A comparison of two continent catheterizable vesicocutaneous techniques.

In a rabbit model we describe and compare two continent catheterizable diversion techniques for which the bladder is intact and the stoma is situated in the lower abdomen. Both mechanisms are formed from a short segment of ileum; one utilizes the principles of the encircling loop technique as described by Koff and the second, the Kock principle (intravesical nipple). Both models were evaluated for the following parameters: ease of catheterization (87%, 79% respectively), continence (91%, 86% respectively), and ease of construction. We present evidence that both techniques are applicable to the clinical setting.     

An assessment of the use of a continent catheterizable stoma in female tetraplegics

OBJECTIVES: To evaluate the success of a continent catheterizable stoma in females with cervical spinal cord injury which resulted in neurogenic bladder dysfunction, the management of which may require clean intermittent catheterization despite altered hand function. PATIENTS AND METHODS: Six female tetraplegic patients with a lesion at C7 or above (age range 12-22 years) had a continent catheterizable abdominal stoma formed as part of their bladder management. As an objective measure of effectiveness, the time to complete catheterization was assessed before and after surgery. A quality-of-life survey at a mean (range) of 44 (6-90) months was also evaluated. RESULTS: All six patients can catheterize while in their wheelchair. The mean (range) time required for catheterization decreased from 27 (10-40) to 7.8 (1-15) min after surgery. All six reported a significant improvement in continence, body image, independence, convenience, time saving and satisfaction. CONCLUSION: Constructing a continent catheterizable stoma is a valuable option in selected tetraplegic patients.     

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.     

Long-term followup and outcome of continent catheterizable vesicocstomy using the Rink modification

PURPOSE: Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. RESULTS: Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. CONCLUSIONS: Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.     

Early experiences with continent bladder substitution

Since January 1987 a total of 14 patients have undergone continent bladder replacement procedure. The bladder substitute was constructed of ileum (ileal neobladder) in three patients, of an ileocaecal segment (Mainz pouch) in five patients while in six patients a segment of ascending colon (Mayo pouch) was used. Nine male patients underwent a complete bladder substitution after cystoprostatectomy. In five patients a bladder augmentation was performed. Four of these patients were female. They were subjected to subtotal cystectomy which left only one cm of the bladder neck, while the ureters were reimplanted into the pouch. Seven of the nine patients with total bladder substitution are continent during the day and seven at night. All patients in the bladder augmentation group are continent day and night, but one of them has to empty his bladder by intermittent catheterization. Because of stenosis at the ureterocolonic anastomosis, reoperation was performed on two patients more than one year after the primary operation. Except for these two patients, who required surgical revision, the initial results are encouraging and patient acceptance has been excellent.     

CONSTRUCTION OF CONTINENT CATHETERIZABLE URINARY CONDUIT FROM AN ISOLATED SEGMENT OF COLON

Background: Continent urinary diversion may be necessary in range of urological abnormalities. In circumstances where the standard techniques are not possible, alternative innovative techniques may be used. Methods: In female patient with bladder exstrophy, continent diversion was recommended. The appendix was not available, the ureters were not suitable and continent stoma was fashioned from an isolated segment of colon. Results: The stoma proved to be continent, although it was somewhat stenotic. However, clean intermittent catheterization maintained its patency. Conclusions: A continent catheterizable stoma may be constructed from segment of colon. The technique may be considered when other well recognized methods are not feasible.     

Urethral duplication with single bladder and multiple genitourinary abnormalities: an example of continent urinary diversion

A 13-year-old girl with multiple genitourinary malformations, incomplete bladder exstrophy, urethral duplication with single bladder, septate vagina, and total urinary incontinence is presented. Prior to admission she had undergone surgery for teratoma and calculi of the bladder and partial fecal incontinence. A continent urinary diversion was done by bladder augmentation using a cecal-colonic segment and by surgical closure of the bladder neck. The distal end of the appendix was brought to the skin as an inconspicuous, easily catheterizable, watertight stoma, our modification of the Mitrofanoff procedure. Excision of the vaginal septum, creation of an introitus, and unification of the split clitoris improved the cosmetic appearance of the external genitalia and improved the outlook for a normal sexual life and pregnancy.     

APPENDICOVESICOSTOMY AND NEWER ALTERNATIVES FOR THE MITROFANOFF PROCEDURE: RESULTS IN THE LAST 100 PATIENTS AT RILEY CHILDREN′S HOSPITAL

PURPOSE: We present our experience using the various Mitrofanoff techniques to create a continent catheterizable stoma as an adjunct to continent urinary tract reconstruction in children and young adults. MATERIALS AND METHODS: Between 1990 and 1998 a Mitrofanoff procedure was performed at our institution in 55 male and 45 female patients with a mean age of 10.5 years. The etiology of incontinence was diverse but more than 90% of the patients had neurogenic bladder, the epispadias-exstrophy complex or a cloacal anomaly. Surgery included appendicovesicostomy in 57 cases, a Yang-Monti ileovesicostomy in 21, continent vesicostomy in 21 and formation of a tapered ileal segment as a catheterizable channel in 1. Simultaneously bladder augmentation was performed in 52 patients, bladder neck reconstruction was done in 48 and a Malone antegrade colonic enema stoma was constructed for fecal incontinence in 17. RESULTS: The abdominal stoma is continent in 98 of our 100 patients. Mean followup is 2 years (range 2 months to 8 years) with the longer followup in the appendicovesicostomy group. One patient with stomal incontinence who underwent revision is now dry. Postoperative complications requiring an additional procedure developed in 20 patients, including stomal stenosis in 12. Continent vesicostomy was most prone to stomal problems (6 of 21 patients, 29%). CONCLUSIONS: The Mitrofanoff procedure is a reliable technique for creating a continent catheterizable urinary stoma. Appendicovesicostomy continues to be our first option for this procedure, although we have also had good results with the Yang-Monti ileovesicostomy and continent vesicostomy. These newer options have allowed preservation of the appendix for the Malone antegrade colonic enema stoma procedure in patients with urinary and fecal incontinence.     

Continent Gastric Tube: New Techniques and Long-Term Followup

Purpose

The successful use of stomach for bladder augmentation and substitution is well documented. Gastric tissue has been used more recently to create continent catheterizable tubes. We describe 2 new techniques of gastric tube construction, and report our long-term followup of catheterizable gastric tubes in children and adults undergoing complex urinary tract reconstruction.

Materials and Methods

A retrospective chart review of 6 male and 4 female patients 5 to 43 years old was done. Primary diagnoses included bladder exstrophy, cloacal exstrophy, rhabdomyosarcoma and neurogenic bladder. Five patients underwent gastrocystoplasty with simultaneous creation of a continent gastric tube from the anterior gastric flap. In 2 patients who had undergone previous gastrocystoplasty a continent gastric tube was created from an anterior flap raised from the existing gastric bladder. Isolated gastric tubes were constructed in 3 patients.

Results

Followup ranged from 2 to 9 years (median 3.5). All patients demonstrated easy reliable catheterization. One patient required revision of the proximal end of the tube for incontinence. At followup all tubes were continent. Complications occurred only in flush or protuberant stomas, and resolved after stomal revision with recessed skin flaps.

Conclusions

Several techniques can be used to create a continent gastric tube. Long-term followup reveals reliable catheterization and good continence rates. Recession of the gastric tube stoma with a skin flap prevents peristomal complications.     

The continent, catheterizable abdominal conduit in adult urological practice

OBJECTIVE

To report a large, single‐centre experience with a continent, catheterizable abdominal conduit in adult patients.

PATIENTS AND METHODS

We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13‐year period. Data on surgical procedure, complications and final outcome were collected and analysed.

RESULTS

The mean age of the patients was 38.4 years and mean follow‐up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent.

CONCLUSIONS

Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long‐term follow‐up.     

Editorial

ABSTRACT

Twenty-four patients, with various combinations of non-healing decubitus ulcers, urethral fistulae, incontinence, and penile skin breakdown were candidates for proximal urinary diversion, having failed intermittent, external, and indwelling catheterization combined with pharmacologic therapy. Seventeen patients underwent bladder neck closure, including seven with multiple sclerosis and ten with spinal cord injury, and because they were unable or unwilling to do catheterization, had their urine diverted by suprapubic catheter. Seven patients, including four with spinal cord injury, underwent bladder neck closure and continent augmentation with formation of a catheterizable cutaneous stoma on the anterior abdominal wall, using right colon and right colon/ileum configurations. When ureteral reflux and obstruction are absent, the patient's bladder was used which spared the added risk of ureteral implantation and possible ureteral stricture while increasing total bladder capacity. In a select group of patients with intractable incontinence, perineal and penile skin breakdown, or urethral fistulae, bladder neck closure and urinary diversion by suprapubic catheter or continent augmentation has proven to be a reliable and effective alternative to an ileal conduit.     

The same-pedicle concept for continent urinary diversion using a Yang-Monti reconfigured tube

OBJECTIVE: To facilitate the anastomosis of a continent valve to the umbilicus or a suitable skin area, we used a reconfigured tube made from the same segment of the intestinal reservoir as that used to construct the urinary pouch. MATERIALS AND METHODS: Seven patients underwent continent ileal-pouch formation using a reconfigured ileal tube following cystectomy for bladder cancer. Two irradiated patients and 1 patient with neurogenic bladder underwent continent colon-pouch construction with a reconfigured colon tube. RESULTS: The average length of the reconfigured ileal tube was 5 cm, while the colon tube was maximally 10 cm long. All procedures were technically straightforward. All the continent pouches functioned well, without catheterization difficulties. CONCLUSIONS: Since the Yang-Monti tube and the pouch are easily mobilized, being based on the same vascular pedicle, and can therefore bridge the gap, making the umbilical anastomosis was greatly facilitated. Sufficient support for the tube is provided by the pouch.     

Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy

PURPOSE: Salvage prostatectomy after full dose radiation therapy is associated with a high risk of urinary incontinence. We evaluated the complications of salvage prostatectomy with continent catheterizable reconstruction and its impact on urinary incontinence. MATERIALS AND METHODS: Between August 1995 and February 1999, 13 patients with biopsy proved, locally recurrent prostate cancer after radiation therapy underwent salvage prostatectomy with complete bladder neck closure and reconstruction with an appendicovesicostomy to the native bladder in 9 and ileovesicostomy in 4. RESULTS: There were no intraoperative complications. Four patients had serious complications necessitating reoperation, including a vesicourethral fistula requiring delayed cystectomy, wound dehiscence with disruption of the appendicovesical anastomosis, leakage from the small bowel anastomosis that resulted in sepsis and death, and stomal stenosis requiring delayed stomal revision in 1 each. Of 12 patients 2 (17%) used pads for incontinence, while 10 were dry during the day and night with a catheterization interval of 2 to 6 hours. CONCLUSIONS: Salvage prostatectomy with continent catheterizable reconstruction is a technically challenging operation with the potential for serious complications. The postoperative continence rate is excellent and appears superior to those in the literature for salvage prostatectomy and vesicourethral anastomosis.     

Serosal lined extramural tunnel (Ghoneim) principle in the creation of a catheterizable channel in bladder augmentation

PURPOSE: The flap valve mechanism is often the preferred technique for creating a continent catheterizable channel in bladder reconstruction. The umbilicus is usually the preferred site for stomal placement. However, it is not always possible to bring the conduit to the umbilicus when creating the flap valve mechanism at the bladder level. To prevent this problem, we applied the Ghoneim technique to construct the flap valve mechanism during ileal bladder augmentation. MATERIALS AND METHODS: A total of 10 patients (7 boys and 3 girls) 5 to 17 years old underwent ileocystoplasty in combination with an appendiceal Mitrofanoff procedure as a catheterizable channel. The U-shaped ileal segment was anastomosed to the bivalve native bladder, leaving redundant bowel on the right side. The musculomucosal edges of the redundant bowel were sutured together, forming the posterior wall of the tunnel. The appendix was positioned onto the musculomucosal suture line, and the proximal end was anastomosed to the reservoir with an advancement suture. The ileal segment was then imbricated over the appendix by interrupted silk sutures, forming a serosal lined extramural tunnel. The stoma was placed at the depth of the umbilicus. RESULTS: The underlying diagnoses included mylomeningocele (8) and posterior urethral valve (2). Mean followup time was 12.5 months (range 7 to 21). All patients were continent, and there were no stoma related complications such as stenosis or difficult catheterization. CONCLUSIONS: The Ghoneim technique creates an effective continence mechanism and allows the conduit to reach the umbilicus easily.     

The mainz-pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent diversion

Summary The ideal urinary reservoir constructed from bowel material should be a low-pressure system with a high capacity, capable of preventing upper tract deterioration resulting from ureteral obstruction or reflux. It should achieve reliable control of continence and assure easy emptying of the reservoir. In the Mainz-pouch, the combination of cecum and ileum, the latter of which is able to absorb pressure waves created by the cecum, produces a low-pressure system with a high capacity immediately postoperatively. By incorporating large bowel in our pouch, ureteral implantation can be done using a simple and reliable standard antireflux technique with a submucosal tunnel. The Mainz-pouch has been done since 1983 in 26 patients. Of these 11 were for bladder augmentation after subtotal cystectomy and 15 for continent urinary diversion. All of the patients with bladder augmentation are completely dry day and night; 2 patients with myelomeningocele are on intermittent catheterization for bladder evacuation. The remainder void spontaneously without significant residual urine. Of 15 patients with Mainz-pouch urinary diversion, 4 had an alloplastic stomal prosthesis implanted for control of continence and 11 have isoperistaltic ileo-ileal invagination, where by the invagination valve can easily be fixed to the intussuscepting ileum by sutures or staples. Of the 4 alloplastic stomal prostheses, 2 have been removed because of infection. In 1 of these patients, an ileo-ileal invagination was performed in the same operation to achieve continent closure. All patients with the invagination valve, as well as the 2 patients with an alloplastic stomal prosthesis, are completely continent, but in 3 cases, revision of the ileo-ileal invagination became necessary due to prolapse of the valve.     

New continent ileocolonic urinary reservoir: Charleston pouch with minimally altered in situ appendix stoma

A new continent urinary reservoir that utilizes minimally altered in situ appendix stoma is described. The reservoir was constructed from segments of terminal ileum and ascending colon which were detubularized and reorientated to provide maximum reduction in filling pressures. The in situ appendix was utilized to provide a continent catheterizable stoma. Appendicular leak pressures were measured intraoperatively to determine the need, if any, for augmentation. Minimal reinforcement of the appendiculo-colonic junction with two or three sutures was performed in most patients. Preliminary experience with 16 patients who had the Charleston pouch with an appendicular stoma as described herein is reviewed.     

Construction of a continent catheterizable urinary valve from a gastric segment in dogs.

We constructed a continent, catheterizable urinary valve from a gastric segment in 7 dogs. A vascularized gastric segment was isolated from the greater curvature and was tubularized. A cuff was made at the distal end of the tube. The gastric tube was anastomosed to the dome of the bladder with intussusception of the cuff portion into the bladder cavity. The valve provided continence over a wide range of bladder pressure. However, an ulcer of the bladder developed where the gastric mucosa of the cuff faced the bladder mucosa in 5 dogs, with a resultant intraperitoneal perforation in 2 dogs. The development of the bladder ulcer may be a serious complication of an anastomosis of an isolated gastric segment to the bladder.     

The Mainz pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent urinary diversion

A new technique for fashioning an ileocecal pouch, applicable for both bladder augmentation and continent urinary diversion, is described. A low pressure reservoir is achieved by antimesenteric longitudinal transsection of ileum and cecum and formation of a pouch from the cecum and two ileal loops. The antireflux procedure consists of submucosal tunnel implantation of the ureters into the cecum. Clinical application of the operative technique in 4 cases for bladder augmentation and in another 6 cases for urinary diversion has proven the validity of our functional concept: all patients with Mainz pouch bladder augmentation are completely dry day and night with normal intervals of bladder evacuation. Of the 6 patients with Mainz pouch urinary diversion, 2 rely on a an all alloplastic stomal prosthesis for continence, another 2 have achieved continence with isoperistaltic ileo-ileal invagination, and the remainder are awaiting implantation of a sphincteric device.     

The Malone antegrade continence enema combined with urinary diversion in adult neurogenic patients: early results

Objectives. Patients with neurogenic voiding dysfunction often have coexisting neurogenic bowel problems. Impaired bowel evacuation is a cause of major morbidity and impaired lifestyle for these patients. The Malone antegrade continence enema (ACE) performed synchronously with a urinary continence procedure has been successful in pediatric patients. We report early experience combining the ACE with a urinary continence procedure in adult neurogenic patients.Methods. Adult patients with neurogenic voiding dysfunction and impaired bowel evacuation refractory to conservative management underwent a urinary continence procedure synchronously with an ACE.Results. Two patients have undergone the procedure. One patient chose a continent catheterizable supravesical bladder augmentation, whereas the other patient chose an ileal conduit. Both patients had a separate appendiceal stoma for their ACE. Both patients are continent of stool at their appendiceal stoma and per rectum. Both patients have stabilized their urinary tracts. Complications were minimal.Conclusions. The ACE may benefit adult patients with impaired bowel evacuation and may be combined with a urinary continence procedure. Further study of the ACE is warranted.