Vesicostomy. Useful means of reversible urinary diversion in selected infants

Long-term outcomes of cutaneous vesicostomy in patients with neuropathic bladder caused by spina bifida

OBJECTIVE

To evaluate the outcomes of patients who underwent cutaneous vesicostomy for management of neuropathic bladder secondary to spina bifida. We hypothesize that vesicostomy, in select patients, is beneficial to prevent upper urinary tract deterioration (UTD), reduce febrile urinary tract infections (UTIs), and preserve renal function.

STUDY DESIGN

We performed a retrospective chart review on patients with spina bifida who underwent cutaneous vesicostomy at our institution between 2000 and 2016. Demographic information, indication for vesicostomy, pre and postoperative laboratory/radiologic studies, incidence of febrile UTIs, and urodynamic findings were abstracted.

RESULTS

A total of 14 patients (eight females and six males) were identified. The indication for vesicostomy was UTD in four, recurrent febrile UTIs in five, parental request in two, both UTD and recurrent febrile UTIs in two, and both UTI and parental request in one patient. Seven patients had a median of three (range one to five) febrile UTI prior to surgery for cutaneous vesicostomy. Median creatinine level before surgery was 0.26 mg/dL (range 0.16-0.97). Either unilateral or bilateral ≥SFU Grade 2 hydronephrosis was present in six patients. Median age at vesicostomy creation was 26.5 months (range 4-96). Mean functional bladder capacity assessed during preoperative urodynamic studies was 107 mL (range 20-279), and detrusor sphincter dysynergia was present in all patients. High-grade vesicoureteral reflux (grade ≥3) was present in three patients, all with UTD. Mean follow-up after vesicostomy was 62.4 ± 39.3 months. After vesicostomy, only two of the seven patients with history of febrile UTIs experienced an additional febrile UTI. The median serum creatinine level was 0.36 mg/dL (range 0.2-0.58) at last follow-up. Moreover, 11/14 patients had no hydronephrosis and just two patients had unilateral SFU grade 1 hydronephrosis (Table).

DISCUSSION

Worsening UTD, recurrent febrile UTIs, and high-pressure bladder despite maximal medical therapy are several reasons to consider more aggressive management of neuropathic bladders. In young patients, vesicostomy is able to protect the upper urinary tract, decrease rates of febrile UTI, and delay the need for bladder augmentation.

CONCLUSION

Vesicostomy is a safe method for temporary diversion of the lower urinary tract in patients with spina bifida who are refractory to conservative and minimally invasive treatments.

Intermittent voiding per urethra as an indicator of cutaneous vesicostomy malfunction

PURPOSE

To present a new approach for management of cutaneous vesicostomy (CV) prolapse, with special emphasis on normal appearing vesicostomy may be malfunctioning. To introduce the application of temporary stoma-free drainage as a diagnostic and therapeutic tool.

MATERIALS AND METHODS

From December 2000 to September 2006, 66 children (61 males and 5 females) with CV were studied. The mean age at vesicostomy was 7 months (range 1-30), and the main underlying disease was posterior urethral valves (in 45 children, 68%). Indications for CV included significant hydroureteronephrosis (HUN) and recurrent urinary tract infection. Patients were followed up for complications and were treated based on our institutional approach. All patients with persistent upper tract dilatation and micturition per urethra underwent temporary bladder (via stoma) free drainage. Patients with stomal stenosis were managed either by a revision surgery or by simple dilatation and intermittent catheterization. Purse string suturing was applied in mucosal prolapses as the first choice.

RESULTS

The complications were observed in 21 patients (31%), including twelve stomal stenosis, nine severe mucosal prolapses, and two recurrent urinary infections. HUN and significant voiding per urethra persisted following initial CV in 19 out of 66 patients (29%), eleven of which having normal appearing CVs. Seventeen of these patients were managed by temporary stoma-free drainage (accompanied by purse string suturing in mucosal prolapse), and two patients with severe stenosis underwent surgical revision. Temporary stoma-free drainage improved HUN in 94% of patients (16 of 17).

CONCLUSIONS

Voiding per urethra is an indicator of CV malfunction, and temporary stoma-free drainage can be a diagnostic and therapeutic option in such children. A seemingly open CV may still be malfunctioning, and ureterovesical or intravesical obstructions should be considered if HUN does not improve following temporary stoma-free drainage.

Cutaneous vesicostomy experience in infants and children

Cutaneous vesicostomy has proved to be a useful form of temporary diversion in children. We report our experience with 35 patients who underwent diversion for either lower tract dysfunction or obstruction. In only 1 child did vesicostomy appear to be of questionable value in adequately draining the upper urinary tracts. Renal functional improvement or stabilization was observed in the remaining 34 children. Complications occurred in 14 patients, with urinary tract infections of a clinically serious nature being observed in 6. Our experience tends to confirm vesicostomy to be an effective, simple and easily reversible means to treat selected conditions in infants and children. Complications are encountered but they have been managed effectively.