Archives of Disease in Childhood, 1973, 48, 199.

Urinary diversion in childrenJOHN E. S. SCOTT

From the Department of Surgery, University of Newcastle upon Tyne, Royal Victoria Infirmary,Newcastle upon Tyne

Scott, J. E. S. (1973). Archives of Disease in Childhood, 48, 199. Urinarydiversion in children. A series of 60 children subjected to urinary diversion isdescribed. Particular emphasis is placed on the long-term results of 41 ileal conduitoperations. The upper urinary tract became dilated postoperatively in 9 childrenin whom it had been normal preoperatively, dilatation increased in 1 child with onlymoderate dilatation preoperatively, and the degree of dilatation remained unchanged ina further 9 children who had preoperative dilatation.

Operative and radiological findings suggested that stenosis of the ileal stoma or ofthe ureteroileal anastomoses was not the cause of the upper urinary tract dilatationwhich appeared in most instances only after a period of several years.Measurement of the pressure changes in the ileal conduit of 11 children selected at

random showed that under normal circumstances intraluminal pressure remainedlow, but that obstruction of the stoma produced an immediate rise in pressure accom-panied by strong ileal contractions. It is suggested that intermittent stomal occlu-sion caused by diversion appliances, clothing, or body posture may, by producingintermittent high pressure in the conduit, result over a period of years in gradualupper urinary tract dilatation.

It is suggested that ureteroileostomy should not be used as a method of controllingurinary incontinence in children with normal upper urinary tracts, and that carefulregard should be given to the unsatisfactory results of this operation in some childrenwith deteriorating upper urinary tracts. It is possible that a sigmoid colon conduitmay be more satisfactory than an ileal conduit.

Diversion of the urinary stream plays an impor-tant role in the management of many congenitaldisorders of the urinary tract. Among the indica-tions for this type of surgery are urinary inconti-nence, severe damage to the drainage system fromthe kidneys, and the necessity for removing thelower urinary tract when it is the seat of malignanttumours. The use of the colon for diversion is apractical proposition only in those children who haveabnormalities which do not affect anorectal function,such as ectopia vesicae, epispadias with inconti-nence, or malignant disease. But even though itenables a child to develop control over the urinarystream, ureterosigmoidostomy has a bad reputationbecause, in the long term, biochemical disturbancesand gradual deterioration in upper urinary tractfunction may occur in some cases, and, in generalthere is a preference for surface over intestinalurinary diversion. When the function of the

Received 20 July 1972.

anorectal region is abnormal, such as in neurogenicdisorders of the spincters or rectal agenesis, urinarydiversion to the surface is obligatory. Sincenormal ureters will not reach the surface of theabdominal wall without risk of vascular insuffi-ciency, it is necessary to interpose a length ofintestinal tract to act as a conduit. Terminalileum is most frequently used for this purposeafter the method of Bricker (1950), but Mogg (1967)advocated the use of sigmoid colon. When therehas been prolonged lower urinary tract obstructionand the ureters are dilated, tortuous, and hyper-trophied, it may be possible to bring them to thesurface directly as a cutaneous ureterostomy.Thus the ultimate aim of urinary diversion in

children is to control urinary incontinence andprevent progressive deterioration in the health ofthe upper urinary tract. It is, however, importantto be certain that the operation will not damage anormal urinary tract and will result in improvedfunction in the damaged urinary tract. The

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purpose of this paper is to examine these criteriain the light of results obtained in a consecutivepersonal series of 60 children subjected to urinarydiversion, and to review recent reports on thesubject.

Clinical material22 of the children were male, and 38 female. The

ratio of males to females was 1: 1 * 7, which is somewhatlower than in other published series in which there werethree times as many girls as boys (Livaditis, 1965;Cook, Lister, and Zachary, 1968; Eckstein and Boyd,1969). The indication for operation, and the sexdistribution are given in Table I which shows that the

TABLE IUrinary diversion: indications

Sex

Male Female

Ectopia vesicae 12 9 3Spina bifida 38 6 32Lower tract obstruction 5 3 2Other congenital anomaly 2 1 1Malignant neoplasm 3 3 0

majority of children in the neurogenic group were

girls. The 'other congenital anomalies' comprised 1boy with gross congenital upper urinary tract dilatationand ureteric reflux without urethral obstruction, and 1girl with a congenitally short, incompetent urethraand absent vagina. The children with ectopia vesicaewere subjected to urinary diversion because theirbladders were small and unsuitable for closure, becausethey had increasing dilatation of their upper urinarytracts, or because they were suffering from hopelessurinary incontinence after bladder reconstruction.

Table II shows the techniques used. Diversion bymeans of an ileal conduit was performed in 41 cases.

TABLE II

Urinary diversion: technique

Total Male Female

Ileal conduit 41 13 28Ureterosigmoid 4 4 0Colon conduit 2 1 1Ureterostomy 14 5 9

(a) unilateral 3 1 2(b) bilateral midline 9 2 7(c) bilateral, with Yanast 1 1 0(d) temporary 1 1 0

The 4 ureterosigmoidostomies included 2 childrenwith ectopia vesicae and 2 with malignant pelvic tumours.Colon conduits were used in 2 children. One had had aventriculoperitoneal shunt for hydrocephalus carriedout previously, and it was found at operation that the

terminal ileum was involved in a mass of adhesionsaround the catheter at the peritoneal end of the shunt.A coloneourethrostomy (Grant, 1964) for ectopiavesicae had been performed previously at anotherhospital in the second child, and on referral to the authorthere was gross dilatation of both sides of the upper

urinary tract. Revision was achieved by excising thebladder and anastomising the ureters to the colonconduit which had been constructed at the previousoperation.The majority of ureterostomies were constructed

with a single 'trouser leg' stoma located in the midlinebetween the umbilicus and symphysis pubis, a techniquethat produces a satisfactory stoma in a position where it iseasy to fit a collecting appliance.

Fig. 1 shows the age at operation. 11 children were

operated in the first year of life and the majority of thesehad ectopia vesicae. 63% were operated before theage of 5 years.

6-5-4-13-12-

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O 10-9

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Ectopia vesicceSpina BifidaOthers

\\\\\\M\\\

-5 - 7 -9 -11 -13

Age (years)FIG. 1.-Urinary diversion. Age at operation.

Table III shows the state of the upper urinary tractat the time of operation. There were only 12 childrenin the spina bifida group whose upper tracts werenormal, a measure of the author's reluctance to performurinary diversion on the grounds of incontinence only.

TABLE III

Urinary diversion: state of upper tract at operation

Ectopia Spina Othersvesicae bifida

Normal 21 7 12 2Moderate { unilateral 4 2 5 4

dilatation bilateral 7Severe 28' unilateral 5 3 20 5

dilatation bilateral 23Other rsingle kidney 3

abnor- 4 dysplasticmality L kidney 1

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Urinary diversion in childrenA total of 39 (65%) children had dilated upper urinarytracts and of these 30 were bilateral. One child who hada ureterosigmoidostomy performed during removal of a

malignant bladder tumour subsequently requiredconversion to an ileal conduit because of increasingupper urinary tract dilatation.The immediate postoperative complications are shown

in Table IV. There were 2 (3 40) cases of intestinal

TABLE IVUrinary diversion: immediate postoperative

complications

NoneIntestinal obstructionUrinary leakBurst abdomenFaecal fistula

54 (90%)2221

obstruction requiring laparotomy for the division ofadhesions. When the adhesions were divided in oneof these cases a leak appeared from one of the ureteroilealanastomoses and it was necessary to refashion it. Onechild developed a faecal discharge from the ileal stomaon the third postoperative day but it ceased sponta-neously after a further week. Two abdominal incisionsdehisced; both were in babies with ectopia vesicaeoperated at the age of 3 months. Paramedian incisionshad been used, and as a result of this disaster all subse-quent children with ectopia vesicae were operatedthrough oblique incisions in the left abdominal wall.There were no further instances of dehiscence. Therewere no deaths in the early postoperative period andnone of the ileal conduits necrosed as a result ofinadequate blood supply.

Table V shows the incidence of urinary infection,

TABLE VUrinary diversion: incidence of urinary infection

Present preoperative 55Present postoperative 38-once only 7

which was present preoperatively in virtually every case,the exceptions being those with malignant tumours.At each postoperative outpatient visit urine wassampled and the volume of residual urine measured bypassing a sterile size 8 FG infant feeding tube into theileal or ureteric stoma. Whenever this urine sampleproduced 100,000 or more organisms per ml on culture,it was assumed that a genuine urinary infection waspresent even though the child was not having symptoms.In view of the open nature of the drainage system andthe fact that Gram-negative organisms usually reside inthe small intestinal tract, it is unlikely that infectedurine in an ileal conduit would produce symptoms.There seemed no advantage in obtaining urine specimensby the method advocated by Bishop, Smith, and Gracey(1971) since the metal sleeve, which they recommended

should be passed into the conduit before introducingthe catheter, would be as likely to contain urine fromthe distal part of the conduit as from the proximal, andthus be contaminated by it. 38 children developed a

urinary infection postoperatively, though this occurredonce only in 7 children. The remainder required con-

tinuous low-dose antibacterial drug therapy in order toprevent organisms reappearing in significant numbersin their urine.

Fig. 2 shows the length of follow-up. 74% of the

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5

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Follow-up (years)

FIG. 2.- Urinary diversion. Length offollow-up.(f ectopia vesicae; L spina bifida; FJ others.)

cases were operated more than 2 years ago. Fig. 3shows the percentage of spina bifida children withnormal upper urinary tracts subjected to urinary diver-sion per year. It is a measure of the author's increasinguneasiness about the merits of this procedure in childrenwhose sole urinary tract disturbance is incontinencethat 7 or more years ago 50% of the children with

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30IV0 25

0 20a)r 15

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<I - 2 -3 -4 -5 - 6 -7 +Years

FIG. 3.-Urinary diversion. Spina bifida cases only.Number with normal upper urinary tracts operated per

year.

3B

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spina bifida had normal upper urinary tracts whereasonly 12% fell into this cgtegory 2 years ago.

ResultsThe late postoperative complications are given

in Table VI. 11 (18%) children developed a

TABLE VIUrinary diversion: late postoperative complications

Ectopia Spina Others TotalNone vesicae bifida 6 28 (47%)7 (58%) 15 (39.5%) (4%)

StomaStenosis 2 4 2 8Fistula 0 5 0 5Slough 1 0 0 1

Total 3 9 2 14 (23%)

Time interval = < 1 year 7 1-3 years 6 > 3 years 3Stoma required shortening in 2 cases

Bladderdischargel 0 I 11 0 11 (18%)

Time interval < 1 year 7 > 1 year 4Organism = coliform 2 pneumococcus 2

Strep. viridans 1 Haem. strep. 1

Death 1 1 3 5

profuse, foul-smelling discharge from the defunc-tioned bladder; all had spina bifida and 7 developedtheir discharge within a year. The organism inmost instances was a coliform, but two childrendeveloped an infection with pneumococci, one withStrep. viridans and one with haemolytic streptococci.The discharge was treated by bladder irrigationsand the instillation of antibacterial solutions, butthere was a tendency for it to relapse and somechildren required regular bladder irrigations overa period of weeks before their discharge finallyceased.

Complications affecting the stoma developed in14 children. In 8 cases there was stenosis due toepithelization of the stoma caused by the encrusta-tions produced by rubber urinary diversion appli-ances. After the introduction of plastic appliancesno further cases of stomal encrustation and stenosisoccurred. 5 children developed a skin levelfistula in the stoma caused by pressure from aninexpertly fitted urinary diversion appliance. Thestoma in 2 children had been made too long initiallyand had to be shortened to prevent it becomingtrapped in the urine collecting bag.There were 5 deaths in the late postoperative

period, 2 of which were due to recurrent malignantdisease. A further 2 children died of chronicrenal failure between 2 and 3 years after urinary

diversion, and 1 infant who had been subjected to aureteroileostomy for ectopia vesicae died of un-controllable septicaemia after laparotomy for lateintestinal obstruction. It was interesting to notethat a total of only 28 (47%) children had nopostoperative complications of any kind.The question of upper urinary tract dilatation

and its relation to urinary diversion was examinedin detail and the findings are set out in Table VII.

TABLE VIIUrinary diversion: upper urinary tract dilatation

Ttl Ectopia Spida Others]Total vesicae bifida

Normal pre- +postoperative 11 4 7 0

No follow-up IVP 4 1 1 2Same as preoperative 9 2 3 4Less than preoperative 28 3 22 3More than preoperative 10 2 6 2

The preoperative radiological state of the urinarytract was known in all children and all but 4 hadpostoperative intravenous pyelography (IVP). Ofthese, one was operated recently and the remainder,who were subjected to cutaneous ureterostomy,died of progressive renal failure between 2 and 3years after operation.IVP was usually performed after an interval of 1

year from operation and again after an interval of3 years. 14 cases with ileal conduits were sub-jected to a retrograde contrast medium study ofthe conduit.There were only 11 children who had normal

urinary tracts both before and after operation.4 of them had ectopia vesicae and 7 spina bifidacystica. There were 37 with preoperative dilatation,of which 28 improved or disappeared postoperative-ly, but 9 remained unchanged. The outstandingfeature, however, was that 10 children developeda significant increase in upper urinary tract dilata-tion postoperatively. 9 of these had a normalupper urinary tract before operation and all hadbeen subjected to ureteroileostomy. When thetime interval between operation and the onset ofupper tract dilatation was examined, it was foundthat in the majority of cases dilatation did notbegin until an interval of more than 2 years hadpassed. Others remained satisfactory for longerperiods such as 3 or 4 years and one child did notdevelop her dilatation until 7 years had elapsed.Thus, in this series, the long-term outcome ofurinary tract diversion, when assessed from the

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Urinary diversion in childrenstandpoint of upper urinary function, was unsatis-factory in no less than 34% of cases either becausepre-existing dilatation failed to improve or becauseurinary tracts which were normal preoperativelybecame dilated after a prolonged interval of time.The retrograde studies of the ileal conduits

carried out in children with dilated upper urinarytracts failed to reveal any obvious cause for thedilatation. Thus, the conduits were well placedin the abdomen with their proximal ends fixed at ahigh level so as to provide dependent drainage.None of them was dilated, and in only one casewas the conduit regarded as being too long. Thecontrast medium flowed readily into the ureterssuggesting that the ureteroileal anastomoses were notobstructed. Peristaltic activity was usually seen inboth the ureters and the ileal conduit.The revision procedures that were necessary in

this series are shown in Table VIII. 13 stomas

TABLE VIIIUrinary diversion: revision procedures

Stoma 13 fileal 10l ureteric 3

Conduit 4Nephrectomy 1Cystectomy 1

were revised because of stenosis caused by epitheli-zation or because of fistula formation. Fourconduits were revised; one was the coloneourethro-stomy previously mentioned, the second was an

ileal conduit in a baby who had developed latepostoperative intestinal obstruction, and two furtherileal conduits were explored because of increasingupper urinary tract dilatation. The conduit in one

of these children was undoubtedly too long and itwas therefore shortened and new ureteroilealanastomoses constructed. A similar operationwas carried out in the second case so that widejunctions between the ureters and the ileum were

established. It is interesting to note that theoriginal ureteroileal anastomoses in both thesechildren seemed to be patent and that it was easy

to pass a probe through them. Furthermore,IVP performed one year after the revision operationsdid not reveal improvement in the upper urinarytract dilatation.A nephrectomy was performed in one child for a

functionless dilated kidney which had failed toimprove after urinary diversion, and a cystectomywas carried out in another child because of persistentinfection and discharge in the residual bladder.

DiscussionThere are numerous published reports on urinary

diversion in children using an ileal conduit, andvirtually all of them mention the fact that somechildren had unsatisfactory results with respect tothe state of their upper urinary tracts. Most ofthe reports do not stress this fact, though Kingand Scott (1962) pointed out that the greater thedegree of prediversion upper urinary tract dilata-tion, the less the chance of improvement in thedilatation postoperatively. They also mentionedthat in most instances, 'deterioration ofthe collectingsystems could not be traced to obstruction at theileal stoma or at the site of ureteroileal anastomosis'.Because they thought that the dilated ureters wereacting as an obstructing segment, they recom-mended anastomosing the ileal conduit directlyto the renal pelvis. There was a high (52%)incidence of stomal obstruction in a series of 70ureteroileostomy procedures published by Rickham(1964), but he claimed that only 1 child developeddilatation of the upper urinary tract. Smith,writing in 1964 and again in 1972, found thatdeterioration occurred in 10% of childrenwhoseupper urinary tracts were normal preoperatively,and in 25% of those with preoperative dilatation.60% of the children in this latter group wereunchanged. It is interesting that though thenumber of cases included in the second of thesetwo reports was larger, the follow-up period wasconsiderably longer and the number of unsatis-factory results significantly higher. Further seriespublished by Logan, Scott, and Laskowski (1965),Fonkalsrud and Smith (1965), Bowles and Tall(1967), Cook et al. (1968), McCoy and Rhamy(1970), Malek, Burke, and DeWeerd (1971) allcontained a small but significant number of child-ren whose urinary tracts failed to improve oractually deteriorated after ureteroileostomy, andthere is a strong impression that the longer thechildren were followed up, the greater was thenumber with unsatisfactory results.

This state of affairs has two important implica-tions: firstly, urinary diversion through an ilealconduit, when carried out solely because of urinaryincontinence, will produce a significant number ofchildren with gradually deteriorating upper urinarytracts, and secondly, the use of ileal conduit urinarydiversion in children with dilated upper urinarytract is no guarantee that the dilatation will improve.Bad results in surgery immediately suggest bad

operative technique. But there is a remarkableuniformity in the techniques described by differentauthors, and it seems that if a technical error isresponsible for the bad results, then it is common

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to operations carried out in many different centresand by many different surgeons. Furthermore, a

technical error should cause early rather than latemalfunction in the urinary drainage system.

If gradual dilatation of the upper urinary tract isnot due to a technical error in the operation, thenit might be due to gradual stenosis of the ileal stomaor the ureteroileal anastomoses. That the formercan cause obstruction in the drainage system isclear, but under these circumstances the ileal con-

duit, as well as the upper urinary tract, becomesdilated and elongated, and the condition respondsrapidly to revision of the ileal stoma. The latterwould produce dilatation of the upper tract only,but the fact that retrograde contrast mediumexaminations of the ileal conduits show free flowfrom the conduits into the ureters is against thisexplanation. Moreover, anastomotic stenosis wasnot found in the cases re-explored in this series andreanastomosis did not significantly improve thedilatation.

It seems that the cause of this complication mustbe sought elsewhere. Smith (1972) postulatedthat the pressure created by peristalsis in an ilealsegment might be greater than the pressure pro-duced by the bladder and that this might beresponsible for upper tract decompensation. Min-ton, Kiser, and Ketcham (1964) carried out a

manometric study of ileal conduits and found threepredominant types of peristaltic pattern withpressures ranging from 10 to 100 mmHg andcorrelated these findings with the presence ofinfection but not the state of the upper urinarytract. In an attempt to find a cause for uretericdilatation after ureteroileostomy, pressure measure-ments were obtained from the ileal conduits of someof the children in the present series.

Pressure changes in the ileal conduit.Pressure changes were recorded in 11 childrenselected at random. A size 8 FG infant feedingtube was passed into the conduit to a depth of

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approximately 5 cm. This size catheter wasselected because it was easy to manipulate into theconduit; finer tubes tended to become caught inmucosal folds. It was noted that the cathetersdid not obstruct any of the ileal stomas and urineflowed out freely around them. The catheterswere connected to a Statham bridge transducerwhose signal was amplified by a SE Laboratories(Engineering) Ltd. multichannel amplifier andrecorded with an ultraviolet trace.

Recording was continued for 20 to 30 minutes todetermine whether there was spontaneous activityin the ileal conduit. The baseline pressure variedbetween 0 and 10 cm water in all cases except one

where it was 15. The only changes in pressurewhich were noted during this phase were causedby respiration and arterial pulsation, except inone child who produced spontaneous contractionswith a low amplitude of between 10 and 20 cm

water pressure, a duration of between 4 and 6seconds, and a frequency of 10 to 14 contractionsper minute (Fig. 4).

Then, 20 ml sterile normal saline solution were

run into the ileal conduit through the catheter viaan intravenous infusion set. At the same time,the stoma of the ileal conduit was compresseddigitally so as to prevent the saline from beingimmediately evacuated. The object of this investi-gation was to determine whether the isolatedlength of ileum would contract under conditionssimulating stomal obstruction. One child com-

plained of colicky abdominal pain as a result of thefluid infusion but none of the others experiencedany discomfort. There was an immediate rise inbaseline pressure in all the children though themagnitude of the rise varied from child to child,being as low as 15 to 20 cm in some, and as highas 50 to 60 cm in others.

This rise in baseline pressure was accompaniedby slow contractions which produced, in 7 cases,

pressures ranging from 65 to 125 cm water.One child had a sustained high baseline pressure

I millFIG. 4.- Tracing of pressure changes in ileal conduit when draining freely.

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Urinary diversion

80

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E 60

L-6 50

', 400.

L 300'B 20

10

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i in children 205b

I

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FIG. 5a and b.-Tracings of pressure changes in ileal conduits after infusion of 20 ml saline and while stoma obstructed.

of 50 cm with no contractions and 3 others hadcontractions generating pressures of 30 to 40 cm

only (Fig. 5a and b). The frequency of thecontractions varied from 1 to 18 per minute,though the mean was approximately 10 per minute.With the exception of the child already mentionedwho developed abdominal colic, not even thestrongest contractions produced any form of sub-jective sensation. So long as the stoma was

obstructed the contractions continued unabated,though this condition was not maintained forlonger than 10 minutes in any of the children.As soon as the stoma was released, fluid ran outaround the catheter with the result that the baselinepressure in the conduit fell and the contractionsdiminished in amplitude and frequency.

It is clear from these recordings that undernormal circumstances, ureteroileostomy provides a

low pressure drainage system for the kidneys, andthe early results of this operation are compatiblewith the experimental findings. However, thegradual dilatation of the upper urinary tract whichoccurs in some cases in the long term in the apparentabsence of a mechanical obstruction suggests thatat times the low pressure system may become ahigh pressure system. The recordings show thatif the ileal stoma is obstructed, there is a rapid andmarked rise in the intraluminal baseline pressurein the conduit accompanied by a series of strongcontractions which generate pressures at least twiceas high as the maximum generated by a normalureter. A close examination of children with ilealconduit urinary diversions while wearing theirurinary collecting appliances and their clothesshows how easily the stoma might become obstruc-ted intermittently by the pressure of underpants,skirts, trousers, nappies, or orthopaedic apparatus.

Similarly, the stoma might become obstructed atnight if the child were to sleep in the prone position.This intermittent increased pressure within theileal conduit acting over a long period of time mighteventually produce ureteric dilatation.

ConclusionThough the early results of ureteroileostomy

were encouraging, there is increasing evidence thatthis method of urinary diversion causes a significantnumber of unsatisfactory results when used inchildren who are followed over a long period oftime. In particular, the incidence of postoperativedilatation in normal urinary tracts is, in the author'sopinion, sufficiently high to contraindicate uretero-ileostomy as a method of controlling urinary incon-tinence. The penial urinal is satisfactory for thispurpose in most boys, and the advent of electricalsphincter pacemakers may improve the outlook forboth sexes. In circumstances where the upperurinary tract is already dilated and urinary diversionis contemplated in order to prevent further deterio-ration in renal function, cutaneous ureterostomy hasproved satisfactory in this series. The operationof pyeloileocutaneous diversion advocated by Kingand Scott (1962), Holland et al. (1967), and Skoglundand Ansell (1968) may produce more direct drainageofthe renal pelvis, but if the hypothesis put forwardin this paper is correct, intermittent high pressurein the ileal conduit will affect the renal tubulesimmediately since the cushioning effect of theureters is eliminated.There is one alternative which deserves further

consideration, namely the use of colon as a urinaryconduit instead of ileum. The physiologicalcharacteristics of colonic motility might theoreticallybe more suitable. Moreover, when taken out of

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206 John E. S. Scottcontinuity as, for example, in the operation ofoesophageal replacement, a length of colon becomesperistaltically inert. It is clear that furtherinvestigation of this possibility should beundertaken.

REEFERENCES

Bowles, W. T., and Tall, B. A. (1967). Urinary diversion in child-ren. J7ournal of Urology, 98, 597.

Bishop, R. F., Smith, E. D., and Gracey, M. (1971). Bacterialflora of urine from ileal conduit. J7ournal of Urology, 105, 452.

Bricker, E. M. (1950). Bladder substitution after pelvic eviscera-tion. Surgical Clinics of North America, 30, 1511.

Cook, R. C. M., Lister, J., and Zachary, R. B. (1968). Operativemanagement of the neurogenic bladder in children: diversionthrough intestinal conduits. Surgery, 63, 825.

Eckstein, H. B., and Boyd, J. (1969). Intestinal conduit urinarydiversion. Zeitschrift fur Kinderchirurgie und Grenzgebiete,7, 507.

Fonkalsrud, E. W., and Smith, J. P. (1965). Permanent urinarydiversion in infancy and childhood. Journal of Urology, 94, 132.

Grant, H. (1964). Colo-neo-urethrostomy. A diversion operationfor urinary incontinence. British Journal of Urology, 36, 198.

Holland, J. M., King, L. R., Schirmer, H. K. A., and Scott, W. W.(1967). High urinary diversion with an ileal conduit in child-ren. Pediatrics, 40, 816.

King, L. R., and Scott, W. W. (1962). Ileal urinary diversion.Success of pyeloileocutaneous anastomosis in correction ofhydroureteronephrosis persisting after ureteroileocutaneous

anastomosis. journal of the American Medical Association,181, 831.

Livaditis, A. (1965). Cutaneous uretero-ileostomy in children.Acta Paediatrica Scandinavica, 54, 131.

Logan, C. W., Scott, R., Jr., and Laskowski, T. Z. (1965). Ilealloop diversion: evaluation of late results in pediatric urology.Journal of Urology, 94, 544.

McCoy, R. M., and Rhamy, R. K. (1970). Ileal conduits inchildren. J7ournal of Urology, 103, 491.

Malek, R. S., Burke, E. C., and DeWeerd, J. H. (1971). Ilealconduit urinary diversion in children. journal of Urology,105, 892.

Minton, J. P., Kiser, W. S., and Ketcham, A. S. (1964). A studyof the functional dynamics of ileal conduit urinary diversionwith relationship to urinary infection. Surgery, Gynecologyand Obstetrics, 119, 541.

Mogg, R. A. (1967). The treatment of urinary incontinence usingthe colonic conduit. Journal of Urology, 97, 684.

Rickham, P. P. (1964). Permanent urinary diversion in childhood.Annals of the Royal College of Surgeons of England, 35, 84.

Skoglund, R. W., Jr., and Ansell, J. S. (1968). Pyeloileocutaneousdiversion in children. Journal of Urology, 100, 257.

Smith. E. D. (1964). Ileo-cutaneous ureterostomy in children.I. Indications and results. Australia and NewZealand Journalof Surgery, 33, 169.

Smith, E. D. (1972). Follow-up studies on 150 ileal conduits inchildren. J7ournal of Pediatric Surgery, 7, 1.

Correspondence to Mr. J. E. S. Scott, Department ofSurgery, University of Newcastle upon Tyne, RoyalVictoria Infirmary, Newcastle upon Tyne NE1 4LP.

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