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Closure pressure studies of the tapered ileal segment and reinforced ileocecal valve in continent urinary diversion
CLOSURE PRESSURE STUDIES OF THE TAPERED ILEAL SEGMENT AND REINFORCED ILEOCECAL VALVE IN CONTINENT URINARY DIVERSION G. ALFONSO LATIFF, M.D. DARWICH E. BEJANY, M.D. VICTOR A. POLITANO, M.D From the Division of Urology, Carle Clinic Association, Urbana, Illinois, and the Department of Urology, University of Miami School of Medicine, Miami, Florida
ABSTRACT-Objective. To evaluate the function of the continent segment, a tapered terminal ileum with reinforced ileocecal valve, utilized in continent colonic urinary reservoir. Methods. Closure pressure study of the continent mechanism was performed in 20 patients with the colonic reservoir empty and at maximum capacity. Results. Maximum pressure within the tapered ileum was recorded at the reinforced ileocecal valve and was recorded when the reservoir was full. Pressure ranged between 60 and 200 cm water (mean, 139.5 cm H,O). The pressure within the reinforced segment exceeded the pressure within the reservoir at all times. Conclusions. When properly reinforced, the ileocecal valve is able to maintain a closing pressure above that of the detubularized urinary reservoir, making it a reliable continent mechanism.
Over the last decade much work has been undertaken in the creation of a continent urinary diversion. There is some disagreement on whether the large or small bowel is more appropriate for constructing the receptacle. Two principal forms have been used. The Kock pouch (ileal reservoir) with an intussuscepted ileal nipple valve for continence’ and various modifications of the ileocecal reservoir.’ These procedures have three primary objectives: urinary continence, adequate storage system, and upper tract protection mechanism. The main challenge was to find an uncomplicated and effective technique to provide reliable continence. Some of the continent mechanisms used are the construction of intussuscepted nipple valves, plication of the distal ileal segment, the Mitrofanoff principle, and hydraulic type valves, the Benchekroun valve as an example.‘-” Tapering of the distal ileum with reinforcement of the ileocecal valve to attain continence was originally described by Bejany and Politano’ and has been used since January 1986 with excellent results. Others have adopted the tech-
614
nique of tapering and the concept of reinforcement of the ileocecal junction with similar results.” In an effort to determine better the mechanics of this continent segment we have studied the closing pressure of the ileal segment in relation to the intraluminal pressure of the colonic pouch. MATERIAL AND METHODS Urodynamic studies were performed in 20 patients, ages ranging from fifty-one to sixty-nine years (mean, 57 years), who had a reinforced ileocecal continent reservoir. Surgical technique of this form of urinary diversion using a detubularized colonic segment with a tapered ileum and reinforced ileocecal valve has been previously described.’ Follow-up for these patients was fifty-two to eighty-nine months. A model 1106 Urolab urodynamics recorder was used to study the pressure within the pouch and the tapered distal ileum. A 7 F double-lumen (Bard) urodynamics catheter was placed through the ileal segment into the urinary reservoir. The pouch was filled with water at a rate of 20 cc/min until the first sensation of fullness, at which point the rate was reduced to 10 cc/min until maximum capacity (discomfort) was reached. Reduction in
frlling rate was to maintain a more physiologic rate of tilling at high volumes, avoiding overstimulation and discomfort and allowing maximal reservoir filling. With the reservoir at maximum capacity, measurement of the pressure within the tapered ileum was then carried out using a 10 F Lifetech urethral pressure profile (UPP) catheter. We introduced this catheter and after inspecting the pressure within the reservoir, using a Harvard pump to mfuse at a constant rate of 5 cc/min, the catheter was withdrawn from the reservoir at a fixed rate of 1 cm/set and the pressure within the ileocecal junction and tapered ileum was monitored. After draining the reservoir. the 10 F UPP catheter was reintroduced into the pouch. Using the same technique, the pressure within the pouch and the tapered ileum was restudied. All pressure changes were recorded and analyzed. Videourodynamic studies, with fluoroscopy, were done in 2 patients. Maximum pressure was recorded at the ileocecal junction. Similar findings in such reservoirs have been reported by other investigators.” Because of the consistent findings of highest pressures at the area of the ileocecal valve, no fluoroscopy was utilized in the rest of the patients studied. RESULTS The maximum capacity of the pouch ranged from 650 to 920 cc (mean capacity, 782 cc). First sensation of filling ranged between 400 and 520 cc. Reservoir pressure recorded at maximum capacity was 20 to 40 cm water. One patient had occasional pressure spikes with maximum pressure recorded at 49 cm water. Pressure recorded within the ileocecal junction and tapered ileum revealed maximum resistance at the proximal 3 to 4 cm, area of the reinforcement sutures. Pressures within the reinforced segment ranged from 40 to 82 cm water (mean, 65.6) while the reservoir was empty, and 65 to 200 cm water (mean. 139.5) with the reservoir at full capacity. There was a significant drop in pressure distal to the ileocecal junction in all of the patients studied, ranging between 5 and 18 cm water. The pressure within the reinforced segment of ileum exceeded the pressure within the reservoir at all times. COMMENT The important principles to the creation of a continent urinary reservoir include consideration of bowel configuration, accommodation, viscoelasticity, and contractility. The larger radius of a detubularized bowel segment provides larger capacity and lower pressure, which significantly contributes to an improved continence rate. Gilchrist ct al.’ noted
that in addition to bladder size, continence was dependent on the competency of the lleocecal valve and the peristaltic action of the ileum. Modification of the Gilchrist procedure consisted of improvement of the efferent limb continence mechanism by plicating the terminal ileum and detubularization of the bowel segment to create a low pressure reservoir. Rowland et t~l.~reported an overall continence rate of 92 percent and a 13 percent revision of the plicated efferent limb. Videourodynamic study of such a reservoir showed the lack of resistance of the ilrocecal valve and plicated ileum in one incontinent po~ch.~ Benchekroun ct CI~.~reported a 92 percent continence rate after revising thirty-six valves (26.5%) in 136 patients when utilizing the hydraulic ileal valve. Adequacy of the ileocecal sphincter in preventing retrograde flow is still questioned, since up to 90 percent of barium enema studies reveal reflux into the ileum.‘O Furthermore, the competency of the ileocecal valve is significantly affected in radiated bowel because of the fixed position of the cecum and distant ileum.” Therefore, we believe that reinforcing the ileocecal valve is essential to maintain continence. To improve continence and avoid the complication of unfolding of the ilcal segment, we adopted the technique of tapering the distal ileum and reinforcement of the ileocecal junction with three purse-string sutures. Our overall continence rate has been 98.6 percent. Rowlandh also reported on his improved continence rate since he adopted the technique of tapering and reinforcement of the ileocecal junction by plicating the terminal ileum. Urodynamic studies demonstrated that the pressure in the reinforced segment exceeded the reservoir pressure at all times, with a marked drop in the pressure distal to the ileocecal reinforcement. We think, as do others,lZ that the pressure inside this segment probably contributes no significant activity toward the role of continence. The possibility exists that the 10 F UPP catheter may have produced an artificial elevation on the intraluminal pressure recorded. Any catheter introduced into a small lumen with the addition of fluid infusion introduces some degree of artificial pressure elevation. Since the catheterizable conduit is large enough to accept an 18 F catheter, we think the degree of artifact elevation is not very large. The same size catheter has been used consistently while evaluating the pressure in the continent segment of all our patients with the reservoir empty and at full capacity. The most important findings are the relative values found. We have found that: ( 1) the pressure is highest at the level of 1he reinforced
ileocecal junction, (2) this pressure exceeded the reservoir pressure at all times, and (3) the pressure distal to the reinforcement falls and does not provide significant activity toward the role of continence. It is possible that a smaller catheter with multiple microtransducers might give a more realistic pressure recording; however, the basic findings reported here would certainly remain the same. Occasional difficulty in catheterizing the continent stoma was noted in 3 of our early cases. This occurred only with marked distention of the reservoir. We attributed this problem to possible angulation of the tapered ileal segment between the pouch and the abdominal wall. Similar problems were encountered by Chin and Ferguson’ i with an Indiana continent reservoir. Because of information gained from our studies, we have shortened the ileal segment without compromising continence. The length of the segment needs to be only long enough to traverse the abdominal wall. So far, no further problems with catheterization have been encountered with this modification. In conclusion, the technique of tapering and reinforcement of the ileocecal valve that we adopted is technically sound, easy to perform, reliable, and has provided our patients with the highest rate of continence. G. Alfonso Latiff. M.D. Division
of Urfllo~
IO. Roberts SS. Minton JP_and Zolingcr KM. Obstruction of the large bowel, in Turrel R (Ed): Discusc of lhc Colon und Rectum. 2nd ed. Philadelphia, WB Saunders, 1969, vol 2, pp 667-683. II. Russell JC, and Welch JP: Operative management of radiation injuries of the intestinal tract. Am J Surg 137: 433-442, 1979. 12. Schiff SF, and Lytton 8: IncontInence after augmentation cystoplasty and internal diversion. Ural Clin North Am 18: 383-392, 1991. 13. Chin JL. and Ferguson IK: Intermittent difficulty with catheterization of Indiana contment urinary reservoir: use of llexlble ureteroscope. J Urol (2ptl) 142: 371. 1989. EDITORIAL COMMENT What are the functional factors in the bowel that arc taken advantage of here to produce continence? Of the four possible ways of increasing pressure in the conduit (sphincteric, peristaltic, equilibrated, and valvular,‘) the tapered distal ileum technique makes use of the first two. First, sphinctrric compression IS achieved by two maneuvers. The terminal ileum is reduced in caliber to 14 F, m this cast b) trimming the excess circumference after longitudinal clamping, and then is reinforced by adding three constricting sutures. Whether sutures distal to the ilcocecal valve “reinforce” it might he questioned; they probably only add to ileal sphincteric action. Second, peristalsis, by reflex contraction of the terminal ileum, also assists continence, as shown by Carroll et llL2 The urodynamic studies by Latlff cl (11.clearly prove the cffectiveness of these simple surgical maneuvers by showing the persistence of a pressure differential between the ileal and plicatlon cecal contents. A word of caution: overenthusiastic can be obstructive. Frank
Cm-k Clinic Associalion
602 w LJniversily Avmue Urbana, Illinois 61801 REFERENCES 1. Kock NC, Nilson AE, Nilsson LO. Norlen LJ, and Phillipson BM: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Ural 128: 469-475, 1982. 2. Gilchrist RK, Merricks JW, Hamlin HH, and Rieger IT: Construction of a substitute bladder and urethra. Surg Gynecol Obstet 90: 752-760, 1950. 3. Mansson W, Colleen S, and Sundin P: Continent caecal reservoir in urinary diversion. Br J Urol 56: 359-365, 1984. 4. Rowland RG, Mitchell ME, Bihrle R, Kahnoskl RJ, and Piser JE: Indiana continent urinary reservoir. J Ural 137: 1136-1139, 1987. 5. Duckett JW, and Snyder HM 3rd: Use of the Mitrofanoff principle in urinary reconstruction. Urol Clin North Am 13: 271-274, 1986. 6. Benchekroun A, Essakalli N, Faik M. Marznuk M, Hachimi M, and Abakka T: Contment urostomy with hydraulic ileal valve in 136 patients: 13 years of experience. J Ural 142: 46-51, 1989. 7. Bejany DE, and Politano VA: Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir. J Urol 140: 491-494, 1988. 8. Rowland RG: A straightforward surgical approach to urinary diversion. Contemp Urol 2: 13-16, 1990. 9. Juma S, Morales A, and Emerson L: The mechanisms of continence in the Indiana pouch: a video-urodynamic study J Ural 143: 973-974, 1990.
Hinman,JI.,
M.D. Urology Iinivrrsil~ ofCuliforniu Room II-.57.5, Box 0738 Ca/$orniu 941450738 Dcpurfrnfnt
Sun Francisto,
cf
REFERENCES 1. Hinman
F Jr: Functional classification of conduits for continent dlversion. J Urol 144: 27, 1990. 2. Carroll PR, Presti JC Jr, McAninch JW, and Tanagho EA: Functional characteristics reservotr: mechanisms 1032, 1989.
of the continent ileocecal urinar) of urinary continence, ] Urol 142:
REPLY BY AUTHORS We appreciate
the comments
by Dr. Hinman. We would like to clarify the reasoning in the location of the reinforcing suture placement. Cohen and co-workers’ performed manometric studies of the human ileocecal junction and found this functional sphincter to measure 4 cm. The authors’ sought to reinforce this functlonal sphincter by placing three sutures, I cm apart, on the ileocecal valve and not on the proximal tapered ileum. REFERENCES 1. Cohen S, Harris LD, and Levitan R: Manometric characteristics of the human ilcocecal junctional zone. Gastroenterology 54: 72, 1968. 2. Bejany DE, and Polirano VA: Stapled and nonstapled tapered distal Ileum for construction of a continent colonic urinary reservoir. J Ural 140: 491, 1988.
ABSTRACT-Objective. To evaluate the function of the continent segment, a tapered terminal ileum with reinforced ileocecal valve, utilized in continent colonic urinary reservoir. Methods. Closure pressure study of the continent mechanism was performed in 20 patients with the colonic reservoir empty and at maximum capacity. Results. Maximum pressure within the tapered ileum was recorded at the reinforced ileocecal valve and was recorded when the reservoir was full. Pressure ranged between 60 and 200 cm water (mean, 139.5 cm H,O). The pressure within the reinforced segment exceeded the pressure within the reservoir at all times. Conclusions. When properly reinforced, the ileocecal valve is able to maintain a closing pressure above that of the detubularized urinary reservoir, making it a reliable continent mechanism.
Over the last decade much work has been undertaken in the creation of a continent urinary diversion. There is some disagreement on whether the large or small bowel is more appropriate for constructing the receptacle. Two principal forms have been used. The Kock pouch (ileal reservoir) with an intussuscepted ileal nipple valve for continence’ and various modifications of the ileocecal reservoir.’ These procedures have three primary objectives: urinary continence, adequate storage system, and upper tract protection mechanism. The main challenge was to find an uncomplicated and effective technique to provide reliable continence. Some of the continent mechanisms used are the construction of intussuscepted nipple valves, plication of the distal ileal segment, the Mitrofanoff principle, and hydraulic type valves, the Benchekroun valve as an example.‘-” Tapering of the distal ileum with reinforcement of the ileocecal valve to attain continence was originally described by Bejany and Politano’ and has been used since January 1986 with excellent results. Others have adopted the tech-
614
nique of tapering and the concept of reinforcement of the ileocecal junction with similar results.” In an effort to determine better the mechanics of this continent segment we have studied the closing pressure of the ileal segment in relation to the intraluminal pressure of the colonic pouch. MATERIAL AND METHODS Urodynamic studies were performed in 20 patients, ages ranging from fifty-one to sixty-nine years (mean, 57 years), who had a reinforced ileocecal continent reservoir. Surgical technique of this form of urinary diversion using a detubularized colonic segment with a tapered ileum and reinforced ileocecal valve has been previously described.’ Follow-up for these patients was fifty-two to eighty-nine months. A model 1106 Urolab urodynamics recorder was used to study the pressure within the pouch and the tapered distal ileum. A 7 F double-lumen (Bard) urodynamics catheter was placed through the ileal segment into the urinary reservoir. The pouch was filled with water at a rate of 20 cc/min until the first sensation of fullness, at which point the rate was reduced to 10 cc/min until maximum capacity (discomfort) was reached. Reduction in
frlling rate was to maintain a more physiologic rate of tilling at high volumes, avoiding overstimulation and discomfort and allowing maximal reservoir filling. With the reservoir at maximum capacity, measurement of the pressure within the tapered ileum was then carried out using a 10 F Lifetech urethral pressure profile (UPP) catheter. We introduced this catheter and after inspecting the pressure within the reservoir, using a Harvard pump to mfuse at a constant rate of 5 cc/min, the catheter was withdrawn from the reservoir at a fixed rate of 1 cm/set and the pressure within the ileocecal junction and tapered ileum was monitored. After draining the reservoir. the 10 F UPP catheter was reintroduced into the pouch. Using the same technique, the pressure within the pouch and the tapered ileum was restudied. All pressure changes were recorded and analyzed. Videourodynamic studies, with fluoroscopy, were done in 2 patients. Maximum pressure was recorded at the ileocecal junction. Similar findings in such reservoirs have been reported by other investigators.” Because of the consistent findings of highest pressures at the area of the ileocecal valve, no fluoroscopy was utilized in the rest of the patients studied. RESULTS The maximum capacity of the pouch ranged from 650 to 920 cc (mean capacity, 782 cc). First sensation of filling ranged between 400 and 520 cc. Reservoir pressure recorded at maximum capacity was 20 to 40 cm water. One patient had occasional pressure spikes with maximum pressure recorded at 49 cm water. Pressure recorded within the ileocecal junction and tapered ileum revealed maximum resistance at the proximal 3 to 4 cm, area of the reinforcement sutures. Pressures within the reinforced segment ranged from 40 to 82 cm water (mean, 65.6) while the reservoir was empty, and 65 to 200 cm water (mean. 139.5) with the reservoir at full capacity. There was a significant drop in pressure distal to the ileocecal junction in all of the patients studied, ranging between 5 and 18 cm water. The pressure within the reinforced segment of ileum exceeded the pressure within the reservoir at all times. COMMENT The important principles to the creation of a continent urinary reservoir include consideration of bowel configuration, accommodation, viscoelasticity, and contractility. The larger radius of a detubularized bowel segment provides larger capacity and lower pressure, which significantly contributes to an improved continence rate. Gilchrist ct al.’ noted
that in addition to bladder size, continence was dependent on the competency of the lleocecal valve and the peristaltic action of the ileum. Modification of the Gilchrist procedure consisted of improvement of the efferent limb continence mechanism by plicating the terminal ileum and detubularization of the bowel segment to create a low pressure reservoir. Rowland et t~l.~reported an overall continence rate of 92 percent and a 13 percent revision of the plicated efferent limb. Videourodynamic study of such a reservoir showed the lack of resistance of the ilrocecal valve and plicated ileum in one incontinent po~ch.~ Benchekroun ct CI~.~reported a 92 percent continence rate after revising thirty-six valves (26.5%) in 136 patients when utilizing the hydraulic ileal valve. Adequacy of the ileocecal sphincter in preventing retrograde flow is still questioned, since up to 90 percent of barium enema studies reveal reflux into the ileum.‘O Furthermore, the competency of the ileocecal valve is significantly affected in radiated bowel because of the fixed position of the cecum and distant ileum.” Therefore, we believe that reinforcing the ileocecal valve is essential to maintain continence. To improve continence and avoid the complication of unfolding of the ilcal segment, we adopted the technique of tapering the distal ileum and reinforcement of the ileocecal junction with three purse-string sutures. Our overall continence rate has been 98.6 percent. Rowlandh also reported on his improved continence rate since he adopted the technique of tapering and reinforcement of the ileocecal junction by plicating the terminal ileum. Urodynamic studies demonstrated that the pressure in the reinforced segment exceeded the reservoir pressure at all times, with a marked drop in the pressure distal to the ileocecal reinforcement. We think, as do others,lZ that the pressure inside this segment probably contributes no significant activity toward the role of continence. The possibility exists that the 10 F UPP catheter may have produced an artificial elevation on the intraluminal pressure recorded. Any catheter introduced into a small lumen with the addition of fluid infusion introduces some degree of artificial pressure elevation. Since the catheterizable conduit is large enough to accept an 18 F catheter, we think the degree of artifact elevation is not very large. The same size catheter has been used consistently while evaluating the pressure in the continent segment of all our patients with the reservoir empty and at full capacity. The most important findings are the relative values found. We have found that: ( 1) the pressure is highest at the level of 1he reinforced
ileocecal junction, (2) this pressure exceeded the reservoir pressure at all times, and (3) the pressure distal to the reinforcement falls and does not provide significant activity toward the role of continence. It is possible that a smaller catheter with multiple microtransducers might give a more realistic pressure recording; however, the basic findings reported here would certainly remain the same. Occasional difficulty in catheterizing the continent stoma was noted in 3 of our early cases. This occurred only with marked distention of the reservoir. We attributed this problem to possible angulation of the tapered ileal segment between the pouch and the abdominal wall. Similar problems were encountered by Chin and Ferguson’ i with an Indiana continent reservoir. Because of information gained from our studies, we have shortened the ileal segment without compromising continence. The length of the segment needs to be only long enough to traverse the abdominal wall. So far, no further problems with catheterization have been encountered with this modification. In conclusion, the technique of tapering and reinforcement of the ileocecal valve that we adopted is technically sound, easy to perform, reliable, and has provided our patients with the highest rate of continence. G. Alfonso Latiff. M.D. Division
of Urfllo~
IO. Roberts SS. Minton JP_and Zolingcr KM. Obstruction of the large bowel, in Turrel R (Ed): Discusc of lhc Colon und Rectum. 2nd ed. Philadelphia, WB Saunders, 1969, vol 2, pp 667-683. II. Russell JC, and Welch JP: Operative management of radiation injuries of the intestinal tract. Am J Surg 137: 433-442, 1979. 12. Schiff SF, and Lytton 8: IncontInence after augmentation cystoplasty and internal diversion. Ural Clin North Am 18: 383-392, 1991. 13. Chin JL. and Ferguson IK: Intermittent difficulty with catheterization of Indiana contment urinary reservoir: use of llexlble ureteroscope. J Urol (2ptl) 142: 371. 1989. EDITORIAL COMMENT What are the functional factors in the bowel that arc taken advantage of here to produce continence? Of the four possible ways of increasing pressure in the conduit (sphincteric, peristaltic, equilibrated, and valvular,‘) the tapered distal ileum technique makes use of the first two. First, sphinctrric compression IS achieved by two maneuvers. The terminal ileum is reduced in caliber to 14 F, m this cast b) trimming the excess circumference after longitudinal clamping, and then is reinforced by adding three constricting sutures. Whether sutures distal to the ilcocecal valve “reinforce” it might he questioned; they probably only add to ileal sphincteric action. Second, peristalsis, by reflex contraction of the terminal ileum, also assists continence, as shown by Carroll et llL2 The urodynamic studies by Latlff cl (11.clearly prove the cffectiveness of these simple surgical maneuvers by showing the persistence of a pressure differential between the ileal and plicatlon cecal contents. A word of caution: overenthusiastic can be obstructive. Frank
Cm-k Clinic Associalion
602 w LJniversily Avmue Urbana, Illinois 61801 REFERENCES 1. Kock NC, Nilson AE, Nilsson LO. Norlen LJ, and Phillipson BM: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Ural 128: 469-475, 1982. 2. Gilchrist RK, Merricks JW, Hamlin HH, and Rieger IT: Construction of a substitute bladder and urethra. Surg Gynecol Obstet 90: 752-760, 1950. 3. Mansson W, Colleen S, and Sundin P: Continent caecal reservoir in urinary diversion. Br J Urol 56: 359-365, 1984. 4. Rowland RG, Mitchell ME, Bihrle R, Kahnoskl RJ, and Piser JE: Indiana continent urinary reservoir. J Ural 137: 1136-1139, 1987. 5. Duckett JW, and Snyder HM 3rd: Use of the Mitrofanoff principle in urinary reconstruction. Urol Clin North Am 13: 271-274, 1986. 6. Benchekroun A, Essakalli N, Faik M. Marznuk M, Hachimi M, and Abakka T: Contment urostomy with hydraulic ileal valve in 136 patients: 13 years of experience. J Ural 142: 46-51, 1989. 7. Bejany DE, and Politano VA: Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir. J Urol 140: 491-494, 1988. 8. Rowland RG: A straightforward surgical approach to urinary diversion. Contemp Urol 2: 13-16, 1990. 9. Juma S, Morales A, and Emerson L: The mechanisms of continence in the Indiana pouch: a video-urodynamic study J Ural 143: 973-974, 1990.
Hinman,JI.,
M.D. Urology Iinivrrsil~ ofCuliforniu Room II-.57.5, Box 0738 Ca/$orniu 941450738 Dcpurfrnfnt
Sun Francisto,
cf
REFERENCES 1. Hinman
F Jr: Functional classification of conduits for continent dlversion. J Urol 144: 27, 1990. 2. Carroll PR, Presti JC Jr, McAninch JW, and Tanagho EA: Functional characteristics reservotr: mechanisms 1032, 1989.
of the continent ileocecal urinar) of urinary continence, ] Urol 142:
REPLY BY AUTHORS We appreciate
the comments
by Dr. Hinman. We would like to clarify the reasoning in the location of the reinforcing suture placement. Cohen and co-workers’ performed manometric studies of the human ileocecal junction and found this functional sphincter to measure 4 cm. The authors’ sought to reinforce this functlonal sphincter by placing three sutures, I cm apart, on the ileocecal valve and not on the proximal tapered ileum. REFERENCES 1. Cohen S, Harris LD, and Levitan R: Manometric characteristics of the human ilcocecal junctional zone. Gastroenterology 54: 72, 1968. 2. Bejany DE, and Polirano VA: Stapled and nonstapled tapered distal Ileum for construction of a continent colonic urinary reservoir. J Ural 140: 491, 1988.