The management of major renal lacerations after blunt trauma is still a matter of controversy. In this study, conservative treatment of major renal lacerations failed in 7 of 18 patients, leading to delayed surgery. Urography after blunt trauma was abnormal in 97% of patients with severe renal injury but a normal urogram did not exclude severe renal injury. Computed tomography had a greater degree of accuracy than urography and ultrasonography in determining the extent of the injury and was more practical to perform than angiography. The results indicate that patients with significant extrarenal leakage on urography, angiography or CT should receive immediate surgical management.

Objective To evaluate the glomerular filtration rate IGFR and incidence of anastomotic stenosis in patients with urinary diversion by ileal or colonic conduit (refluxing or anti-reflux uretero-intestinal anastomosis) or with a continent caecal reservoir. Patients and methods All conduit urinary diversions performed from 1 9 i 7 to 1984 were randomized by type (ileal or colonic) and by the method of ureteric implantation (with or without anti-reflux technique).In continent caecal reservoirs anti-reflux implantation was used for both ureters. Total and separate GFR were measured pre-operatively and after a mean follow-up of 123 months (range 36-198) with 51Cr-EDTA and scintillation renography. Results Of the 56 evaluable patients. 18 had an ileal and 20 a colonic conduit, and 18 had a continent reservoir. The total mean GFR fell from 88 to 71 mllmin in the ileal group. from 84 to 65 mI,/min in the colonic group and from 1 0 0 to 85 mL/min in the reservoir group. Separate GFR did not differ significantly between kidneys with and without reflux protection in the patients with a conduit diversion. Strictures occurred in 1 5 uretero-intestinal anastomoses and were unrelated to the mode of ureteric implantation (in the conduit groups). Renal function improved after ureteric reimplantation in six of Seven kidneys. but after balloon dilatation in only one of fire. Conclusion GFR fell moderately in all three groups. with no significant intergroup difference. and the continent caecal reservoir compared favourably with conduit diversion. The fall in separate GFR did not differ significantly between kidneys with and without reflux protection. Surgical exploration of uretero-intestinal stenosis is recommended if renal function is threatened. Keywords Glomerular filtration rate. ileal conduit. colonic conduit. continent caecal reservoir, refluxing ureteric anastomosis. anti-retlux ureteric anastomosis introduction 'The number of proposed techniques for continent cutaneous urinary diversion and bladder substitution as alternatives to conduits has increased dramatically during the past decade. To achieve acceptability. these nrw methods must be shown to protect renal function at least as well as conduit diversion. which should serve as the 'gold standard'. However, there are some controversial aspects of conduit diversion. These include the choice of intestinal segment for the conduit and. in particular, whether nonrefluxing or refluxing uretero-intestinal anastomosis is optimal for the preservation of renal function. The generally held belief that anti-reflux ureteric implantation is beneficial for preservation has been proven only experimentally [ 11. The results from long-term follow-up after anti-reflux implantation into colonic conduits havr tended to be unsatisfactory. possibly due to failure of the anastomosis to prevent reflux. and not superior to those achieved with ileal conduit [ 2.31.To explore the choice of optimal intestinal segment for urinary conduit and methods of ureteric implantation, a prospective study was b...

Anti-reflux ureteric anastomosis seems to be important for preventing scarring and bacteriuria in the upper urinary tract of patients with a conduit urinary diversion. Despite the anti-reflux technique of ureteric implantation, most patients with a continent reservoir had renal scarring, though it was generally less severe than in patients with a conduit urinary diversion.

Incorporating bowel into the urinary tract sets the stage for a potentially dangerous situation for the upper part of this tract. Obstruction, reflux and chronic bacteriuria may develop, all of which can all be detrimental. Most reports on renal function have used IVP and serum creatinine only, methods which are inadequate for proper assessment. Long-term follow-up of patients with ileal conduit diversion reveals a high incidence of morphological and/or functional damage to the kidneys. Refluxing techniques for implanting the ureters have usually been employed. In patients with continent cutaneous diversion or orthotopic bladder substitution, some recent publications have shown rather well preserved glomerular filtration rates. Traditionally, antirefluxing ureteric implantation has been used in these patients. There is presently a trend towards refluxing anastomosis in this setting, providing a low pressure pouch has been constructed. However, pressure can be high in such pouches and bacteriuria is common. The consequences for the fate of the upper urinary tract is unknown and caution should be exercised in recommending such techniques. There is clearly a need for prospective randomized controlled studies on the issue of refluxing versus antirefluxing anastomosis in continent urinary reconstruction. Patients with continent or non-continent diversion should have lifelong follow-up with regard to the upper urinary tract.

Objective To study the morphology and function of the upper urinary tract over the long‐term in dogs with an enterocystoplasty and a refluxing or anti‐refluxing uretero‐intestinal anastomosis. Materials and methods Subtotal cystectomy and ‘cup’ ileocystoplasty were performed in 13 dogs. The right ureter was implanted into the cystoplasty with a refluxing technique in seven and with an anti‐reflux procedure in six dogs. The le ft renal unit acted as an intact control in 11 dogs, while in two the intramural part of the left ureter was incised to produce reflux. Thus, of the 26 renal units, nine had a refluxing junction (anastomosis), six were anti‐refluxing and 11 served as intact controls. Total and separate glomerular filtration rates (GFRs) were measured pre‐operatively and regularly thereafter, and cystometry, urography and ascending enterocystography were performed. At necropsy, urine was obtained for culture from the cystoplasty and renal pelves, and both kidneys were examined histologically. Results The cystometric pressure was low in 12 of the 13 dogs; urography showed no obstruction. The fall in separate GFR did not differ significantly among the groups (with and without reflux protection, and control units). Reflux was detected in three of nine renal units with refluxing anastomosis and in three of 11 control units. Bacteriuria was found in the cystoplasty in all dogs; the incidence in the upper urinary tract was seven of eight renal units with a refluxing anastomosis, one in five of those with an anti‐refluxing anastomosis and three of nine control units. Pyelonephritis was found in none of the control kidneys, in six of nine kidneys with a refluxing and in two of six with an anti‐refluxing anastomosis; it was less severe in the latter. Conclusion Refluxing ureteric implantation in a low‐pressure enterocystoplasty was commonly associated with bacteriuria in the upper urinary tract and with pyelonephritis. Thus, anti‐reflux implantation was beneficial for renal preservation in this setting.