Updated experience with the Monti catheterizable channel.

OBJECTIVES: The Monti catheterizable channel is used as an integral part of continent bladder reconstruction in children. We have updated our ongoing experience at Riley Children's Hospital with 199 patients. METHODS: We identified 199 patients for retrospective review, including all patients for whom a Monti ileovesicostomy was created from January 1997 to August 2004. We assessed the complications, surgical procedures, and stomal continence. RESULTS: At mean follow-up of 28 months, we found that 194 of 199 patients (97.5%) continued to use their Monti catheterizable channel for bladder drainage. Early surgical complications occurred in 7 patients (3.5%), usually in those who had undergone simultaneous bladder augmentation (5 of 7). Revision was required in 16 patients (8%) for stomal stenosis (n = 11), prolapse (n = 2), or superficial stomal problems (n = 3). Of the 199 patients, 17 (8.5%) required 19 bladder or channel revisions. The primary indications were related to elongation and angulation of the channel in 7 and deficient tunnel length in 8. Minor difficulty with catheterization was noted in 16 patients (8%), and endoscopy with minor procedures was required in 4 patients (2%). Leakage from the channel was uncommon, occurring in only 4 of 115 patients (3.5%). CONCLUSIONS: With increasing demand for simultaneous appendicocecostomy for stool continence at bladder reconstruction, we continue to use the Monti ileovesicostomy for bladder drainage. Our experience with nearly 200 patients has demonstrated the durability and success of this technique.

A comparison of the Monti and Casale (spiral Monti) procedures.

PURPOSE: We present our long-term followup and comparison of outcomes between the Monti and Casale (spiral Monti) procedures in a large group of children and young adults. MATERIALS AND METHODS: A retrospective chart review was done, including all patients undergoing the Monti or Casale procedure at our institution with a minimum followup of 6 months. Age at surgery, the bowel segment used, stomal location, the number and type of revisions or endoscopic procedures required after channel creation, problems catheterizing and channel continence were documented, and a database was created. RESULTS: Of 188 patients identified with at least 6 months of followup 109 underwent a Monti procedure, while 79 underwent a Casale procedure. Patient age at surgery was 10 months to 31 years (mean 10.2 years). Mean followup was 43 months for the entire cohort, and 47.2 and 37.2 months for the Monti and Casale groups, respectively. A total of 43 open revisions were required in 36 patients (19.1%). Stomal revisions accounted for 18 procedures, while subfascial revisions accounted for 25 in 17 (9.0%) and 21 (11.2%) patients, respectively. A total of 21 endoscopic procedures requiring anesthesia were performed in 17 patients (9.0%). In the Monti group stomal revision was required in 11 patients (10.1%), while subfascial revisions were required in 9 (8.3%). In the Casale group stomal revision was required in 6 patients (7.6%), while subfascial revisions were required in 12 (15.2%). Of the channels 98% were completely continent at the stoma. CONCLUSIONS: In a large population of children and young adults we report durable and reliable long-term results with the Monti and Casale procedures, including continence at the stoma. The only significant difference noted between the 2 procedures was a higher incidence of subfascial revisions for umbilical stomas in each group. The need for subfascial revision is highest in spiral Monti channels placed in the umbilicus.

Small intestinal submucosa bladder neck slings for incontinence associated with neuropathic bladder.

PURPOSE: We assess the results using small intestinal submucosa (SIS) for neuropathic urinary incontinence in a large single institutional experience. Ambulatory status was considered as a possible predictor of success. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients treated with SIS bladder neck sling procedures for neuropathic urinary incontinence with a leak point pressure less than 25 cm H2O and a minimum of 6 months followup. Continence was defined as wet (requiring pads or diapers) or dry (requiring no pads and dry underwear). Patients were classified as ambulatory (able to ambulate without assistance or using braces, crawling at home) or nonambulatory (confined to a wheelchair). Results were analyzed with regard to patient sex, ambulatory status and simultaneous bladder neck repair. RESULTS: A total of 21 females and 15 males 3 to 10 years old (mean age 9 years) were treated with SIS bladder neck slings (sling alone 27, bladder neck repair with SIS sling 9). Slings were performed along with reconstructive surgery in all cases (all had creation of urinary catheterizable channels and simultaneous or prior bladder augmentations). Minimum followup was 6 months (mean 15, range 6 to 42). Overall, 27 of the 36 patients (75%) are dry following bladder neck sling. In patients treated with the sling procedure alone 6 of 8 (75%) nonambulatory females and 8 of 10 (80%) ambulatory females were continent, and 3 of 4 (75%) nonambulatory males and 2 of 5 (40%) ambulatory males were dry. CONCLUSIONS: SIS has equivalent rates of continence compared to series using rectus fascia in patients with neuropathic urinary incontinence. The ambulatory status of males should be considered when determining which treatment option is best for the patient with myelodysplasia and neuropathic sphincteric incontinence, as in our series ambulatory males undergoing sling placement alone had a poor outcome.

Alternative uses of dextranomer/hyaluronic acid copolymer: the efficacy of bladder neck injection for urinary incontinence.

PURPOSE: Urinary continence in children with neuropathic bladder and other urological disorders depends on a bladder with adequate low pressure storage capacity and a competent outlet. Various procedures are performed with the goal of achieving continence in these patients. Recently, dextranomer/hyaluronic acid copolymer (Dx/H) has been introduced for the correction of vesicoureteral reflux. We evaluated the efficacy of submucosal bladder neck (BN) injection of Dx/H for urethral incontinence in children. MATERIALS AND METHODS: We retrospectively reviewed continence status after Dx/H injection into the BN for incontinence. Parameters examined include gender, underlying disease, prior BN surgery and means of emptying the bladder. Continence was described by the patients and/or their parents as unchanged (no change in requirements for diapers or pads), improved (longer dry intervals or requiring fewer pads/diapers) or dry (requiring no pads and dry in underwear). RESULTS: A total of 6 males and 10 females underwent injections for treatment of incontinence. Mean followup was 9.5 months (range 3 to 24). Volumes injected ranged from 0.8 to 4.4 ml (mean 1.88). Of the patients 3 achieved dryness after injection, all of whom had catheterizable urinary stomas and two-thirds had undergone bladder augmentations. All 5 patients who improved had undergone augmentation and had catheterizable channels. No improvement was seen in 8 patients. CONCLUSIONS: Injection at the BN is well tolerated and relatively easy to perform. Success rates may be better in females and in patients with neuropathic incontinence. Despite limited success it remains an option for all patients who are poor surgical candidates and those who want to avoid extensive BN reconstruction.

The colon flap/extension Malone antegrade continence enema: an alternative to the Monti-Malone antegrade continence enema.

PURPOSE: In situations where the appendix is not available for the Malone antegrade continence enema (MACE) procedure a Yang-Monti channel or a colon flap conduit can be created. We report our experience with colonic flap conduits used for the MACE. MATERIALS AND METHODS: A total of 169 MACE procedures were performed between February 1997 and March 2003. In 11 patients 12 colon flaps or cecal extensions were used to construct the MACE conduit. Diagnoses included myelomeningocele (8 patients), caudal regression (1), sacral agenesis (1) and gunshot wound (1). Mean age at creation of MACE was 11.3 years (range 4.4 to 16.9). Seven cecal flaps, 1 descending colon flap and 4 cecal extension flaps were created. RESULTS: Average followup was 22.8 months (range 2.6 to 34.6). Indications for colon flap MACE were appendicovesicostomy (6 patients), short appendix (2), shortened mesentery (1), retrocecal appendix (1), prior appendectomy (1) and right hemicolectomy (1). Initially all patients easily catheterized and flushed the MACE once daily. All 11 patients achieved fecal continence. Complications occurred in 3 cases. One obese patient could not visualize the umbilical stoma and it stenosed, requiring conversion to a spiral Monti-MACE. One patient with a cecal extension had development of a false passage, resulting in complete channel stenosis. One patient had development of stomal leakage, which was successfully treated with dextranomer/hyaluronic acid copolymer injection. CONCLUSIONS: A colon flap MACE conduit is a simple technique to provide access to the colon for irrigation. When faced with situations were the appendix is not available for the MACE procedure the colon flap can be a good option.

Upper and lower urinary tract outcome after surgical repair of cloacal malformations: a three-decade experience.

OBJECTIVE: To report the urological outcome of the surgical correction of persistent cloaca, which is technically demanding and may require many procedures in an effort to preserve renal function and provide urinary continence. PATIENTS AND METHODS: A retrospective chart review from 1971 to 2003 identified 23 patients with cloacal malformations (two posterior, 21 classical) that were reconstructed. The confluence of the urethra, vagina and rectum was noted to be high in 16, low in five and unknown in two; one patient was a conjoined twin. RESULTS: The mean (range) follow-up was 9.3 (0.4-31.6) years. Urinary anomalies included 14 patients with renal anomalies (six solitary kidneys, four renal dysplasia, two pelvi-ureteric junction, one each duplex and crossed fused) and two duplicated bladders. Vesico-ureteric reflux was present in 13 patients (57%), hydronephrosis at birth in 13, a bony vertebral abnormality in 14 and the VACTERL association in four. Total urogenital mobilization (TUM) was used in six patients and spinal cord untethering in four; a nephrectomy was required in three and partial nephrectomy in one. Upper tract dilation was still present in six patients. Age-adjusted creatinine levels were abnormal in four (18%) patients and borderline in another six (26%). In the nine patients with a solitary kidney (six solitary, three after nephrectomy), the age-adjusted creatinine level was abnormal in two and borderline in four. A vesicostomy was initially performed in 11 patients. The method of bladder emptying is known in 22; 10 void, 11 require clean intermittent catheterization (five abdominal stoma, six urethral) and one was diverted with a conduit. Of the 18 patients aged > 47 months 15 were continent (14 complete > 4 h, one partial 2-4 h), and three are wet (one conduit). Reconstruction of the lower urinary tract included four bladder augmentations (one ureteric, one ileal, two colon), five bladder neck procedures (two artificial sphincter, one each bladder neck repair, sling, bladder neck division) and six catheterizable channels (one now with a colon conduit). The ureters were re-implanted in 12 patients. CONCLUSION: Although the surgical correction of this rare malformation is complex, the upper urinary and lower urinary tract outcome can be favourable, albeit after several reconstructive procedures. TUM has emerged as the primary method for vaginal reconstruction, but the long-term lower tract outcome after this procedure is awaited.

In situ Malone antegrade continence enema in 127 patients: a 6-year experience.

PURPOSE: The initial description of the Malone antegrade continence enema (MACE) relied on a reversed, tunneled and reimplanted appendix. In 1999 we reported our in situ technique that uses windows developed in the appendiceal mesentery for imbrication. We present our long-term results. MATERIALS AND METHODS: From 1997 to 2003, 168 patients were identified who had undergone a MACE procedure. An in situ technique was performed in 76 females and 51 males. Average patient age at the time of surgery was 9.6 years (range 2.9 to 28.4). Diagnoses included myelomeningocele in 116 cases, lipomeningocele in 6, spinal cord injury in 2, posterior urethral valves in 1, sacral agenesis in 1 and functional constipation in 1. RESULTS: Cecal plication/imbrication was performed in 100 patients, appendix intussusception and imbrication in 24, and creation of tenia flaps in 3. The abdominal stoma was umbilical in 50 cases, right lower quadrant in 74 and periumbilical in 3. Concomitant genitourinary reconstruction was performed in 87% of patients. Mean followup was 26.9 months (range 0.7 to 68.1). Fecal continence was reported by 91% of the patients. Thirteen stomal revisions (stenosis 10, prolapse 2 and leakage 1) were required in 11 patients. Major complications included a cecal volvulus requiring a right hemicolectomy in 1 patient, small bowel obstruction in 2, and shunt infection and/or malfunction in 2. Four patients have elected to no longer use the MACE for non-technical reasons. CONCLUSIONS: The in situ MACE procedure has reliable long-term results for treating fecal incontinence associated with neuropathic bowel.

Continence and classic bladder exstrophy treated with staged repair.

PURPOSE: Urinary continence rates after reconstruction of the urinary tract for classic bladder exstrophy are variable. We review our experience with procedures required to optimize continence. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients with classic bladder exstrophy undergoing staged reconstruction between 1976 and 2001. Continence was reviewed and associated with the procedures performed. Patients were considered continent if dry for greater than 3 hours with no stress incontinence and dry at night. Partial continence required dryness for 1 to 3 hours, minor stress incontinence and occasional nighttime leakage. Incontinent patients were dry for less than 1 hour, had significant stress incontinence or were wet at night. Patients were followed for a median of 12.5 years. RESULTS: Continence was achieved in 43 of 48 patients (90%), partial continence in 4 (8%) and 1 (2%) remains incontinent. Continence occurred before bladder neck repair in 4 patients. Bladder neck repair alone (without augmentation) was performed in 38 patients at a median of 4.25 years, resulting in continence in 13 patients (34%). However, 6 of these 13 patients later required augmentation. Augmentation was performed in 33 patients, with 30 (91%) attaining continence after this procedure. Of those continent patients 10 void per urethra, and 8 void and use clean intermittent catheterization. Of the patients treated with bladder augmentation 93% required clean intermittent catheterization. CONCLUSIONS: Continence can be achieved in most patients with classic bladder exstrophy. However, augmentation was required in 30 of 43 patients (70%). Bladder neck reconstruction alone resulted in continence in only a third of the cases.

Complications of small intestinal submucosa for corporal body grafting for proximal hypospadias.

PURPOSE: Small intestinal submucosa (SIS) has been described for corporal body grafting in cases of severe penile curvature. We reviewed our experience with a 2-stage repair using corporal body grafting with SIS for proximal hypospadias and severe chordee. MATERIALS AND METHODS: A retrospective chart review was performed on 12 patients with penoscrotal hypospadias and severe chordee. Corporal grafting was performed with a 4-layer SIS graft (STRATASIS, Cook Biotech, Spencer, Indiana). Patients were evaluated postoperatively with clinic visits after both stages of repair to assess results. RESULTS: Corporal body grafting with SIS was performed in 12 patients between June and December 2001. Average patient age at the time of stage 1 repair was 9 months. Of the 12 patients 8 (66%) had no complications and 10 (83%) have a straight phallus following stage 2 repair. Complications occurred in 4 patients (33%), 2 of which were minor and did not require surgical correction. There were 2 major complications related to the SIS graft, 1 of which required excision of the graft and replacement with a tunica albuginea flap, and the other required 3 dorsal plications to correct residual chordee. CONCLUSIONS: Our experience using the 4-layer SIS resulted in 2 major complications requiring surgical correction during stage 2 repair. This rate exceeds the complications reported with either dermal or tunica vaginalis grafts. Currently we have stopped using SIS for corporal grafting.

Long-term outcome of the surgical treatment of concealed penis.

PURPOSE: The term concealed penis describes a spectrum of disorders ranging from penoscrotal webbing to a completely buried penis. A number of surgical procedures have been described to correct this condition but little has been written about long-term results. We report our long-term results of the surgical correction of concealed penis based on a survey of parents. MATERIALS AND METHODS: A retrospective review of patients treated from 1995 to 1999 identified 18 males with a minimum of 21 months of followup whose parents were available for evaluation via telephone interview. The parents were questioned about the initial problems that they associated with concealed penis, such as appearance and accessibility of the penis, ease of hygiene, severity of concealment and negative feelings about the appearance of the penis. Parents were also questioned about the results of surgery and how the surgical result improved or failed to improve their concerns. Specifically, they were questioned about whether the surgery helped to alleviate negative concerns, improve hygiene and make the penis more assessable. RESULTS: Of the 18 patients 14 were infants/toddlers (group 1) and 4 were adolescents (group 2). Group 1 patients with a mean age of 2 years were evaluated at a mean of 41.7 (range 21 to 76) months and group 2 patients with a mean age of 12 years were evaluated at a mean of 38.8 (25 to 63) months after surgery. Before surgery 57% of patients in group 1 and 50% in group 2 complained of difficulty with hygiene. Of the parents 64% of group 1 and 75% of group 2 described their child as having a completely hidden penis. On the other hand, only 57% of parents in group 1 expressed negative feelings about the appearance of the penis compared to all parents in group 2. Following surgery group 1 patients fared better reporting improvements in hygiene (87%), accessibility (86%) and improved appearance of the penis (100%). Results from surgical intervention were less successful in group 2, with improved hygiene in 50%, improved penile accessibility in 75% and improved appearance in 50% of patients. Interestingly, all group 2 parents would still recommend the same surgery to a friend with the same problem despite less than perfect results compared to 79% of group 1 parents who would recommend surgery to others. CONCLUSIONS: Our long-term outcome survey data demonstrate that surgical correction of concealed penis addresses an array of presenting complaints. According to the parents of patients surgery is almost uniformly successful in toddlers and less often successful in adolescents. However, despite its limited success in older patients, most parents thought that surgery was a positive intervention and would recommend it to a friend with a similar condition.

Lipopolysaccharide and inflammatory cytokines cause an inducible nitric oxide synthase-dependent bladder smooth muscle fibrotic response.

PURPOSE: Bladder wall fibrosis is a sequela of recurrent urinary tract infection (UTI). Inducible nitric oxide synthase (iNOS) has been shown to mediate the fibrotic response to inflammation in other tissues. We determined if iNOS could be involved in the fibrotic response to recurrent UTI. MATERIALS AND METHODS: Human bladder smooth muscle cells (SMC) were treated with bacterial lipopolysaccharides (LPS) and a mixture of inflammatory cytokines. The level of collagen type III, and the levels of iNOS mRNA, protein and activity were determined. The effect of the iNOS inhibitor aminoguanidine on collagen type III expression was then assessed. RESULTS: Expression of collagen type III, iNOS mRNA and iNOS protein as well as iNOS activity were increased in bladder SMC treated with the combination of LPS and cytokines. The increase in collagen type III expression was inhibited by pretreatment of cells with aminoguanidine. CONCLUSIONS: LPS and inflammatory cytokines induce collagen type III expression in an iNOS dependent manner in human bladder SMC. This finding suggests that iNOS may be a critical mediator of the bladder wall fibrotic response to chronic UTI and iNOS inhibitors may be of therapeutic value in patients with chronic UTI.

Intravesical phallus in cloacal exstrophy.

We report a case of a fused phallus located within the urinary bladder in a child with cloacal exstrophy. Surgical exploration revealed a phallus formed by fusion of the left and right corpus cavernosum and completely covered by bladder urothelium. The phallus was surgically separated from the bladder and mobilized to a more normal position and a neourethra created from tubularized bladder urothelium. Skin coverage was done using perineal skin flaps to cover the penile shaft, with the bladder urothelium covering the tip of the phallus being left intact to provide the appearance of a glans penis.

The Indiana experience with artificial urinary sphincters in children and young adults.

PURPOSE: We reviewed a 22-year single institutional experience with the artificial urinary sphincter in children and adolescents. To our knowledge this report represents the largest series in the world in children. MATERIALS AND METHODS: Between 1980 and 2002, 142 patients underwent implantation of an artificial urinary sphincter, of whom 93 males and 41 females with a median age of 10 years (range 3 to 39) were available for analysis. A total of 59 patients initially received an AMS 742/792 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter, of whom 33 were subsequently changed to an AMS 800, while 75 initially received an AMS 800 model. Sphincter followup was terminated at device removal or at the last documented contact. The etiology of incontinence was neuropathic bladder in 107 cases (80%), the exstrophy/epispadias complex in 21 (16%) and other in 6 (4%). Outcome measures included continence, mechanical complications (leakage, tube kink and pump malfunction), functioning sphincter revisions (change in cuff size, pump repositioning and bulbar cuff placement), surgical complications (erosion, infection and misplacement) and associated surgical procedures. Mean followup of the pre-800 and 800 models was 6.9 (range 0.2 to 21.5) and 7.5 years (range 0.1 to 17.1), respectively. Fisher's exact test, Kaplan-Meier life analysis and the chi-square test were used for statistical analysis. RESULTS: After artificial urinary sphincter placement in the 134 patients continence was achieved in 86%, improved in 4% and not achieved in 10%. Of those with a sphincter in place 92% were continent. In terms of bladder emptying after artificial urinary sphincter insertion 22% of patients voided, 11% voided combined with clean intermittent catheterization, 48% performed clean intermittent catheterization only via the urethra, 16% performed it via a catherizable channel and 3% used urinary diversion. A mechanical complication developed in 38 of the 59 patients (64%) with pre-800 model compared with 33 of the 109 (30%) with the 800 model (p <0.0001). A mechanical complication occurred every 7.6 versus 16 patient-years for the pre-800 versus 800 models (p = 0.0001). Revision was required in 15 of the 59 patients (25%) with a pre-800 model versus 17 of the 109 (16%) with the 800 model (p = 0.103). Revision was performed every 22.7 versus 44.3 patient-years for the pre-800 versus the 800 model (p = 0.023). The artificial urinary sphincter eroded in 11 of the 59 patients (19%) with the pre-800 versus 17 of the 109 (16%) with the 800 model (p = 0.52). Ten patients experienced a total of 12 perforations of the augmented bladder after artificial urinary sphincter implantation. A total of 164 secondary surgical procedures were performed, including 38 of 134 bladder augmentations (28%). A total of 30 sphincters were permanently removed. CONCLUSIONS: The artificial urinary sphincter is the only bladder neck procedure that allows spontaneous voiding in the neuropathic population, obviates the need for clean intermittent catheterization and yet is compatible with it when necessary. It is also equally versatile in the 2 genders. Mechanical complications occur but they were dramatically decreased by the modifications of the AMS 800 model. In addition, secondary bladder augmentation was required in 28% of our patients. Lifelong followup is mandatory in all patients with an artificial urinary sphincter.

The Malone antegrade continence enema procedure: quality of life and family perspective.

PURPOSE: Since introducing the Malone antegrade continence enema (MACE) procedure into our practice, it has been our bias that social confidence and independence are significantly improved and satisfaction is overwhelmingly high. We objectively determine outcomes after the MACE to refine patient selection, and maximize the quality of perioperative counseling and teaching. MATERIALS AND METHODS: An anonymous questionnaire was mailed to all patients who had undergone the MACE procedure within the last 4 years. Patient/parent satisfaction, impact on quality of life and clinical outcome were assessed with Likert scales. Demographic information, MACE specifics, preoperative expectations, and unanticipated benefits and problems were also recorded. RESULTS: A total of 65 questionnaires were returned from our first 92 patients (71%). Myelodysplasia was the primary diagnosis in 88% of patients. Complete or near complete fecal continence was achieved in 77% of patients and all others had improved incontinence. The highest level of satisfaction was reported by 89% of patients. Social confidence and hygiene were significantly improved. Daily time commitment, pain/cramping, intermittent constipation and time for fine-tuning the regimen were cited as unanticipated issues. CONCLUSIONS: The MACE procedure has received high praise from patients and families after years of battling constipation and fecal incontinence. Significant improvement rather than perfection is the realistic expectation. Objective feedback from patients and families will continue to improve patient selection and education.

Long-term followup and outcome of continent catheterizable vesicocstomy using the Rink modification.

PURPOSE: Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. RESULTS: Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. CONCLUSIONS: Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.