This paper reviews a unique experience from a different technique of ureterocolonic diversion to improve continence in failed bladder exstrophy patients without being dependent to clean intermittent catheterization (CIC) or collecting bag.
The classical procedure named after Duhamel, which has been successfully used in patients with Hirschsprung’s disease for years, was refashioned wisely to turn its disadvantage of leaving a complication prone rectal pouch, to a reservoir for collecting urine temporarily before it is evacuated through normal, continent anus. This was achieved by antireflux anastomosis of both ureters to the rectal pouch left after Duhamel’s procedure.
Looking at the results, after a period of adaptation, the technique has provided urinary continence rates superior than most current anatomical repair series and bladder neck repairs combined with augmentations. Regarding urinary continence, it may only be less reliable than bladder neck closure combined with enterocystoplasty and a continent stoma (Mitrofanoff) for CIC. But the well-known inherent risks of bladder neck closure such as; increased stone formation, inability to leak at high pressures, and perforation are eliminated with this method. The patient and family compliance is of utmost importance for CIC. The rates of patients using urethral route for CIC is much lower in bladder exstrophy patients compared to those with neurogenic bladder due to normal urethral sensation. Besides, the idea of having a stoma, although continent, may not be readily acceptable for patients living in areas where health services supporting such practices that require appliances and specific education, are not ideal.
This method is not free of increased risk of carcinoma formation after urinary diversion to gastrointestinal tract or segments. The contact of gastrointestinal content with urine as a risk factor for carcinogenesis is not proved. Ileal or colonic segments separated from GI tract are also prone to development of carcinoma. The long-term occurrence of carcinoma after mean 20 years makes it difficult to calculate the risks legitimately. As the authors have clearly pointed out, real long-term follow-up will enlighten this issue.
The technique is straightforward, reproducible, and seems effective. It may be a reasonable alternative to direct ureterosigmoidostomy, or to bladder neck closure and augmentation with bowel segments particularly in patients noncompliant or unhappy with CIC.
Written by:
Ibrhaim Ulman
Merkezi Pediatric Surgery & Urology, Mimar Sinan Mh., Turkey