Pediatric Urinary Undiversion

Abstract

Undiversion of the urinary tract is now a practical and valued addition to the urologist’s armamentarium. During the preceding 5 years undiversion procedures were done on 20 children. These 20 undiversions were categorized into 2 groups. Group 1 consisted of 11 children who required small bowel interposition between the ileal/jejunal conduit and/or kidney to the bladder. One of these children required an ileocecal cystoplasty because of a contracted bladder. Group 2 consisted of 9 children who required remodeling and rearrangement of the ureters to establish continuity of the urinary tract.All children had an extensive urologic appraisal to ascertain the level of renal function and reserve, and roentgenographic assessment of the kidneys, conduit, ureters and bladder. Every effort was made to identify the precise indication for the initial diversion and the feasibility of undiversion. Cystoscopy was performed uniformly to exclude valvular and/or stricture urethral disease. Bladder capacity determination with the insertion of a percutaneous suprapubic catheter was done to facilitate urodynamic appraisal of bladder integrity and sphincter function. In most instances hydrostatic filling of the bladder before undiversion facilitated increased bladder capacities in 3 to 4 days.Since undiversion all patients have experienced stable renal function. Radiographs have remained stable or improved. This is particularly gratifying, since 6 of 7 patients with bowel interposition demonstrated persistent reflux with sterile urine. The role of the bowel segment in buffering the hydrostatic effects of voiding questions the need for an antireflux mechanism in these instances. All patients have experienced positive psychosocial benefits after undiversion. Furthermore, improvement in school performance and peer relationships give evidence to improved self-image.