Urinary diversion and orthotopic bladder substitution in children and young adults with neurogenic bladder: A safe option for treatment?

Purpose: Combined pharmacotherapy, clean intermittent catheterization and i nfection prophylaxis is currently the gold standard of treatment for neurog enic bladder. However, as the adolescent gains independence from parental s upervision, the intervals of clean intermittent catheterization compliance with medical treatment and regularity of followup examinations may decrease , and neurological and/or orthopedic status may change. This situation some times leads to failure of conservative treatment, resulting in incontinence and/or deterioration of the upper urinary tract. A multidisciplinary team was established at our institution 30 years ago to assess all aspects of ca re for patients with neurogenic bladder, or which urological function is ju st 1 aspect of the complex problem. Patient desires and essential medical g oals, such as preservation of renal function, are considered by this team. An adequate compromise is sought and achieved in some cases by urinary dive rsion. We investigated the long-term safety of urinary diversion in these p atients and its ability to protect the upper urinary tract. Materials and Methods: Between 1967 and 1997 urinary diversion was performe d in 149 patients with neurogenic bladder. Mean followup was 11.8 years (ra nge 0.8 to 28.5) in 129 cases. Mean patient age at surgery was 12.1 years ( range 0.8 to 20). A colonic conduit was created in 59 patients, mainly befo re the era of clean intermittent catheterization and continent diversion, w hile orthotopic bladder substitution was performed in 12 and continent urin ary diversion (Mainz pouch I) in 58, of whom 50% were wheelchair bound. Results: The upper urinary tract improved or remained stable in 97% of the renal units in patients with a colonic conduit or Mianz pouch I, and in 95% of the renal units in those with orthotopic bladder substitution. All pati ents with bladder substitution were continent during the day 1, required oc casional pads at night and 7 of 12 performed clean intermittent catheteriza tion. Complete continence was achieved in 98% of those with a continent sto ma. Conclusion: After failure of conservative treatment in patients with neurog enic bladder urinary diversion represents a safe long-term compromise. Dayt ime and nighttime continence is provided by the Mainz pouch bladder substit ution and urinary diversion, which the upper urinary tract is protected by antireflux ureteral implantation.