Bladder reconstruction in children.

Bladder reconstruction in children attempts to provide for a low pressure reservoir of urine that is continent and may be emptied completely at appropriate intervals. The most common underlying causes of bladder dysfunction that may require reconstruction include neuropathic bladders associated with spina bifida, posterior urethral valves, and bladder exstrophy. Indications and patient selection for reconstruction have greatly improved and a variety of methods are available; each with its own advantages and drawbacks. The recent increased application of gastric segments in augmenting the bladder to increase size and compliance has been very successful, and particularly in patients with impaired renal function. The continent catheterizable stoma (Mitrofanoff principle), using appendix or ureter, has gained widespread acceptance in reconstructive procedures and provides a reliable, convenient, and well-accepted means of achieving continence. Although advances have been made in reconstructive techniques, new complications are being experienced, including stone formation and metabolic abnormalities. Gastrocystoplasty, although an excellent option in reconstruction, has produced a symptom complex of hematuria and dysuria in some patients, at times to a significant degree. With experience, these complications are becoming better understood and new strategies for management are being developed. On the horizon, new approaches to bladder replacement are being explored, and new investigation into the pathophysiology of pediatric bladder dysfunction is ongoing.