time showed a capacity of 400 ee with no evidence of reflux (Fig. 1B). The patient catheterizes the neobladder without difficulty four times during the daytime and not at all during the night. She continues to remain completely continent between catheterizations twentyseven months after the procedure. UROLOGY
/
JULY 1990
/
VOLUME XXXVI, NUMBER 1
Surgical Technique
$3 ~'IGURE2. Preoperative view illustrating ileal conduit and short ureters.
The operative procedure utilized is similar to the technique described by Rowland, Mitchell, and Bihrle v for construction of the Indiana continent urinary reservoir using an ileal patch. A 14F catheter with a 3-ce balloon is placed in the ileal conduit until the proximal end is reached (Fig. 2). A midline incision is made from a point halfway between the xiphoid process and the umbilicus to the symphysis pubis. Initially all intestinal adhesions from the previous operation are incised. The ileal conduit is then mobilized from the abdominal wall, being careful to avoid injury to this intestinal segment itself as well as to its mesentery. The ureters are amputated at the ureteroileal anastomotie site, and the ileal conduit is opened on the antimesenterie border along its entire length using electroeautery (Fig. 3). The right colon is mobilized to the hepatic flexure, and a segment of intestine including 15 em of distal ileum and 20 em of ascending colon is isolated. An ileoeolostomy is then performed to re-establish intestinal continuity. The ascending colon of the isolated segment is opened on
:~on
$t FICURE 3.
Ileal conduit being opened on its antimesenteric border. Insert (upper left): Segment of intestine utilized in construction of neobladder.
UF
~m F
~
J
S~ornm e~d
~mu~ery
~ROLOGY / JULY1990 / VOLUMEXXXVI,NUMBER1
17
urete*~ imp~nted into neo~'~daer-
b
[f
To:i f
f To s k i n (stornal /
......
/
,!
,( ~,
!
~..~,~;,..,!i;.~:
FICURE 4. Ileal conduit, with its separate mesentery, is being sewn to the ascending colon to construct the posterior wall o] the neobladder.
,' S!~ii:II '3 ,:!!)
its antimesenteric border to the ileocecal valve and sewn to the previously opened ileal conduit to construct the posterior wall of the neobladder (Fig. 4). The ureters are then implanted along the taenia of the eolon according to the technique described by Coffey 1° and by Leadbetter, n A 24F Maleeot catheter is placed as a eeeostomy tube, and the anterior wall of the reservoir is closed (Fig. 5). The terminal ileum of the isolated intestinal segment is plicated as described by R o w l a n d and coworkers 7 and brought to the abdominal wall as a continent catheterizable stoma. Finally, the neobladder is anchored in position to the adjacent psoas muscle and anterior abdominal wall with several absorbable sutures. All potential spaces between the separate mesenteries are closed to prevent internal hernias. After placing a dosed drain posterior to the neobladder, the w o u n d is closed in the standard manner. Comment The ileoceeal (Indiana) continent urinary reservoir as described by Rowland and associates v has proven to be a safe and reliable method for managing the lower urinary tract without the need for an external applianee in
18
FICURE 5. Completed neobladder with plicated terminal ileum. Insert (lower right): Left-to-right transureteroureterostomy w i t h neobladder anchored to psoas muscle. patients whose bladder has been removed2 By its very design, it is relatively simple to construct, and it employs only those teehniques that have been shown to be eonsistently successful over the years. The ureteral implantations are performed according to the time-proven technique originally described by Coffey in 19111° and later modified by Leadbetter n to incorporate a mueosa-to-mucosa anastomosis. The technique for achieving continence also is strueturally sound, utilizing the ileoeecal valve and a plieated segment of terminal ileum. This mechanism is easier to construct and appears to be more dependable over the long term than the intussuscepted nipple. The reservoir itself is constructed of detubularized cecum and ileum to give a large-capacity, low-pressure neobladdef.
UROLOGY
/
JULY 1990
/
V O L U M E XXXVI, N U M B E R I
To construet the neobladder with an ileal patch, however, as much as 50 to 60 cm of intestine, including up to 30 to 40 em of terminal ileum, may be utilized. In the patient who has undergone an ileal conduit diversion previously, this may represent a significant compromise to this portion of the intestinal tract sinee a 20-em segment of terminal ileum usually is utilized in the construction of the Brieker ileal conduit. 9 As a result, we have employed the ileal eonduit itSelf in the eonstruetion of the Indiana eontinent urinary reservoir. In this manner, only 10 to 15 cm of additional terminal ileum are utilized, namely, for the construction of the eontinenee imeehanism. Neither of the 2 patients presented ~!n this report has suffered from folate, vitamin :Bi2, or carotene deficiency nor from diarrhea. 12 Both patients have large-eapaeity, highly eompliant reservoirs that are eontinent and easily atheterized. Of note, however, is that the ileal conduit . . . ~ iu. s t be moblhzed with care to avoid injury to iihe intestinal segment itself as well as to the mesentery. It must also be of sufficient length liifter the mobilization process is complete. In ~(he 2 eases presented herein, the ileal conduit ker mobilization and amputation of both ure:ers was 15 cm or longer. Care also must be talon during the eonstruetion of the neobladder !6 ensure that the ileal conduit remains oriented ~operly with respect to its separate mesentery. Kt the eonclusion of the proeedure, all potential }paces between the separate mesenteries to the ~eobladder must be obliterated to prevent an internal hernia. I n summary, these 2 patients illustrate the ecessful use of the ileal eonduit in the eon~uetion of the Indiana eontinent urinary reser~iir. By utilizing the ileal conduit, the amount i;intestine removed from the functioning gasI bintestinal tract ean be kept to a minimum. In I ~s manner, hopefully, potential side effeets 'teh as vitamin Bt2, folate, and carotene defieneies as well as diarrhea can be obviated in ese patients.
i~
!~
~)~LOCY
/
JULY 1990
/
VOLUME XXXVI, NUMBER 1
Addendum An additional 8 patients have undergone continent urinary diversion in whieh the previously constructed ileal conduit was used to augment the eontinent urinary reservoir. Seven patients underwent construction of the Indiana continent urinary reservoir; in an additional 5 patients, the Benehekroun procedure was performed. All patients have daytime continence w h e n performing intermittent catheterization every four to six hours. Two patients require catheterization at least once during the night to maintain eontinence. The upper urinary tracts are stable in all patients. None of the individuals has suffered from diarrhea or intestinal absorptive abnormalities. The Mayo Clinie 200 First Street, S.W. Rochester, Minnesota 55905
(DR. OESTEIILING) References 1. Mitchell ME, and Hensle TW: Total bladder replacement in ehildren, in King LR, Stone AR, and Webster GD: Bladder Reeonstruction and Continent Urinary Diversion, Chicago, Year Book Medical Publishers, Inc., 1987, chap 21, p 312. 2. Mitchell ME: The role of bladder augmentation in undiversion, J Pediatr Surg 16:790 (1981). 3. Mitchell ME: Urinary tract diversion and undiversion in the pediatric age group, Surg Clin North Am 61:1147 (1981). 4. Perlmutter AD: Experiences with urinary undiversion in children with neurogenic bladder, J Urol 123:402 (1980). 5. Gearhart JP, Albertsen PC, Marshall FF, and Jeffs RD: Pediatric applications of augmentation cystoplasty: The Johns Hopkins Experience, J Urot 136:430 (1986). 6. Gearhart JP, and Jeffs RD: Augmentation cystoplasty in the failed exstrophy reconstruction, J Urol 139:790 (1988). 7. Rowland RG, Mitchell ME, and Bihrle B: The eeeoileal continent urinary reservoir, World J Urol 3:185 (1985). 8. Rowland RG, et ah Indiana continent urinary reservoir, J Urol 137:1136 (1987). 9. Brieker ME: Bladder substitution after pelvic evisceration, Surg Clin North Am 30" 1511 (1950). 10. Coffey ttC: Physiologic implantation of the severed ureter or common bile-duet into the intestine. JAMA 56:397 (1911). 11. Leadbetter WF: Consideration of problems incident to performanee of uretero-enterostomy: report of a technique, Trans Am Assoe Genitourin Surg 42:39 (1950). 12. Gearhart JP, Canning DA, and Jeffs RD: Nutritional eonsequences of bladder augmentation and replaeement (abstr.), American Academy of Pediatrics Meeting, San Francisco, California, Oetober 16-19, 1988.
19
UTILIZATION OF ILEAL CONDUIT IN CONSTRUCTION OF CONTINENT URINARY RESERVOIR JOSEPH E. OESTERLING, M.D. JOHN E GEARHART, M.D. From the Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital; and the Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
ABSTRACT--Two patients with ileal conduits underwent planned urinary undiversion; in both oatients, the previously constructed ileal conduit was utilized to augment the continent urinary reservoir. Both patients are totally continent with stable upper urinary tracts; neither individual uffers from diarrhea or intestinal absorption abnormalities. This variation in the construction of ihe continent urinary reservoir allows for the usage of less terminal ileum, and as a result, the risk of htractable diarrhea as well as folate and vitamin BIe malabsorption should be diminished. The ~iteria that must be met to utilize the ileal conduit in the construction of the continent urinary ~eservoir include: (1) adequate remaining conduit length after mobilization, and (2) a normalappearing conduit with sufficient mesenteric length after mobilization.
the recent past, a wide variety of techniques ;for bladder augmentation and bladder substitui;tion have been developed. 1-6 Recent interest in ~avoiding cutaneous urinary collecting devices i!has resulted in further refinements of older pro!~dures and the development of new techniques ~6r bladder replaeementd ,8 Our initial expe:~lenee with the Indiana continent urinary reseryoir has been most favorable However, we l~liavebeen concerned about vitamin malabsorpitihn and the possibility of intractable diarrhea i!inthese patients, especially younger people and myelodysplasia. In an attempt of these potential side effects, the previously constructed ileal !ient and the ileotrigonal conr to construct the continent :; both patients were undergo[nary undiversion. The expew-up of these 2 patients is re-
i
I
:
~!,U~OLOGy /
JULY 1990
h
/
VOLUME XXXVI, NUMBER 1
Case Reports Case 1 A seventeen-year-old female presented for consideration of urinary undiversion. She was born with an L3-$2 myelomeningoeele that was closed shortly after birth. Because of persistent urinary incontinence, she underwent an ileotrigonal conduit at six years of age. Her clinical course was uneventful until age ten when she began having recurrent episodes of pyelonephritis and increasing bilateral hydronephrosis. At age fourteen, she began having severe stoma problems, and one year later she underwent a stoma revision. At age sixteen, she presented with inquiries about the possibility of urinary undiversion. However, she weighed 180 pounds and was 5 feet 2 inches in height. Dieting and psychologic counseling were instituted, and the patient lost 60 pounds over the next year. With this apparent desire to be free of a 15
FIGURE 1. (A) Intravenous pyelogram four weeks following construction of neobladder shows prompt function bilaterally with excellent drainage into reservoir, (B) Contrast study of neobladder four weeks following surgery shows 400-cc capacity with no reflux.
collecting device, urinary undiversion was considered. The patient underwent construction of a standard Indiana continent urinary reservoir with one exception. The patient's ileotrigonal conduit was taken down, and the trigone of the bladder was excised. The ureters were implanted into the cecum in an antirefluxing manner. After plieating the terminal ileum over a 14F red rubber catheter, the ileal segment remaining from the ileal trigonal conduit was used to augment the cecal segment, completing a composite urinary structure. The patient is totally continent thirty-six months following her surgery and catheterizes her neobladder at four-hour intervals during the day. A mild metabolic acidosis is corrected easily with oral bicarbonate therapy. The upper urinary tracts are stable, and her previous hydronephrosis has improved. Case 2
A twenty-five-year-old female was born with an L3-L5 myelomeningoeele and hydrocephalus. At three days of age, the spinal cord defect was closed, and a ventrieulo-peritoneal (VP) shunt was placed. By age five, a markedly trabeeulated, noneompliant, small-capacity bladder with bilateral grade III vesieoureteral reflux had developed. The patient underwent a eysteetomy and a Brieker ileal conduit urinary diversion2 Over the ensuing years, multiple renal calculi developed, and she had recurrent episodes of acute pyelonephritis bilaterally. On two separate occasions, marked stenosis of the abdominal stoma developed, necessitating surgical revision. In March 1988, the patient presented to the pediatric urology clinic at The Johns Hopkins
16
Hospital with intermittent left flank pain and eomplained that she could no longer keep an appliance on her stoma. An intravenous pyelogram demonstrated multiple left renal calculi and a left mid-ureteral stricture. The patient underwent a percutaneous nephrolithotomy to remove all calculi and balloon dilatation of the ureteral stricture. A subsequent Whitaker test confirmed no pressure gradient across the involved area. Because the patient desired to be appliancefree, a continent urinary reservoir utilizing a eatheterizable a b d o m i n a l stoma was constructed. The ileal conduit was mobilized carefully and opened on the antimesenterie border along its entire length. Both ureters were amputated at the level of the ureteroileal anastomosis, and the left ureter was retunneled beneath the mesentery of the sigmoid colon eephalad to the inferior mesentery artery. The continent urinary reservoir with a eatheterizable abdominal stoma was constructed. In this patient, however, a left-to-right transureteroureterostomy was performed because of the short length of the left ureter, and a right ureteroeolonie anastomosis was accomplished according to the technique described by Coffey 1° and later modified by Leadbetter. 1~ An intravenous pyelogram four weeks following the procedure demonstrated prompt function bilaterally and excellent drainage of the upper tracts (Fig. 1A). A contrast study of the neobladder ("neobladdergram") at the same time showed a capacity of 400 ee with no evidence of reflux (Fig. 1B). The patient catheterizes the neobladder without difficulty four times during the daytime and not at all during the night. She continues to remain completely continent between catheterizations twentyseven months after the procedure. UROLOGY
/
JULY 1990
/
VOLUME XXXVI, NUMBER 1
Surgical Technique
$3 ~'IGURE2. Preoperative view illustrating ileal conduit and short ureters.
The operative procedure utilized is similar to the technique described by Rowland, Mitchell, and Bihrle v for construction of the Indiana continent urinary reservoir using an ileal patch. A 14F catheter with a 3-ce balloon is placed in the ileal conduit until the proximal end is reached (Fig. 2). A midline incision is made from a point halfway between the xiphoid process and the umbilicus to the symphysis pubis. Initially all intestinal adhesions from the previous operation are incised. The ileal conduit is then mobilized from the abdominal wall, being careful to avoid injury to this intestinal segment itself as well as to its mesentery. The ureters are amputated at the ureteroileal anastomotie site, and the ileal conduit is opened on the antimesenterie border along its entire length using electroeautery (Fig. 3). The right colon is mobilized to the hepatic flexure, and a segment of intestine including 15 em of distal ileum and 20 em of ascending colon is isolated. An ileoeolostomy is then performed to re-establish intestinal continuity. The ascending colon of the isolated segment is opened on
:~on
$t FICURE 3.
Ileal conduit being opened on its antimesenteric border. Insert (upper left): Segment of intestine utilized in construction of neobladder.
UF
~m F
~
J
S~ornm e~d
~mu~ery
~ROLOGY / JULY1990 / VOLUMEXXXVI,NUMBER1
17
urete*~ imp~nted into neo~'~daer-
b
[f
To:i f
f To s k i n (stornal /
......
/
,!
,( ~,
!
~..~,~;,..,!i;.~:
FICURE 4. Ileal conduit, with its separate mesentery, is being sewn to the ascending colon to construct the posterior wall o] the neobladder.
,' S!~ii:II '3 ,:!!)
its antimesenteric border to the ileocecal valve and sewn to the previously opened ileal conduit to construct the posterior wall of the neobladder (Fig. 4). The ureters are then implanted along the taenia of the eolon according to the technique described by Coffey 1° and by Leadbetter, n A 24F Maleeot catheter is placed as a eeeostomy tube, and the anterior wall of the reservoir is closed (Fig. 5). The terminal ileum of the isolated intestinal segment is plicated as described by R o w l a n d and coworkers 7 and brought to the abdominal wall as a continent catheterizable stoma. Finally, the neobladder is anchored in position to the adjacent psoas muscle and anterior abdominal wall with several absorbable sutures. All potential spaces between the separate mesenteries are closed to prevent internal hernias. After placing a dosed drain posterior to the neobladder, the w o u n d is closed in the standard manner. Comment The ileoceeal (Indiana) continent urinary reservoir as described by Rowland and associates v has proven to be a safe and reliable method for managing the lower urinary tract without the need for an external applianee in
18
FICURE 5. Completed neobladder with plicated terminal ileum. Insert (lower right): Left-to-right transureteroureterostomy w i t h neobladder anchored to psoas muscle. patients whose bladder has been removed2 By its very design, it is relatively simple to construct, and it employs only those teehniques that have been shown to be eonsistently successful over the years. The ureteral implantations are performed according to the time-proven technique originally described by Coffey in 19111° and later modified by Leadbetter n to incorporate a mueosa-to-mucosa anastomosis. The technique for achieving continence also is strueturally sound, utilizing the ileoeecal valve and a plieated segment of terminal ileum. This mechanism is easier to construct and appears to be more dependable over the long term than the intussuscepted nipple. The reservoir itself is constructed of detubularized cecum and ileum to give a large-capacity, low-pressure neobladdef.
UROLOGY
/
JULY 1990
/
V O L U M E XXXVI, N U M B E R I
To construet the neobladder with an ileal patch, however, as much as 50 to 60 cm of intestine, including up to 30 to 40 em of terminal ileum, may be utilized. In the patient who has undergone an ileal conduit diversion previously, this may represent a significant compromise to this portion of the intestinal tract sinee a 20-em segment of terminal ileum usually is utilized in the construction of the Brieker ileal conduit. 9 As a result, we have employed the ileal eonduit itSelf in the eonstruetion of the Indiana eontinent urinary reservoir. In this manner, only 10 to 15 cm of additional terminal ileum are utilized, namely, for the construction of the eontinenee imeehanism. Neither of the 2 patients presented ~!n this report has suffered from folate, vitamin :Bi2, or carotene deficiency nor from diarrhea. 12 Both patients have large-eapaeity, highly eompliant reservoirs that are eontinent and easily atheterized. Of note, however, is that the ileal conduit . . . ~ iu. s t be moblhzed with care to avoid injury to iihe intestinal segment itself as well as to the mesentery. It must also be of sufficient length liifter the mobilization process is complete. In ~(he 2 eases presented herein, the ileal conduit ker mobilization and amputation of both ure:ers was 15 cm or longer. Care also must be talon during the eonstruetion of the neobladder !6 ensure that the ileal conduit remains oriented ~operly with respect to its separate mesentery. Kt the eonclusion of the proeedure, all potential }paces between the separate mesenteries to the ~eobladder must be obliterated to prevent an internal hernia. I n summary, these 2 patients illustrate the ecessful use of the ileal eonduit in the eon~uetion of the Indiana eontinent urinary reser~iir. By utilizing the ileal conduit, the amount i;intestine removed from the functioning gasI bintestinal tract ean be kept to a minimum. In I ~s manner, hopefully, potential side effeets 'teh as vitamin Bt2, folate, and carotene defieneies as well as diarrhea can be obviated in ese patients.
i~
!~
~)~LOCY
/
JULY 1990
/
VOLUME XXXVI, NUMBER 1
Addendum An additional 8 patients have undergone continent urinary diversion in whieh the previously constructed ileal conduit was used to augment the eontinent urinary reservoir. Seven patients underwent construction of the Indiana continent urinary reservoir; in an additional 5 patients, the Benehekroun procedure was performed. All patients have daytime continence w h e n performing intermittent catheterization every four to six hours. Two patients require catheterization at least once during the night to maintain eontinence. The upper urinary tracts are stable in all patients. None of the individuals has suffered from diarrhea or intestinal absorptive abnormalities. The Mayo Clinie 200 First Street, S.W. Rochester, Minnesota 55905
(DR. OESTEIILING) References 1. Mitchell ME, and Hensle TW: Total bladder replacement in ehildren, in King LR, Stone AR, and Webster GD: Bladder Reeonstruction and Continent Urinary Diversion, Chicago, Year Book Medical Publishers, Inc., 1987, chap 21, p 312. 2. Mitchell ME: The role of bladder augmentation in undiversion, J Pediatr Surg 16:790 (1981). 3. Mitchell ME: Urinary tract diversion and undiversion in the pediatric age group, Surg Clin North Am 61:1147 (1981). 4. Perlmutter AD: Experiences with urinary undiversion in children with neurogenic bladder, J Urol 123:402 (1980). 5. Gearhart JP, Albertsen PC, Marshall FF, and Jeffs RD: Pediatric applications of augmentation cystoplasty: The Johns Hopkins Experience, J Urot 136:430 (1986). 6. Gearhart JP, and Jeffs RD: Augmentation cystoplasty in the failed exstrophy reconstruction, J Urol 139:790 (1988). 7. Rowland RG, Mitchell ME, and Bihrle B: The eeeoileal continent urinary reservoir, World J Urol 3:185 (1985). 8. Rowland RG, et ah Indiana continent urinary reservoir, J Urol 137:1136 (1987). 9. Brieker ME: Bladder substitution after pelvic evisceration, Surg Clin North Am 30" 1511 (1950). 10. Coffey ttC: Physiologic implantation of the severed ureter or common bile-duet into the intestine. JAMA 56:397 (1911). 11. Leadbetter WF: Consideration of problems incident to performanee of uretero-enterostomy: report of a technique, Trans Am Assoe Genitourin Surg 42:39 (1950). 12. Gearhart JP, Canning DA, and Jeffs RD: Nutritional eonsequences of bladder augmentation and replaeement (abstr.), American Academy of Pediatrics Meeting, San Francisco, California, Oetober 16-19, 1988.
19
