肠膀胱扩大加阑尾输出道在小儿可控性尿流改道手术中的应用

目的 探讨肠膀胱扩大加阑尾输出道手术在小儿可控性尿流改道中的应用效果.方法小儿肠膀胱扩大加阑尾输出道可控性尿流改道手术患儿22例.男12例,女10例.年龄5～14岁,平均8岁.脊髓脊膜膨出术后致神经性膀胱11例,男童陈旧性骨盆骨折致后尿道断裂、反复手术后尿道狭窄伴尿失禁2例,女童陈旧性骨盆骨折致尿道狭窄合并尿道阴道瘘反复手术修补失败3例,尿生殖窦畸形伴高位肛门闭锁术后完全性尿失禁2例,膀胱外翻和尿道上裂膀胱颈重建术后尿失禁2例,男童后尿道瓣膜2例.肾、输尿管扩张积水17例28侧,其中15例24侧伴Ⅱ～Ⅴ级膀胱输尿管反流,术中行输尿管与贮尿囊再吻合术.患儿均自阑尾输出道间歇清洁导尿.术前与术后行尿动力学检查、IVU,B超、排尿性膀胱尿道造影及血尿素氮、肌酐和生化电解质等检查.比较手术前后膀胱及上尿路功能的变化,评估手术疗效. 结果 术后随访1.5～6.0年,平均3.6年.22例阑尾输出道均无漏尿.2例术后早期阑尾输出道皮肤造口狭窄,扩张1～3个月后插管顺利.2例仍自尿道漏尿,其中1例手术缝合膀胱颈口后治愈,1例进行盆底肌肉训练.术前和术后贮尿期末膀胱内压力分别为(45.47±14.15)、(16.24+5.25)cm H2O(1 cm H2O=0.098 kPa),膀胱最大测压容积分别为(65.5±43.5)、(337.0±189.50)ml,残余尿量(56.0±22.5)ml,导尿后完全排空,术前最大尿道闭合压力和术后最大输出道闭合压力分别为(35.24 ±14.46)、(78.40±20.15)cm H2O,膀胱顺应性分别为(8.25 ±7.33)、(26.75 ±8.45)ml/cm H2O,手术前后比较差异均有统计学意义(P<0.01).肾、输尿管积水较术前无加重,膀胱输尿管未见反流. 结论 肠膀胱扩大加阑尾输出道可控性尿流改道手术是治疗小儿膀胱和尿道解剖及功能障碍的一种有效方式,可以避免上尿路进一步损害,提高患儿生活质量.     

阑尾或肠管可控输出道在神经源性膀胱治疗中的应用

目的：评价阑尾或肠管可控输出道在高反射性神经源性膀胱治疗中的应用价值。方法：采用阑尾输出道（Mitrofanoff法）治疗高反射性神经源性膀胱患者4例,采用回肠腹壁造口（Yang-Monti法）治疗2例。3例采用膀胱自扩大,同时行阑尾输出道2例,回肠腹壁造口1例;3例行回肠膀胱扩大,同时采用阑尾腹壁造口2例,回肠腹壁造口1例。结果：术后随访3～39个月（平均20个月）。1例采用回肠扩大阑尾VZQ造口的患者术后2周造口部皮瓣感染坏死,改行阑尾直接造口;1例阑尾输出道出现造口部位漏尿,缩短导尿间隔为2h,漏尿消失;其他患者控尿良好。5例术后肾功能恢复正常,1例保持稳定。结论：阑尾或回肠可控输出道在高反射性神经源性膀胱治疗中是一种安全可靠的方法。     

阑尾输出道可控性去带盲升结肠膀胱术

目的　探讨膀胱全切术后阑尾输出道可控性去带盲升结肠膀胱的选择与应用。方法　回顾性分析7例阑尾输出道可控性 去带盲升结肠膀胱术患者的临床资料。结果　随访8～36个月,7例患者术后恢复良好,储尿囊平均容量380mL,平均压力 3.10kPa,排尿控制良好,插管简单,并发症少。结论　阑尾输出道可控性去带盲升结肠膀胱术是一种较为理想的肠代膀胱术。     

Mitrofanoff 可控性尿流改道术

可控性尿流改道术的应用使患者摆脱了尿失禁的痛苦和系集尿袋 的不便，提高了患者的生活质量。插管导尿容易，而可控率高的尿液输出道是整个可控 性尿流改道术的关键。1980年Mitrofanoff首次描述采用阑尾作输出道为一神经源性膀胱患 儿行可控性膀胱造口术取得成功。此后人们将细管状结构作为输出道包埋于储尿囊壁达到 控制尿液的原理称为Mitrofanoff原理。近20年的临床实践证明，Mitrofanoff可控性尿流 改道术方法简单，尿液可控率高，对可控性尿流改道术临床普及起到了积极的推动作用 。 　　一、Mitrofanoff原理 　　Mitrofanoff原理实际上是瓣膜机理，当储尿囊内压力增高传导至软性Mitrofanoff管，将 这一包埋于粘膜下或包裹于储尿囊壁的细管挤压于相对较硬的储尿囊壁使管腔闭合，达到阻 止尿液流出的目的（图1）。一般情况下，输出道管腔内压比储尿囊内压高2～3倍，且 随储尿囊内压增高而增高，因此即使腹内压突然增高也不至于发生尿失禁。只要粘膜下 或储尿囊壁包埋的Mitrofanoff管长度与管腔直径之比达5∶1，即能发挥尿液可控作用 ［1］。临床应用证明，采用不同细管状结构（阑尾、输尿管、小肠、输卵管等）成形 的Mitrofanoff管和不同的储尿囊（自然膀胱、扩大或成形的新膀胱），可控率达90%以 上［2］。 　　二、适应证     

可控性尿路改道治疗下尿路功能严重障碍

目的尝试采用可控性尿路改道术治疗因外伤、手术后并发症而导致的膀胱颈部后尿道狭窄闭塞、膀胱挛缩、肾盂输尿管返流以及严重尿失禁.方法对于膀胱容量基本正常者,采用膀胱前壁肌瓣形成肌管斜行通过腹直肌的方式,形成膀胱可控性造口;对于膀胱颈部后尿道狭窄闭塞、膀胱挛缩、肾盂输尿管返流者,采取阑尾原位脐造口可控性肠代膀胱术,输尿管与肠代膀胱粘膜下隧道吻合,旷置原来的膀胱和尿道.结果两种术式术后患者膀胱或肠代膀胱均控尿能力良好,造瘘口无须覆盖,未发生感染.患者自我插管方便顺利.结论可控性尿路改道不仅适用于中晚期的膀胱肿瘤患者的膀胱替代,也可以用于下尿路功能严重障碍者膀胱和尿道的暂时性或永久性替代.     

可控回盲肠扩大膀胱术治疗复杂性膀胱挛缩患者的可行性分析

目的:探讨阑尾输出道的MainzⅠ可控膀胱术用于复杂性尿道狭窄合并膀胱萎缩治疗的可行性。方法:回顾性分析9例因复杂性尿道狭窄致膀胱废用性挛缩及12例膀胱结核导致膀胱挛缩患者的临床资料,均采用MainzⅠ可控膀胱术行膀胱扩大手术,分析此种手术患者的接受度、并发症及术后效果。结果:所有患者术后严密随访11～26个月,平均18.5个月,2例有夜间漏尿,其他患者控尿情况满意。我们建议患者采用Fr12、14号导尿管行自家导尿,白天平均2 h 1次,临睡前再导尿1次。每次导尿量280～450 mL。1例术后导尿困难,经输出道扩张后可顺利插入Fr12导尿管。所有患者术后9个月查膀胱容量350～550 mL,均行膀胱造影均未见输尿管反流。结论:阑尾输出道可控回盲肠扩大膀胱术在治疗复杂性膀胱萎缩患者中,手术并发症发生率低,短期疗效较好,并能显著改善患者生活质量。     

直接吻合的膀胱小口径回肠输出道的尿动力学研究

目的初步探讨根部无处理的小口径输出道的可控性机制.方法实验用小型猪8只,经手术形成两个不同长度的小口径回肠输出道并直接与原位膀胱吻合,根部不做隧道式包埋,随后将输出道斜置于腹直肌内,经皮造口.术后8周行尿流动力学及组织学检查.结果1例动物术中因麻醉过量而死亡.其余动物术后皆存活.不同长度的14个输出道中有10个在术后8周获得了良好的控尿能力.可控性输出道在膀胱平均容量400ml时的最大尿道压为60～115cmH2O,最大尿道闭合压为45～93 cmH2O,功能性尿道长度为2.14～4.20cm.在5～7cm长度范围内随输出道长度的增加,最大尿道压也增加(P＜0.05).组织学检查证实10例位于腹直肌内的可控性输出道状态良好,插管顺利.结论在原位膀胱这个理想的储尿囊基础上,适当长度的不经隧道包埋而直接与膀胱吻合的小口径回肠输出道,在腹直肌的加强支持下获得了满意的控尿能力.     

Mitrofanoff可探性尿流改道术

可控性尿流改道术的应用使患者摆脱了尿失禁的痛苦和系集尿袋的不便,提高了患者的生活质量。插管导尿容易,而可控率高的尿液输出道是整个可控性尿流改道术的关键。1980年Ｍｉｔｒｏｆａｎｏｆｆ首次描述采用阑尾作输出道为一神经源性膀胱患儿行可控性膀胱造口术取得成功。此后人们将细管状结构作为输出道包埋于储尿囊壁达到控制尿液的原理称为Ｍｉｔｒｏｆａｎｏｆｆ原理。近20年的临床实践证明,Ｍｉｔｒｏｆａｎｏｆｆ可控性尿流改道术方法简单,尿液可控率高,对可控性尿流改道术临床普及起到了积极的推动作用。一、Ｍｉｔｒｏｆａｎｏｆｆ…     

应用阑尾作可控膀胱输出道的疗效观察

目的 :探讨阑尾作可控膀胱输出道的疗效。方法 :采用 Riedmiller方法并加以改进共施行阑尾输出道可控膀胱术 12例。结果 :随访 8～ 5 3个月 ,术后控尿、导尿效果理想。结论 :阑尾输出道可控膀胱术方法简单 ,使用肠管少 ,术后效果好     

异位可控膀胱术后合并贮尿囊结石的内窥镜治疗

目的:探讨全膀胱切除异位可控膀胱术后合并贮尿囊结石的内窥镜治疗方法。方法:2003年3月～2011年5月期间对11例全膀胱切除异位可控膀胱术后合并贮尿囊结石的患者采用摄像监视系统、灌洗泵、不同内窥镜及碎石系统经输出道进入贮尿囊进行碎石及取石,其中3例阑尾输出道患者采用F8/9.8Wolf输尿管硬镜或输尿管软镜进入贮尿囊内行气压弹道碎石或钬激光碎石;4例回肠输出道患者采用F19.5Wolf尿道膀胱镜进入贮尿囊内行气压弹道碎石或钬激光碎石;4例回肠输出道患者采用F21Wolf肾镜进入贮尿囊内行EMS超声碎石。结果:11例患者经输出道将贮尿囊内结石全部取出,并发症出现少,对输出道的抗尿失禁作用影响少。结论:对全膀胱切除异位可控膀胱术后合并贮尿囊结石,可采用不同的碎石系统和不同的内窥镜经输出道进入贮尿囊内进行碎石,其并发症少,效果满意。     

The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children

The Mitrofanoff principle has been used to achieve clean intermittent catheterisation (CIC) and urinary continence in 28 children. The mean age at operation was 10.1 years (range, 1 to 19 years). A catheterisable conduit was created using the appendix (19), ureter (8), or vas deferens (1). CIC was commenced 10 to 28 days postoperatively (median, 15 days). After a mean follow-up of 13 months (range, 2 to 45 months), 24 children (86%) have achieved successful CIC and urinary continence. Use of the Mitrofanoff principle is a valuable adjunct to the treatment of urinary incontinence in children and may allow successful CIC in patients who are unable to catheterise urethrally.     

Continent cutaneous diversions in children: experience with the Mitrofanoff procedure.

Continent cutaneous diversions with a urinary reservoir emptied by clean intermittent self-catheterisation (CISC) using a non-refluxing conduit--the Mitrofanoff principle--were carried out in 10 children. Their age range was 3.9 to 17.1 years (average 12.2). The underlying diagnoses were ectopia vesicae (7), myelodysplasia (2) and a cervical cord injury secondary to birth trauma (1). The indications were incontinence secondary to poor bladder neck resistance in 8 children and an inaccessible urethral orifice in 2. The catheterising conduits used were the appendix in 9 and a vascularised gastric tube in 1. Eight children are bone-dry with CISC. Another child needed a reoperation following dehiscence of her bladder neck closure. The other child has an intact bladder neck and urethra and occasionally leaks overnight. Mitrofanoff diversions are a reliable means of continence with CISC. This means of urinary diversion can be permanent or temporary in children who cannot or will not catheterise urethrally. Elective appendicectomy in children with potential urinary incontinence or complicated urogenital anomalies is not recommended.     

Surgical management of incontinence in bladder exstrophy.

Between 1978 and 1990, 86 patients with previously closed classical bladder exstrophy and 10 patients seeking undiversion have presented for continence management and have undergone selective reconstruction designed for voiding and/or intermittent urethral catheterisation. The reconstruction in these 96 patients has been reviewed. Eight of the 10 patients undergoing undiversion achieved a satisfactory state of continence but 4 required Mitrofanoff procedures to enable catheterisation. Of the other 86 patients, 2 reached a satisfactory state of continence without further surgery; 79 underwent bladder neck surgery for continence either without augmentation (n = 32) or with augmentation (n = 47). Twenty of the 32 patients who were treated by bladder neck reconstruction alone were later found to require augmentation. Five patients had very early augmentation either to facilitate neonatal closure or on account of severe upper tract dilatation. Of these, 1 became continent without further surgery and 4 demonstrated the need for bladder neck reconstruction. Thus 12 children achieved successful continence (n = 6) or are evolving satisfactorily with potential success (n = 6) as a result of bladder neck reconstruction. Of the 71 patients requiring bladder neck reconstruction and augmentation, 68 have completed their surgery. The current status of these patients is: satisfactory in 57 (80%) (42 void/urethral clean intermittent catheterisation (CIC), 7 waiting to learn CIC, 5 Mitrofanoff, 3 artificial urinary sphincter (AUS]. Of the remaining 11 patients (20%), 8 are unsatisfactory to varying degrees and the status of the other 3 is unknown.     

Continent Urinary Diversion: The Children's Hospital Experience

Purpose

Continent urinary diversion has become increasingly important for treating childhood urinary tract pathology that cannot be managed by direct reconstructive techniques. We review our 9-year experience with continent diversion.

Materials and Methods

Since 1986 continent diversions were created in 74 patients 3 to 38 years old (mean age 13.7). The underlying pathological condition was the exstrophy/epispadias complex in 34 patients, neurological disorders in 23, malignancy in 13 and other congenital anomalies in 4. Followup averaged 5.2 years after the last procedure. Nonbladder reservoirs in 39 patients (53%) were fashioned from ileocolic (17), colic (7), gastrocolic (6), sigmoid (3), gastrosigmoid (2), ileosigmoid (2), ileal (1) and gastroileac (1) segments. When possible, the native bladder was incorporated into the reconstructive strategy. A total of 26 patients underwent bladder augmentation with intestine or stomach, including ileal (11), gastric (8), sigmoid (3), gastroileac (2) and ileocolic (2) segments. Nine other patients did not require bladder augmentation. Continence mechanisms were a flap valve (Mitrofanoff principle) in 50 patients, nipple valve in 15 and ileal plication (Indiana pouch) in 9. When the Mitrofanoff principle was used with a native bladder reservoir in 30 cases, outlet resistance was altered by bladder neck division (15), fascial sling placement (6) or Young-Dees-Leadbetter bladder neck reconstruction (2). In the remaining 7 patients the bladder neck remained intact.

Results

Excellent continence was obtained. The Mitrofanoff principle initially provided continence in 41 patients (82%). Six of the 9 incontinent patients were dry after a single revision. A total of 13 patients (87%) with nipple valves and 7 (78%) with Indiana pouches were dry, and the remaining 5 were cured after a single revision. Ultimately continence was achieved in 71 of the 74 patients (96%) after a maximum of 2 operations. Of the 48 complications in 29 patients the most common were difficulty in catheterizing (11), stones (11), infection (8) and upper tract deterioration (4).

Conclusions

Many options exist for reconstructing complex anomalies. Choices must be individualized based on patient anatomy. The dry state may be achieved in most cases without resorting to a bag on the abdomen.     

The consequence after introduction of clean intermittent catheterization (CIC) in children with neurogenic bladder dysfunction secondary to spina bifida--the comparison of patients with and without upper urinary tract dilation at the time CIC was introduced

PURPOSE: The aim of current study was to review the consequence after introduction of clean intermittent catheterization (CIC) in children with neurogenic bladder dysfunction secondary to spina bifida. PATIENTS AND METHODS: We retrospectively reviewed the records of 34 children (19 girls and 15 boys) presenting our clinic in a 18-year period. The patients were divided concentrating on the radiological upper urinary tract findings when CIC was introduced. 18 children had dilated upper urinary tract. In these patients, 10 children already had dilated upper urinary tract at first visiting to our clinic(group A). In remaining 8 patients, dilatation of upper urinary tract was found out in the course of followup (group B). 16 children had normal upper urinary tract when CIC was introduced. In 7 patients, CIC was applied for post-void residual and urinary tract infection (group C). In remaining 9 patients, CIC was introduced for urodynamically low compliance bladder (group D). RESULTS: In group A, 5 patients underwent enterocystoplasty and 3 patients underwent anti-reflux surgery consequently. Two patients, including 1 patient who underwent enterocystoplasty, have chronic renal dysfunction. In group B, 3 patients underwent enterocystoplasty and 2 patients underwent anti-reflux surgery. In group C, all patients have normal upper urinary tract. In group D, 8 patients have normal upper urinary tract. However, 1 patients underwent enterocystoplasty for low compliance bladder with vesicoureteral reflux (VUR). CONCLUSION: Some patients show the improvement of dilated upper urinary tract or VUR after introduction of CIC. However, enterocystoplasty or anti-reflux surgery was needed for many patients to prevent upper urinary tract deterioration. The patients whom CIC was introduced for postvoid residual and urinary tract infection have not shown any deterioration of upper urinary tract. The efficacy of CIC for incontinence was poor because many patients have urethral sphincter incompetence.     

THE MITROFANOFF PROCEDURE IN PAEDIATRIC URINARY TRACT RECONSTRUCTION

Methods : Between 1991 and 1996, 23 children underwent urinary tract reconstruction of varying complexity together with a continent diversion according to the Mitrofanoff principle. The appendix was used in 14 patients and the ureter in seven. Two patients had previously had an appendicectomy and the ureters were not suitable. One had a catheterizable channel made from an isolated segment of colon and the other had a detrusor tube constructed. Background : Urinary tract reconstruction is required in many congenital and some acquired urological conditions in childhood. The majority are managed by clean intermittent catheterization (CIC), for which purpose the appendix or other tubular structure may be used to provide a continent catheterizable abdominal stoma. Results : Twelve patients with an appendix conduit, six with a ureteric conduit, and one with a colonic tube are continent, although the latter has had some problems with stomal stenosis. All manage CIC with comfort, the older children doing the procedure themselves. One appendix conduit has stomal incontinence and another was inadvertently divided during renal transplantation. The detrusor tube strictured and was removed. Conclusions : A continent abdominal stoma using the Mitrofanoff principle gives reliable results in children and is well tolerated. It should be considered in the management of children undergoing urinary tract reconstruction when CIC is necessary. The appendix is eminently suitable for this purpose but the ureter provides a satisfactory alternative in selected cases. When neither is available, alternative techniques for constructing a catheterizable continent channel may be considered.     

Vesicostomy revisited: the best treatment for the hostile bladder in myelodysplastic children?

OBJECTIVE: To evaluate the effects of vesicostomy on the urinary tract of myelodysplastic children in whom conservative bladder management with clean intermittent catheterization (CIC) has failed to preserve upper and lower urinary tract function. PATIENTS AND METHODS: Sixteen children with myelodysplasia underwent vesicostomy. Indications included worsening hydronephrosis, vesico-ureteric reflux (VUR), recurrent urinary tract infections (UTIs), and increasing renal insufficiency despite CIC and/or difficulty with CIC. The mean (range) age at vesicostomy was 36.5 (9-82) months and the follow-up 7.4 (2-16) years. RESULTS: Hydronephrosis resolved or improved in 12 of 14 children, the incidence of UTI decreased to one or fewer per year in 10, VUR resolved or improved in nine, and renal function improved or stabilized in six of seven patients. One patient initially presented with renal insufficiency and subsequently required dialysis despite vesicostomy. Complications occurred in three of 15 children, and included stomal stenosis and bladder calculi. The vesicostomy was closed in six patients after a mean of 4.4 (1.5-9) years. Four of these patients required concomitant bladder augmentation. CONCLUSIONS: Vesicostomy in myelodysplastic children is effective in preventing and/or resolving the deleterious consequences of a 'hostile' bladder. The procedure is uncomplicated, well tolerated, reversible and should be considered in managing children in whom conservative management by CIC has failed.     

Kidney Transplantation in Patients with Neurovesical Dysfunction

Background: Five renal recipients with neurovesical dysfunction (NVD) were retrospectively reviewed focusing on anatomical and urodynamic abnormalities of the lower urinary tract and their management prior to kidney transplantation.
Methods: The underlying anomalies in these 5 patients were a posterior urethral valve (1 with an imperforate anus; n = 2), meningomyelocele (n = 2) and a congenital short urethra with an imperforate anus (n = 1). Their urinary tracts were evaluated prior to transplantation with voiding cystourethrography, urethrocystoscopy, cystometrography and electromyography of the external urethral sphincter to identify a possible focus of urinary tract infection, urine storage and voiding function.
Results: All 5 patients had NVD proven by urodynamic studies or by documentation of urinary retention in the absence of mechanical outlet obstruction. Bilateral high grade vesicoureteral reflux was noted in all patients, requiring ureteroneocystostomy. Clean intermittent catheterization (CIC) was ultimately employed for bladder emptying in all patients. Two patients with poor bladder compliance underwent augmentation cystoplasty before transplantation. The Mitrofanoff procedure was used in 2 patients with structural urethral abnormalities to access the bladder for catheterization. After eradication of possible sources of infection and establishment of a low-pressure urine storage system with bladder emptying by CIC, kidney transplantation was performed. Following kidney transplantation, all of the recipients were asymptomatic for urinary tract infections using CIC. Although 1 patient lost his graft due to chronic rejection, the other 4 other patients have good renal function.
Conclusion: Kidney transplantation in patients with NVD can be performed provided that their urinary tract problems are properly resolved.     

Bladder calculi in children who perform clean intermittent catheterization

OBJECTIVE: To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients. PATIENTS AND METHODS: The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed. RESULTS: Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months. CONCLUSION: These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.     

Continent urinary diversion in childhood

We review 24 children and young adults who underwent continent urinary diversion. The indications for an operation included bladder exstrophy in 11 patients, myelomeningocele in 8, sacral agenesis in 3, cloacal anomaly in 1, and traumatic disruption of the bladder neck and urethra in 1. The operations performed included an Indiana pouch in 19 patients, including 12 whose stoma was brought to a perineal position and 7 whose stoma was placed in the anterior abdominal wall. A Kock pouch was used in 2 patients and the Mitrofanoff principle was used in 3. The particular indications for the different procedures are discussed at length. Postoperative daytime continence as defined by at least 4 hours of dryness is present in all 24 patients to date, while 4 have nocturnal incontinence. Renal function is stable in all patients to date. In 18 patients postoperative urine cultures were positive during followup. All patients are on clean intermittent catheterization and reoperation has been required in 2 relating to an inability to perform postoperative intermittent catheterization. Two patients underwent reoperation for small bowel obstruction. The series supports the use of continent urinary diversion as a viable alternative to traditional forms of conduit diversion in children and young adults.