Urinary Diversion In Children Research Articles

Robot-assisted continent urinary diversion in children according to the Mitrofanoff principle: It is safe and feasible even in low-volume centers – a bi-institutional study

Robot-assisted continent urinary diversion in children according to the Mitrofanoff principle: It is safe and feasible even in low-volume centers – a bi-institutional study

Modern view on the problem of urine diversion in children with severe urinary disorders

Urination is a complex multicomponent process. Urinary disorders often lead to serious consequences on the urinary system, social maladaptation, and impairment of the quality of children's lives. Due to the large number of pathologies leading to these disorders and the involvement of several systems (for example, the nervous system in myelodysplasia), the doctor must be extensively knowledgeable and experienced in related fields. Surgical methods of urinary diversion have a long history. Surgeons worldwide have been trying to solve this problem for many decades, but it remains relevant and unsolved. The wide variety of urinary disorders has a correspondingly impressive number of types and options of surgical interventions. The goals of these surgical techniques are to correct the anatomical and clinical aspects of the disorders and assure the childs socio-psychological adaptation. Surgeons must consider many factors such as all the pathogenetic nuances of an underlying disease, comorbidities, the childs constitutional features, prospects for his or her social adaptation, the family home environment, parents willingness to and focus on long and challenging treatment. Based on these details, it is evident that urinary diversion in children is a multifaceted problem. It requires a very careful and individualized approach to each patient to ensure choosing the optimal treatment method in each case. This choice will affect many aspects of the childs life, including his or her social adaptation, the ability to obtain an education and lead an almost normal lifestyle. The aim of this study is to review and systematize the accumulated knowledge on this subject.

Long-term outcome of transplant ureterostomy in children: A National Review.

CAKUT are the most common cause of end-stage renal failure in children (Pediatr Nephrol. 24, 2009, 1719). Many children with CAKUT have poor urinary drainage which can compromise post-transplant outcome. Identifying safe ways to manage anatomical abnormalities and provide effective urinary drainage is key to transplant success. Much debate exists regarding optimum urinary diversion techniques. The definitive formation of a continent urinary diversion is always preferable but may not always be possible. We explore the role of ureterostomy formation at transplantation in a complex pediatric group. We report six pediatric patients who had ureterostomy formation at the time of transplantation at the National Paediatric Transplant Centre in Dublin, Ireland. We compared renal function and burden of urinary tract infection to a group with alternative urinary diversion procedures and a group with normal bladders over a 5-year period. There was no demonstrable difference in estimated glomerular filtration rate between the groups at 5-year follow-up. The overall burden of UTI was low and similar in frequency between the three groups. Ureterostomy formation is a safe and effective option for temporary urinary diversion in children with complex abdominal anatomy facilitating transplantation; it is, however, important to consider the implications and risk of ureterostomy for definitive surgery after transplantation.

Long-term outcomes of catheterizable continent urinary diversion in children

Introduction/Objective. The use of bladder augmentation and/or continent urinary diversion has gained wide acceptance, particularly in children with small, abnormally developed bladder or high-pressure bladder that poses great risk for renal deterioration and incontinence. We discuss indications, results, and complications with various types of continent vesicostomy (CV) in children. Methods. Sixty-eight patients with CV are retrospectively reviewed (51 boys and 17 girls) 1987?2008. The median follow-up time was 17.8 years (3?22 years). CV included appendicovesicostomy in 31 (41.3%), vesicostomy with distal ureter in 27 (36.0%), and preputial CV in 10 (13.3%) patients. CV in patients with augmented bladder was in 18 (26.47%) children. The indications for performing CV were various types of neurogenic and myogenic dysfunctions of urine bladder with incontinence due to the following pathoanatomical substrates: anomalies of the brain?spine segment development (27), bladder exstrophy (10), posterior urethral valve (15), expansive processes (4), and other anatomical defects in 12 patients. Results. Continence was achieved in 94.64% of the cases, without statistically significant difference between particular types of the stoma (p = 0.065). Early complications included stoma necrosis, stoma bleeding, peristomal infection in 5/68 (7.35%) patients, and late complications included calculosis, in 20/68 (29.4%), stomal stenosis, in 8/68 (11.5%), and difficulties of catheterization, in 3/68 patients (4.08%). Calculosis was predominant in appendicovesicostomy (p = 0.012). Conclusion. CV is a safe procedure applied with the main purposes of achieving continence, preservation of renal function, and improvement of the quality of life, along with an acceptably low rate of complications.

Laparoscopy-Assisted Cutaneous Ureterostomy in Children: Early Experience.

Laparoscopy-assisted cutaneous ureterostomy (LA-CU) is a minimally invasive approach for temporary urinary diversion in children. We describe the technique, its feasibility, potential advantages, and outcomes in 12 children treated for a variety of conditions. Three trocars were used transperitoneally, one transumbilical, and another placed at the later stoma site. In the semilateral position, with a panoramic view, the ureter of interest is easily identified, mobilized, and exteriorized for stoma creation. We retrospectively reviewed our experience at two tertiary-care centers and included both refluxing and end ureterostomies. The study period was between October 2014 and February 2017. Renal function and growth curves were noted at follow-up. Twelve children underwent LA-CU: 3 end and 9 refluxing ureterostomy. Mean age was 18.75 ± 17.60 months. Mean operating time was 94.44 ± 34.86 minutes. Follow-up ranged from 10 to 38 months. No major postoperative complications occurred. Renal function and growth curves improved in the majority of children. Primary surgical correction of obstructive or refluxing uropathy is the gold standard; however, temporary urinary diversion is useful in specific scenarios. In these patients, laparoscopic assistance may offer better and direct visualization, achieves accurate and rapid identification of ureter, and provides adequate mobilization, tension-free exteriorization, and excision of redundant ureter in some to optimize drainage. One trocar at the eventual stoma site minimizes scarring.

The Cologne pouch procedure for continent anal urinary diversion in children with bladder exstrophy–epispadias complex

In children who remain incontinent after reconstruction of bladder exstrophy-epispadias complex (BEEC), continent anal urinary diversion (CAD) is one option to achieve continence. Known problems after CAD are an increased stool frequency and ureterointestinal stenosis. We devised a new surgical technique of CAD that we named the "Cologne pouch procedure" (CPP) that renders the possibility of separate evacuation of urine and feces. Furthermore, we connect the bladder plate to the rectosigmoid pouch instead of performing a ureterosigmoidostomy to reduce the rate of ureterointestinal stenosis. In this study, we want to introduce the CCP and critically evaluate our results. In CPP a detubularized sigmoid-bladder pouch is created, which is naturally connected to the rectum. A retrospective study was performed including all patients with BEEC and CPP treated in our hospital between January 1, 2007, and December 31, 2016. Epidemiological and surgical key data, complications, and the need for alkaline supplementation were assessed. At follow-up examinations, we evaluated continence, ability of independent urine and feces evacuation, need for bicarbonate supplementation, status of the upper urinary tract, and complications such as urinary tract infections or urolithiasis. In total, 29 patients with BEEC and CPP were included. The mean age at surgery was 4.2±3.3 years (range 0.1-12.7 years). Overall, 14 short-term complications occurred in nine patients. Postoperatively, all patients were continent for urine and feces during daytime and only one child occasionally lost small portions of urine at night. An independent evacuation of urine and feces was accomplished in 22 patients (81.5%). Continued bicarbonate supplementation was necessary in 15 patients (55.6%). During the follow-up period six patients (22.2%) had a single urinary tract infection and four patients (14.8%) calculi of the urinary tract. No urinary tract abnormalities-especially no vesicoureteral reflux (VUR) or stenosis-were detected during follow-up ultrasound examination. In two children, a preoperatively known hydronephrosis decreased after CPP. CPP is a novel technique that yields excellent results concerning continence. In contrast to other forms of rectosigmoid urinary diversion, functional separation of defecation and urination can be achieved in most patients.

Long-term outcome after urinary diversion using the ileocecal segment in children and adolescents: Complications of the efferent segment

Long-term outcomes are of special concern in children after urinary diversion. In a single institution study we evaluated retrospectively the long-term outcomes of urinary diversion in children, in whom the ileocecal segment had been used, in respect to complications of the efferent segment. The Mainz pouch was used in 107 children for continent urinary diversion. Indications were neurogenic bladder (53%, 57/107), exstrophy-epispadias complex (25%, 27/107), malignancy (13%, 14/107), and others (9%, 9/107). Continent cutaneous diversion was performed in 95 patients, and 12 patients received bladder augmentation/substitution with a continent cutaneous stoma. As efferent segment, we used the in situ submucosally embedded appendix in 55/107, and an intussuscepted ileal nipple valve in 45/107 patients, other in seven patients. Complication rates and degree of satisfaction with urinary diversion were evaluated by assessing medical records and using follow-up questionnaires. The median follow-up time was 15.9 years (0.4-27.6 years). There was a significant difference between the stenosis rates of appendical stoma and the intussuscepted ileal nipple valve. In general, 38% of patients (41/107) with a continent cutaneous stoma developed a stoma stenosis at the skin level, with 41% (17/41) of those having recurrent stenoses (2-6×). Of the patients with an appendix stoma, 49% (27/55) developed a stenosis, compared with 20% (9/45) of those with an intussuscepted ileal nipple valve (p<0.001). In an attempt to reduce the incidence of stenosis, we implemented use of the ACE stopper during the last 2 years, but whether this is successful is subject to further investigations. For surgical treatment of stoma stenosis, reanastomosis of the efferent segment to the skin (n=37, re-stenosis rate 37%, [14/37]) was superior to endoscopic scar incision (n=44, re-stenosis rate 59% [26/44], OR 2.4). The overall continence rate was 85% (91/107). At the latest follow-up, 89% (49/55) of patients with an appendix stoma and 82% (37/45) of those with an intussuscepted ileal nipple valve were completely continent. The in situ submucosally embedded appendix and the intussuscepted ileal nipple valve are reliable continence mechanisms in the long-term median follow-up of nearly 16 years. The stomal stenosis rate is approximately double for the submucosal appendix, likely because of its smaller diameter in comparison with the ileal valve. Although we encountered a high overall rate of complications, the satisfaction rate with the diversion was high (99% [88/89] satisfied or very satisfied patients).

Bricker Conduit for Pediatric Urinary Diversion—Should we Still Offer It?

We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean ± SD baseline (64.5 ± 46 ml/minute/1.73 m(2)) and last followup estimated glomerular filtration rate (54.1 ± 44.9 ml/minute/1.73 m(2)), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19hospital readmissions were required in 14 patients to treat diversion related complications. The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population.

Metabolic bone loss after urinary diversion in children.

It has been widely known for some time that bone loss can be seen in certain subpopulations of children undergoing urinary diversion and/or enterocystoplasty. This review will hopefully look at the recent evidence in the field and help understand the multifactorial cause of bone loss in this group of individuals, as well as look at evidence for this phenomenon in growth retardation in certain groups of these individuals. Most of the recent publications indicate that in normal individuals, decreased bone mineralization does not appear to affect final growth or adult height. It would appear that over time, demineralization allows compensation of the acidosis. However, it should be noted that it does lead to an increase in both osteoclastic and osteoblastic activity. It is very likely that enterocystoplasty in childhood can lead to significant metabolic acidosis and that compensation with bone buffering does take place. It would appear that the bone demineralization secondary to increased osteoblastic and osteoclastic activity is the price paid for metabolic compensation and continued normal and near normal linear growth.

Intractable Hemorrhagic Cystitis After Hematopoietic Stem Cell Tranplantation—Is There a Role for Early Urinary Diversion in Children?

Severe hemorrhagic cystitis is a major complication in the pediatric population undergoing hematopoietic stem cell transplantation. Percutaneous nephrostomy tube drainage as a treatment for severe hemorrhagic cystitis has rarely been investigated. We examined children undergoing hematopoietic stem cell transplantation for risk factors associated with severe hemorrhagic cystitis, as well as our experience with percutaneous nephrostomy tube placement as an adjunctive management strategy. Using prospectively collected data from the Blood and Marrow Transplant Database at the University of Minnesota, we reviewed 40 pediatric patients with severe hemorrhagic cystitis from 1996 to 2010. Specific treatment for each patient was administered at the discretion of the attending physician and generally included bladder irrigation before bladder fulguration or percutaneous nephrostomy tube placement. A percutaneous nephrostomy tube was placed in 11 patients due to the intractable nature of the hemorrhagic cystitis. Of the 11 patients who underwent percutaneous nephrostomy tube drainage 5 (45%) had improvement of the hemorrhagic cystitis within 30 days and the same number had long-term resolution. Among the patients with long-term resolution hemorrhagic cystitis resolved an average of 12.4 days after percutaneous nephrostomy tube placement, and the tubes were removed an average of 8.8 weeks after placement. Through September 2011 mortality among patients with percutaneous nephrostomy tubes was 55% (6 of 11 patients), which was identical to the overall mortality in the severe hemorrhagic cystitis group (22 of 40). No death could be directly attributed to hemorrhagic cystitis or percutaneous nephrostomy tube placement. Placement of percutaneous nephrostomy tubes for treatment of severe hemorrhagic cystitis results in long-term improvement in intractable hemorrhagic cystitis, and is a safe and viable option for the majority of patients.

Posterior Urethral Valve Treatments and Outcomes in Children Receiving Kidney Transplants

We evaluated the impact of surgical approaches to posterior urethral valves on renal transplant survival and compared transplant survival in children with vs without posterior urethral valves. We reviewed the records of all children who underwent renal transplantation from January 1984 to March 2008 and performed univariate subgroup analysis in those with posterior urethral valves. We evaluated the ureteroneocystotomy method, immunosuppression and valve treatment. In patients with posterior urethral valves we regarded nocturnal and/or daytime incontinence, severe urgency and the need for intermittent catheterization or double voiding for increased post-void residual urine as signs of bladder dysfunction. The initial renal transplant was received by 418 children at a mean age of 5.6 years. The 59 boys with posterior urethral valves received a total of 69 kidneys. By 8-year followup the kidney had failed in 24 of 59 boys with and 143 of 359 without posterior urethral valves (OR 0.9665, 95% CI 0.5462-1.692, p = 0.9105). Immunosuppression was consistent in the 2 groups. Outcomes were similar across all ureteroneocystotomy techniques. Initial management for posterior urethral valves was valve ablation alone in 12 boys, vesicostomy in 7 and supravesical diversion in 11. There was no difference in transplant survival or bladder dysfunction based on valve intervention. In 18 boys (55%) we noted overlapping signs of bladder dysfunction, of whom 11 performed intermittent catheterization or had increased post-void residual urine, 4 had severe urgency, 4 had daytime incontinence and 7 had nocturnal incontinence. Bladder dysfunction did not predict increased graft loss (OR 3.306, 95% CI 0.7615-16.27, p = 0.1134). Of children who undergo renal transplantation boys with posterior urethral valves do not have a higher graft failure rate. Treatment for posterior urethral valves did not significantly impact transplant survival or bladder dysfunction.

V1709 ROLE OF LAPAROSCOPY IN URINARY DIVERSION IN CHILDREN: DESCRIPTION OF DIFFERENT URETEROSTOMY TECHNIQUES

You have accessJournal of UrologyPediatrics & Reconstruction1 Apr 2011V1709 ROLE OF LAPAROSCOPY IN URINARY DIVERSION IN CHILDREN: DESCRIPTION OF DIFFERENT URETEROSTOMY TECHNIQUES Yaser El-Hout, Tarek H. El-Ghazaly, and Walid A. Farhat Yaser El-HoutYaser El-Hout Toronto, Canada More articles by this author , Tarek H. El-GhazalyTarek H. El-Ghazaly Toronto, Canada More articles by this author , and Walid A. FarhatWalid A. Farhat Toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2034AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In pediatric urology, upper tract urinary diversion in the form of cutaneous ureterostomy may be clinically indicated as a temporizing procedure whenever the definitive reconstructive surgery has to be delayed for technical or clinical considerations. With expansion of the application of pediatric minimally invasive approaches, performing laparoscopic urinary diversion is an attractive alternative, owing to better visualization and limited dissection, hence a perceived decreased adhesions in the secondary definitive reconstruction. Herein, we describe two cases of laparoscopic ureterostomy, performed through different approaches:retroperitoneal and transperitoneal. METHODS This is a single center case study that reports on the clinical presentation, indications for urinary diversion, and description of surgical technique and short-term postoperative outcome on two pediatric patients that underwent retroperitoneoscopic unilateral cutaneous end ureterostomy and laparoscopic bilateral loop ureterostomies. RESULTS Retroperitoneal approach is ideal for unilateral ureterostomy creation, as it allows for direct access to the ureter along its entire course on the psoas. Transperitoneal approach is beneficial for bilateral creation, or whenever a diagnostic laparoscopy is clinically desired. In our reported patients, no intraoperative complications were encountered. Ultrasound and physical examination at three months follow-up confirmed upper tract decompression, stable renal function and patent stomas. CONCLUSIONS When indicated,minimally invasive urinary diversion, in the form of ureterostomies, is a feasible alternative in the pediatric population. Owing to the rarity of this entity, pediatric urologists may opt for this alternative in select patients. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e687 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yaser El-Hout Toronto, Canada More articles by this author Tarek H. El-Ghazaly Toronto, Canada More articles by this author Walid A. Farhat Toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

POD-07.03: The Mitrofanoff continent external urinary diversion in children: indications and results

POD-07.03: The Mitrofanoff continent external urinary diversion in children: indications and results

Bladder Augmentation and/or Continent Urinary Diversion: 10-Year Experience

We evaluated the success and the long-term complications associated with augmentation cystoplasty and/or continent urinary diversion in children with urinary incontinence due to neurogenic or malformed bladder. The records of 23 patients (12 females, 11 males) who underwent such procedures between 1994 and 2004 were reviewed retrospectively. The most common type of augmentation cystoplasty was ileocystoplasty. The most common type of conduit for the urinary continent diversion was appendicovesicostomy. Combined bladder neck closure was not performed systematically. Neocystoureterostomy was done in 14 refluxing ureters. Of the 21 patients who underwent augmentation cystoplasty, only one was incontinent after the procedure and required reconstruction of the bladder neck using the Young-Dees procedure. The most common complications were stomal stenosis and bladder stone formation. Augmentation cystoplasty and continent urinary diversion procedures can increase the functional capacity of the small bladder and allow the majority of patients to achieve continence while preserving renal function. Combined bladder neck closure is not necessary to obtain urinary continence; on the contrary, it eliminates a useful pop-off mechanism. Neocystouretrostomy is not required for every refluxing ureter unless it can be performed on the original bladder. Bladder stones and stomal stenosis are the most significant long-term complications in these patients.

Outcomes of Urinary Diversion in Children With Spinal Cord Injuries

Purpose: To gain a better understanding of the outcomes of the Mitrofanoff procedure for urinary diversionin children with spinal cord injury (SCI).Design: Descriptive retrospective.Participants/Methods: Individuals 6 to 27 years of age with SCI with at least 1 year follow-up after the Mitrofanoff procedure. Objective data collected via retrospective chart review include general demographics and medical/surgical history. Data collected via structured telephone interview include history of adverse urological events, bladder management, bladder management independence scores, patient satisfaction, and quality of life.Results: Sixteen subjects (13 female, 3 male) with a mean age of 19 years (range 6-27 y) who underwent the Mitrofanoff procedure were interviewed. Length of postoperative follow-up ranged from 1 to 8 years (mean 4.25 y). Complications included stomal stenosis 25% (n = 4) with a mean of 19 months to first occurrence of stenosis; urethral incontinence 75% (n = 12); renal /bladder calculi 19% (n = 3); and stomal leakage 44% (n = 7). Independence scores for bladder management after the Mitrofanoff procedure improved in 84% of subjects with tetraplegia and 25% of subjects with paraplegia. Eighty-eight percent (n = 14) were satisfied with the procedure, while 12% (n = 2) were somewhat satisfied. A thematic analysis of quality of life revealed that freedom (35%) and independence (35%) were most commonly cited.Conclusion: While some subjects experienced complications, satisfaction was relatively high and level of independence in bladder management was greatly improved. This study demonstrates that the Mitrofanoff procedure is a beneficial option to improve independence and ease of bladder management in children with SCI.

Continent Cutaneous Urinary Diversion in Children: Experience With Charleston Pouch I

Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children. A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and long-term functional status. Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory. Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable.

Bladder function associated with posterior urethral valves after primary valve ablation or proximal urinary diversion in children and adolescents.

We retrospectively reviewed 2 series of patients with posterior urethral valves treated initially with valve ablation preceded by bilateral cutaneous ureterostomies or valve ablation alone to evaluate and compare bladder function behavior of each treatment group. From 1970 to 1983, 19 males 22 days to 21 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including upper tract diversion, delayed undiversion and ablation in 11 (group 1), and primary valve ablation only in 8 (group 2). Median patient age at the time of cutaneous urinary diversion and primary valve ablation for groups 1 and 2 was 7 and 9 months, respectively. Median duration of bladder defunctionalization was 48 months. All patients were evaluated urodynamically after initial ablation or re-functionalization of the bladder using standard rapid fill cystometry. Median patient age for groups 1 and 2 was 14 and 9.5 years, respectively, at the time of urodynamic testing 16 and 12.6 years, respectively, at followup. Urodynamic assessment revealed detrusor instability in 5 group 1 patients but in only group 2 1 patient. Group 2 patients had significantly lower median end filling pressure (4 versus 15 cm. water, p <0.03) and higher maximum bladder capacity (1.4 versus 0.8, p <0.005) than those in group 1. Group 1 patients had lower compliance than those in group 2 (median 15 versus 82 cm. water, p <0.05). Further analysis showed no difference between groups 1 and 2 in overall median voiding detrusor pressure at maximum flow (51 versus 52.6 cm. water, respectively). Cystometric detrusor under activity patterns were noted in 5 group 1 and 2 group 2 patients. Residual urine volumes were 17%, 31%, 19% and 8% of bladder capacity, respectively, in 2 group 1 and 2 group 2 patients. At final followup 5 group 1 and 2 group 2 patients had renal function deterioration. Two other group 1 patients and group 2 had progression to end stage renal failure. A higher ureteral reimplantation rate was noted in group 1 (63%) than group 2 (6%). This retrospective study revealed that long-term bladder function of patients with posterior urethral valves treated with temporary supravesical diversion is affected more adversely than those treated with valve ablation alone.

Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience

After the failure of conservative treatment of neurogenic bladders, urinary diversion has to be considered. For patients with chronic renal failure, severe dilated upper urinary tracts with deterioration of the renal function and those who are not able to perform a self-catheterization, the colonic conduit diversion is our therapy of choice. In this part of the study, we investigate the long-term safety of our concept for these patients in regard to protecting the upper urinary tracts. Between 1968 and 2002, colonic conduit urinary diversion was performed in 88 patients, in most of them in the era before continent diversion. Overall, 11 patients with a colonic conduit were converted to bladder substitution or continent cutaneous diversion during the follow-up period. These patients are no longer included in the long-term follow-up of colonic conduit patients. Of the 77 patients with colonic conduit diversion, 21 patients were not available for follow-up: 11 were deceased and 10 were lost to follow-up. Three of the deaths were related to nephrological complications in patients who already had impaired renal function before conduit diversion. An average follow-up of 21.8 years (2-32.7; median 23.8 years.) is available in 56 patients with 99 RUs (6 solitary kidneys, 7 nephrectomies). Five non-functioning kidneys were removed after recurrent pyelonephritis and two kidneys with pyonephrosis. Ureter stenoses were corrected in 6% of the RUs. As compared to preoperatively, the upper urinary tracts remained stable or improved in 97/99 RUs at the latest follow-up. A revision of the stoma was necessary in 16% (conduit elongation n =2, stenosis n =7) and calculi formations were treated in 8% of the RUs. For patients with chronic renal failure or who are unable to perform a catheterization of a continent stoma, the colonic conduit is a safe alternative in the long run.

Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience

After failure of conservative treatment of neurogenic bladders (deterioration of the upper urinary tract/incontinence) continent cutaneous diversion has to be considered in those patients with irreparable urethral sphincter defects or those who are unable to perform trans-urethral self-catheterization. In this second part of the study we investigated the long-term safety of using the Mainz pouch I with regard to protecting the upper urinary tracts and to provide urine continence. Between 1985 and 2002, operations to form an ileocaecal pouch with umbilical stoma (Mainz pouch I) were performed on 70 children and adolescents of median age 15.3 years (range 5.7-20 years). During the follow-up period five patients died 2.4-14 years postoperatively of causes not related to urinary diversion. A follow-up period of 8.7 years (0.9-18) was achieved in 65 patients with 118 renal units (RUs). As compared to preoperatively, the upper urinary tracts had remained stable or improved in 113/118 RUs (95.8%) at the latest follow-up. Complete continence was achieved in 97% of patients with a continent cutaneous diversion. Surgical revisions were required for: incontinence of the outlet mechanism in 9%, stoma prolapse in 2%, stoma stenosis in 23%, pouch calculi in 15%, symptomatic reflux in 1%, ureter stenosis in 16% of the RUs with submucosal tunnel and in 3% of the RUs with an extramural tunnel. We conclude that, in patients with irreparable sphincter defect and those who are unable to perform urethral self-catheterization, continent cutaneous urinary diversion with the Mainz pouch I provides a high continence rate with preservation of the upper urinary tracts in the long run. In patients with dilated ureters, the extramural tunnel technique results in a lower complication rate.

Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience

After the failure of conservative treatment of neurogenic bladders (deterioration of the upper urinary tract/incontinence), bladder augmentation/bladder substitution and supravesical urinary diversion have to be considered. In our concept, bladder augmentation is indicated for hyperreflexive and small low compliance bladders with normal upper urinary tracts. In cases with combined sphincteric incompetence, a fascial sling (FS) can be required to achieve continence. In patients with small and hyperreflexive bladders, high-grade reflux and/or dilatation of the upper tracts, bladder substitution and ureteral reimplantation are appropriate. For patients with irreparable sphincter defects and those who are unable to perform transurethral self-catheterization, continent cutaneous diversion is offered. For patients with chronic renal failure, deterioration of the upper urinary tract and those who are not able to perform a self-catheterization of a continent stoma, colonic conduit diversion is our therapy of choice. The current study aims to investigate the long-term safety of our concept for these patients in regard to protecting the upper tracts and providing continence. Between 1968 and 2002, 170 children and adolescents underwent surgery. Of these, 24 received an orthotopic reservoir (bladder augmentation, n =10; combined with FS, n =1; orthotopic bladder substitution with ureteral reimplantation, n =14). The material, methods and results of the remaining 146 patients are reported in parts II and III. One of the 24 patients with an orthotopic reservoir was lost to follow-up. An average follow-up of 9 years (1.3-18 years; median 8.7 years) was available in 23 patients with 42 RUs. As compared to preoperatively, the upper urinary tracts remained stable or improved in all ten patients with bladder augmentation and in 20/23 renal units (RUs) with bladder substitution at the latest follow-up. Eight of ten patients with bladder augmentation are continent. All 13 patients with bladder substitution are continent during the day; one requires a safety pad at night. Bladder augmentation has been effective in patients with hyperreflexive and small low compliance bladders and normal upper urinary tracts. In those with high-grade reflux and/or dilatation of the upper tracts, bladder substitution and ureteral reimplantation are recommended. In very selected patients a fascial sling (FS) can be required to achieve continence.