The correlation between bladder volume wall index and the pattern of uroflowmetry/external sphincter electromyography in children with lower urinary tract malfunction

ObjectiveTo evaluate the relationship between bladder volume wall index (BVWI) and the pattern of uroflowmetry in children with lower urinary tract malfunction.Patients &; methods91 children aged 4–15 years with history of bladder dysfunction and 59 age/sex-matched healthy children with negative urine culture in previous month were enrolled. Uroflowmetry and kidney and bladder sonography were performed in all children. BVWI was measured by dividing maximum bladder volume index by mean bladder thickness. It was expressed as percentage by dividing calculated BVWI by expected BVWI, and values between 70% and 130% were presumed normal. Urodynamic study was done in symptomatic cases.ResultsThe bladder was thick (<70%) in 39 (28 cases, 11 controls) and thin (>130%) in 35 (18 cases, 17 controls) (P > 0.05). Uroflowmetry was abnormal in 82 (61 cases, 21 controls) (P < 0.05). Severe sphincter dyssynergia was detected in 47% of cases compared with 20% of controls (P < 0.05).There was no relationship between BVWI and uroflowmetry in cases or in controls (P > 0.05). The median post-void residual urine was not statistically different between the groups (20 vs 12.3 ml) (P > 0.05). When both bladder sonography and uroflowmetry were abnormal, they had an association with abnormal urodynamics (P < 0.05).ConclusionAmong children with lower urinary tract dysfunction, the pattern of uroflowmetry could not be predicted from the BVWI, but in cases with combined abnormal bladder sonography and uroflowmetry results, there was a significant association with an abnormal urodynamic study.     

Urinary bladder dysfunction in diabetic children with and without subclinical cardiovascular autonomic neuropathy

The aim of this study was to assess the relationship between bladder dysfunction and impaired cardiovascular reflexes in diabetic children with no clinical symptoms of autonomic neuropathy. After 15 ml/kg of water intake, the time to first sensation to void, the voiding volume, the voiding time, the average and maximum urinary flows, and the time to maximum urinary flow were estimated by sonography and uroflowmetry in diabetic children with and without cardiovascular autonomic dysfunction (CAD), and in a healthy control group. The three groups of children were matched for age, weight and height. CAD was considered to be present if the results of cardiovascular tests were more than 2SD from the mean of healthy controls. Diabetic children with and without CAD had increased time to first sensation to void, voiding volume, and average urinary flow when compared with healthy children. Voiding volume and average and maximum urinary flows were higher in diabetic children with CAD than in those without CAD. Diabetic children with CAD had also a higher maximum urinary flow than diabetic children without CAD and healthy children. Diabetic children with CAD had a longer diabetes duration and a higher mean fructosamine level during the preceding 3 years than those without CAD. These findings suggest that diabetic children may have diminished sensation of bladder filling independent of impaired cardiovascular reflexes, however, the degree of bladder dysfunction parallels with CAD, both depending on diabetes duration and long-term glycaemic control.Presented in part at the First Meeting of Diabetic Neuropathy Study Group of the EASD, Cork/Ireland, 9–10 September, 1991     

Evaluation of the BladderScan® in estimating bladder volume in paediatric patients

ObjectiveTo evaluate the reliability of estimates of bladder volume (BV) in children with the BladderScan BVI 9400 (BS) compared with the volume obtained at catheterization (CV).Materials and methodsBV was measured using the BS in 50 children (age range 6 weeks–14 years) who required urinary catheter placement during surgery or urodynamic studies. BS measurements were taken prior to catheter insertion. BV was compared with CV.ResultsBS volumes ranged from 0 to 513 mL (mean = 79 mL, median = 34 mL) and CV from 0 to 500 mL (mean = 81 mL, median = 31 mL). There was high correlation between the BS and CV measures (rho = 0.96). The mean difference between BS and CV volumes was −2.1 mL (SD 21). Where the CV ≤ 100 mL the BS volumes ranged from 0 to 84 mL (mean = 74 mL, median = 30 mL) and the CV from 0 to 88 mL (mean = 76 mL, median = 25 mL) (rho = 0.89). The mean difference = 0.5 mL (95% limits of agreement ± 23 mL). In a small sample of 12 children <36 months, correlation between BS and CV volumes was not as strong with rho = 0.82.ConclusionsOverall the BladderScan showed a high correlation with catheter volume and there was good clinical agreement between the measures.     

Characteristics of the bladder in infants with urinary tract infections: an ultrasound study

BACKGROUND: Patients with urinary tract infection (UTI) are known to have impaired bladder function as demonstrated by urodynamic (UD) studies. UD is rarely performed in infants. OBJECTIVE: To evaluate bladder function in infants with UTI using a dynamic US protocol. Maximal bladder volume (MaxBV), residual volume (RV) and bladder wall thickness (BWT) were measured and compared with values from normal controls. MATERIALS AND METHODS: A total of 57 consecutive infants (47 males, 10 females; mean age 0.48+/-0.30 years) with proven UTI, and 63 age-matched normal controls (37 males, 26 females; mean age 0.47+/-0.37 years) were recruited. MaxBV was determined just before voiding, and RV and BWT were measured after spontaneous voiding. RESULTS: Infants with UTI had smaller MaxBV (34.89 vs. 42.91 ml), larger RV (3.46 vs. 1.51 ml) and greater BWT (4.21 vs. 3.68 mm) than normal infants (P<0.05, Mann-Whitney test). CONCLUSION: Smaller bladder volume, larger residual volume and thicker bladder wall in infants with UTI can be explained by bladder instability, hypercontractility and infection-induced oedema of the bladder wall during UTI. The US measurement of bladder parameters might serve as an objective guide for clinical diagnosis and allow objective evaluation of bladder function during posttreatment follow-up.     

膀胱自体扩大术在神经性膀胱患儿中的应用评价

目的评价逼尿肌部分切除、膀胱自体扩大术的临床疗效。方法选择脊髓脊膜膨出患儿6例,其中男性3例,女性3例,年龄18个月至9岁。患儿均口服索利那新和行清洁间歇导尿3个月后无好转而行逼尿肌部分切除、膀胱自体扩大术,术后予清洁间歇导尿,手术前及术后1年行泌尿系超声、排泄性膀胱尿道造影,并行尿动力评价,评价指标为膀胱容量、膀胱顺应性和充盈末逼尿肌压。结果术前尿动力学检查显示6例患儿膀胱容量减小、膀胱顺应性下降及逼尿肌压升高,其中5例膀胱容量低于预期容量的50%。排泄性膀胱造影4例合并膀胱输尿管反流,其中左、右侧Ⅳ°反流各1例,双侧Ⅳ°反流2例。6例患儿手术后恢复顺利,无穿孔、感染发生。术后1年尿动力学检查显示6例患儿膀胱容量略有增加,但膀胱容量与预期膀胱容量(年龄×30+30)、膀胱顺应性及逼尿肌压力无明显变化,VCUG显示4例输尿管反流无减轻。结论对于膀胱容量明显变小的神经性膀胱患儿,逼尿肌部分切除、膀胱扩大术不能有效增加膀胱容量和顺应性,降低逼尿肌压,临床不能取得满意的效果。     

Effect of Botox injection at the bladder neck in boys with bladder dysfunction after valve ablation

ObjectiveAfter posterior urethral valve ablation, some boys are still have a hostile bladder. We conducted a prospective randomized study to determine if Botox injection at the bladder neck will help improve vesical dysfunction in this subgroup of boys or not.Patients and methodsTwenty boys with history of posterior urethral valve ablation and severe bladder dysfunction with a mean age of 16 months were studied. Cases were further randomized into two groups. Group I (study group) had endoscopic injection of a single dose of 100 IU of Botox into the hypertrophied bladder neck at 3, 6, and 9 o’clock. Group II (control group) patients with the same parameters had urethroscopy to exclude residual valves. Both groups had the standard conservative treatment. Cases were followed after 6 months of initiating the management protocol. This includes laboratory studies (urine culture and sensitivity, blood urea nitrogen, serum creatinine), ultrasound of the urinary tract. Voiding cysto-urethrogram and urodynamic study (pressure flow study).ResultsThere was no statistical difference in both groups regarding rate of urinary tract infection, improvement of hydronephrosis, resolution of vesico-ureteral reflux, creatinine level at the start or at the end of the study. Urodynamic parameters revealed an increase in cystometric capacity in both groups at the end of the study but without statistical difference. The mean voiding pressure reduced significantly in both groups but without statistical difference.ConclusionsTemporarily abolishing the effect of bladder neck by Botox injection does not seem to improve the outcome of those boys who had a severe voiding dysfunction after valve ablation.     

Effects of male sex hormones on urodynamics in childhood: intersex patients are a natural model

 The effects of sex hormones on bladder function have been evaluated in adult females, especially in regard to postmenopausal incontinence and bladder irritability syndromes. These have not been investigated in children in regard to urodynamic findings. An intersex patient whose bladder is under the influence of androgens is a natural model to investigate the effects of male sex hormones on bladder function in females. To evaluate the urodynamic findings and clinical symptoms in a group of intersex patients and to determine how androgens influence bladder function in female children, clinical and urodynamic records of 12 intersex patients with adrenogenital syndrome were investigated retrospectively. The mean age was 9 ± 5.7 years (1.5–18) and the mean follow-up period was 5.1 ± 4.4 years (1–12). Congenital adrenal hyperplasia (CAH) was present in all cases. Only 3 patients had urinary symptoms and incontinence, but these findings did not correlate with their urodynamic findings. None of the patients required medications for their urinary symptoms. Nine are still being treated medically by the pediatric endocrine team with hydrocortisone for CAH. The upper urinary tract was found to be normal with no hydronephrosis. The mean bladder capacity (269 ± 122 ml) was lower (86.7%) than the estimated capacity for age. The mean compliance was 20 ± 13.7 ml/cmH₂O. No unstable detrusor contractions were encountered. The most remarkable finding was this reduced bladder capacity of androgenized female patients for age, which shows the antagonistic effect of androgens on bladder urodynamics in females. Accepted: 11 January 2000     

Renal transplantation and congenital anomaly of the kidney and urinary tract

Paediatric renal transplantation in children differs from adult series because of the high incidence of abnormalities of the lower urinary tract. We report our experience concerning five children with end-stage renal disease and associated bladder dysfunction due to posterior urethral valves, and lower urinary tract abnormalities (‘valve bladder’), who underwent renal transplantation without prior correction of the uropathy. Of 151 paediatric patients (aged 34 months to 23 years) who underwent renal transplantation, 58 had lower urinary tract abnormalities, and 42 underwent surgical correction of the uropathy prior to renal transplantation. In 15 patients, the uropathy was fibrotic bladder secondary to posterior urethral valves (‘valve bladder’). After clinical and urodynamic evaluation, all 15 patients were considered as candidates for bladder augmentation. In 10 patients, the bladder augmentation was performed prior to renal transplantation. The remaining five patients presented with oligoanuria at the time of the evaluation, and the decision to consider bladder augmentation was postponed until the post-transplant period. At the time of renal transplantation, 2 of the 5 patients underwent ureterostomy, and three had a ureteral reimplant associated with a suprapubic catheter for 2 months. Periodic assessment of renal function and bladder capacity/compliance was performed, as was renal ultrasound. After 4 months, the five patients were re-evaluated for the need for bladder augmentation. At 1, 2, 3 and 4 months follow-up, the five patients had normal renal function with improvement of bladder capacity and absence of hydronephrosis. In 3 of the 5 children, bladder augmentation was judged to be no longer necessary due to the complete restoration of clinical and urodynamic parameters. Therefore, renal transplantation can be safely performed without pre-emptive reconstruction of the lower urinary tract. When possible, ureteral reimplantation is recommended, even in a very small valve bladder, since the initial indication for bladder augmentation may be modified once normal diuresis has been restored.     

Bladder-sphincter dysfunction in myelomeningocele

 Pediatric urodynamics taught us that detrusor-sphincter dyssynergia creates a bladder outlet obstruction in about 50% of any population of children with myelomeningocele. This functional obstruction causes renal damage due to obstructive uropathy, exactly the same way as a congenital anatomical urethral obstruction does. Pediatric urodynamics also taught us that in children with myelomeningocele pelvic floor activity and detrusor activity can be abnormal (hyperactive or inactive) completely independent from each other. These insights have changed the management of myelomeningocele. Children with overactivity of the pelvic floor can be singled out at infant age, and started on clean intermittent catherization, to prevent obstructive uropathy and preserve renal function. Children with detrusor overactivity can be singled out too at very early age, and treated with anticholinergics, to prevent irreversible structural damage to the detrusor and preserve normal bladder capacity and compliance. Received: 20 July 1999 / Accepted: 24 January 2001     

Bladder-neck repair in urinary bladder exstrophy

A simple modification of an existing technique for bladder-neck reconstruction in exstrophy of the urinary bladder is reported. The technique involves tubularization of the posterior urethra up to just below the ureteric orifices. It differs from other techniques in that no part of the bladder tissue is used for buttressing the repair, but all is utilized for enhancing the bladder volume. Only 2 of 20 patients remained incontinent after bladder-neck reconstruction; the remaining 18 have achieved socially acceptable continence. Accepted: 17 June 1998     

Paediatric bladder augmentation and substitution: From diversions to tissue engineering

OBJECTIVES:

To review the evolution of urinary diversion, bladder augmentation and bladder replacement in the paediatric population over the past century and to outline the possible direction of future management.

DATA SOURCES:

Original and review articles obtained from a PubMed search of English language publications dating from 1970 to 2001. The search terms were “bladder augmentation”, “bladder substitution”, “bladder autoaugmentation”, “ureterocystoplasty” and “bladder engineering”. The age group was “all child 0-18”.

DATA SELECTION:

Articles selected were those with relevance to the scope of the topic.

DATA EXTRACTION:

The articles were analyzed with the primary focus being the problems encountered with various forms of urinary diversion, bladder augmentation and bladder replacement, and the subsequent evolution of materials and techniques.

DATA SYNTHESIS:

Bladder tissue may need to be replaced in the paediatric population because of congenital malformation, disease or trauma. The unique structure and function of urothelium and bladder muscle make this a challenging task. Management has evolved from a mindset of attempting to divert urine from the bladder completely to that of trying to preserve what is salvageable of the organ. Historically and contemporarily, the gastrointestinal tract has provided the raw material for urinary diversion, bladder augmentation and bladder substitution. Experience, however, has highlighted the potential complications inherent in the use of the bowel in the urinary tract including mucus production, stone disease, metabolic abnormalities, growth retardation, spontaneous perforation and malignancy. However, despite these drawbacks, the bowel is the gold standard in terms of functional utility and longevity. In efforts to develop alternatives, research has focused on the use of both natural and synthetic materials. With these materials, a whole new list of potential problems has been characterized. Tissue engineering may hold promise in resolving the issues of bladder replacement or repair by providing the necessary biocompatible raw material.

CONCLUSIONS:

Bowel segments have been and continue to be the clinically most useful material for urinary diversion, bladder augmentation and bladder replacement. Complications associated with the use of bowel in the urinary tract have prompted considerable research into alternative materials and methods.     

Harmonic versus conventional ultrasound imaging of the urinary tract in children

Background:Harmonic imaging (HI) is a relatively new US method. Its usefulness in children has yet to be determined. Objective: To evaluate the value of HI in urinary tract imaging of infants and children. Materials and methods: The bladder and kidneys of 29 unselected patients, aged 2 months to 12.8 years (mean, 6.8 years), were examined from ventral and dorsal approaches using conventional (= fundamental) imaging (FI) (6.5 and 3.4 MHz) and HI (3.3 MHz). In addition to global image quality, visualization of bladder wall, retrovesical space, renal contrast to liver/spleen, the pelvicalyceal systems, and the difference between cortex and medulla were assessed. Parameters were rated by two independent examiners and statistical analysis was performed. Results: There were significant differences between the three imaging settings for all parameters studied (P<0.003). With the dorsal approach, HI was superior to FI for all parameters analysed (P<0.05). Using the ventral approach, a significant improvement of imaging with HI was found for the bladder and the renal pelvis (P<0.02). Conclusions: HI is a useful additional tool for imaging the urinary tract in children of all ages. The method particularly improves visualization of the bladder and the kidney from a dorsal approach.     

Color Doppler ultrasonography in the assessment of vesicoureteric reflux in children with bladder dysfunction

To determine whether color Doppler ultrasound (DUS) evaluation of ureteric jets could predict vesicoureteric reflux (VUR) in children with non-neuropathic and neuropathic bladder/sphincter dysfunction, 129 children were evaluated to identify the vesicoureteric orifice and measure the distance from the orifice to the midline of the dorsal bladder wall (MVU distance). The type of bladder dysfunction was determined by urodynamic studies. Forty-two children with no history of kidney or bladder disease were examined by DUS as a control group. MVU distances were compared between several groups of children with different urodynamic findings, and the significance was tested. Jets were visualized in 81% of children. MVU distances were significantly lower in children without VUR compared to those with VUR. No statistically significant differences were observed between children without VUR and those with VUR and more severe urodynamic disturbances like dysfunctional voiding. In children with neuropathic bladders, jets were visible in only 57% of refluxive units and the range of MVU distances was very wide (5–22 mm). If a cut-off point of 10 mm is used, in children without bladder dysfunction the sensitivity of MVU measurement in the diagnosis of VUR was 87.5% and the specificity 97%. However, in children with non-neuropathic and neuropathic bladder dysfunction, the sensitivity was only 55% and the specificity 79%. Color Doppler (DUS) and measurement of the MVU distance proved useful in predicting VUR only in children with normal bladder function. In children with neuropathic and non-neuropathic bladder dysfunction it can be used to visualize ureteric jets, but cannot replace radiographic or radionuclide voiding cystourethrography. Accepted: 21 March 2001     

Factors responsible for successful primary closure in bladder exstrophy

 To assess the important factors for successful primary closure in staged reconstruction of bladder exstrophy, 25 patients (18 males, 7 females) underwent primary bladder closure during the years 1993–1997. Twenty-one were more than 72 h old; all of these underwent bilateral posterior iliac osteotomies followed by primary bladder closure during the same anesthetic. Bladder closure was done in a double layer. The ureteric catheters were removed after 2 weeks and the bladder catheter after 3.5–4 weeks. Only 1 patient had a bladder dehiscence on the 10th postoperative day due to infection; 3 had partial wound dehiscences but no bladder dehiscence. One had a partial bladder prolapse. The osteotomies needed no drainage, and no complications occurred. One patient needed a urinary diversion 3 years after surgery as the bladder capacity did not increase. Eleven important factors play a pivotal role for successful primary bladder closure: (1) Proper patient selection; (2) A staged approach; (3) Anterior approximation of the pubic bones with placement of the bladder and urethra in the true pelvis; (4) Posterior bilateral iliac osteotomies in all indicated cases; (5) Double-layered closure of the bladder; (6) Two weeks' proper ureteric catheter drainage; (7) Prevention of infection; (8) Prolonged and proper postoperative immobilization; (9) Prompt treatment of bladder prolapse; (10) Prevention of abdominal distension postoperatively; and (11) Ruling out bladder-outlet obstruction before removing the bladder catheter. Accepted: 12 July 1999     

Management of urinary tract infections

Urinary tract infection (UTI) is common in childhood. It may result in long-term complications due to renal scaring. Younger children are at higher risk of renal scarring. The diagnosis of UTI is based on urine culture. The bacterial count for diagnosis of UTI depends on the method of urine collection. Urinalysis is useful for making a presumptive diagnosis of UTI and allows initiation of empirical treatment in high-risk patients, after urine culture has been obtained. The treatment of UTI is guided by the severity of illness and age of the patient. Following a UTI, investigation should be performed to identify an underlying urinary tract anomaly. Recurrence of UTI occurs in 30–50% children. Important predisposing factors include VUR, urinary tract obstruction, voiding dysfunction and constipation. Vesicoureteric reflux (VUR) is seen in 30–50% children with UTI. The cornerstone of management of VUR is long-term antibiotic prophylaxis, which has been found to be as effective as surgical reimplantation.     

Development of bladder and bowel control: significance of prematurity, perinatal risk factors, psychomotor development and gender

Development of bladder and bowel control from 6 months to 6 years was investigated in 140 preterm children and a control group of 349 healthy term children. Structured parental interviews and neurodevelopmental assessments were carried out when the child was 1, 3, 6, 9, 12, 18 and 24 months, and at yearly intervals thereafter. Even though preterm children were put on the potty at significantly earlier ages and significantly more frequently than term children, they expressed their need for evacuation and attained day and night bladder and bowel control at the same corrected age as term children. Initiation and intensity of toilet-training were not significantly correlated with the development of bladder and bowel control. Gestational age, being too small for gestational age, adverse perinatal conditions and mild to moderate neurological impairment did not affect the occurrence of the child's initiative and the development of bladder and bowel control. Neither developmental and intelligence quotients at the age of 1 to 3 years nor the socioeconomic status of the families influenced the age at which the child became clean and dry. Girls were significantly more advanced in expressing their needs and gaining bladder and bowel control than boys in both the preterm and term groups. Conclusion Development of bladder and bowel control is largely a maturational process which cannot be accelerated by an early onset or a high intensity of training. It is not affected by prematurity, adverse perinatal events or mild to moderate neurological impairment, nor is it related to psychomotor development or actual Swiss socioeconomic conditions. Received: 19 March 1998 / Accepted: 11 September 1998     

Replacement of the urinary bladder with rectum

The rectum can be used as a substitute for the urinary bladder such that the normal outlet for feces at the anus is left undisturbed and continent. Perfect and complete continence is achieved by creating a narrow neck of the rectal bladder with a sphincter around it and a narrow urinary outlet, a neourethra, also with a sphincter around it. Three different types of anomaly necessitating reconstruction of the urinary bladder were operated upon by this procedure. Three patients are doing well in respect to micturition and defacation, having achieved total continence for both.     

Outcomes of renal transplantation in children with and without urinary tract abnormalities: is there any difference?

PurposeTo evaluate if children with urinary tract abnormalities, particularly bladder disorders, have different long-term outcome after renal transplantation, compared to those with non-urological cause of ESRD.Material and Methods211 children (age <19 years) were submitted to 226 renal transplantations between 1989 and 2005. They were separated in three groups: 136 children with ESRD due to non-urological cause (GROUP 1), 56 children with urological disorders but with adequate bladders (GROUP 2) and 19 children with lower urinary tract dysfunction associated or not to inadequate bladder emptying (GROUP 3). In group 3, 15 children were submitted previously to a bladder augmentation (ureterocystoplasty in 6 and enterocystoplasty in 9), one to a bladder autoaugmentation, two children to a continent urinary diversion, and one to an appendical Mitrofanoff procedure. The renal transplantation was performed in a classical, extraperitoneal access, and the ureter implanted, whenever possible, with an antireflux technique.ResultsAfter a mean follow-up of 75 months, 13 children died, 59 grafts were lost, and 15 children received a second transplant. Two patients of GROUP 3 required a complementary urological procedure to preserve renal function (one enterocystoplasty and one vesicostomy). There was a total of 12 (5.3%) major surgical complications, with an equal incidence in the three groups. The overall graft survivals at 5 years were 75% (GROUP 1), 74% (GROUP 2) and 84% (GROUP 3).ConclusionsWith an individualized treatment, children with urological abnormalities, including those with lower urinary tract disorders, have the same long-term outcome as those with non-urological cause of ESRD.     

神经源性膀胱扩大术远期疗效观察

目的 评价保留膀胱黏膜的双层肠管浆肌层膀胱扩大术的远期疗效.方法 病例选择条件:术前有明确支配膀胱的神经性损害,膀胱容量明显小于同龄儿童的正常值,同时伴有Ⅳ度以上膀胱输尿管反流,经过一段时间的口服抗胆碱能药物、清洁间歇导尿等保守治疗后,膀胱内压仍然较高,输尿管反流无明显改善,我们对符合上述条件的75例神经源性膀胱患儿行切除部分逼尿肌保留膀胱黏膜的双层肠浆肌层膀胱扩大术,同时根据患儿的具体情况选择性联合应用膀胱输尿管移植抗反流、膀胱颈紧缩、膀胱颈悬吊等手术方式,术后对患儿进行长期随访,对手术前后临床症状、肾脏功能、尿流动力学(膀胱容量、残余尿、逼尿肌压和顺应性)等方面进行评价.结果 75例手术患儿中68例获得随访,随访时间平均4.3年,术后无一例发生肾脏功能衰竭,45例获得一定的临床治疗改善.23例术后在尿流动力学、临床症状方面无明显改善.结论 术后膀胱容量不能有效扩大是导致术后疗效不理想的重要原因,保留膀胱黏膜的双层肠浆肌层膀胱扩大术是治疗神经源性膀胱的一种方法,但该方法有待改进.     

A new technique of bladder enlargement and continent urinary diversion using the ceco-appendicular unit

 The authors developed a new technique using the cecum with in-situ appendix to simultaneously achieve bladder enlargement and continent urinary diversion (CUD) in five cases of neuropathic bladder or serious complications of abdominopelvic trauma. The cecoplasty provides a large-capacity, low-pressure reservoir; the submucosally-embedded appendix gives complete continence with 3 to 5 intermittent catheterizations daily. It is an alternative to the Mitrofanoff principle when bladder augmentation and CUD are necessary, and easier to achieve when faced with a neuropathic bladder where the thickness of the detrusor makes appendicular implantation difficult. Accepted: 24 August 2000