Continent Urinary Diversion

Abstract

The need for complete bladder substitution is uncommon in the pediatric population and is usually the result of a congenital bladder agenesis or anomaly, cloacal exstrophy, pelvic malignancy, or severe pelvic trauma. Paramount to performing a continent urinary reservoir (CUR) is appropriate preoperative evaluation and patient selection, as a CUR demands a lifetime commitment and imparts significant long-term risks. A multitude of options for bladder replacment and substrates have been described but are founded on four basic principles: stores adequate urine volumes at low-pressure, a continent of urine, no vesicoureteral reflux, and has a simple and reliable means of emptying. The comparison of different types of reservoirs is exceedingly difficult because all pediatric CUR studies are limited to small case series, usually from a single institution. This chapter will review preoperative evaluation, assess the four basic types of CURs with a critical appraisal of current pediatric CUR literature, and provide a comprehensive evaluation of long-term conditions associated with CUR creation. Pediatric CUR literature is scant and therefore data from adult bladder reconstruction literature (e.g., neobladder, Indiana pouch) was utilized to augment and support pediatric CUR literature. Furthermore, some of this review (particularly long-term complications) is extrapolated from experience with pediatric bladder augmentation; however, these principles seem to be applicable to pediatric CURs. Regardless of the type of CUR or its indication, the pediatric surgeon must fully understand the weight and impact of performing a bladder substitution in a pediatric patient. This decision, we believe, can significantly improve the patient’s quality of life; however, if done inappropriately can negatively impact the quality of life (for the patient, parent/caregivers) and result in reliance, strain, and an overutilization of the medical community.