Continent urinary undiversion to modified ureterosigmoidostomy in bladder extrophy patients.

Abstract

The objectives of urinary diversion are expanding from merely preserving kidney functions to enabling the patient to have a good quality of life while maintaining an acceptable certain body image. During the new era of continent urinary diversion the psychological drawbacks of noncontinent skin stoma in young adolescents cannot be overlooked. Ureterosigmoidostomy has been the technique of choice for continent urinary diversion in bladder extrophy patients when bladder reconstruction is not feasible or has failed. Although it provides a good daytime continence it is associated with a high rate of nighttime incontinence and delayed complications of pyelonephritis and hyperchloremic acidosis. We managed five male bladder extrophy patients with noncontinent skin stoma (sigmoid colon conduit in three and ileal conduit in two) including two patients who had previously had complicated classic ureterosigmoidostomy. They underwent urinary undiversion to the valved and augmented rectum (three patients) and the valved S-shaped rectosigmoid pouch (two patients) with some modifications. The conduit was used in the construction, and the ureters were implanted behind an isolated intussusception ileal nipple valve. Tube cecostomy and total parenteral nutrition was used for 7 to 10 days instead of a temporary defunctioning transverse colostomy. With a mean follow-up of 19.8 months (range 9-36 months) all the patients are fully continent during the day and night, with an emptying intervals of 3 to 6 hours. Follow-up intravenous pyelography and renal scans revealed improvement or stabilization of the function and configuration of the upper tracts in all renal units. No prophylactic alkali therapy was given. No clinical evidence of acidosis or symptomatic urinary tract infection was observed. Modified ureterosigmoidostomy is a good alternative for continent urinary undiversion even in those who have previously had complicated classic ureterosigmoidostomy. Our modification of using tube cecostomy and parenteral nutrition instead of a temporary transverse colostomy warrants attention; it made the technique simpler and more attractive.