**13.2. Incontinent diversion**

**11. External sphincterotomy**

70 Microbiology of Urinary Tract Infections - Microbial Agents and Predisposing Factors

upper urinary tract is not damaged [91].

**12. Bladder augmentation**

this procedure.

rostomy tube.

**13. Urinary diversion**

**13.1. Continent diversion**

The efficacy of the sphincterotomy has been well documented since Emmett JL and Dunn JH described the trans-urethral resection of the bladder neck and prostate in SCI patients with outlet obstruction. Ross JC introduced the resection of the external urinary sphincter. Large series have shown that sphincterotomy is successful in the treatment of vesical outlet obstruction in certain male patients with quadriplegia, in order to reduce detrusor leak point pressure, followed by condom catheter drainage. Patients who develop UTIs after sphincterotomy are should undergo assessment of PVR to ensure adequate bladder emptying. Urodynamic testing should also be considered to assess the efficacy of the sphincterotomy. If there is evidence of urethral obstruction, repeat sphincterotomy may be indicated. Sphincterotomy can also be indicated when patients use Credé or Valsalva to empty their bladder, but first, surgeons must have assessed that the lower urinary tract is urodynamically safe and that the

The aim of bladder augmentation is to reduce detrusor overactivity (DO), improve bladder compliance and reduce the pressure effect of DO [92, 93]. Complications associated with these procedures are recurrent infection, stone formation, perforation or diverticula, possible malignant changes, metabolic abnormality, mucus production and impaired bowel function [94–96]. Special attention should be paid to patients with preoperative renal scars since metabolic acidosis can develop [97]. Several different techniques have been published [98–106]. Bladder substitution, even by performing a supratrigonal cystectomy [93], is also indicated in patients with a severely fibrotic bladder wall. IC may become necessary after

Following supravesical urinary diversion, pyelonephritis may occur, usually accompanied by fever, chills, leukocytosis, nausea and vomiting. Upper tract imaging should be performed, due to possible urinary obstruction. If there is an obstruction, the system should be drained via percutaneous nephrostomy. In this case, urine culture should be obtained from the neph-

It is the first choice for urinary diversion. The continent urinary reservoir is indicated when the native bladder and urethra are severely devastated functionally or anatomically, as well as bladder neck closure and ureteral re-implantation are not avoidable. All of the different techniques have complications such as leakage or stenosis. The short-term continence rates

are >80% and good protection of the UUT is achieved [107–119].

If catheterization is impossible, incontinent diversion is indicated. The ileal conduit is the most common form of incontinent urinary diversion used. It could be considered in patients who show intractable and untreatable incontinence, in patients with LUT dysfunction, when the upper urinary tract is severely compromised and in patients who refuse other therapy [119]. An ileal segment is used for the deviation in most cases [120–124] and patients gain better functional status and quality of life [125]. Incontinent diversion has also an acceptable rate of complications. Especially in children, there are concerns about long-term effects on renal function, and while conduit diversion may be considered in this population, alternative methods may be preferable.
