URINARY UNDIVERSION IN ADULTS WITH MYELODYSPLASIA - LONG-TERM FOLLOW-UP

A total of 14 women and 6 men 19 to 39 years old (mean age 27 years) w ith myelodysplasia underwent undiversion 8 to 29 years (mean 16) after ileal conduit diversion. The main reasons for diversion were incontin ence in 17 patients and failed ureteral reimplants in 3, and those for undiversion were a desire for an improved quality of life in 16, incr easing hydronephrosis in 4 and stomal problems in 3. Preoperative asse ssment included upper and lower tract imaging, and video urodynamics. Operations on the ureters included reimplantation into an intussuscept ed nipple valve in 8 patients, tunneled reimplants into a sigmoid augm entation in 3 and the ureters joined to either the bladder or lower ur eter without interposing bowel in 9. All reimplantations were done wit h nonrefluxing techniques. A total of 18 patients underwent bladder au gmentation and 2 women in whom cystectomy was performed for pyocystis underwent substitutions. Simultaneous continence procedures in 18 pati ents included trigonal tubularization in 2, artificial sphincter impla ntation in 2, a bladder neck sling in 5 or bladder neck tapering and a sling in 9. The patients were followed for a mean of 69 months (range 21 to 133). Eight patients required reintervention within 1 year for problems, such as anastomotic leak in 1, bladder neck obstruction in 1 , incontinence in 1, artificial urinary sphincter revisions in 1 and b ladder stones in 1. One patient had a recurrent renal calculus 10 year s after undiversion. All patients experienced either persistence of no rmal upper tract appearance or improvement and/or stabilization of hyd ronephrosis. Mean bladder capacity was 77 cc preoperatively and 480 cc postoperatively, while mean pressure at capacity decreased from 50 to 14 cm. water with detubularized augmentation. Of the patients 17 are completely dry, 2 wear 1 pad per day and 1 has enuresis. All but 1 pat ient who voids with straining are on intermittent self-catheterization . All patients, on followup interviews, reported an improved quality o f life without a stoma. We conclude that undiversion provides an impro ved quality of life and an acceptable morbidity rate. The choice of op eration depends on the anatomy of the patient. We prefer a nonprosthet ic type of incontinence procedure when intermittent self-catheterizati on is to be done. No long-term morbidity has yet been noted.