Ileal Valve Pouch for Urinary Tract Diversion

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FOR many years surgeons have known that exstrophy of the bladder can be corrected by utilizing the rectum as a reservoir for the urine, and many types of surgical procedures have been advocated for transplanting the ureters into the rectosigmoid. In 1894, Maydl1 recommended that the trigone of the bladder be implanted in the rectosigmoid, in the hope of minimizing the incidence of postoperative ureteral stenosis, stasis, and eventual pyelonephritis. However, until 1911, the operation was but infrequently advocated because the operative mortality and morbidity were extremely high. In 1911, Coffey2 advocated the trough principle of implanting the ureters into the bowel; his technic (the Coffey I technic) has been widely used and has brought about a pronounced reduction in the operative mortality and morbidity.

Within the last few years, the Coffey I technic has been modified by performing a mucosa-to-mucosa anastomosis between the ureter and the rectosigmoid, in the hope of minimizing the incidence of stenosis at the site of implantation. Unfortunately, despite the meticulous care with which the anastomosis is made, one potentially formidable complication may ensue, namely, ureteral obstruction. If the obstruction is slight and the patient has no renal infection, he may live a comparatively normal life for many years. Hyperchloremic acidosis, which may follow this surgical procedure, may be minimized or controlled by administering 10 per cent sodium citrate, the dosage being influenced by blood chemistry studies. But, only too often, as a review of published statistics reveals, ureteral obstruction and stasis cause pyelonephritis, and . . .



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