Rectus sheath tunnels for continent stomas

Pilot study of the vesicocutaneous continent catheterizable stoma (mitrofanoff) in adults--high complication rates

OBJECTIVE

To report our experience with an adult vesicocutaneous Mitrofanoff, an alternative to standard appendiceal or ileal Mitrofanoff.

MATERIAL AND METHODS

Retrospective chart review was performed on 3 patients who underwent a vesicocutaneous Mitrofanoff by a single surgeon. Data were collected on etiology, complications, and number of procedures to correct the complication.

RESULTS

Indications for the procedure included neurogenic bladder and urinary retention. Mean follow-up time was 485 days with mean time to first complication of 24 days. One-hundred percent of patients saw stenosis and dehiscence of their wounds. All 3 patients required subsequent surgery. Sixty-six percent required reoperation to the standard Mitrofanoff with a mean time to this procedure of 222 days. The mean number of procedures was 4 (range 2-6).

CONCLUSION

Continent catheterizable stomas have been a continuous challenge for adults who have had multiple abdominal surgeries, making a typical appendix, ureter, or small bowel Mitrofanoff difficult. We looked at our experience with a cutaneous Mitrofanoff (an extraperitoneal procedure often done in pediatrics but never before in adults) as an alternative but found complication rates of 100%. These included stenosis and dehiscence eventually requiring reoperation, with some even requiring conversion to an ileal or appendiceal Mitrofanoff. Although there are high complication rates in the standard Mitrofanoff, we conclude that a vesicocutaneous Mitrofanoff is not an effective alternative.

Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail

PURPOSE

We evaluated the functional outcome of continent catheterizable outlet using the serous lined extramural tunnel technique as a continence mechanism in children and adolescents.

MATERIALS AND METHODS

We retrospectively studied all patients who underwent continent catheterizable stoma using the serous lined extramural technique between May 1993 and March 2008. Patient records were reviewed for age, sex, indication for surgery, surgical details and postoperative course. All patients were evaluated for continence with emphasis on frequency of clean intermittent catheterization. Urodynamic evaluation was done for patients with leaking stoma. Stoma related complications were also recorded.

RESULTS

A total of 37 boys and 23 girls 3 to 18 years old underwent continent catheterizable stoma using the serous lined extramural technique. Total bladder substitution was performed in 13 patients using continent ileal W-shaped reservoir, and 47 patients underwent augmentation ileocystoplasty mounted with serous lined outlet. The outlet channel was appendix in 39 patients (65%), tapered ileal segment in 13 (21.5%) and Monti ileal tube in 8 (13.5%). After a median followup of 43 months (range 10 to 180) 55 patients (91.6%) achieved continence, with catheterization frequency of 3 to 5 times during the daytime and 1 to 2 times at night. Stoma related complications were leaking stoma in 5 patients (8.4%), stomal stenosis in 6 (10%), parastomal hernia in 2 (3.3%) and reservoir stones in 8 (13.3%). Reoperation rate was 18.3% (11 patients).

CONCLUSIONS

The serous lined continent outlet seems to be a durable and efficient technique for treating children with incontinence, with an acceptable complication rate.

Use of cutaneous flap for continent cystostomy (daoud technique)

PURPOSE

We present the results of a new technique using a pedicled cutaneous flap for continent cystostomy.

MATERIALS AND METHODS

A total of 15 boys and 8 girls (mean +/- SD age 13.4 +/- 6.4 years) underwent continent cystostomy for neurogenic bladder (20), bladder exstrophy (2) and sequelae of hypospadias (1) between 1999 and 2008. In this procedure a rectangular pedicled flap is surgically elevated from a hairless area on the abdomen. The flap is tubularized and passed through the anterior abdominal wall directly into the bladder. A submucosal detrusor incision is made to expose the bladder mucosa, and the distal part of the flap is anastomosed to the bladder mucosa in a circular manner. The tube is positioned along the incised detrusor, which is closed over. Viability of the flap, self-catheterization management and continence status are then evaluated.

RESULTS

Mean +/- SD followup was 4.5 +/- 3.1 years. There was 1 case of distal necrosis of the flap, which required a secondary surgery using the Mitrofanoff technique. The 22 remaining flaps were initially viable, although 2 patients were eventually lost to followup and 3 subsequently presented with false-passage incidents requiring a few days of calibration using a balloon catheter. Dryness was achieved immediately in 73% of the cases. After adding a complementary bulking agent the dryness rate reached 77%.

CONCLUSIONS

We present a novel approach to continent cystostomy that is safe and easy to perform. This technique is a less invasive and more efficient alternative to other commonly used approaches.