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Bladder replacement with sigmoid colon after radical cystoprostatectomy
BLADDER REPLACEMENT WITH SIGMOID COLON AFTER RADICAL CYSTOPROSTATECTOMY PRATAP K. REDDY, M.D. PAUL H. LANGE, M.D. From the Department of Urologic Surgery, University of Minnesota Health SciencesCenter and the Veterans Administration Medical Center, Minneapolis, Minnesota
ABSTRACT-Sigmoid colon was used to replace the bladder after radical cystoprostatectomy in 10 patients with bladder cancer. A U- or l-shaped segment of the sigmoid colon was anastomosed at the most dependent portion to the urethral stump. The ureters were implanted in each end of the loop via an antireflux tunneling technique. There was no operative mortality, and the complications associated with this form of bladder replacement were minimal. All 10 patients had sensations of filling, and 8 of 10 achieved full daytime continence with complete voluntary emptying. Enuresis was present in all patients and required condom catheters during sleep, which were well tolerated. We believe that a tubular sigmoid segment is an acceptable alternative to tubular ileum or cecum for total bladder replacement.
Over the past four decades, many types of urinary diversion have been performed on patients after total cystectomy; ileal and colon conduits have been the most popular diversion procedures performed in this country.1-6 Interest in the creation of a continent urinary reservoir after cystectomy has increased recently because of (1) the disappointing long-term results with ileal and colon conduits,e-le (2) the increased demand for more socially and psychologically acceptable forms of urinary diversion, and (3) the recent acceptable morbidity rates with both radical cystectomy and continent urinary reservoir procedures. The continent urinary reservoir may be composed of ileum alone (the Kock pouch)13*14 or ileum in combination with the right side of the colon,l*l”l* with a catheterizable stoma on the abdominal wall or on the perineum in the female. Alternatively, the continent urinary reservoir may be “non-stomal,” in which tubular segments of the ileum or colon serve as a reservoir and are anastomosed to the membranous 368
urethra to achieve continence.le,zo Currently, the ileal segment positioned in a U configuration (the CameyiQ procedure) has gained the widest popularity. For the last two years we have used a tubular segment of sigmoid colon shaped in a U or J configuration for total bladder replacement in appropriate patients after radical cystoprostatectomy. Herein we report our surgical technique, clinical results, and urodynamic findings with this form of bladder replacement. Material and Methods Ten male patients underwent sigmoid bladder replacement after radical cystoprostatectomy for bladder cancer. Table I shows the age, tumor grade and stage, and the months of postoperative follow-up in these patients. Cold cup transurethral biopsies of the prostatic and bulbous urethra were performed preoperatively on all patients; these revealed no tumor or dysplasia. Barium enema studies were performed to rule out colon pathology. UROLOGY
/
APRIL
1987
I
VOLUME
XXIX,
NUMBER
4
1. Technique for bladder replacement with stgmoid colon after radical cystoprostatectomy: (A) anastomosis of sigmoid segment to urethral stump using six interrupted 2-O polyglactin sutures over 20-F Foley catheter; (B) implantation of ureters into each end of bowel segment via antireflux tunneling technique, using tunnels of approximately 5 to 6 cm; and (C) intubation of ureters with Silastic stents and placement of suprapubic catheter. Ureteral stents and suprapubic catheter are brought through bowel wall and abdominal wall. FIGURE
Radical cystoprostatectomy was performed in the standard fashion. Care was taken to transect the prostate at its apex and to avoid dissection around the pelvic floor, much in the fashion of a radical retropubic prostatectomy. Multiple specimens for frozen sections were obtained from the urethral margins to confirm that there was no residual tumor, and that no portion of the prostatic tissue or capsule was left behind. The sigmoid and descendingcolon was mobilized and a segment measuring 35 to 45 cm was isolated on its mesentery. Intestinal continuity was reestablished with a tension-free anastomosis; occasionally the splenic flexure had to be taken down to accomplish this. The isolated segment of colon was then folded with its “U” facing the pelvis. Depending on the mesentery, a U- or J-shaped configuration of the sigmoid colon was positioned and anastomosedat the most dependent part to the urethral stump using six 2-Opolyglactin (Vicryl) sutures over a 20-F Foley catheter (Fig. 1A).
TABLE
Pt. Age (Yrs.)
/
Clinical features in 10 patients with sigmoid bladder
‘Rumor Grade; Histology*
Stage Clinical Pathologic
Follow-up (Moss)
69 67
IV TCCB IV TCCB
T2 T3A
P2 P3B
20 14
77 67 57 70 57 62 52 46
V TCCB IV TCCB III TCCB IV TCCB IV TCCB, CIS III TCCB III TCCB, CIS V TCCB
T3A T3A Tl
P3Nl P3A Pl PO P2 P3A Pl, PlS P3A
14 14 13 12 11 9 8 8
‘TCCB tDaytime
UROLOGY
I.
era1
APRIL
= transitional continence.
1987
/
VOLUME
:; T3A Tl, TlS T3A
cell carcinoma
XXIX,
of bladder;
NUMBER4
CIS
= carcinoma
Comments Continent t Continent; cisplatin and doxorubicin Deceased Deceased Continent Continent Continent Continent Continent Continent
in situ.
369
The length of the mesentery in all cases was adequate to bring the loop into the pelvis without making deep incisions into the mesentery. The ureters were implanted into each limb of the colon segment using the Leadbetter tunneling technique; the tunnels were approximately 5 to 6 cm in length (Fig. 1B). The ureters were intubated with Silastic stents. The stems, along with a suprapubic catheter, were led out through the bowel wall and abdominal wall (Fig. 1C). Penrose drains were placed in the pelvis, and the 20-F Foley catheter was positioned transurethrally to drain the limb of the bowel segment opposite the suprapubic catheter. The urethral and suprapubic catheters were not irrigated the first seventy-two hours postoperatively since most of the urine drained through the ureteral stents. Thereafter, the bowel segment was irrigated with normal saline once every six hours to prevent the formation of mucous plugs. Two weeks postoperatively a cystogram and catheterogram were performed. If no leak was detected, the ureteral stents and Penrose drain were removed. The following day the urethral and suprapubic catheters were removed as appropriate. The patients were followed up with isotopic renography, voiding cystography, and evaluation of serum electrolytes, blood urea nitrogen, and creatinine at threemonth intervals. Cystoscopy with random biopsies of the urethral margins was performed at six-month intervals. Results There was no operative mortality. Temporary perineal palsy secondary to surgical positioning developed in 1 patient but gradually resolved, Another patient required re-exploration to remove a retained portion of an abdominal drain. Significant mucous production from the bowel segment caused occasional outlet obstruction in 1 patient; this resolved with time and the use of acetic acid irrigations by self-intermittent catheterization. No serum electrolyte abnormalities were recorded. Renal function was stable postoperatively with no changesobserved on intravenous pyelography or renography. Reflux was not observed. Urine cultures remained sterile in all patients. Eight of 10 patients achieved daytime continence within four to six weeks. Voiding was accomplished through a combination of ab370
TABLE
II.
Urodynamic features in 10 patients with sigmoid bladder
Median (Range) Urodynamics (ml*> Residualurine 12 (5-20) First sensationto void 215 (60-260) Maximum cystometriccapacity 500 (200-760) (leak) Pressureat maximum cystometric 50 cm (40-100) capacity
dominal straining, sigmoid bladder contractions, and relaxation of the pelvic floor muscles. A sensation of fullness was felt by all patients. Urodynamic studies performed in all 10 patients revealed pressure spikes that began at high volumes and peaked at 40 to 60 cm of water. Table II shows the residual urine, first sensation of filling, and capacity and pressure of the sigmoid bladder. Urinary frequency ranged from four to six hours. Some patients seemed to have less frequency earlier in the day, presumably because of fatigability of the external sphincter. Although the patients had a brief urge to void and occasional dampness at the urinary meatus on the first sensation of filling, they quickly learned to delay voiding until the urge was persistent. This usually occurred at or near the capacity of the bowel segment. Continence improved with time, rehabilitation, and practice. All patients were able to maintain continence at night if they awoke every two hours. However, most found this requirement unacceptable and chose to wear a condom catheter or external urethral compression device* instead; these were found to be of minor inconvenience. All 8 patients who achieved daytime continence were without evidence of disease. One patient received a cisplatin and doxorubicin (Adriamytin) regimen as adjuvant therapy for Stage P3B diseasewithout significant side effects developing. Two patients did not achieve daytime urinary continence, probably owing to poor selection of the candidates. One patient with Stage P3Nl diseasenever regained his strength, and metastatic diseasedeveloped within three months of surgery. The other patient initially achieved daytime continence but was psychologically unstable and could not master voiding exercises. ‘Baumrucker
UROLOGY
I
clamp,
Greenwald
APRIL
1987
/
Co.,
VOLUME
Lake
Station,
XXX,
Indiana.
NUMBER
4
Six months later squamous cell carcinoma of the lung developed, and he died soon after bone metastasis developed. Comment Bladder replacement with a segment of ileum has been described by Camey and others.15J6JQ Although patient acceptance and the long-term results of ileocystoplasty have appeared to be favorable, there is often a high incidence of nocturnal incontinence, ureteral reflux on the left side, urinary frequency, and a prolonged interval to achieving daytime continence after this procedure. In addition, the ileal segment cannot be brought down to the urethra for anastomosisin many patients. Tubular ileal and sigmoid segments were used by Hradec2 and K&s et ~1.~ in the 1960s. These investigators preferred the sigmoid over the ileal segment because of its greater capacity and better evacuation. They also believed it took longer to achieve continence with the ileal bladder after surgery. In our experience with sigmoid bladder replacement, patients achieved continence soon after removal of the catheter. The antireflux tunneling technique used to anastomose the ureters to each end of the loop proved securein all cases. Reflux has not been demonstrated in any of our patients to date. The length of the sigmoid mesentery was adequate to bring the loop into the pelvis in all cases. Voiding has been fairly complete with an acceptable frequency of four to six hours. As with the ileal bladder, the main problem with the sigmoid bladder is enuresis, presumably because of peristaltic contractions in the sigmoid bladder and relaxation of the pelvic floor muscles during sleep. Whether the use of detubularized bowel segments will obviate this problem remains to be seen. We have not considered it advisable to leave a cuff of prostatic capsule to improve continence.21Although our patients readily accepted condom catheter drainage at night, we are beginning to evaluate the use of the artificial urinary sphincter AS-800* to achieve nocturnal continence. Nonetheless, we believe that *American Medical Systems, Minneapolis,
UROLOGY
I
APRIL 1987
I VOLUME
Minnesota.
XXIX, NUMBER 4
a tubular sigmoid segment is a suitable alternative to tubular ileum or cecum for total bladder replacement. Box 394 Mayo Memorial Building Minneapolis, Minnesota 55455-0321 (DR. REDDY) References 1. Gilchrist RK, Merricks JW, Hamlin HH, and Rieger IT: Construction of substitute bladder and urethra, Surg Gynecol Obstet 96: 752 (1950). 2. Hradec EA: Bladder substitution: indications and results in 114 operations, J Uro194: 406 (1965). 3. Kiiss R, et al: Indications and early and late results of intestine-cystoplasty: a review of 185 cases, ibid 103: 53 (1970). 4. Charghi A, Charbonneau J, and Gauthier GE: Colocystoplasty for bladder enlargement and bladder substitution: a study of late results in 31 cases, ibid 97: 849 (1967). 5. Bricker EM: Bladder substitution after pelvic evisceration, Surg Clin North Am 30: 1511 (1950). 6. Mogg RA: The treatment of neurogenic urinary incontinence using the colonic conduit, Br J Urol 37: 681 (1965). 7. Daughtry JD, Susan LR Stewart BH, and Straffon RA: Ileal conduit and cystectomy: a lo-year retrospective study of ileal conduits performed in conjunction with cystectomy and with a minimum 5-year follow-up, J Urol 118: 556 (1977). 8. Pitts WR Jr, and Muecke EC: A 20-year experience with ileal conduits: the fate of the kidneys, ibid 122: 154 (1979). 9. Dunn M, Roberts JBM, Smith PJB, and Slade N: The longterm results of ileal conduit urinary diversion in children, Br J Urol 51: 458 (1979). 10. Orr JD, Shand JEG, Watters DAK, and Kirkland IS: Ileal conduit urinary diversion in children, an assessment of the longterm results, ibid 53: 424 (1981). 11. Altwein JE, Jonas U, and Hohenfellner R: Long-term follow-up of children with colon conduit urinary diversion and ureterosigmoidostomy, J Urol 118: 832 (1977). 12. Elder DD, Moisey CU, and Rees RWM: A long-term follow-up of the colonic conduit operation in children, Br J Urol 51: 462 (1979). 13. Kock NG, et al: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients, J Urol 128: 469 (1982). 14. Skinner DG, Boyd SD, and Lieskovsky G: Clinical experience with the Kock continent ileal reservoir for urinary diversion, ibid 132: 1101 (1984). 15. Rowland RG, Mitchell ME, and Bihrle R: The cecoileal continent urinary reservoir, World J Urol3: 185 (1985). 16. Steven K, et al: Transpubic cystectomy and ileocecal bladder replacement after preoperative radiotherapy for bladder cancer, J Urol 135: 470 (1986). 17. Thuroff JW, et al: The Mains pouch (mixed augmentation ileum’n zecum) for bladder augmentation and continent urinary diversion, Eur Urol 11: 152 (1985). 18. Mansson W, Colleen S, and Sundin T: The continent cecal reservoir for urinary diversion, World J Uro13: 173 (1985). 19. Camey M: Bladder replacement by ileocystoplasty following radical cystectomy, ibid 3: 161 (1985). 26. Allen TD, Peters PC, Sagalowsky AI, and Roehrborn C: The Camey procedure: preliminary results in 11 patients, ibid 3: 167 (1985). 21. Zinman L, and Libertino JA: Right colocystoplasty for bladder replacement, Urol Clin North Am 13: 321 (1986).
371
ABSTRACT-Sigmoid colon was used to replace the bladder after radical cystoprostatectomy in 10 patients with bladder cancer. A U- or l-shaped segment of the sigmoid colon was anastomosed at the most dependent portion to the urethral stump. The ureters were implanted in each end of the loop via an antireflux tunneling technique. There was no operative mortality, and the complications associated with this form of bladder replacement were minimal. All 10 patients had sensations of filling, and 8 of 10 achieved full daytime continence with complete voluntary emptying. Enuresis was present in all patients and required condom catheters during sleep, which were well tolerated. We believe that a tubular sigmoid segment is an acceptable alternative to tubular ileum or cecum for total bladder replacement.
Over the past four decades, many types of urinary diversion have been performed on patients after total cystectomy; ileal and colon conduits have been the most popular diversion procedures performed in this country.1-6 Interest in the creation of a continent urinary reservoir after cystectomy has increased recently because of (1) the disappointing long-term results with ileal and colon conduits,e-le (2) the increased demand for more socially and psychologically acceptable forms of urinary diversion, and (3) the recent acceptable morbidity rates with both radical cystectomy and continent urinary reservoir procedures. The continent urinary reservoir may be composed of ileum alone (the Kock pouch)13*14 or ileum in combination with the right side of the colon,l*l”l* with a catheterizable stoma on the abdominal wall or on the perineum in the female. Alternatively, the continent urinary reservoir may be “non-stomal,” in which tubular segments of the ileum or colon serve as a reservoir and are anastomosed to the membranous 368
urethra to achieve continence.le,zo Currently, the ileal segment positioned in a U configuration (the CameyiQ procedure) has gained the widest popularity. For the last two years we have used a tubular segment of sigmoid colon shaped in a U or J configuration for total bladder replacement in appropriate patients after radical cystoprostatectomy. Herein we report our surgical technique, clinical results, and urodynamic findings with this form of bladder replacement. Material and Methods Ten male patients underwent sigmoid bladder replacement after radical cystoprostatectomy for bladder cancer. Table I shows the age, tumor grade and stage, and the months of postoperative follow-up in these patients. Cold cup transurethral biopsies of the prostatic and bulbous urethra were performed preoperatively on all patients; these revealed no tumor or dysplasia. Barium enema studies were performed to rule out colon pathology. UROLOGY
/
APRIL
1987
I
VOLUME
XXIX,
NUMBER
4
1. Technique for bladder replacement with stgmoid colon after radical cystoprostatectomy: (A) anastomosis of sigmoid segment to urethral stump using six interrupted 2-O polyglactin sutures over 20-F Foley catheter; (B) implantation of ureters into each end of bowel segment via antireflux tunneling technique, using tunnels of approximately 5 to 6 cm; and (C) intubation of ureters with Silastic stents and placement of suprapubic catheter. Ureteral stents and suprapubic catheter are brought through bowel wall and abdominal wall. FIGURE
Radical cystoprostatectomy was performed in the standard fashion. Care was taken to transect the prostate at its apex and to avoid dissection around the pelvic floor, much in the fashion of a radical retropubic prostatectomy. Multiple specimens for frozen sections were obtained from the urethral margins to confirm that there was no residual tumor, and that no portion of the prostatic tissue or capsule was left behind. The sigmoid and descendingcolon was mobilized and a segment measuring 35 to 45 cm was isolated on its mesentery. Intestinal continuity was reestablished with a tension-free anastomosis; occasionally the splenic flexure had to be taken down to accomplish this. The isolated segment of colon was then folded with its “U” facing the pelvis. Depending on the mesentery, a U- or J-shaped configuration of the sigmoid colon was positioned and anastomosedat the most dependent part to the urethral stump using six 2-Opolyglactin (Vicryl) sutures over a 20-F Foley catheter (Fig. 1A).
TABLE
Pt. Age (Yrs.)
/
Clinical features in 10 patients with sigmoid bladder
‘Rumor Grade; Histology*
Stage Clinical Pathologic
Follow-up (Moss)
69 67
IV TCCB IV TCCB
T2 T3A
P2 P3B
20 14
77 67 57 70 57 62 52 46
V TCCB IV TCCB III TCCB IV TCCB IV TCCB, CIS III TCCB III TCCB, CIS V TCCB
T3A T3A Tl
P3Nl P3A Pl PO P2 P3A Pl, PlS P3A
14 14 13 12 11 9 8 8
‘TCCB tDaytime
UROLOGY
I.
era1
APRIL
= transitional continence.
1987
/
VOLUME
:; T3A Tl, TlS T3A
cell carcinoma
XXIX,
of bladder;
NUMBER4
CIS
= carcinoma
Comments Continent t Continent; cisplatin and doxorubicin Deceased Deceased Continent Continent Continent Continent Continent Continent
in situ.
369
The length of the mesentery in all cases was adequate to bring the loop into the pelvis without making deep incisions into the mesentery. The ureters were implanted into each limb of the colon segment using the Leadbetter tunneling technique; the tunnels were approximately 5 to 6 cm in length (Fig. 1B). The ureters were intubated with Silastic stents. The stems, along with a suprapubic catheter, were led out through the bowel wall and abdominal wall (Fig. 1C). Penrose drains were placed in the pelvis, and the 20-F Foley catheter was positioned transurethrally to drain the limb of the bowel segment opposite the suprapubic catheter. The urethral and suprapubic catheters were not irrigated the first seventy-two hours postoperatively since most of the urine drained through the ureteral stents. Thereafter, the bowel segment was irrigated with normal saline once every six hours to prevent the formation of mucous plugs. Two weeks postoperatively a cystogram and catheterogram were performed. If no leak was detected, the ureteral stents and Penrose drain were removed. The following day the urethral and suprapubic catheters were removed as appropriate. The patients were followed up with isotopic renography, voiding cystography, and evaluation of serum electrolytes, blood urea nitrogen, and creatinine at threemonth intervals. Cystoscopy with random biopsies of the urethral margins was performed at six-month intervals. Results There was no operative mortality. Temporary perineal palsy secondary to surgical positioning developed in 1 patient but gradually resolved, Another patient required re-exploration to remove a retained portion of an abdominal drain. Significant mucous production from the bowel segment caused occasional outlet obstruction in 1 patient; this resolved with time and the use of acetic acid irrigations by self-intermittent catheterization. No serum electrolyte abnormalities were recorded. Renal function was stable postoperatively with no changesobserved on intravenous pyelography or renography. Reflux was not observed. Urine cultures remained sterile in all patients. Eight of 10 patients achieved daytime continence within four to six weeks. Voiding was accomplished through a combination of ab370
TABLE
II.
Urodynamic features in 10 patients with sigmoid bladder
Median (Range) Urodynamics (ml*> Residualurine 12 (5-20) First sensationto void 215 (60-260) Maximum cystometriccapacity 500 (200-760) (leak) Pressureat maximum cystometric 50 cm (40-100) capacity
dominal straining, sigmoid bladder contractions, and relaxation of the pelvic floor muscles. A sensation of fullness was felt by all patients. Urodynamic studies performed in all 10 patients revealed pressure spikes that began at high volumes and peaked at 40 to 60 cm of water. Table II shows the residual urine, first sensation of filling, and capacity and pressure of the sigmoid bladder. Urinary frequency ranged from four to six hours. Some patients seemed to have less frequency earlier in the day, presumably because of fatigability of the external sphincter. Although the patients had a brief urge to void and occasional dampness at the urinary meatus on the first sensation of filling, they quickly learned to delay voiding until the urge was persistent. This usually occurred at or near the capacity of the bowel segment. Continence improved with time, rehabilitation, and practice. All patients were able to maintain continence at night if they awoke every two hours. However, most found this requirement unacceptable and chose to wear a condom catheter or external urethral compression device* instead; these were found to be of minor inconvenience. All 8 patients who achieved daytime continence were without evidence of disease. One patient received a cisplatin and doxorubicin (Adriamytin) regimen as adjuvant therapy for Stage P3B diseasewithout significant side effects developing. Two patients did not achieve daytime urinary continence, probably owing to poor selection of the candidates. One patient with Stage P3Nl diseasenever regained his strength, and metastatic diseasedeveloped within three months of surgery. The other patient initially achieved daytime continence but was psychologically unstable and could not master voiding exercises. ‘Baumrucker
UROLOGY
I
clamp,
Greenwald
APRIL
1987
/
Co.,
VOLUME
Lake
Station,
XXX,
Indiana.
NUMBER
4
Six months later squamous cell carcinoma of the lung developed, and he died soon after bone metastasis developed. Comment Bladder replacement with a segment of ileum has been described by Camey and others.15J6JQ Although patient acceptance and the long-term results of ileocystoplasty have appeared to be favorable, there is often a high incidence of nocturnal incontinence, ureteral reflux on the left side, urinary frequency, and a prolonged interval to achieving daytime continence after this procedure. In addition, the ileal segment cannot be brought down to the urethra for anastomosisin many patients. Tubular ileal and sigmoid segments were used by Hradec2 and K&s et ~1.~ in the 1960s. These investigators preferred the sigmoid over the ileal segment because of its greater capacity and better evacuation. They also believed it took longer to achieve continence with the ileal bladder after surgery. In our experience with sigmoid bladder replacement, patients achieved continence soon after removal of the catheter. The antireflux tunneling technique used to anastomose the ureters to each end of the loop proved securein all cases. Reflux has not been demonstrated in any of our patients to date. The length of the sigmoid mesentery was adequate to bring the loop into the pelvis in all cases. Voiding has been fairly complete with an acceptable frequency of four to six hours. As with the ileal bladder, the main problem with the sigmoid bladder is enuresis, presumably because of peristaltic contractions in the sigmoid bladder and relaxation of the pelvic floor muscles during sleep. Whether the use of detubularized bowel segments will obviate this problem remains to be seen. We have not considered it advisable to leave a cuff of prostatic capsule to improve continence.21Although our patients readily accepted condom catheter drainage at night, we are beginning to evaluate the use of the artificial urinary sphincter AS-800* to achieve nocturnal continence. Nonetheless, we believe that *American Medical Systems, Minneapolis,
UROLOGY
I
APRIL 1987
I VOLUME
Minnesota.
XXIX, NUMBER 4
a tubular sigmoid segment is a suitable alternative to tubular ileum or cecum for total bladder replacement. Box 394 Mayo Memorial Building Minneapolis, Minnesota 55455-0321 (DR. REDDY) References 1. Gilchrist RK, Merricks JW, Hamlin HH, and Rieger IT: Construction of substitute bladder and urethra, Surg Gynecol Obstet 96: 752 (1950). 2. Hradec EA: Bladder substitution: indications and results in 114 operations, J Uro194: 406 (1965). 3. Kiiss R, et al: Indications and early and late results of intestine-cystoplasty: a review of 185 cases, ibid 103: 53 (1970). 4. Charghi A, Charbonneau J, and Gauthier GE: Colocystoplasty for bladder enlargement and bladder substitution: a study of late results in 31 cases, ibid 97: 849 (1967). 5. Bricker EM: Bladder substitution after pelvic evisceration, Surg Clin North Am 30: 1511 (1950). 6. Mogg RA: The treatment of neurogenic urinary incontinence using the colonic conduit, Br J Urol 37: 681 (1965). 7. Daughtry JD, Susan LR Stewart BH, and Straffon RA: Ileal conduit and cystectomy: a lo-year retrospective study of ileal conduits performed in conjunction with cystectomy and with a minimum 5-year follow-up, J Urol 118: 556 (1977). 8. Pitts WR Jr, and Muecke EC: A 20-year experience with ileal conduits: the fate of the kidneys, ibid 122: 154 (1979). 9. Dunn M, Roberts JBM, Smith PJB, and Slade N: The longterm results of ileal conduit urinary diversion in children, Br J Urol 51: 458 (1979). 10. Orr JD, Shand JEG, Watters DAK, and Kirkland IS: Ileal conduit urinary diversion in children, an assessment of the longterm results, ibid 53: 424 (1981). 11. Altwein JE, Jonas U, and Hohenfellner R: Long-term follow-up of children with colon conduit urinary diversion and ureterosigmoidostomy, J Urol 118: 832 (1977). 12. Elder DD, Moisey CU, and Rees RWM: A long-term follow-up of the colonic conduit operation in children, Br J Urol 51: 462 (1979). 13. Kock NG, et al: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients, J Urol 128: 469 (1982). 14. Skinner DG, Boyd SD, and Lieskovsky G: Clinical experience with the Kock continent ileal reservoir for urinary diversion, ibid 132: 1101 (1984). 15. Rowland RG, Mitchell ME, and Bihrle R: The cecoileal continent urinary reservoir, World J Urol3: 185 (1985). 16. Steven K, et al: Transpubic cystectomy and ileocecal bladder replacement after preoperative radiotherapy for bladder cancer, J Urol 135: 470 (1986). 17. Thuroff JW, et al: The Mains pouch (mixed augmentation ileum’n zecum) for bladder augmentation and continent urinary diversion, Eur Urol 11: 152 (1985). 18. Mansson W, Colleen S, and Sundin T: The continent cecal reservoir for urinary diversion, World J Uro13: 173 (1985). 19. Camey M: Bladder replacement by ileocystoplasty following radical cystectomy, ibid 3: 161 (1985). 26. Allen TD, Peters PC, Sagalowsky AI, and Roehrborn C: The Camey procedure: preliminary results in 11 patients, ibid 3: 167 (1985). 21. Zinman L, and Libertino JA: Right colocystoplasty for bladder replacement, Urol Clin North Am 13: 321 (1986).
371