Advantages and risks of ileovesicostomy for the management of neuropathic bladder

Urinary undiversion by conversion of the incontinent ileovesicostomy to augmentation ileocystoplasty in spinal cord injured patients

Context: Spinal cord injury (SCI) patients with neurogenic bladder and the inability to self-catheterize may require incontinent diversion to provide low-pressure drainage while avoiding the use of indwelling catheters. We demonstrate that in patients with significant functional improvement, the ileovesicostomy can be a reversible form of diversion, with simultaneous bladder augmentation using the same segment of ileum utilized for the ileovesicostomy. Multidisciplinary management should be utilized to assure mastery of intermittent catheterization before urinary undiversion. This technique allows for transition to a regimen of intermittent self-catheterization with excellent functional and urodynamic outcomes.Design: Case Series.Setting: Tertiary care hospital, Philadelphia, Pennsylvania.Participants: Three individuals with an SCI.Interventions: Conversion of bladder management from an incontinent ileovesicostomy to an augmentation ileocystoplasty, with intermittent catheterization.Outcome Measures: Ability to regain urinary continence with preservation of renal function as determined by serum creatinine and renal ultrasound.Results: Three SCI patients who had an incontinent ileovesicostomy developed sufficient functional improvement to intermittently self-catheterize reliably and underwent conversion of ileovesicostomy to ileocystoplasty. For each, the ileovesicostomy channel was taken down and detubularized, then used to create an ileal patch for augmentation ileocystoplasty. Intermittent catheterization was then used for periodic bladder drainage. All achieved large capacity, low-pressure bladders with complete continence and stable creatinine.Conclusion: In motivated SCI patients, it is possible to regain continence by converting the ileovesicostomy into augmentation ileocystoplasty, avoiding the disadvantages of a urostomy. A multidisciplinary collaborative approach facilitates the optimal rehabilitation of SCI individuals.

Non-continent urinary diversion (ileal conduit) as salvage therapy in patients with refractory lower urinary tract dysfunctions due to multiple sclerosis: results of a national cohort from the French Association of Urology (AFU) Neurourology Committee and the French-speaking Neurourology Study Group (GENULF)

OBJECTIVE

To describe the outcomes of ileal conduit as a salvage therapy for refractory lower urinary tract dysfunctions (LUTDs) due to multiple sclerosis (MS) in a national neurourology referral center network.

METHODS

A retrospective multicenter French study was carried out to identify MS patients who underwent non-continent urinary diversion for refractory LUTDs from January 2010 to December 2015. Multiple sclerosis status, urological history, surgical indication and technique, postoperative complications, renal anatomy and function at last follow-up as well as number of rehospitalizations for urinary tract infections (UTI) were collected. Preoperative and postoperative urinary-related quality of life (urQoL) through the Qualiveen^TM short-form questionnaire (QSF^TM) and patient global impression of improvement (PGI-I) were collected and analyzed.

RESULTS

Overall, 10 centers identified 211 patients with a mean age of 54±11 and mean preoperative EDSS (expanded disability status scale) score of 7.3±0.9. The main indication for diversion was MS progression leading to impossible intermittent self-catheterization (55%). Cystectomy was performed either by open (34.6%), laparoscopic (39.3%) or robotic (21.8%) approach (unknown: 4.2%) with cystectomy in all cases. Early complications were reported in 42% of the patients, mainly Clavien I or II grades. There was no difference in GFR (glomerular filtration rate) after surgery. After diversion, patients had fewer hospitalizations for UTI and better urQoL on QSF™ confirmed by evaluation of PGI-I.

CONCLUSION

This study, reporting the largest series of ileal conduit in selected MS patients with end-stage LUTDs, showed significant improvement in symptomatic UTI and quality of life with a low high-grade complication rate.

Neurogenic bladder: management of the severely impaired patient with complete urethral destruction: ileovesicostomy, suprapubic tube drainage or urinary diversion-is one treatment modality better than another?

Background

Management of the severely impaired patient (pt) with a neurogenic bladder (NGB) and complete urethral destruction employs three therapeutic options; bladder neck closure (BNC) with ileovesicostomy, BNC with suprapubic tube (SPT) placement or in pts with an end-stage bladder, cystectomy with enteric conduit diversion. This paper was performed to test the hypothesis that pts managed with an ileovesicostomy would have the best long-term prognosis.

Methods

Patients with a NGB and complete urethral destruction managed between 1986-2018 were reviewed. Three treatment populations were assessed, pts treated with BNC with ileovesicostomy, BNC with SPT placement or cystectomy with enteric conduit diversion. A minimal follow-up interval of 2 years was necessary to be entered into the study. The number of uroseptic episodes, development of urolithiasis, the onset of new renal scars, ≥ stage 3 chronic renal failure, or need for additional surgery were recorded. Statistical evaluations used either chi-squared contingency table analysis, Fisher's exact 2-tailed tests, or Kaplan-Meier curve analysis where indicated. P values of <0.05 were considered significant.

Results

Ten pts were managed by cystectomy, and enteric conduit, 17 by BNC and ileovesicostomy and 21 by BNC and SPT placement, median follow up of 8 yrs (range, 2-30 yrs). No significant differences between the three groups regarding the development of urolithiasis (30%, 3/10 pts; 53%, 9/17 pts; 52%, 11/21 pts; respectively), new onset of renal scarring (30%, 6/20 kidneys; 41%, 14/34 kidneys; 45%, 19/42 kidneys; respectively) or stage 3 chronic renal failure (40%, 4/10 pts; 47%, 8/17 pts; 24%, 5/21 pts; respectively. However, the number of hospitalizations for uroseptic episodes significantly increased in patients managed with an ileal conduit (60%, 6/10 pts) and ileovesicostomy (82%; 14/17 pts) compared to those maintained with a SPT (29%, 6/21 pts) P=0.025 and 0.006, respectively. When evaluating the need for delayed surgical intervention due to either urolithiasis or other complications, a total of 50% (5/10 pts) of the patients managed by an ileal conduit, 88% (15/17 pts) of the ileovesicostomy and 52% (11/21 pts) of the patients with a SPT required additional operations. In essence, significantly more pts undergoing BNC and ileovesicostomy required delayed surgical interventions for complications arising from the surgery compared to patients managed with either a cystectomy and ileal conduit (P=0.0285) or BNC and SPT placement (P=0.0180).

Conclusions

In severely impaired pts with a NGB and urinary outlet destruction, BNC and ileovesicostomy are associated with a significantly increased incidence of urosepsis and late surgical complications that required operative intervention compared to alternative treatments. This finding has resulted in the abandonment of the ileovesicostomy from our surgical armamentarium.

Follow-up of the neuro-urological patient: a systematic review

OBJECTIVES

To systematically review the long-term urological follow-up strategies for patients with neurogenic lower urinary tract dysfunction (NLUTD), focusing on three main groups of neurological diseases: (i) spinal cord injuries, (ii) spinal dysraphism, and (iii) multiple sclerosis.

PATIENTS AND METHODS

Data acquisition comprised electronic search on the Medical Literature Analysis and Retrieval System Online (MEDLINE) database and the EMBASE database in August 2014 to retrieve English language studies. MEDLINE and EMBASE search included the following medical subject heading (MeSH) terms: (i) neurogenic bladder and (ii) neurogenic bladder dysfunction. Each of these terms was crossed with (i) long-term care and (ii) long-term surveillance. Only studies related to NLUTD and urological follow-up were included. Studies were also identified by hand search of reference lists and review articles.

RESULTS

Initial records identified through database searching included 265 articles. In all, 23 articles were included in the quantitative synthesis. The proposed time schedule of investigations as well as the amount and type of investigation were different according to specific neurological lesions. They depend on the dysfunctional pattern of the lower urinary tract (LUT) and its risk profile. However, there is a lack of high-evidence level studies to support an optimal long-term follow-up protocol.

CONCLUSIONS

The goal of neuro-urological management is the best possible preservation of upper urinary tract (UUT) and LUT function in relation to the individual neurological disorder. Regular and risk adapted controls ('urochecks') allow detection of risk-factors in time before irreversible changes of the LUT and UUT have occurred. With risk- and patient-oriented lifelong regular urological care an optimised quality of life and life-expectancy can be achieved, although there is a complete lack of high-evidence level studies on this topic.

WITHDRAWN: Anticholinergics for urinary symptoms in multiple sclerosis

This review has been withdrawn for the following reasons:

‐ a review author contravenes Cochrane's Commercial Sponsorship Policy. This policy ensures the independence of Cochrane reviews by making sure that there is no bias associated with commercial conflicts of interest in the conduct of Cochrane reviews. The author was employed by the biopharmaceutical company AstraZeneca and cannot say with certainty that the company did not produce or have any financial interest in the interventions in this review

‐ the review is substantially out of date

To view the published versions of this article, please click the 'Other versions' tab.

The editorial group responsible for this previously published document have withdrawn it from publication.

Completely intracorporeal robotic-assisted laparoscopic ileovesicostomy: initial results

We present a series of robotic-assisted laparoscopic ileovesicostomies with bowel work performed completely intracorporeally. The four patients selected for this procedure were all diagnosed with neurogenic bladder and failed conservative medical therapy. Preoperative patient data included age, body mass index (BMI), and urodynamic (UD) study results. Intra-operative data included estimated blood loss (EBL), operative time, and intra-operative complications. Post-operative data included return to bowel function, post-operative complications, and length of hospital stay (LOS). All bowel work was completed intracorporeally with the exception of stoma maturation. Four robotic ileovesicostomies were performed. Pre-operative urodynamic study results showed either elevated detrusor pressures or limited bladder capacities in addition to the inability to perform self-catheterization. The mean patient age was 40 years and mean BMI was 26 kg/m². Average EBL and operative time were 131 ml and 290 min, respectively. No intra-operative complications occurred. Bowel function, as defined as flatus, returned on average 3.8 days after surgery and average LOS, defined as discharge home or discharge to the spinal cord unit, was 7.5 days. Mean follow-up time was 25.8 months. Post-operative urodynamic studies revealed low stomal leak point pressure (<10 cmH₂O). This study is the first to describe a completely intracorporeally robotic-assisted laparoscopic ileovesicostomy with safe and effective outcomes after more than 2 years of follow-up.

Completely intracorporeal robotic-assisted laparoscopic ileovesicostomy

We present a report of a completely intracorporeal robotic-assisted laparoscopic ileovesicostomy with long term follow-up. The patient was a 55-year-old man with paraplegia secondary to tropical spastic paresis resulting neurogenic bladder dysfunction. The procedure was performed using a da Vinci Surgical system (Intuitive Surgical, Sunnyvale, CA) and took 330 minutes with an estimated blood loss of 100 mL. The patient recovered without perioperative complications. He continues to have low pressure drainage without urethral incontinence over two years postoperatively.

Options for independent bladder management in patients with spinal cord injury and hand function prohibiting intermittent catheterization

AIMS

Choosing the appropriate bladder management strategy for the spinal cord injury patient with neurogenic bladder and hand function prohibitive of self catheterization (urethral or stomal) catheterization is complex and based on limited literature. We have catalogued the available data in this review.

METHODS

A literature review was conducted on external sphincterotomy, suprapubic tube, ileal conduit, and ileovesicostomy between 1994 and 2012. Articles on neurogenic bladder focused primarily on spinal cord injury were included. Important aspects of each technique, patient selection, urologic events, and quality of life are described.

CONCLUSION

The available literature consists primarily of level 3 data. Patient reported outcomes were rarely measured. External sphincterotomy is a good option for males who are candidates for an external catheter and who wish to avoid a complicated reconstruction-most will need re-operations for failure. Suprapubic tube is an option in both genders. Complaints usually involve urine leakage and urinary tract infection, which typically resolve with conservative measures. There is some evidence to support patient satisfaction. Ileal conduit is an option for all patients with quadriplegia, offering continuous drainage and absence of foreign material. Many providers and patients will choose more conservative options first. The ileovesicostomy is best applied to small bladders with severe overactivity. The "reversibility" of this procedure makes it attractive to those not interested in an ileal conduit and who have had complications from prolonged suprapubic tube placement. The authors conclude with recommendations for future research, most importantly more standard reporting of objective data.

Outcomes of incontinent ileovesicostomy in the pediatric patient

PURPOSE

Ileovesicostomy is a reconstructive option in complex urological cases but pediatric specific outcomes are lacking. We report our results with pediatric ileovesicostomy.

MATERIALS AND METHODS

We retrospectively evaluated patients younger than 18 years undergoing incontinent ileovesicostomy at Vanderbilt University. History, urinary tract management and operative course were reviewed in the electronic medical record. Particular attention was given to immediate and long-term postoperative complications.

RESULTS

Nine patients underwent incontinent ileovesicostomy between 2000 and 2013 at a mean age of 10.3 years (range 1.4 to 15.5). Surgical indication was sequelae of neurogenic or nonneurogenic neurogenic bladder (such as infection or worsening hydronephrosis) in 5 patients, reversal of vesicostomy in 3 and closure of cloacal exstrophy in 1. All 9 patients were thought incapable of reliable clean intermittent catheterization due to family unwillingness, poor social support or patient refusal. Median followup was 11.5 months (mean 48.2, range 1.3 to 144.8). Immediate postoperative complications included ileus requiring total parenteral nutrition and a wound infection in 1 patient. Long-term complications included urinary tract infection in 2 patients (febrile in 1 and positive culture for foul smelling urine in 1), stomal issues in 2 and temporary urethral leakage in 1. Constipation affected 3 children in long-term followup (all with neurogenic bowel preoperatively). Postoperative creatinine was stable or improved in all patients.

CONCLUSIONS

Ileovesicostomy is a viable approach in children left with few other options, particularly those who are noncompliant or physically/socially unable to handle catheterization. This operation can help keep such patients out of diapers.

Supine and upright urodynamic evaluation of incontinent ileovesicostomy in wheelchair-bound adults with neurogenic bladder

STUDY DESIGN

Prospective.

OBJECTIVES

To evaluate detrusor leak point pressure (DLPP) of the incontinent ileovesicostomy in the supine and upright position.

SETTING

California, USA.

METHODS

Urodynamic assessment of patients, 6-36 months after ileovesicostomy, was performed in the supine position and then immediately repeated in the upright position in the patient's wheelchair.

RESULTS

Upright and supine urodynamic evaluation was performed following the Good Urodynamic Practice Guidelines. Ten patients (seven male and three female) were evaluated. Etiology of neurogenic bladder (NGB) included seven patients with spinal cord injury and one patient each with multiple sclerosis, myelomeningocele and cerebral palsy. Mean DLLP in the supine position was 8.6 cm H2O (range 2-20); mean DLLP in the sitting position was 11.6 cm H2O (range 5-25). Mean change in DLPP from supine to sitting was 3.1 cm H2O (range 1-12). The difference in DLPP between supine and sitting is statistically significant (P=0.0429); however, this does not appear to be a clinically significant difference.

CONCLUSION

Ileovesicostomy is a safe option for management of the NGB in a selected patient population. A small and clinically insignificant or no change in DLPP was documented in all ten patients. We demonstrated that DLPP remains low within an ileovesicostomy while in the sitting position.

Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice

As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.

Ileovesicostomy for the neurogenic bladder patient: outcome and cost comparison of open and robotic assisted techniques

OBJECTIVES

To compare the outcomes and cost of open and robotic-assisted ileovesicostomy techniques for the adult neurogenic bladder patient.

METHODS

Consecutive open and robotic-assisted ileovesicostomy procedures were retrospectively reviewed for demographic, operative, and postoperative recovery data. Surgical outcome was assessed by examining the incidence of postprocedure urinary incontinence, urinary tract infections (UTIs), and upper tract compromise. Total cost was calculated through summation of inpatient costs, including room/board, operating/recovery room, surgical supplies, professional fees, intensive care unit, and robotic maintenance.

RESULTS

Fifteen ileovesicostomy procedures (7 open, 8 robotic) were reviewed. Both groups had similar demographic and urodynamic data. Operative times (293 min open vs 330 min robotic, P = .24) were similar between techniques. There were trends toward lower operative blood loss (100 mL vs 257 mL, P = .09) and shorter hospital stays in the robotic group (8 days vs 11 days, P = .14). Ileovesicostomy was associated with improved urinary continence (P = .02) and trended toward a decreased incidence of postoperative chronic UTI (P = .13) for the entire group, and there was no difference between techniques regarding continence, chronic UTIs, and complications. No patients in either group developed postoperative hydronephrosis. Total inpatient cost for the open and robotic groups was $14,356 and $17,344 (P = .05), which differed primarily because of higher robotic operating room supply costs ($609 vs $3770, P <.001).

CONCLUSION

Robotic and open ileovesicostomy had similar surgical outcomes in this patient cohort, although total inpatient costs were significantly higher in the robotic group.

Ileovesicostomy update: changes for the 21st century

Objectives. To review the literature regarding ileovesicostomy and evaluate our patient population for clinical characteristics. Methods. Various surgical reconstructive techniques allow management of difficult clinical scenarios involving patients with neurogenic bladder, irretraceable lower urinary tract symptoms, lower urinary tract disaster, and urethrocutaneous fistulae. One such reconstructive technique employed is the ileovesicostomy. This procedure provides patients with a low-pressure urinary conduit utilizing the ileum and native bladder that empties without catheterization. We describe our patient population who underwent ileovesicostomy for 5 consecutive years ending 2007 at Detroit Receiving Hospital. Results. Most common diagnosis was neurogenic bladder secondary to spinal cord injury. Our population and clinical outcomes are similar to those previously reported in the literature. Conclusions. Based on our experience, we suggest that patients with severe lower urinary tract symptoms and who are unable to perform clean intermittent catheterization and/or refractory to medical therapy ileovesicostomy should be the procedure of choice.

Robotic-assisted ileovesicostomy: initial results

OBJECTIVES

To assess the safety and efficacy of robotic-assisted ileovesicostomy in treating patients with a neurogenic bladder that is unsuitable for clean intermittent self-catheterization.

METHODS

Robotic-assisted ileovesicostomy was performed using a 5-port approach for patients with a neurogenic bladder unable to tolerate clean intermittent or chronic bladder catheterization. Intraperitoneal operative steps included the creation of a full thickness U-shaped posterior bladder wall flap, intracorporeal harvesting of 15 cm of terminal ileum for use as a urinary conduit, and intracorporeal enterovesical anastomosis. Then, a counter incision was made over the marked stoma site on the abdominal wall, and bowel continuity was restored through an extracorporeal side-side anastomosis by the stomal incision. Ileovesicostomy stoma maturation was then completed.

RESULTS

Eight robotic ileovesicostomies were performed. The median patient age was 53 years, body mass index was 29.0 kg/m(2), and preoperative bladder compliance was 5.7 mL/cm/H(2)O. The median blood loss was 100 mL. The median operative time was 330 minutes (range 240-420). No intraoperative complications occurred. Four patients had postoperative complications, including urethral incontinence (2) and ileus (2). No wound complications occurred. Bowel function returned after a median of 4.8 days after surgery, and median hospital stay was 7.7 days. Over a median 14-month follow-up, all patients had a functioning ileovesicostomy, and median postoperative residual bladder volume was 10 mL.

CONCLUSIONS

This study is the first to describe the robotic ileovesicostomy procedure. Robotic ileovesicostomy appears to be safe and effective, with low morbidity.

Anticholinergics for urinary symptoms in multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is the commonest physically disabling chronic neurological disease affecting young people. Urinary symptoms are present in about 68% of people with MS but their basis has a number of potential aetiologies that can change with time.

OBJECTIVES

To assess the absolute and comparative efficacy, tolerability and safety of anticholinergic agents in MS patients.

SEARCH STRATEGY

We searched the Cochrane Multiple Sclerosis Group Specialised Trials Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue1), MEDLINE (January 1966 to January 2008), EMBASE (January 1974 to January 2008), supplemented with search of reference lists, personal communication with authors and relevant drug manufacturers.

SELECTION CRITERIA

Randomised trials and cross-over trials (blinded and unblinded) that are either placebo-controlled or comparing two or more treatments.

DATA COLLECTION AND ANALYSIS

All four review authors independently assessed eligibility and trial quality, and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Our search strategy identified 33 articles of which thirty were excluded. Three single centre trials were included. No details were given regarding randomisation and blinding in the first two trials but side effects were frequent with all treatments.The first (Hebjorn 1977) was a double blind randomised crossover trial. Thirty four persons with MS received three drugs Methantheline Bromide, Flavoxate Chloride and Meladrazine Tartrate each for 14 days, washout periods were not mentioned. Median volume measurements at the first bladder contraction were statistically significant at a 5% level for Methantheline Bromide only compared to no treatment.The second (Gajewski 1986) was a prospective parallel group randomised study. Thirty four persons with MS were treated for 6-8 weeks with Oxybutynin (19 subjects) or Propantheline (15 subjects). For frequency, nocturia, urgency, and urge incontinence differences in symptom grade in favour of Oxybutynin were found. However, only for frequency the difference was statistically significant at 5% level.The third (Fader 2007) was a double blind crossover trial. Sixty four persons with MS received oral Oxybutynin or intravesical Atropine for 14 days. Details of randomisation and blinding were given. There was no significant difference between the two treatments in any efficacy outcome measure. Side effects and QOL scores showed significant differences in favour of atropine.

AUTHORS' CONCLUSIONS

From the available evidence we cannot advocate the use of anticholinergics in MS.

Ileovesicostomy for adults with neurogenic bladders: complications and potential risk factors for adverse outcomes

AIMS

Risk factors for complications following ileovesicostomy have not been well defined. This study's purpose was to examine outcomes following ileovesicostomy in adults and identify possible risk factors that may contribute to post-operative complications.

METHODS

Retrospective database review identified ileovesicostomy procedures from August 1999 to September 2003. Demographic, pre-operative, and post-operative data were extracted. Statistical analysis determined whether risk factors influenced outcomes of urethral continence, re-operation, and post-operative complications. Factors included age, tobacco use, diabetes, neurogenic bladder etiology, body mass index, pre-operative indwelling catheterization, or simultaneous procedures including pubovaginal sling/urethral closure.

RESULTS

50 adults status-post ileovesicostomy were identified. At last follow-up, 36 patients (72%) were continent per urethra. The incidence of complications decreased significantly from 3.38 per patient to 1.16 post-operatively (P < 0.0001). Twenty-seven averaged 1.52 inflammatory or infectious post-operative complications per patient, 19 averaged 1.47 stomal complications, and 11 averaged 2.09 ileovesicostomy mechanical obstructions. Overall, 27 required 2.85 re-operations or additional procedures following ileovesicostomy. Sub-group analysis identified BMI (P = 0.0569) as a possible risk factor. Differences in outcomes based on age, tobacco use, diabetes, neurogenic bladder etiology, pre-operative indwelling catheterization, or urethral closure were not significant.

CONCLUSIONS

Ileovesicostomy is a valuable management option for adults with neurogenic bladder unable to perform intermittent catheterization. The incidence of urinary tract comorbid events significantly decreased following ileovesicostomy though the onset of other complications should be considered. The morbidity associated with ileovesicostomy requires careful patient selection, close long-term follow-up, and potential subsequent interventions to address post-operative complications.

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.

Current management of neurogenic bladder in patients with MS

Multiple sclerosis (MS) is a common neurological problem and many sufferers are affected by urinary symptoms that negatively impact on their quality of life. Nurses are intimately involved in management of continence and other bladder problems with MS patients and need to be aware of appropriate assessment techniques and treatment options so that patients can be managed optimally. Nurses can have a significant role to play in reducing bladder symptoms and directly improving patients' quality of life. This article presents a review of current behavioural, pharmacological and surgical options for management of the neurogenic bladder in MS.

Incontinent ileovesicostomy in the management of neurogenic bladder dysfunction

AIMS

To report outcome and urodynamic follow-up of incontinent ileovesicostomy in quadriplegic patients with neurogenic bladder.

METHODS

Seven patients (five male, two female; mean age, 33.7 yr) with neurogenic bladder underwent ileovesicostomy for management of leakage or complications of chronic catheter drainage. Five had chronic indwelling catheters: three suprapubic and two urethral. Preoperatively, all had upper tract evaluation and videourodynamics. All seven patients had detrusor hyperreflexia. Preoperative detrusor leak point pressures averaged 42.7 cm H(2)O. Two females had intrinsic sphincteric deficiency from prolonged Foley catheter drainage. Ileovesicostomy involves isolation of a 15-20-cm segment of terminal ileum. The proximal 6-8 cm of this segment is opened on the antimesenteric border. The dome of the bladder is opened widely in a transverse manner and the proximal portion of the bowel is sutured onto the bladder. The distal portion of the ileum remains tubularized and becomes the stoma.

RESULTS

There were no intraoperative complications. Operative time averaged 159 minutes. Associated procedures included removal of bladder calculus (n = 1), pubovaginal sling (n = 2), and Marshall Marchetti Krantz suspension (n = 1). Mean blood loss was <200 cc in six patients. Mean hospital stay was 8 days. Complications in two patients included: fascial stenosis requiring stoma revision (n = 1), wound infection (n = 1), and postoperative ileus (n = 1). Mean follow-up was 37.4 months. Postoperatively, mean detrusor leak point pressures were 16.7 cm H(2)O (P = 0.0061). Patient satisfaction is high with only one complaint of occasional difficulty fitting the appliance.

CONCLUSIONS

Ileovesicostomy is an effective method of urinary drainage in quadriplegic patients. Detrusor leak point pressures were lowered, and upper tracts were preserved. No long-term complications were encountered.

Urinary diversion and reconstruction

Orthotopic bladder augmentation and substitution has been established as the standard procedure for urinary diversion in many institutions, with current studies reporting mainly on continence rates and procedure-associated complications, such as the risk of impairment of neobladder function by local tumor recurrences in the small pelvis. Similarly, in other types of continent diversion, such as continent cutaneous diversion and rectal reservoirs, current interest is primarily directed towards minimization of surgery-associated complications.