Augmentation ureterocystoplasty in bladder exstrophy: 5-year follow-up in two cases

OBJECTIVE: To report two cases of bladder exstrophy managed successfully by augmentation ureterocystoplasty (UCP) together with bladder neck surgery and continent diversion. PATIENTS: Two boys, age 5 and 1 years respectively, had augmentation UCP. The left refluxing megaureter was used in the first case together with bladder neck reconstruction. In the second patient, bilateral obstructed magaureters were used in tandem together with bladder neck division. Both patients had appendicovesicostomy according to Mitrofanoff. RESULTS: In follow-up for over 5 years, both patients are continent with improved upper urinary tracts and normal or stable renal function. They are managed by clean intermittent catheterization (CIC) via the continent stoma with bladder capacities of 220 cc and 150 cc, respectively. Cystogram showed no vesicoureteric reflux (VUR). The procedures were considered to be successful although one patient was on oxybutinin because urodynamics showed high intravesical pressures. CONCLUSIONS: Augmentation UCP should be considered in patients with bladder exstrophy when a suitable megaureter is available. This may be combined with simultaneous bladder neck reconstruction together with a continent diversion.     

Ureterocystoplasty: a novel approach to augment small capacity urinary bladder in adults

Ureterocystoplasty is a novel operation well suited for patients having small capacity urinary bladder with unilateral poorly functioning kidney and megaureter. The megaureter is detubularized and used for urinary bladder augmentation. The ureter lining has advantage of being non-secretory and free from the metabolic complications of enterocystoplasty. This operation is mainly done in children. This is one of the very few from the Asian subcontinent which describes the short term results of ureterocystoplasty in an adult patient. We report a case wherein ureterocystoplasty was performed in an 18-year male presented with a small capacity neurogenic bladder with a grossly dilated and tortuous left ureter and a non-functioning left kidney. Left ureter was detubularized and used for augmentation after left nephrectomy. Blood supply to the left ureter was preserved during the dissection. After the operation, the bladder capacity increased adequately and he is doing well at a followup of 1 year. Ureterocystoplasty works well in the adult patients also and the bladder capacity increases adequately following this procedure.     

Embryogenesis of ureteral anomalies: a unifying theory

Extensive gross, microscopic and clinical studies of various ureteral anomalies have enabled investigators to set forth theories regarding the aetiologies of these anomalies consistent with observed fact. Synthesis of these observations allows for a simplified classification of mega-ureter (primary obstructed, reflux and non-obstructed, non-reflux mega-ureters), ureterocele, duplex ureters and ectopic ureters based upon some combination of mesenchymal differentiation anomalies and location anomalies. A defect early in mesenchymal differentiation would be expected to result in panureteral disease. A defect later in development would result in a focal abnormality anywhere along the course of the ureter. Influence upon ureteral bud mesenchyme by local expansion factors in the bladder base may result in various types of ureterocele. Position of the ureteral orifice on the trigone or in Wolffian duct derivatives would occur in accordance with the Weigert-Meyer principle and would correlate with upper tract dysplasias. Thus, an attempt has been made to systematize and trace the origins of mega-ureter, ureterocele, duplex ureters and ectopic ureters to defects of differentiation of the basic mesoblastic cell in aberrant locations of the ureteral bud.     

Ureterocystoplasty in bilaterally functional kidneys

OBJECTIVE: Traditional augmentation cystoplasty using gastrointestinal segments is known to be associated with metabolic abnormalities and alterations in the bladder causing potential carcinogenesis. In this respect alternative techniques have been searched preferably lined by urothelium. We performed ureterocystoplasty in 7 patients with a diagnosis of neurogenic bladder and investigated the clinical and functional aspects. PATIENTS AND METHODS: Between 1995 and 1999, ureterocystoplasty was performed using both ureters in 4 male and 3 female children with bilaterally functional kidneys. Patients' ages varied between 1 and 7 (mean 4.7) years. Before the operation all the children were incontinent, had a small-capacity noncompliant bladder, and high-grade (IV-V, International Classification System) reflux on voiding cystouretrography (VCU). Technetium-99m DTPA renal scintigraphy was also performed in all children to evaluate renal function before and after the operation. RESULTS: Before the operation the mean end-filling intravesical pressure was 45.6 (35-60) cm H(2)O which decreased to 18.9 cm H(2)O 3 months postoperatively. The mean bladder capacity 3 months after ureterocystoplasty was found to be 279.3 (250-330) ml. All the children were continent and VCU showed the absence of reflux. There was mild to moderate improvement in renal function after surgery in both kidneys on technetium-99m DTPA renal scintigraphy. Three (43%) patients could void spontaneously with abdominal straining, whereas 4 (57%) children could empty their bladders by clean intermittent catheterization. A double-J stent was inserted in 1 (14%) patient because of a rise in serum creatinine after the removal of the ureteral catheter. Patients were followed for a mean period of 30 (8-50) months and all the children remained continent. The bladder capacity and end-filling pressure measurements were also stable. CONCLUSION: Ureterocystoplasty was found to be an effective method for bladder augmentation in bilaterally functional kidneys with an acceptable complication rate     

Continent urinary diversion and bladder augmentation in children: the Mainz pouch procedure

The formation of a bowel reservoir of large capacity at low pressure by using small and large bowel (ileocaecal segment) has proved reliable for achieving continent urinary diversion (n=80), for bladder augmentation (n=42) as well as for total bladder replacement (n=24). Encouraged by the results we obtained in our adult patients, we have used this technique during the last 3.5 years in 29 children. Indications for urinary diversions in children have been: neurogenic bladder with diplegia (n=8), bladder exstrophy (n=2), traumatic loss of the bladder (n=1), urogenital sinus (n=1) and rhabdomyosarcoma of the prostate or bladder (n=2). Bladder augmentation was indicated in 6 children with iatrogenic bladder loss, in 5 children with neurogenic bladder without diplegia and in 4 boys with incontinent epispadias or exstrophy. In children with bladder exstrophy or incontinent epispadias, continence was achieved using a modified Young-Dees technique with formation of a long intra-abdominal muscular tube made out of the bladder plate or the low-capacity bladder. The capacity of the urinary reservoir was guaranteed by bladder augmentation or bladder replacement with an ileocaecal pouch. During a mean follow-up period of 26 months (bladder augmentation) and 21 months (continent diversion) there was only one postoperative complication (intussusception ileus) which required operative revision. Two children had to undergo reoperation because of nipple problems. Follow-up, with monitoring of biochemical and metabolic parameters, is necessary to show whether this technique will provide a long-term successful solution for these problems.     

Influence of enterocystoplasty on linear growth in children with exstrophy

PURPOSE: Many children with bladder exstrophy undergo reconstruction incorporating bowel into the lower urinary tract, which may result in metabolic changes affecting height. Linear growth in children with exstrophy who underwent enterocystoplasty was studied. MATERIALS AND METHODS: We retrospectively reviewed the charts of children with classic bladder exstrophy who underwent bladder augmentation with small or large bowel, or creation of a bowel neobladder before age 11 years. Mean followup plus or minus standard error was 9.4 +/- 0.9 years. Most patients were assessed yearly with measurement of height and serum electrolytes. Metabolic acidosis was treated with oral bicarbonate. Preoperative height percentiles at enterocystoplasty were compared to height percentiles at the most recent visit. In addition, height percentiles in a control group of individuals with exstrophy who did not undergo enterocystoplasty were compared to postoperative height percentiles in the enterocystoplasty group. The t test was used for statistical analysis. RESULTS: Data on 18 children who underwent bladder reconstruction with bowel were compared with those on a control group of 18 with exstrophy. The mean preoperative height percentile at a mean age of 5.2 years was 35.6 +/- 4.5 and the postoperative height percentile at a mean age of 14.6 years was 20.3 +/- 5.7 (p <0.01). The mean height percentile in the control group at a mean age of 15.2 years was 30.6 +/- 7.8 (p <0.01 versus the postoperative height percentile in the study group. In the enterocystoplasty group 2 patients were receiving oral bicarbonate for metabolic acidosis. Five patients who underwent enterocystoplasty and 6 controls were below the third percentile for height. CONCLUSIONS: In children with bladder exstrophy bladder augmentation or neobladder creation may have an adverse effect on linear growth. The height of children with bladder exstrophy is less than average compared with standard growth charts.     

Intermittent Catheterization and Recurrent Urinary Tract Infection in Spinal Cord Injury

Purpose:

To study the association of recurrent symptomatic urinary tract infections (UTIs) with the long-term use of clean intermittent catheterization (CIC) for the management of neurogenic bladder in patients with spinal cord injury (SCI).

Methods:

Retrospective study of 61 SCI patients with neurogenic bladder managed by CIC. Subjects were selected from 210 SCI patients seen at the Yale Urology Medical Group between 2000 and 2010. Medical UTI prophylaxis (PRx) with oral antimicrobials or methenamine/ascorbic acid was used to identify patients with recurrent UTI. The number of positive cultures (≥10³ cfu/mL) within a year prior to starting PRx was used to confirm the recurrence of UTI.

Results:

Fifty-one male and 10 female subjects were managed with CIC. Forty-one (67%) subjects were placed on medical PRx for symptomatic recurrent UTI. Seventeen (28%) subjects had at least 3 positive cultures within the year prior to starting PRx. Fifteen of 20 (75%) subjects not on PRx had no complaints of UTI symptoms in the final year of follow-up.

Conclusion:

Recurrent symptomatic UTIs remain a major complication of long-term CIC in SCI patients. Although CIC is believed to have the fewest number of complications, many SCI patients managed with long-term CIC are started on medical PRx early in the course of management. Future studies are needed to determine the efficacy of routine UTI PRx in these patients as well as determine what factors influence why many patients on CIC experience frequent infections and others do not.     

The neurogenic bladder: introducing four contributions

Neurogenic bladder dysfunction in children is frequently seen in patients with meningomyelocele (MMC). The disorder carries a high risk for all kinds of complications, with renal damage being the most important. More than 95% of MMC patients have a neurogenic bladder, the paramount manifestation of which is a disturbed coordination between detrusor and sphincter muscles. This vesicourethral dysfunction leads to defective filling and emptying of the urinary bladder. Voiding at will is almost never possible. According to the location and extent of the neural tube lesion, patients have either an atonic or a hypertonic pelvic floor and either an atonic or a hypertonic detrusor, leading to four classic combinations. Hypertonic sphincter and detrusor hyperactivity lead to the most dangerous form of neurogenic bladder, referred to as the “unsafe” bladder. The presence of residual urine in a high-pressure container causes either decompensation of the detrusor with vesicoureteral reflux or deterioration of the bladder wall with hypertrophy and stiffness resulting in uterovesical obstruction. The subsequent insufficient drainage of the upper urinary tract leads to decompensation of the ureters and finally to chronic renal disease, the process being accelerated by urinary tract infections. The aim of treatment is to restore as much as possible both essential functions: urine storage and timely emptying of the reservoir. What should and can be achieved is a more or less adequate, low-pressure, functional capacity of the bladder that is emptied as completely as possible by clean intermittent catheterization (CIC). MMC leads to the prototype of neurogenic bladder in childhood. What we know and what we do for MMC patients can roughly be applied to all other forms of neurogenic bladder, either congenital or acquired.     

Clinical and urodynamic evaluation after ureterocystoplasty and kidney transplantation

PURPOSE: We assessed clinical and surgical results in renal transplantation candidates with voiding dysfunction and end stage renal disease who underwent bladder augmentation. MATERIALS AND METHODS: We analyzed 8 patients 3 to 30 years old with dilated ureters, voiding dysfunction and end stage renal disease who underwent renal transplantation following bladder augmentation from 1995 to 2003. The etiology of bladder dysfunction was neurogenic bladder in 3 patients, posterior urethral valves in 3 and vesicoureteral reflux in 2. All cases were assessed by ultrasonography, voiding cystourethrography and urodynamic studies. RESULTS: Mean followup was 50 months (range 4 to 93). Previous urodynamic evaluation revealed a bladder capacity of 75 to 294 ml (mean +/- SD 167.38 +/- 77.32) and an intravesical pressure of 28 to 100 mm H2O (mean 51.25 +/- 22.17). Urodynamic study after augmentation and kidney transplantation showed a bladder capacity of 191 to 400 ml (mean 335.25 +/- 99.01) and an intravesical pressure of 15 to 35 mm H2O (mean 28 +/- 9.45). Mean serum creatinine was 1.65 mg/dl (range 0.8 to 2.5). All patients remained continent. Three patients with neurogenic bladder empty the bladder by clean intermittent catheterization and the others empty by the Valsalva maneuver. None of the grafts were lost and the most common complication was asymptomatic urinary tract infection. CONCLUSIONS: Bladder augmentation is a well-known procedure for low capacity and poorly compliant bladders even in candidates for a renal transplant. Ureterocystoplasty combines the benefits common to all enterocystoplasties without adding to complications or risks.     

Ureterocystoplasty: an alternative reconstructive procedure to enterocystoplasty in suitable cases

PURPOSE: The objective of the report is to present the results of ureterocystoplasty in 6 children with megaureters and low-capacity, high-pressure bladders. METHODS: Of the 6 patients, 2 had valve bladders, 1 had Hinmann's syndrome, 1 had neuropathic bladder, and the remaining 2 with ureterocutaneostomy were mainly diverted because of refluxing megaureters. Nephrectomy was performed in both of the boys with posterior urethral valve because of vesicoureteral reflux dysplasia (VURD) syndrome, and the ipsilateral ureter was used for the augmentation. In 2 patients with ureterocutaneostomy and in 1 with Hinmann's syndrome, a transureteroureterostomy was carried out, and the distal part of the ureter was used to perform augmentation. The patient with neuropathic bladder had a nonfunctioning crossed ectopic left kidney with an associated ipsilateral, refluxing megaureter, and the ureter was used for augmentation after the nephrectomy. RESULTS: All of the patients are continent, and 4 patients who are neurologically normal void spontaneously without requiring clean intermittent catheterization (CIC). The average increase in bladder capacity is 263% (range, 190% to 340%). CONCLUSIONS: Ureterocystoplasty is the bladder augmentation of choice for patients with a nonfunctioning kidney with an associated ipsilateral, refluxing megaureter and for patients with kidneys both in good function and megaureters suitable for a transureteroureterostomy.     

Augmentation ureterocystoplasty in children: 7-years follow-up

OBJECTIVES: We retrospectively reviewed our experience of augmentation ureterocystoplasty in children to evaluate its long-term results. MATERIALS AND METHODS: From February 1996 to March 1999 four children (2 boys and 2 girls) with neurogenic bladder had augmentation cystoplasty using dilated ureter in our institute. After trans-uretero-ureterostomy the lower two thirds of the unilateral ureter was used to perform the augmentation cystoplasty. Follow-up varied between 59 and 96 months (mean 85). RESULTS: In early post-operative period bladder volume and compliance increased from 96 (64-150) to 113 (40-220) ml and from 2.7 (1.3-5.8) to 4.5 (2.0-11.0) ml/H2O respectively. Incontinence was improved in all children and two had dry interval of 3-hour catheterization. Although bladder volume and compliance kept increasing gradually (239 (237-241) ml, 11.5 (5.7-18.5) ml/H2O respectively) over 5 years postoperatively, 2 elder patients had repeat augmentation cystoplasty using gastrointestinal tract because of hydronephrosis and deterioration of renal function. CONCLUSION: Our long-term result of ureterocystoplasty was no good. Ureter is not an ideal material to provide adequate bladder capacity and compliance for elder children unless their bladder becomes as large as that of adults early post-operatively.     

Transplantation of en bloc pediatric kidneys with a partial bladder segment in an adult recipient

The success of transplantation of the urinary bladder en bloc with pediatric kidneys remains undetermined. We transplanted a large portion of the bladder with en bloc kidney allografts from a 13-month-old donor into a 45-year-old adult male. The recipient, who was on long-term hemodialysis, had a small urinary bladder consistent with long-standing anuria. Informed consent was given and bilateral kidneys were transplanted en bloc with both ureters and bladder. The patient's bladder was augmented with the donor bladder and bilateral ureteroneocystotomies of small ureters was avoided. At 3 and 18 months post-transplantation, cystoscopies revealed a viable bladder with new vessels and normal donor bladder. Cystogram revealed no reflux. The bladder segment was reperfused via blood supply from both ureters and then from the recipient's bladder. It seems that bladder transplantation en bloc with pediatric kidneys is a viable option for augmentation of a small recipient bladder that allows avoidance of very small bilateral ureteroneocystotomies.     

AUGMENTATION DURACYSTOPLASTY IN NEUROGENIC BLADDER DYSFUNCTION

Background
Augmentation cystoplasty is the treatment of choice for patients with neurogenic bladder dysfunction in cases that are unresponsive to other medical treatment. Although intestinal segments as bladder substitutes are preferred over the other alternatives at present, they are not ideal bladder replacements due to several potential hazards. The purpose of this study was to determine whether or not augmentation duracystoplasty can be an afternative to augmentation enterocystoptasties.
Methods:
Ten patients with neurogenic bladder dysfunction unresponsive to conservative measures, underwent augmentation duracystoplasty by using the modified Bramble-Clam technique. The follow-up period was T-28 months.
Results:
At present, seven of 10 patients are completely continent for with clean intermittent catheterization. The remaining three patients required oral oxybutinin therapy, postoperatively, to achieve continence although lower dosages than those required in the preoperative period. We did not observe any serious pre- or postoperative complications.
Conclusions:
Based on these preliminary findings we think that duracystoplasty can be considered as a treatment alternative for hyperreflexic and/or low compliant neurogenic bladders.     

Nonrefluxing colon conduit for temporary or permanent urinary diversion in children.

Colon conduit, with nonrefluxing ureterosigmoid anastomoses, was performed upon 21 children in the past 3 1/2 yr for the following indications: (1) previously unoperated exstrophy of the bladder; (2) exstrophy of the bladder with prior ileal conduit; (3) previously unoperated neurogenic bladder; (4) neurogenic bladder with prior ileal conduit; and (5) with anterior pelvic exenteration for sarcoma of the prostate. In some of these patients the conduit will be a permanent diversion; in others it will be anastomosed later to the colon, providing a staged method of ureterosigmoid urinary diversion. Nine patients have undergone the second stage of anstomosis of the conduit to the colon with satisfactory outcome. Colon conduit diversion is a more time-consuming procedure than ileal loop diversion. It can require 6-8 hr in a patients with a prior ileal diversion, particualarly if the ureters require tapering. Our experience with this procedure leads us to the following conclusions: (1) this is a better method than ileal conduit for permanent diversion; (2) it offers an alternative way for treating patients with bladder exstrophy; (3) it is useful in patients with pelvic cancer; and (4) it should be considered for those patients with ileal conduits who are not doing well, i.e., who have infection and renal deterioration.     

Surgical management of urinary incontinence in children with anatomical bladder-outlet anomalies

BACKGROUND: Pediatric urinary incontinence secondary to anatomical anomalies of the bladder outlet is relatively rare, and there is no consensus on its surgical treatment. We reviewed the clinical courses and surgical management of children with this pathology. METHODS: From 1991 to 2001, we performed bladder neck reconstruction on seven children (three boys and four girls). The mean age at the first intervention was 7 years (range 5-12 years). The underlying diagnosis was bladder exstrophy in two children, pseudoureterocele-type ectopic ureter in three, bladder neck incompetence from unknown etiology in one boy with hypospadias, and bilateral single ectopic ureter associated with cloacal malformations in one child. Lower urinary tract was evaluated through various imagings, endoscopy, and urodynamic studies. RESULTS: The methods used to reconstruct the bladder neck was the Young-Dees-Leadbetter procedure (performed on four children); the Kropp procedure (two children); and the Pippi-Salle procedure (one child). Bladder augmentation with intestinal segment was performed on four children; Mitrofanoff continent stoma was created in all patients. Urethral catheterization could not be routinely used in all patients, because of pain, stricture, or complicated urethral anatomy. All patients achieved urinary continence. CONCLUSION: The treatment of pediatric urinary incontinence from anatomical anomalies is technically challenging. Depending on the underlying disorders and anatomy, one needs to decide which method of reconstruction to perform. It would be safer to employ simultaneous augmentation and to create catheterizable continent stoma.     

INTRAVESICAL THERAPY FOR THE TREATMENT OF NEUROGENIC BLADDER IN CHILDREN

Background : Oral pharmacotherapy has been commonly used as an adjunct to clean intermittent catheterization (CIC) in the treatment of neurogenic bladder in order to achieve continence, but may be associated with unacceptable side effects. The authors' experience with sterile intravesical preparations of oxybutynin hydrochloride and ephedrine in children is reported here. Methods : Patients requiring CIC for neurogenic bladder but with incontinence that was unresponsive to standard oral therapy or that was associated with severe systemic side effects were studied over a 1-year period. Clinical, radiological and urodynamic assessments were made prior to commencing treatment with intravesical oxybutynin hydrochloride. Patients who remained incontinent with poor internal sphincter muscle tone had intravesical ephedrine added. Results : Seven patients were involved in the study over a 1-year period. Two patients became continent and one patient had an improvement in upper tract dilatation. One patient had a limited improvement with oxybutynin alone but became continent with the addition of ephedrine. Three patients had no response to treatment. There were few side effects. Conclusion : Intravesical agents have a role in the management of paediatric neurogenic bladder for those children with significant adverse sequelae from oral pharmacotherapy who would otherwise require surgical intervention. Intravesical therapy is a safe technique in children with sterile preparations. Further investigation of this modality should be pursued.     

Bladder neck sling and appendicovesicostomy without augmentation for neurogenic incontinence in children

PURPOSE: Most children undergoing bladder neck sling for neurogenic urinary incontinence also have undergone bladder augmentation. However, complications from enterocystoplasty and uncertainty regarding its indication during bladder outlet enhancement led us to perform slings without augmentation. Herein we report outcomes in consecutive patients. MATERIALS AND METHODS: A total of 30 patients with neurogenic bladder underwent tight 360-degree fascial sling wrap around the bladder neck and appendicovesicostomy without augmentation. Indications included detrusor leak point pressure less than 50 cm water and stress urinary incontinence. Urodynamics were obtained in all patients preoperatively, in 26 at a mean of 6 months postoperatively and in 16 at a mean of 24 months postoperatively. RESULTS: Satisfactory continence defined as 2 or fewer damp pads daily was achieved in 83% of patients with followup of 6 to 60 months (mean 22). Symptomatic hyperreflexia and/or loss of compliance developed in 8 patients postoperatively, which responded to anticholinergics in 7. The remaining patient underwent enterocystoplasty 18 months later, for an augmentation rate of 3%. No patient had hydronephrosis or reflux. CONCLUSIONS: Evaluated parameters, including bladder capacity and compliance determined during preoperative urodynamics, did not predict the need for augmentation. Satisfactory continence can be achieved for neurogenic bladder by sling without enterocystoplasty.     

Pediatric urinary tract reconstruction using intestine

OBJECTIVE: To analyse the outcome of urinary tract reconstruction in children. MATERIAL AND METHODS: Fifteen children with bladder exstrophy or neurogenic bladder, 4-18 years old, were followed in accordance with a predetermined program for bladder augmentation (13 pat) or continent urinary reservoir (2 pat). The follow-up time was 1.7-6.3 years, median 3.7 years. RESULTS: All were dry, though one case had occasional leaks. Three bladder neck reconstructions, two artificial sphincters, one sling plasty and one fistula closure with subsequent bladder neck injection were required. Bladder volumes were adequate for age at low pressures. Reflux resolved in 12/13 ureters. A boy with preoperative renal insufficiency was transplanted. Total renal function remained otherwise stable despite acidosis in one case and some glomerular impairment in all. Progressive parenchymal lesions were seen in combination with abundant mucus, infections and calculi only. Growth and bowel function was unaffected. Bone mineral density showed overall increase; some low values were not consistent between investigations. CONCLUSIONS: Urinary tract reconstruction in children results in continence and regression of reflux. Growth, bone mineralization and renal function are unimpaired during the first years, but irrigation of the bladder is essential to minimize the risk of urinary tract infection. However, glomerular function might be affected and the possible risk of metabolic complications in later life can only be determined by continuous close monitoring over an extended period of time. ABBREVIATIONS: Voiding cystourethrogram (VCUG), dimercapto-succinic acid (DMSA), Chrome51-Ethylenediaminetetraacetic acid (Cr-EDTA), single photon absorption (SPA), bone mineral content (BMC), bone mineral density (BMD), dual photon x-ray absorption (DEXA), glomerular filtration rate (GFR), urinary tract infection (UTI), immunoglobulin G (IgG), clean intermittent catheterization (CIC) and subureteral teflon injection (STING).     

Fecal and urinary continence after ileal cecal cystoplasty for the neurogenic bladder

PURPOSE: In patients with a neurogenic bladder augmentation with the ileal cecal segment has generally been disregarded as an option due to concerns regarding fecal incontinence. We report our results using a hemi-Indiana pouch bladder augmentation for neurogenic bladder. MATERIALS AND METHODS: A review of 63 patients with neurogenic bladder dysfunction treated with a hemi-Indiana pouch bladder augmentation was performed. None of the patients had fecal incontinence before surgery. RESULTS: Median followup interval was 6 years (range 1 to 10). Etiology of the neurogenic bladder was spinal cord injury in 42 patients (66%), myelodysplasia in 18 (29%) and sacral agenesis in 3 (5%). One patient (1.5%) died immediately postoperatively from a pulmonary embolus. Of the remaining 62 patients, urinary continence was achieved in 54 (87%) and 8 were incontinent per the abdominal stoma. All 8 patients were treated with Contigen injections into the stoma and 4 (50%) became continent. The 4 patients with persistent urinary incontinence became continent after open surgical revision. Postoperatively, fecal continence was improved in 14 patients (23%), unchanged in 46 (74%) and worse in 2 (3%). In 2 patients with deterioration in bowel function stool frequency and fecal soilage increased in conjunction with antibiotic usage. No patient had chronic fecal incontinence. CONCLUSIONS: In select patients with neurogenic bladder dysfunction ileal cecal bladder augmentation with a continent tapered ileal limb results in a 100% incidence of urinary continence with minimal alterations in fecal continence.     

小儿阑尾输出道可控性肠膀胱术(附七例报告)

目的 探讨阑尾输出道可控性肠膀胱术在小儿泌尿外科的应用效果。方法 报道7例小儿阑尾输出道可控性肠膀胱术治疗经验。男3例女4例,平均年龄8岁。车祸致膀胱、石输尿管及双睾丸缺失1例,先天性完全性尿失禁4例（尿生殖窦畸形、膀胱外翻各1例,短尿道2例）,神经源性膀胱2例。结果 5例（70％）达到预期效果,2例仍有尿自尿道排出。结论 阑尾输出道可控性膀胱术对需行尿流改道的患儿是一种有效的手术方式。