title: Efficacy and safety of continent anal urinary diversion for complicated bladder exstrophy in children by using modified Duhamel's procedure.
abstract: BACKGROUND
  A high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence and a miserable life even after a well-performed staged reconstruction in specialized centers. Most of those children usually have a normal anal sphincter allowing construction of a neobladder from the rectum, so they are continent without an abdominal stoma, and do not require frequent catheterization, which greatly contribute to a favorable body image.
  
  
  OBJECTIVE
  In this study a modified Duhamel's rectal pouch done for 19 children, with implication of suitable stapler adopted to construct a rectal bladder with a non-refluxing urterorectostomy, there is a theoretical advantage in our procedure of avoiding a mix of urine and feces. All patients were followed for up to 6 years (2-8 years) for efficacy, safety, subsequent renal complications, and surveillance for any rectal neoplastic changes in this new diversion.
  
  
  METHODS
  Assessment of electrolytes, acid base balance, and renal function were carried out regularly and all data were analyzed using the SPSS 9.0.1 statistical package and compared using a paired t test; data were considered significant if p < 0.05. Proctoscopy was performed 6 monthly in the first year then annually thereafter, and at any time if there was any rectal bleeding.
  
  
  RESULTS
  In this group of patients, follow-up revealed no neoplastic changes in the rectal bladder, deterioration in renal function, or major electrolytes disturbance. They can hold up to 400 mL (350-550 mL) of urine and all are continent during the daytime with an emptying frequency of 3-5 h; three patients had infrequent (4 episodes/month) nocturnal enuresis; and four cases developed pyelonephritis controlled with medical treatment.
  
  
  CONCLUSIONS
  The continent rectal bladder created by using the principles of the Duhamel pull-through is feasible, easy to perform, successful in the immediate short term with low complications after 6 years of follow-up and appropriately accepted by the children and their families with marked improvement in quality of life regarding continence; longer-term follow-up is requested to rule out rectal neoplastic changes. A comparative review of the complications, patient's acceptance, and longer-term follow-up with other well-known procedures, such as Mainz II, is required.
authors.affiliation: Al Azher University, Department of Pediatric Surgery, Cairo, Egypt. Electronic address: mabfahmy@hotmail.com.
authors.forename: Mohamed A Baky
authors.initials: MA
authors.lastname: Fahmy
authors.affiliation: National Institute of Urology, Cairo, Egypt.
authors.forename: Alae A
authors.initials: AA
authors.lastname: Al Shenawy
authors.affiliation: Alexandria University, Department of Pediatric Surgery, Egypt.
authors.forename: Sameh M
authors.initials: SM
authors.lastname: Shehata
mesh_terms: D001003:Anal Canal / Q000601:surgery*; D001746:Bladder Exstrophy / Q000150:complications / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D018666:Ureteroscopy; D001743:Urinary Bladder / Q000601:surgery*; D014547:Urinary Diversion / Q000379:methods*; D014549:Urinary Incontinence / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D016476:Urinary Reservoirs, Continent
keywords: Bladder exstrophy; Duhamel's pull-through; Urinary diversion