Continent and Incontinent Bladder Augmentation and Diversion

Urinary incontinence has a detrimental effect on a patient's quality of life. The problem is even more devastating when patients experience fecal incontinence and other disabilities that prevent them from managing their incontinence independently. Numerous techniques have been used in the effort to achieve urinary continence, such as indwelling urethral catheters or suprapubic tubes, penile clamps, external catheters, pads, and diapers; all harbor their own complications and limit quality of life. Initially, most patients with neurologic disorder and a neurogenic bladder are treated pharmacologically. The adjunct of clean intermittent catheterization (CIC) helps many patients with neurogenic bladders. Despite the immediate objection, nearly all patients with hand function are able to learn and perform CIC. Subpopulations that are unable to perform CIC are tetraplegic patients with poor manual dexterity, cognitive impairment, or body posture that prevents easy access to the urethra and patients with damaged or scarred urethras not suitable for urethral reconstruction. Caretakers rather than the patient may perform CIC. Simon described the first urinary diversion, ureterosigmoidostomy, in 1852. Since then numerous solutions have been proposed, all of them with the same intent of providing a low-pressure manageable diversion. The Mitrofanoff procedure and the Indiana pouch with its modification for an ileocystoplasty have gained great popularity in the last 10 to 15 years. In this article, we review patient selection, operative goals, and surgical technique to obtain better bladder management for these chronically disabled patients.