Le Duc-Camey antireflux ureteroileal reimplantation for continent ileal reservoir]

Le Duc-Camey antireflux ureteroileal reimplantation was used on 15 patients with 30 ureters reimplanted into the ileum as part of a bladder substitution procedure (Kock pouch or ileal neobladder: U-bladder) or augmentation cystoplasty (Goodwin ileocystoplasty). In our experience, no reflux was observed, while hydronephrosis was identified in one ureter of ileal neobladder (4%). Le Duc-Camey antireflux ureteroileal reimplantation is suitable for reconstruction with the ileal reservoir.     

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE: A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure. MATERIALS AND METHODS: Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases. RESULTS: Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully. CONCLUSIONS: The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.     

Antireflux ureteroileal reimplantation: an alternative for urinary diversion

Direct antireflux ureteroileal reimplantation with a short (2 to 2.5 cm.) intraintestinal ureteral segment was used in 14 patients with 26 ureters reimplanted into the ileum as part of a bladder augmentation procedure, substitution cystoplasty or continent supravesical diversion. Our incidence of reflux was 3.8 per cent (1 ureter), while ureteroileal obstruction occurred in 11.4 per cent (3 ureters). The over-all short-term technical success (maximum 18 months) with this operation was 84.8 per cent. These encouraging results make antireflux ureteroileal reimplantation an attractive alternative for its use in urinary tract reconstruction with ileal reservoirs.     

Quo vadis? Ureteric reimplantation or ignoring reflux during augmentation cystoplasty

OBJECTIVE: To decide whether antireflux surgery should be used in the presence of vesico-ureteric reflux (VUR) in children, in whom an augmentation procedure is needed, because secondary VUR in children with a neurogenic bladder, infravesical obstruction and primary VUR in the exstrophy-epispadias complex is expected to resolve after augmentation, which decreases the intravesical pressure and increases capacity. PATIENTS AND METHODS: Between 1987 and 2001, the bladder was augmented in 38 children, using no antireflux surgery in group 1 (15 patients) and antireflux surgery in group 2 (23 patients). RESULTS: VUR was detected in all patients on cysto-urethrography before surgery; reflux resolved after augmentation cystoplasty in 97% and 93% of refluxing units in groups 1 and 2, respectively. The increase in the expected bladder capacity was from 35% to 86% in group 1 and from 38% to 90% in group 2. No patient had any deterioration in renal function. CONCLUSIONS: We recommend using only augmentation in patients with low- or high-grade VUR and a neurogenic bladder, infravesical obstruction and exstrophy-epispadias. Combining antireflux surgery with cystoplasty has no significant effect on either the resolution of VUR or renal function.     

Nonrefluxing ureteroileal cystoplasty for bladder augmentation or replacement of ureters: long-term results of own technique

The technique of a nonrefluxing end-to-end ureteroileal anastomosis is described. The conjoined ends of both ureters are formed into a 4 to 5 cm. long ureteral tube that is placed loosely into the bowel lumen. Increased intraluminal pressure during micturition closes the valve by compressing the ureter wall from outside, thus, preventing reflux. An end-to-end enteroureteral anastomosis has been used in 32 ileal or colon conduits and in 6 patients with ureteroileal cystoplasty. The followup (range 1 to 15 years) of these 6 patients who underwent bladder augmentation or ureteral replacement is presented. Based on this experience, this type of anastomosis appears to be fast and safe, without urine leakage, stenosis or reflux. The nonrefluxing safety valve mechanism makes this anastomosis applicable for bladder augmentation, with no ill-effects and good long-term function.     

Clinical evaluation on Le Duc-Camey antireflux ureteroileal implantation

Le Duc-Camey antireflux ureteroileal implantation was evaluated clinically; by applying to various types of urinary reconstruction utilizing the ileum. Nineteen ureters in 10 cases including five Kock continent ileal urinary reservoirs (Kock pouches); five ileal conduit urinary diversions and one Goodwin ileocystoplasty were performed from March 1987 to August 1988. Male and female ratio was 8 to 2 and the average age was 61.7 years old. The post operative observation period was 13.9 months on the average. The outline of the operative procedure was as follows: a 3 cm sulcus was created in the mucosa along the long axis of the ileum; the ureter was passed from the serosal surface to the luminal surface and the adventitia of the ureter and the mucosa were sutured at three points in each side using 3-0 absorbable ligature to implant the ureter in the mucosal sulcus. The ureteral end was spatulated 3 mm in the upper wall and it was fixed to the mucosa by three stitches. A ureteral stent catheter, 7-8 Fr. in diameter, was indwelled in the ureter. Additional stitches were placed to strengthen the fixation on the outside surface of Kock pouches or a Goodwin ileocystoplasty. The afferent limb was not fabricated in Kock pouches because ileoureteral reflux could be prevented by the implantation technique on the pouch. Radiological evaluation was done taking IVP, loopography, pouchgraphy and cytography periodically after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

De-serosalized muscle layer covering method for antireflux ureteroileostomy: a new operative technique and pressure study with ureterometry at the ureteroileal anastomotic site in dogs

PURPOSE: In pursuit of a more effective antireflux ureteroileostomy with a lower postoperative complication rate we performed a new operative technique and evaluated intraureteral pressure with ureterometry to examine the mechanism of antireflux function. MATERIALS AND METHODS: A total of 11 beagle dogs were used in this study. A 3 x 2 cm. section of the ileal serosa was removed, the severed ureter was directly anastomosed to the de-serosalized area and 1 cm. of terminal ureter and the direct anastomotic site were covered with the de-serosalized ileal wall. The bladder was augmented with the ileum containing the ureter. Postoperative evaluations were performed monthly and ureterometry of the reimplanted ureter was done 6 months postoperatively. RESULTS: Complete reflux prevention and a low stricture rate were achieved with this procedure. Direct ureteroileal anastomosis caused stricture in 1 of the 11 ureters but the covering procedure to prevent ureteral reflux caused no ureteral strictures. When the bladder was empty, ureteral closure pressure at the intramural portion of the ureter was low. At the phase of high intravesical pressure ureteral closure pressure at the intramural ureter was as high as intravesical pressure. CONCLUSIONS: The de-serosalized muscle layer covering method prevented ureteral reflux completely with a low stricture rate. The antireflux function of this method seems to depend on the flexibility of the terminal ureter covered with the de-serosalized ileal wall. Reflux prevention in the low intravesical pressure phase seems to be due to extension of the ileal wall.     

肠代膀胱术中输尿管吻合方法的改进

目的：探讨肠代膀胱输尿管吻合的理想方法。方法：对60例肠代膀胱术后118侧作肠代膀胱输尿管吻合的患者进行随访．对不同吻合方法的效果作对比分析。采用黏膜下隧道法吻合6例11侧，黏膜沟法吻合10例19侧，改良黏膜沟法吻合42例84侧．改良乳头种植法吻合2例4侧。结果：吻合一侧所需时间．黏膜下隧道法和黏膜沟法为25min，改良黏膜沟法8min，改良乳头种植法5min。无吻合口漏及输尿管反流并发症，吻合口狭窄均见于黏膜下隧道法。结论：改良黏膜沟法和直接种植法是肠代膀胱输尿管吻合的理想方法。     

Dynamics of upper urinary tract during vesico-ureteral reflux

Two types of experiments were performed in dogs to clarify physiological state during vesico-ureteral reflux (VUR). In the first experiment, VUR was established by performing operations to disturb the VUR protecting mechanism. In the second experiment, a tube was inserted into the uretero-vesical junction to prepare VUR model and using this model VUR was induced experimentally. In these experiments, recordings of ureteral myogram, intravesical pressure and intrapelvic pressure as well as macroscopic observations of the ureter were made and the following results were obtained. Functional failure of the ureteral orifice was the most important factor for the development of VUR. When the ureteral orifice showed functional failure, VUR appeared at a mean intravesical pressure of 20 cmH2O. During VUR developed, ureteral peristalsis occurred frequently, whereas no ureteral contraction was observed macroscopically. Antiperistalsis was not an immediate factor responsible for the induction of VUR. In the presence of VUR, intrapelvic pressure became lower than intravesical pressure. These findings seemed to have properly reflected the physiological states in patient with VUR.     

Wallace direct versus anti-reflux Le Duc ureteroileal anastomosis: comparative analysis in modified Studer orthotopic neobladder reconstruction

Objectives: To investigate and compare Wallace direct ureteroileal anastomosis with Le Duc anti‐reflux procedure in modified Studer orthotopic neobladder reconstruction after radical cystectomy. Methods: A total of 72 consecutive patients who underwent modified Studer orthotopic bladder reconstruction after a radical cystectomy for bladder cancer were investigated. They were examined for vesicoureteral reflux, hydronephrosis, and pyelonephritis at 6 months after surgery according to the type of ureteroileal anastomosis. Results: Vesicoureteral reflux occurred in 29 ureters (38.2%) after the Wallace procedure compared to six ureters (9.6%) with the Le Duc (P < 0.05). Hydronephrosis was detected in 12 ureters (18.8%) in the Le Duc patients compared to seven (9%) in the Wallace patients (P > 0.05). Six months after the operation, all three patients with vesicoureteral reflux‐related hydronephrosis improved using clean intermittent catheterization in the Le Duc patients; five of seven patients were cured by clean intermittent catheterization and two improved without any treatment in the Wallace patients. Seven of nine cases of ureteroileal anastomosis stenosis causing hydronephrosis were cured without any treatment but one case resulted in a non‐functional kidney despite treatment of the stenosis. Conclusions: Direct ureteroileal anastomosis using the Wallace method is effective for minimizing ureteroileal anastomosis stenosis and it represents a simple surgical procedure when combined with a modified Studer procedure.     

Does the type of bladder augmentation influence the resolution of pre‐existing vesicoureteral reflux? Urodynamic studies

AIMS: The type of bladder augmentation on pre-existing vesicoureteral reflux (VUR) was assessed. The effects of urodynamic changes on the resolution of VUR following augmentation cystoplasty performed with various gastrointestinal segments were examined. It was queried whether elimination of high-pressure bladder is sufficient to resolve pre-existing reflux. METHODS: A retrospective record review of patients who underwent bladder augmentation between 1987 and 2004. Patients were divided into two groups. Group I included patients who had a simultaneous augmentation and ureteral reimplantation. Group II included patients with reflux in whom only a bladder augmentation was performed. Pre-and post-augmentation urodynamic results were compared in both groups. The outcome of VUR and the role of various gastrointestinal (GI) segments on the resolution of VUR were studied. RESULTS: Sixty-three patients underwent bladder augmentation during the study period. Twenty-six of them had VUR before augmentation. There were 10 patients in Group I and 16 patients in Group II. In Group I, VUR ceased in all patients, while in group II, VUR resolved in 14 patients and persisted in two patients. Small and large bowel segments used for augmentation had no effect on the resolution of VUR but the results of gastrocystoplasties were less favorable. Urodynamically there was no significant difference between the various augmentation cystoplasties. CONCLUSIONS: Bladder augmentation alone without simultaneous antireflux repair is usually sufficient for the resolution of pre-existing reflux. The various GI segments used for augmentation have no effect on urodynamic results and the resolution of VUR.     

The need for ureteric re‐implantation during augmentation cystoplasty: video‐urodynamic evaluation

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To evaluate video‐urodynamic (VUD) results before and after surgery in children with high‐pressure, low‐compliance bladders and vesico‐ureteric reflux (VUR), who had augmentation cystoplasty with no antireflux surgery, hypothesising that in these patients, poor preoperative bladder dynamics is not always the cause of the associated VUR, as VUR persists in some patients.

PATIENTS AND METHODS

We assessed objective VUD criteria where antireflux surgery might potentially be necessary to avoid reflux after augmentation, and retrospectively evaluated the clinical consequences of persistent VUR and compared it to those whom VUR resolved. In all, 19 patients with VUR and hypocompliant bladders (mean age 11.4 years, range 5–21) had augmentation ileocystoplasty. Lower urinary tract function was assessed before surgery and at 3 and 6 months afterward with VUD. Symptomatic febrile urinary tract infections (UTIs) and progressive renal scarring on scintigraphy were retrospectively evaluated in all patients.

RESULTS

VUR persisted in nine patients despite a low‐pressure bladder. In all patients with persistent VUR, VUD at 6 months after surgery showed that VUR started at low bladder volumes (mean 29.6 mL, range 19–52) and low pressures (mean 14.6 cmH₂O, range 9.6–25) when compared to the group with no persistent VUR. Before surgery VUD showed that reflux started at the beginning of the filling phase (mean 14.8 mL, range 8–33) with very low intravesical pressures (mean 7.8 cmH₂O, range 4–17) in these nine patients. During the follow‐up febrile UTIs were significantly more frequent in the group with persistent VUR. One patient had progressive renal scarring on scintigraphy after cystoplasty.

CONCLUSION

Preoperative VUD findings might be a very important predictor of the spontaneous resolution of VUR. In these patients concomitant VUR should be corrected simultaneously during bladder augmentation if it starts at low pressures on preoperative VUD, as persistence of VUR can induce scarring from febrile UTIs.     

Thirteen year experience with ileal loop diversion in children with myelodysplasia

Fifty-eight patients representing one hundred fourteen renal units with myelodysplasia who have undergone urinary diversion by cutaneous ureteroileostomy were studied. Postoperative complications, radiologic findings, and the incidence of urinary tract infection are presented. The value of the conjoined technic of ureteroileal implantation as compared to the standard Bricker technic is discussed. The conjoined technic has yielded a decreased rate of postoperative complications in our patients.     

Recurrent pyelonephritis without vesicoureteral reflux: is there a role for an antireflux procedure?

PURPOSE: To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms. PATIENTS AND METHODS: From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (< 5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years). RESULTS: There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P < 0.01). CONCLUSION: Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.     

Simultaneous augmentation cystoplasty is associated with earlier rather than increased artificial urinary sphincter infection

PURPOSE: While artificial urinary sphincter infection or erosion occurs in 20% of implantations, the risk factors are poorly understood. One of the most contentious factors reported to increase prosthesis infection is simultaneous sphincter implantation and augmentation cystoplasty. In contrast to some reports, to date our results have not shown an increased infective risk with the simultaneous procedure. We reviewed the long-term infective complications of 195 sphincters to investigate for predisposing infective factors and review the role of augmentation cystoplasty. MATERIALS AND METHODS: We performed a retrospective case note review of 144 patients with a median followup of 112 months. Augmentation cystoplasty performed in 86 patients (60%) and was simultaneous in 56. All patients were reviewed within the last year or followed until death or sphincter failure. Patient, surgical and treatment factors were statistically analyzed for associations with prosthesis infection. RESULTS: A total of 108 sphincters failed from infection (25%), tissue atrophy (5%) or mechanical reasons (25%). The overall infective failure rate was similar in patients who underwent simultaneous augmentation (30%) compared with the other patients (23%), although there was a statistically significant difference within the first 3 postoperative years (log rank p = 0.009). While no other variables were significantly associated with sphincter infection, intermittent self-catheterization did not increase sphincter infection and females appeared to have more prosthesis infections. CONCLUSIONS: Our results suggest that, while simultaneous augmentation cystoplasty and artificial urinary sphincter implantation lead to an initial increase in prosthesis infection, this difference disappears after 3 years.     

Intravesical Jackson-Pratt drain for urinary diversion after augmentation cystoplasty

PURPOSE: Augmentation cystoplasty has become a primary form of bladder management in children with a noncompliant bladder. Excellent urinary drainage is required for anastomotic healing and the removal of mucous buildup. Suprapubic drainage traditionally involves a Malecot catheter, although poor irrigation and dislodgment of this type of catheter are well-known complications. We report the placement of an intravesical Jackson-Pratt drain for urinary diversion in augmented bladders. MATERIALS AND METHODS: We reviewed our use of an intravesical Jackson-Pratt drain for urinary diversion between 1995 and 1999 in 17 patients. Postoperative catheter drainage and irrigation characteristics were assessed as well as catheter related complications. RESULTS: Average patient age was 13 years (range 3 to 27). The majority of patients underwent ileal (11) or sigmoid (4) cystoplasty and 1 each underwent composite and ureteral cystoplasty. Drains remained in place an average of 27 days (range 6 to 57). All patients had excellent drainage during the postoperative period. Irrigation was subjectively easier than with a Malecot catheter. Average cost of a latex-free Malecot catheter was 2.7-fold that of a Jackson-Pratt drain. No catheters became nonfunctional before removal, although 1 was inadvertently pulled during patient transfer. CONCLUSIONS: A Jackson-Pratt drain provides excellent urinary drainage in patients undergoing augmentation cystoplasty. Multiple openings along the tube seem to improve irrigation in contrast to the single opening in a Malecot catheter, which often aspirates a region of the augmented bladder. The ready availability, decreased cost, ease of irrigation, increased pliability with decreased chance of dislodgment and lack of latex make an intravesical Jackson-Pratt drain a superior choice for augmented neurogenic bladder.     

Use of external ureteral catheters and internal double J stents in a modified ileal neobladder for continent diversion: a comparative analysis

INTRODUCTION: Open-ended straight ureteral stents are typically used for the support of the ureteroileal anastomosis during the creation of an orthotopic 'S-pouch' ileal neobladder. The use of double J stents as an alternative in this setting is evaluated. MATERIALS AND METHODS: Medical charts from 43 patients undergoing radical cystectomy with formation of an ileal 'S-pouch' neobladder were retrospectively evaluated. In 30 patients (group A), a 6-Fr open-ended straight ureteral catheter was used to stent the ureteroileal anastomosis, while a double J stent was used for the same reason in 13 patients (group B). The ureteral catheter was removed 15 days after the procedure while the double J stent 3 weeks postoperatively. Hospital stay, early and late complications were evaluated for both groups during a mean follow-up period of 22.5 and 19.6 months respectively. RESULTS: Stricture of the ureteroileal anastomosis was observed in 2 (6.6%) and 1 (7.6%) patient of groups A and B respectively. All complications presented with similar rates, except for an increased but not statistically significant incidence of urethrovesical anastomotic leakage and early urinary tract infections in group B. Hospital stay was significantly (p<0.005) shorter for patients of group B (9.9 vs. 15.2 days). CONCLUSIONS: The use of double J stents to support the ureteroileal anastomosis can be used as an alternative to open-ended ureteral stents. With double J stents a shorter hospital stay was achieved with similar complication rates but a higher incidence of upper urinary tract infections.     

Bricker's ileal conduit urinary diversion with a simple non-refluxing uretero ileal anastomosis

Fifty consecutive patients had ileal conduits constructed with a technically and quick simple antireflux ureteroileal anastomosis. Complications related to the ureteral implantation were studied retrospectively, and at follow-up (8 months-12 years later, median 3 years) conduit dysfunction and ureteral reflux were assessed in 18 patients out of the 25 patients who were still alive. Early complications and signs of late upper urinary tract deterioration were similar to those found after other operative techniques had been used. One patient had a postoperative urinary leak from the uretero ileal anastomosis. which was treated successfully by two weeks drainage. Hydronephrosis deteriorated in 18 (26%) of the renal units, remained unchanged in 39 (57%) and improved in 11 (16%). Increases in plasma creatinine concentrations up to 200 mumol/l were found in eight patients, and in one patient it increased from 300 to 420 mumol/l. Partial ureteral reflux was present in three (2 patients) of 33 ureters studied and minimal conduit dysfunction was found in 8 patients. In conclusion we find this method of urinary diversion to be quick, easy, and safe.     

回肠膀胱扩大术治疗结核性挛缩膀胱的效果观察

目的探讨回肠膀胱扩大术治疗结核性挛缩膀胱的诊治经验及疗效。方法回顾性分析2016年9月至2017年8月遵义医科大学附属医院7例晚期泌尿系结核患者的临床资料。所有患者经抗结核治疗2~4周后行患肾切除术,并在抗结核治疗2~6个月后行保留原膀胱的回肠膀胱扩大术。结果所有患者术后平均住院13.6d,均能自行排尿,术后2周最大膀胱容量扩大至120~209mL,平均180mL。术后1个月膀胱最大容量扩大至310~375mL,平均354mL。健侧肾积水、肾功能损伤以及膀胱残余尿情况在术后有加重趋势,尤其在术后3个月最严重,但术后6个月上述情况均较术后3个月时明显好转(P<0.05),而与术前比较差异无统计学意义(P>0.05)。术后1个月生活质量评分(SF-36)与术前比较差异无统计学意义(P>0.05),而术后3个月及术后6个月生活质量较术前改善,差异具有统计学意义(P<0.05)。所有患者尿频、尿急、尿失禁症状均有明显改善,肾功能未出现进一步恶化。结论保留原膀胱的回肠膀胱扩大术是治疗晚期肾结核挛缩膀胱的有效方法。     

Experience with the Kropp anti-incontinence procedure

The experience of 2 surgeons working independently at separate institutions is reported to demonstrate the use of the Kropp urethral lengthening and implantation procedure. This experience includes 18 patients between 6 and 19 years old (median age 11.6 years) with neurogenic bladder dysfunction. The etiology of the neuropathic bladder was myelodysplasia in 16 patients and sacral agenesis in 2. There were 10 boys and 8 girls. All patients had failed trials of clean intermittent catheterization with adjunctive pharmacological manipulation. Incontinence was a significant social problem. Of the 18 patients 2 had undergone prior urinary diversion and the Kropp procedure was used as part of undiversion. One patient had had 2 previous failed attempts at continence using an artificial urinary sphincter. Augmentation cystoplasty was an adjunctive maneuver in 14 patients; ileum was used in 8, sigmoid in 4 and the ileocecum in 2 (both of whom had been diverted previously). The bladder capacity in the 4 patients in whom augmentation was not performed ranged from 200 to 450 ml. Of the 18 patients 17 achieved a good result and 14 were considered to have achieved an excellent result. The 1 failure is the patient who previously had failed to gain control with an artificial sphincter. Of the 4 patients who did not undergo bladder augmentation 3 required adjunctive anticholinergics to achieve continence.