CODE: 17 - Late therapeutic results in children with bladder extrophy treated by a unique method of internal urinary diversion
Article published in Urologia Polska 2006/59/Suplement 1.

authors

Wiesław Urbanowicz, Michał Wolnicki, Janusz Sulisławski

Klinika Urologii Dziecięcej Katedry Chirurgii Pediatrycznej Collegium Medicum UJ w Krakowie

summary

Introduction. At present, the classic management method in a congenital malformation represented by bladder extrophy and epispadiasis is a bladder reconstruction, even when the surgeon is aware that in the future, bladder augmentation will be necessary. In cases of failures and when such a procedure is impossible to be performed, an orthotopic bladder substitution is performed, which provides continent cutaneous diversion. There are still centers where internal urinary diversion is preferred, which is achieved through a Mainz Pouch II ureterosigmoidostomy. Major reservations associated with the above methods of urinary diversion are ascending infections, metabolic abnormalities, oncological risk and difficult endoscopic approach to the ureteral outlets.

Objectives. The authors present the results of their analysis of 21 patients with bladder extrophy selected from the total of 28 children operated on using the unique technique of a two-step internal urinary diversion with the creation of a valve at the site of the rectosigmoid anastomosis in the years 1981-1990.

Materials and methods. The group of 28 patients included 12 children after failed attempts at bladder reconstruction, nine with complications following prior Descomps-Duchamel internal urinary diversion procedures and seven, in whom the presented procedure was to be the primary operation. The surgical technique was based on a two-step procedure. In stage 1, the surgeon performed an indirect external urinary diversion using an isolated segment of the sigmoid colon. The outlet of the implanted segment was situated at the site of the excised, extrophied bladder. Having confirmed normal urine flow without urinary reflux by a loopography using the 100-120 cm water column pressure, the surgeons proceeded to stage 2. The terminal segment of the sigmoid colon implant was then anastomosed with the rectal ampulla at the distance of 4-5 cm from the muco-cutaneous margin. A flat valve was constructed at the anastomosed site to prevent mixing of the feces and urine.

Results. Only 21 patients did report for follow-up. The follow-up period extended over 15 to 24 years. Three patients were reoperated following step 1. In view of feces and urine incontinence, in two patients, continent cutaneous diversion was performed. Radiological signs of past inflammatory lesions of the kidneys were detected in 15 children. Two had nephrolithiasis requiring surgical interventions. Eight patients still require oral alkalinizing drugs in view of their moderate hyperchloremic acidosis. All patients receive prophylactic anti-inflammatory agents. Four male patients got married, but are childless. Two females are married, one of them born a healthy child. Endoscopic and ultrasound examinations did not reveal proliferative lesions at the site of ureter implantation.

Conclusions. 1. Inflammatory lesions and metabolic abnormalities (acidosis) are the most common disturbances in patients with internal urinary diversion. 2. This type of urinary diversion does not rule out pregnancy and delivering a child at term. 3. The two-stage procedure involving monitoring the competence of uretero-rectal anastomosis allows for minimizing the contact of ureteral outlets with feces and the mixing of feces and urine, what may prevent or decrease the consequences of such contacts.