Cutaneous vesicostomy: 10-year survey

Follow-up and Outcomes of Patients With Long-term Cutaneous Vesicostomies at a Single Institution

OBJECTIVE

To identify and describe the characteristics of a group of patients at our institution who are satisfied with cutaneous vesicostomy for long-term bladder management and never undergo subsequent continence surgery.

METHODS

Using an IRB-approved registry of our patients undergoing reconstructive urinary tract surgery since 1985, we identified patients who underwent vesicostomy creation and were 15 years or older as of October 2017 and performed a retrospective chart review.

RESULTS

Sixty-seven patients were included with the most common diagnosis being spina bifida and the average duration of vesicostomy 14.3 years (range 8 months to 35 years). In follow-up, 38 patients (56.7%) had conversations regarding further surgery and 31 (46.3%) had their vesicostomies taken down. Of the 36 patients who still had their vesicostomy at last follow-up, 29 (80.6%) had spina bifida and 14 (38.9%) were satisfied, 1 (2.8%) was unhappy, 4 (11.1%) were deceased and satisfaction was unknown for 17 (47.2 %).

CONCLUSION

Although often intended to be temporary, in our experience many patients keep their vesicostomy for a long time and into adulthood, with generally high satisfaction and low complications. In the properly selected patient, vesicostomy may be a good long-term operation to prevent infection and renal deterioration, though more rigorous studies of these patients are needed.

Chapitre B-5 B - Dérivation cutanée non continente en neuro-urologie

Non-continent urinary diversions can be proposed temporarily in neurological patients or at end-stage. They are especially proposed in patients in chronic retention in whom intermittent catheterization cannot be performed for anatomical or practical reasons (severity of neurological handicap). In this study, the authors present the various non-continent urinary diversions reported in the literature, describing the technical modalities of each diversion, their main complications and their short-term, medium-term and long-term results.

Primary adenocarcinoma of cutaneous vesicostomy 40 years later: a rare case

We present a case of adenocarcinoma developing at the vesicocutaneous edge of a vesicostomy, 40 years after it was created, in a patient who underwent cadaveric kidney transplant. Although transitional and squamous cell carcinoma of a vesicostomy have been reported, to our knowledge, the presence of adenocarcinoma at the vesicostomy edge has not been reported previously.

Incontinent ileo-vesicostomy urinary diversion in the treatment of lower urinary tract dysfunction

The combination of high spinal cord injury and neurovesical dysfunction can present formidable problems in urological management. The lack of upper extremity function often prevents intermittent catheterization and leads to alternative methods. A total of 23 patients underwent incontinent ileo-vesicostomy in an effort to gain a low pressure bladder and control of urinary soiling: 17 had been previously treated by catheter drainage, 9 had bladder and/or renal calculi, 9 experienced recurrent sepsis, and 7 had urethrocutaneous fistula and total urinary incontinence. Most patients had poorly compliant bladder dysfunction associated in 9 cases with poor urethral continence function. At a mean followup of 45 months (range 3 to 240 months) 22 of 23 patients had a low pressure reservoir with low pressure degrees of urine into a collection device. Complications included stomal stenosis in 3 patients and poor drainage across the ileovesical junction requiring revision in 2. One of these patients ultimately underwent ileal loop diversion. Upper tract function improved or remained stable in all patients.

Functional and pharmacological effects of ureteral diversion

Urinary diversion is the final therapeutic approach in several bladder pathologies including selected cases of bladder cancer, neurogenic bladder, and painful bladder syndrome. While there have been a few experimental studies on the effects of urinary diversion and subsequent undiversion on bladder capacity, the pharmacological changes occurring with diversion and undiversion have not yet been investigated. Our primary objectives were to determine the functional and pharmacological alterations in the defunctionalized bladder and the effects of refunctionalization on these changes. Thirty-two male adult canines weighing 15 to 20 lb. were used for this study. Three groups of dogs were urine diverted for one, three, and six month durations (four dogs per group). Another three groups of dogs were urine diverted for one, three, and six months (four dogs per group); these dogs were then undiverted for three months. Six control animals received either one or two sham operations at one, three, and six months. In all groups the functional and contractile characteristics of the bladders were assessed by urodynamics and in vitro contractile studies; bladder weight and muscarinic receptor density were also measured. Intravesical capacities determined by in vivo cystometry were reduced significantly to 74%, 63%, and 47% of control values at one, three, and six months respectively after urinary diversion. Bladder capacity returned to above normal levels in bladders diverted and then subsequently undiverted. Similarly, the compliance and bladder weight of the diverted bladders were significantly less than control, while diverted bladders subsequently undiverted were similar to controls. Maximal bladder contractility in response to bethanechol stimulation was less in diverted bladders compared to control. This decrease in contractility was accompanied by a decrease in muscarinic receptor density. After undiversion maximal bladder contractility to bethanechol reached control levels; this was accompanied by a parallel increase in muscarinic receptor density to control values. There was no effect of diversion or undiversion on the maximal response of bladder strips to methoxamine stimulation. Thus, a bladder that has been diverted (defunctionalized) for a period of time showed decreases in capacity, compliance, and contractility to muscarinic stimulation along with a decrease in muscarinic receptor density. All of these parameters were restored after refunctionalization of the bladder.

Pediatric urinary diversion and undiversion

Many things have changed in our management of the urinary tract of children and young adults. Important contributions from many sources have resulted in the refinement of therapy and the progression from diversion to undiversion and reconstruction. Primary urinary diversion is now uncommon. Patients with exstrophy, for example, are treated with primary bladder closure as newborns, and newborns with valves often are treated with primary valve ablation. Children with neurogenic bladder dysfunction resulting from myelodysplasia are rarely diverted, but are started at an early age with ICC. It is hoped that in future the contents of this article on diversion techniques and undiversion will be of historical interest, however. Note: The editors also have found the use of the Mitrofanoff procedure, utilizing a nonrefluxing tunnel and a catheterizable stoma made out of the ureter or appendix, to be a very valuable addition to the reconstructive surgeon's armamentarium. We also feel that use of detubularized bowel for either bladder augmentation or replacement provides more efficient storage capability. Occasional reports of extremely significant diarrhea after removal of the ileocecal segment from the intestinal tract have been reported in children with myelodysplasia.

Urinary tract diversion and undiversion in the pediatric age group

Undiversion is an interesting phenomenon but may in part be self-limiting. As the experience with techniques in reconstruction increases, the need for diversion may give way to that of earlier correction of the original pathology, Thus, reversal of diversion by offering a wealth of experience in reconstruction may well lead to its own demise. Nevertheless, even with newer reconstructive techniques, there is, to date, a definite place for diversion of the urinary tract in the pediatric age group and there are now many pediatric patients still to be considered candidates for undiversion

Twenty-year outcome of cutaneous vesicostomy

Forty cutaneous vesicostomy urinary diversions were done at our hospital from 1958 to 1961. Of these cases 30 patients have been followed every 6 months or until death. The vesicostomy-related failure rate was 8.6 per cent, with new stones forming in 3 additional kidneys. Cutaneous vesicostomy provides long-term preservation of renal function in patients requiring urinary diversion. However, close followup is mandatory to ensure a good result.

Cutaneous vesicostomy for temporary urinary diversion in infants with neurogenic bladder dysfunction

Cutaneous vesicostomy was used for temporary urinary diversion in 12 infants with neurogenic vesical dysfunction. Hydronephrosis, azotemia and clinical urinary infection were resolved in all patients. Postoperative complications consisted of diaper dermatitis in 42 per cent and vesical prolapse in 25 per cent.