sion. A composite of stomach and small bowel provided asatisfactory urinary reservoir with a continent channel andstoma for intermittent catheterization. In 3 of the 9 referredcases the cecum was incorporated in the initial bladderclosure, which is inadvisable, and an ileostomy was per-formed. The ileostomy with its watery stool was converted toa continent Kock fecal reservoir, thus, eliminating the ileos-tomy bag. In other cases in which the cecum was preservedpull-through of the colostomy through the perineum wasfeasible.

Finally, the aim of treatment in children born with cloacalexstrophy is to give them the best life possible wherever theylive in this world. Therefore, it is my belief that the surgicalstrategy and management should be individualized and basednot only on anatomical, but also on social and cultural factors.

Moneer K. HannaDepartment of Urology

New York Hospital-Weill Cornell Medical CenterNew York, New York

REPLY BY AUTHORS

This article was meant to be conceptual and to raise ques-tions regarding the optimal management of this difficult andrare anomaly based on our experience. We agree that treat-ment should be individualized based on multiple factors.However, the fact remains that almost all of these patientswill likely require construction of a continent reservoir. Thetiming of this reconstruction was between 18 and 24 monthsin our small series, and we do not disagree with reconstruc-tion at an earlier age. We did use transverse innominatepelvic osteotomies followed by stabilization with an externalfixation device. Although we have not applied the gradualdiastasis reduction method, it has clearly been shown to beuseful in patients with severe pelvic diastasis. Because con-tinence is unlikely following primary bladder closure, initialapproximation of the bladder halves allows these patients togrow, may reduce the number of future operations andmakes construction of a continent reservoir easier.

FIRST STAGE APPROXIMATION OF EXSTROPHIC BLADDER IN CLOACAL EXSTROPHY1636