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URETEROCYSTOPLASTY: IS IT NECESSARY TO DETUBULARIZE THE DISTAL URETER?
0022-5347/98/1603-0851$03.00/0
W EJOURNAL OF UROLOGY
Vol. 160, 851-853, September 1998 Printed in U.S.A.
Copyright 0 1998 by AMERICAN UROLOCICAL ASSOCIATION, INC
URETEROCYSTOPLASTY: IS IT NECESSARY TO DETUBULARIZE THE DISTAL URETER? MARK C. ADAMS, JOHN W. BROCK, 111, JOHN C. POPE, IV AND RICHARD C. RINK From the Vanderbilt University Children's Hospital, Nashville, Tennessee, and James Whitcomb Riley Hospital for Children, Indiana University, Indianapolis, Indiana
ABSTRACT
Purpose: The conventional technique for ureterocystoplasty includes complete mobilization and incision of the ureter. We describe a modified procedure in which the distal 3 cm. of ureter are left in place and intact. Materials and Methods: This modification has been used in our last 13 cases of ureterocystoplasty. The first 7 patients with followup of more than a year (mean 28 months) are included in this series, and 6 have undergone video urodynamic evaluation before and after reconstruction. Results: Clinical results have been good. Four patients who have been toilet trained are continent. There have been no problems from stagnant urine in the intact ureter with only 1 case of pyelonephritis and no bladder calculi. Mean bladder capacity on cystometrogram has increased from 103 to 236 ml. after reconstruction and reached 137%of expected capacity for age and size (range 110 to 155%).No uninhibited contractions or problems with compliance have been noted. Conclusions: The distal ureter may be left intact for ureterocystoplasty to protect ureteral blood supply. This modified technique is sound from a physiological standpoint, technically easier and associated with good results. KEY WORDS:ureter, bladder, urodynamics Since early reports ureterocystoplasty for bladder augmentation in appropriate patients with a dilated ureter has been associated with good results.l.2 Churchill et a1 presented good clinical and urodynamic results in a large group of pediatric patients after ureterocystoplasty.3 They later compared children matched for age and diagnosis undergoing either ureterocystoplasty or ileocystoplasty, and documented equivalent results on cystometry.4 Clearly if enough dilated ureter can be used in the bladder, a compliant reservoir with urothelial lining can be achieved with less potential for side effects than enterocystoplasty. The technique of ureterocystoplasty has essentially remained the same and has largely been accepted as convention since these reports. The technique involves mobilization of the entire ureter with the ureteral adventitia and longitudinal blood supply. The ureter is then incised, with the incision carried through the ureteral orifice where it connects with the cystotomy incision. A month after the initial report of Bellinger,2 Wolf and E k . 1. If bladder is considered to be sphere before and after Turzan described a single case of ureterocystoplasty in which ureterocystoplasty and ureter is uniform cylinder (A), final bladder the proximal ureter was opened and reconfigured, and the surface area and volume can be calculated whether entire ureter is distal ureter was left undisturbed.5 Before using a similar used in bladder ( B ) or not (C).d , diameter. I , length. r , radius. modification, we attempted to evaluate the net effect on end bladder volume to be achieved using a mathematical model based on several simple assumptions (fig. 1). Disregarding sents a surface area of 104 cm.'. A ureter of 3 cm. in width the compliance of the bladder and ureteral tissue, we as- (1.5 cm. in diameter) and 18 cm. in length contributes 170 sumed that the bladder is a sphere before and after uretero- cm.' of surface area to potentially use in the bladder if the cystoplasty. Consequently, a starting and end bladder sur- entire ureter is incised but only 141 cm.2 if the distal 3 cm. of face area and volume can be calculated using the formulas ureter are left intact. The final surface area of the bladder 4m2 and 4/3m3,respectively. The ureter is considered a uni- after ureterocystoplasty will be 274 cm.' or 245 cm.' dependform cylinder of a given length and diameter, again resulting ing on whether the entire ureter is used. The final volume of in a fixed surface area and volume (2me, d C ) . The final the lower tract will be 426 ~ r n or . ~383 ~ m .a~difference , of 43 bladder volume can easily be calculated for any set of param- ~ mor. 10%. ~ For numerous examples used in the model the eters whether the distal end of the ureter is incised and differences in end bladder volume range from 5 to 12%. This detubularized for use in the bladder as opposed to when the model is obviously simplistic and might be inaccurate in distal ureter is left intact. some cases. Failure to account for tissue compliance might As an example, a starting bladder of 100 ml. ( ~ m .repre~) contribute to an error in some cases if ureteral is much better than bladder compliance. On the other hand, the distal ureAccepted for publication April 24, 1998.
6. C.
85 1
852
URETEROCYSTOPLASTY WITH INTACT URETER
ter in most of these cases of megaureter secondary to bladder dysfunction is often much less dilated than the proximal ureter and would contribute less to the bladder. The modest differences in end volume noted with the model do not seem prohibitive based on the clinical results achieved in previous ~eries.~.~
prevents any chance of injury to the superior vesical artery or its branches. The proximal ureter was reconfigured and approximated to the bladder using absorbable suture as with the conventional procedure (fig. 2, B ) . A suprapubic cystotomy tube was left in place to drain for 3 weeks during healing. After a cystogram documented no leakage, the tube was clamped and a trial of voiding was begun.
MET H 0D S
Since 1987 we have performed ureterocystoplasty in 17 patients. The technique of leaving the distal ureter in tubular form has been used in the last 13 consecutive pediatric patients, the first 7 of whom have a mean followup of 28 months (minimum 16) and are included in this series. Of the 7 patients 6 are boys and mean patient age at bladder reconstruction was 6 years (range 1 to 17). The diagnoses resulting in bladder dysfunction included posterior urethral valves in 3 patients, neurogenic dysfunction in 2 and nonneurogenic, neurogenic dysfunction in 2. Bladder reconstruction was undertaken because of infection and hydronephrosis in 4 patients, in preparation for renal transplantation in 2 or as part of an undiversion procedure in 1. There were 5 patients with refluxing megaureters associated with bladder dysfunction and 2 had obstructive systems. All patients underwent urodynamic evaluation before reconstruction, and all but 1 were on anticholinergic medications at the time of those studies. Procedures associated with ureterocystoplasty included ipsilateral nephrectomy in 6 patients, transureteroureterostomy in 1, contralateral ureteral reimplantation in 3, contralateral nephrectomy in 2, creation of a continent stoma in 1 and renal transplantation in 1. In each case the proximal ureter was carefully mobilized with the adventitia to preserve longitudinal blood supply. Unlike conventional technique when the entire ureter must be mobilized to be moved medially into the bladder, we did not have to mobilize the distal quarter of the ureter away from the iliac vessels, which allowed preservation of a consistent source of ureteral blood supply from the iliac artery.6 The ureter was incised and reconfigured to use as a bladder patch. However, the longitudinal incision in the ureter was stopped approximately 3 cm. above the ureteral orifice often where the ureter was narrowed relative to the proximal portion (fig. 2, A). The bladder was likewise incised in a slightly different manner. Cystotomy was carried to the side of the ureter and stopped at a position about 2 cm. from the orifice. The anterior or posterior aspect of the incision can be carried near the orifice, although we have generally used an anterior approach (fig. 2, A). Avoiding an incision through the orifice
RESULTS
Of the 7 patients 2 with neurogenic dysfunction require intermittent catheterization, 4 void to completion and require no catheterization, and 1who initially presented with nonneurogenic, neurogenic bladder dysfunction primarily voids but requires catheterization twice a day. The physiological results on cystometrography have been good. Postoperative video urodynamic studies in 6 patients revealed good capacity in terms of absolute and expected volumes7 (fig. 3). Compliance has been excellent up to capacity in each case, and there have been no uninhibited contractions noted. In most cases the intact limb of ureter filled freely with contrast material on video studies (fig. 4). No residual urine in the ureter after voiding or catheterization has been noted. No patient has had a bladder calculus, and cystitis has not occurred in the boys. One patient on clean intermittent catheterization had pyelonephritis 3 months postoperatively. One patient underwent renal transplantation at the time of ureterocystoplasty and 2 have subsequently required transplantation due to inevitable progression of renal failure. One boy died of viral pneumonitis 6 months after transplantation and immunosuppression. One patient with neurogenic dysfunction has had intermittent moderate unilateral hydronephrosis postoperatively that was present preoperatively yet disappears with bladder emptying. Despite good bladder size and compliance for age production of large volumes of urine requires oral anticholinergic medications and increased catheterization (every 3 hours). DISCUSSION
Ureterocystoplasty has been performed with good results using a conventional technique of incising and using the entire length of mobilized ureter. It has become the procedure of choice for patients requiring bladder augmentation when a remarkably dilated ureter is present.8 If an adequate segment of ureter is available, a good result should be achieved with ureterocystoplasty unless there is a technical error. One such problem, ischemia of the mobilized ureter, might ultimately result in fibrosis and inadequate bladder volume or compliance. When mobilizing the ureter distally for ureterocystoplasty, it is generally simple to avoid manipulation or injury of the vas deferens in boys. If the entire ureter is incised and the incision is then carried through the orifice and bladder, care should be taken to avoid injury to the superior vesical artery 175
I
I
600
U
150
Q
75
Q
I
1
Q
E
’
400
0
200
50
1 FIG. 2. A, distal ureter is not mobilized and ureteral incision is stop ed about 3 cm. above orifice. Cystotomy incision is stopped 2 cm. %om orifice. B,proximal ureter is reconfigured before anastomosis to bladder.
25
FIG.3. Bladder capacity before and after ureterocystoplasty in 6 of 7 patients. Mean preoperative @re) bladder capacity was 103 ml., 43% of expected capacity for age and size (range 27 to 67%). Postoperatively (post),mean capacity increased to 236 cc, 137% of expected capacity (range 110 to 155%).
853
URETEROCYSTOPLASTY WITH INTACT URETER
FIG. 4. Video urodynamic study after ureterocystoplasty shows free flow into intact limb of ureter on left side, which emptied well with voiding.
and its consistent branch passing cephalad t o the orifice (fig. 5). Both may be divided with impunity with regard to the bladder but are an important blood supply to the mobilized ureter. Another source of blood supply to the distal ureter is a small but consistent vessel originating from the iliac vessels lateral in the pelvis. This branch must usually be divided
if the distal most ureter is to be mobilized medially into the bladder. Largely based on these concerns for ureteral blood supply, we believe that the simple modification to leave the distal 3 cm. of ureter undisturbed and intact is sound from a physiological standpoint. Because the critical area at the ureterovesicaljunction is not always easy to visualize clearly, and the imDortant blood vessels must be identified and avoided. this modification becomes technically easier and faster. Em: ier is not necessarily better but we believe that the modification results in less potential for an ischemic ureter after mobilization. If inclusion of the few distal centimeters of ureter in the bladder made a significant difference in final bladder volume, complete mobilization and incision of the ureter would be warranted, but it does not. A simple mathematical model predicts a difference of only about 10% whether or not the distal ureter is used in the bladder. That figure is probably inflated if the distal ureter is not as dilated as the more proximal ureter, which was the case in our series. The urodynamic results of our series have been good and support the use of this modification. Likely because the distal ureter is widely open to the bladder in most cases at both ends, we have had no problems related to stagnant urine in the intact ureter. In each case the limb has filled and drained freely on video studies. In conclusion, the distal ureter does not need to be incised and reconfigured for ureterocystoplasty. Leaving the distal ureter intact is sound from a physiological standpoint, technically easier and associated with good results in our experience. REFERENCES
Uret
FIG. 5. Superior vesical artery (a)and its branch cephalad to ofifice ( b ) provide blood supply to mobilized ureter, and should be msualized and Dresewed. Note consistent vessel -joining- ureter from iliac artery lattirally (c).
1. Mitchell, M. E., Rink, R. C. and Adams, M. C.: Augmentation cystoplasty, implantation of artificial urinary sphincter in men and women and reconstruction of the dysfunctional urinary tract. In: Campbell’s Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 3,chapt. 71, pp. 2630-2653, 1992. 2. Bellinger, M. F.: Ureterocystoplasty: a unique method for vesical augmentation in children. J. Urol., 149 811,1993. 3. Churchill, B. M., Aliabadi, H., Landau, E. H., McLorie, G. A., Steckler, R. E., McKenna, P. H. and Khoury, A. E.: Ureteral bladder augmentation. J. Urol., 150: 716,1993. 4. Landau, E. H., Jayanthi, V. R., Khoury, A. E., Churchill, B. M., Gilmour, R. F., Steckler, R. E. and McLorie, G. A,: Bladder augmentation: ureterocystoplasty versus ileocystoplasty. J . Urol., 152 716, 1994. 5. Wolf, J. S.,Jr. and Turzan, C. W.: Augmentation ureterocystoplasty. J. Urol., 149 1095, 1993. 6. Mitchell, M. E.,Adams, M. C. and Rink, R. C.: Urethral replacement with ureter. J. Urol., 139 1202,1988. 7. Kaefer, M., Zurakowski, D., Bauer, S.B., Retik, A. B., Peters, C. A., Atala, A. and Treves, S. T.: Estimating normal bladder capacity in children. J . Urol., 168 2261, 1997. 8. Rink.R. C.: Choice of materials for bladder auwentation. Curr. Opin. Urol., 5 300, 1995. I
W EJOURNAL OF UROLOGY
Vol. 160, 851-853, September 1998 Printed in U.S.A.
Copyright 0 1998 by AMERICAN UROLOCICAL ASSOCIATION, INC
URETEROCYSTOPLASTY: IS IT NECESSARY TO DETUBULARIZE THE DISTAL URETER? MARK C. ADAMS, JOHN W. BROCK, 111, JOHN C. POPE, IV AND RICHARD C. RINK From the Vanderbilt University Children's Hospital, Nashville, Tennessee, and James Whitcomb Riley Hospital for Children, Indiana University, Indianapolis, Indiana
ABSTRACT
Purpose: The conventional technique for ureterocystoplasty includes complete mobilization and incision of the ureter. We describe a modified procedure in which the distal 3 cm. of ureter are left in place and intact. Materials and Methods: This modification has been used in our last 13 cases of ureterocystoplasty. The first 7 patients with followup of more than a year (mean 28 months) are included in this series, and 6 have undergone video urodynamic evaluation before and after reconstruction. Results: Clinical results have been good. Four patients who have been toilet trained are continent. There have been no problems from stagnant urine in the intact ureter with only 1 case of pyelonephritis and no bladder calculi. Mean bladder capacity on cystometrogram has increased from 103 to 236 ml. after reconstruction and reached 137%of expected capacity for age and size (range 110 to 155%).No uninhibited contractions or problems with compliance have been noted. Conclusions: The distal ureter may be left intact for ureterocystoplasty to protect ureteral blood supply. This modified technique is sound from a physiological standpoint, technically easier and associated with good results. KEY WORDS:ureter, bladder, urodynamics Since early reports ureterocystoplasty for bladder augmentation in appropriate patients with a dilated ureter has been associated with good results.l.2 Churchill et a1 presented good clinical and urodynamic results in a large group of pediatric patients after ureterocystoplasty.3 They later compared children matched for age and diagnosis undergoing either ureterocystoplasty or ileocystoplasty, and documented equivalent results on cystometry.4 Clearly if enough dilated ureter can be used in the bladder, a compliant reservoir with urothelial lining can be achieved with less potential for side effects than enterocystoplasty. The technique of ureterocystoplasty has essentially remained the same and has largely been accepted as convention since these reports. The technique involves mobilization of the entire ureter with the ureteral adventitia and longitudinal blood supply. The ureter is then incised, with the incision carried through the ureteral orifice where it connects with the cystotomy incision. A month after the initial report of Bellinger,2 Wolf and E k . 1. If bladder is considered to be sphere before and after Turzan described a single case of ureterocystoplasty in which ureterocystoplasty and ureter is uniform cylinder (A), final bladder the proximal ureter was opened and reconfigured, and the surface area and volume can be calculated whether entire ureter is distal ureter was left undisturbed.5 Before using a similar used in bladder ( B ) or not (C).d , diameter. I , length. r , radius. modification, we attempted to evaluate the net effect on end bladder volume to be achieved using a mathematical model based on several simple assumptions (fig. 1). Disregarding sents a surface area of 104 cm.'. A ureter of 3 cm. in width the compliance of the bladder and ureteral tissue, we as- (1.5 cm. in diameter) and 18 cm. in length contributes 170 sumed that the bladder is a sphere before and after uretero- cm.' of surface area to potentially use in the bladder if the cystoplasty. Consequently, a starting and end bladder sur- entire ureter is incised but only 141 cm.2 if the distal 3 cm. of face area and volume can be calculated using the formulas ureter are left intact. The final surface area of the bladder 4m2 and 4/3m3,respectively. The ureter is considered a uni- after ureterocystoplasty will be 274 cm.' or 245 cm.' dependform cylinder of a given length and diameter, again resulting ing on whether the entire ureter is used. The final volume of in a fixed surface area and volume (2me, d C ) . The final the lower tract will be 426 ~ r n or . ~383 ~ m .a~difference , of 43 bladder volume can easily be calculated for any set of param- ~ mor. 10%. ~ For numerous examples used in the model the eters whether the distal end of the ureter is incised and differences in end bladder volume range from 5 to 12%. This detubularized for use in the bladder as opposed to when the model is obviously simplistic and might be inaccurate in distal ureter is left intact. some cases. Failure to account for tissue compliance might As an example, a starting bladder of 100 ml. ( ~ m .repre~) contribute to an error in some cases if ureteral is much better than bladder compliance. On the other hand, the distal ureAccepted for publication April 24, 1998.
6. C.
85 1
852
URETEROCYSTOPLASTY WITH INTACT URETER
ter in most of these cases of megaureter secondary to bladder dysfunction is often much less dilated than the proximal ureter and would contribute less to the bladder. The modest differences in end volume noted with the model do not seem prohibitive based on the clinical results achieved in previous ~eries.~.~
prevents any chance of injury to the superior vesical artery or its branches. The proximal ureter was reconfigured and approximated to the bladder using absorbable suture as with the conventional procedure (fig. 2, B ) . A suprapubic cystotomy tube was left in place to drain for 3 weeks during healing. After a cystogram documented no leakage, the tube was clamped and a trial of voiding was begun.
MET H 0D S
Since 1987 we have performed ureterocystoplasty in 17 patients. The technique of leaving the distal ureter in tubular form has been used in the last 13 consecutive pediatric patients, the first 7 of whom have a mean followup of 28 months (minimum 16) and are included in this series. Of the 7 patients 6 are boys and mean patient age at bladder reconstruction was 6 years (range 1 to 17). The diagnoses resulting in bladder dysfunction included posterior urethral valves in 3 patients, neurogenic dysfunction in 2 and nonneurogenic, neurogenic dysfunction in 2. Bladder reconstruction was undertaken because of infection and hydronephrosis in 4 patients, in preparation for renal transplantation in 2 or as part of an undiversion procedure in 1. There were 5 patients with refluxing megaureters associated with bladder dysfunction and 2 had obstructive systems. All patients underwent urodynamic evaluation before reconstruction, and all but 1 were on anticholinergic medications at the time of those studies. Procedures associated with ureterocystoplasty included ipsilateral nephrectomy in 6 patients, transureteroureterostomy in 1, contralateral ureteral reimplantation in 3, contralateral nephrectomy in 2, creation of a continent stoma in 1 and renal transplantation in 1. In each case the proximal ureter was carefully mobilized with the adventitia to preserve longitudinal blood supply. Unlike conventional technique when the entire ureter must be mobilized to be moved medially into the bladder, we did not have to mobilize the distal quarter of the ureter away from the iliac vessels, which allowed preservation of a consistent source of ureteral blood supply from the iliac artery.6 The ureter was incised and reconfigured to use as a bladder patch. However, the longitudinal incision in the ureter was stopped approximately 3 cm. above the ureteral orifice often where the ureter was narrowed relative to the proximal portion (fig. 2, A). The bladder was likewise incised in a slightly different manner. Cystotomy was carried to the side of the ureter and stopped at a position about 2 cm. from the orifice. The anterior or posterior aspect of the incision can be carried near the orifice, although we have generally used an anterior approach (fig. 2, A). Avoiding an incision through the orifice
RESULTS
Of the 7 patients 2 with neurogenic dysfunction require intermittent catheterization, 4 void to completion and require no catheterization, and 1who initially presented with nonneurogenic, neurogenic bladder dysfunction primarily voids but requires catheterization twice a day. The physiological results on cystometrography have been good. Postoperative video urodynamic studies in 6 patients revealed good capacity in terms of absolute and expected volumes7 (fig. 3). Compliance has been excellent up to capacity in each case, and there have been no uninhibited contractions noted. In most cases the intact limb of ureter filled freely with contrast material on video studies (fig. 4). No residual urine in the ureter after voiding or catheterization has been noted. No patient has had a bladder calculus, and cystitis has not occurred in the boys. One patient on clean intermittent catheterization had pyelonephritis 3 months postoperatively. One patient underwent renal transplantation at the time of ureterocystoplasty and 2 have subsequently required transplantation due to inevitable progression of renal failure. One boy died of viral pneumonitis 6 months after transplantation and immunosuppression. One patient with neurogenic dysfunction has had intermittent moderate unilateral hydronephrosis postoperatively that was present preoperatively yet disappears with bladder emptying. Despite good bladder size and compliance for age production of large volumes of urine requires oral anticholinergic medications and increased catheterization (every 3 hours). DISCUSSION
Ureterocystoplasty has been performed with good results using a conventional technique of incising and using the entire length of mobilized ureter. It has become the procedure of choice for patients requiring bladder augmentation when a remarkably dilated ureter is present.8 If an adequate segment of ureter is available, a good result should be achieved with ureterocystoplasty unless there is a technical error. One such problem, ischemia of the mobilized ureter, might ultimately result in fibrosis and inadequate bladder volume or compliance. When mobilizing the ureter distally for ureterocystoplasty, it is generally simple to avoid manipulation or injury of the vas deferens in boys. If the entire ureter is incised and the incision is then carried through the orifice and bladder, care should be taken to avoid injury to the superior vesical artery 175
I
I
600
U
150
Q
75
Q
I
1
Q
E
’
400
0
200
50
1 FIG. 2. A, distal ureter is not mobilized and ureteral incision is stop ed about 3 cm. above orifice. Cystotomy incision is stopped 2 cm. %om orifice. B,proximal ureter is reconfigured before anastomosis to bladder.
25
FIG.3. Bladder capacity before and after ureterocystoplasty in 6 of 7 patients. Mean preoperative @re) bladder capacity was 103 ml., 43% of expected capacity for age and size (range 27 to 67%). Postoperatively (post),mean capacity increased to 236 cc, 137% of expected capacity (range 110 to 155%).
853
URETEROCYSTOPLASTY WITH INTACT URETER
FIG. 4. Video urodynamic study after ureterocystoplasty shows free flow into intact limb of ureter on left side, which emptied well with voiding.
and its consistent branch passing cephalad t o the orifice (fig. 5). Both may be divided with impunity with regard to the bladder but are an important blood supply to the mobilized ureter. Another source of blood supply to the distal ureter is a small but consistent vessel originating from the iliac vessels lateral in the pelvis. This branch must usually be divided
if the distal most ureter is to be mobilized medially into the bladder. Largely based on these concerns for ureteral blood supply, we believe that the simple modification to leave the distal 3 cm. of ureter undisturbed and intact is sound from a physiological standpoint. Because the critical area at the ureterovesicaljunction is not always easy to visualize clearly, and the imDortant blood vessels must be identified and avoided. this modification becomes technically easier and faster. Em: ier is not necessarily better but we believe that the modification results in less potential for an ischemic ureter after mobilization. If inclusion of the few distal centimeters of ureter in the bladder made a significant difference in final bladder volume, complete mobilization and incision of the ureter would be warranted, but it does not. A simple mathematical model predicts a difference of only about 10% whether or not the distal ureter is used in the bladder. That figure is probably inflated if the distal ureter is not as dilated as the more proximal ureter, which was the case in our series. The urodynamic results of our series have been good and support the use of this modification. Likely because the distal ureter is widely open to the bladder in most cases at both ends, we have had no problems related to stagnant urine in the intact ureter. In each case the limb has filled and drained freely on video studies. In conclusion, the distal ureter does not need to be incised and reconfigured for ureterocystoplasty. Leaving the distal ureter intact is sound from a physiological standpoint, technically easier and associated with good results in our experience. REFERENCES
Uret
FIG. 5. Superior vesical artery (a)and its branch cephalad to ofifice ( b ) provide blood supply to mobilized ureter, and should be msualized and Dresewed. Note consistent vessel -joining- ureter from iliac artery lattirally (c).
1. Mitchell, M. E., Rink, R. C. and Adams, M. C.: Augmentation cystoplasty, implantation of artificial urinary sphincter in men and women and reconstruction of the dysfunctional urinary tract. In: Campbell’s Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 3,chapt. 71, pp. 2630-2653, 1992. 2. Bellinger, M. F.: Ureterocystoplasty: a unique method for vesical augmentation in children. J. Urol., 149 811,1993. 3. Churchill, B. M., Aliabadi, H., Landau, E. H., McLorie, G. A., Steckler, R. E., McKenna, P. H. and Khoury, A. E.: Ureteral bladder augmentation. J. Urol., 150: 716,1993. 4. Landau, E. H., Jayanthi, V. R., Khoury, A. E., Churchill, B. M., Gilmour, R. F., Steckler, R. E. and McLorie, G. A,: Bladder augmentation: ureterocystoplasty versus ileocystoplasty. J . Urol., 152 716, 1994. 5. Wolf, J. S.,Jr. and Turzan, C. W.: Augmentation ureterocystoplasty. J. Urol., 149 1095, 1993. 6. Mitchell, M. E.,Adams, M. C. and Rink, R. C.: Urethral replacement with ureter. J. Urol., 139 1202,1988. 7. Kaefer, M., Zurakowski, D., Bauer, S.B., Retik, A. B., Peters, C. A., Atala, A. and Treves, S. T.: Estimating normal bladder capacity in children. J . Urol., 168 2261, 1997. 8. Rink.R. C.: Choice of materials for bladder auwentation. Curr. Opin. Urol., 5 300, 1995. I