Long-term complications of continent catheterizable channels: a problem for transitional urologists

Long-term risks of childhood surgery

INTRODUCTION

Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery.

MATERIAL AND METHODS

Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery.

RESULTS

Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up.

CONCLUSION

Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.

Repurposing an ACE Malone Channel for Continent Intermittent Catheterization During Re-augmentation Cecocystoplasty: The MACEtrofanoff Procedure

OBJECTIVE

To describe a surgical alternative option in select patients with neurogenic bladder and a history of Malone antegrade continence enema (MACE) who now require revision augmentation of the bladder, and/or creation of a new continent catherizable urinary channel (CCC).

METHODS

Herein, we describe a novel surgical approach for patients who have had prior MACE creation who subsequently require surgical revision and creation of a new CCC. Rather than the traditional approach of creating a new CCC utilizing bowel, we perform a cecocystoplasty and leave the previously created MACE intact. The prior MACE channel becomes repurposed as the new Mitrofanoff, which we have termed the MACEtrofanoff channel. Concomitant cecostomy tube placement for bowel management can be performed at the time of surgery.

RESULTS

We have successfully performed this procedure in 2 patients with good outcomes to date. This technique does not require the sacrifice of the prior appendix channel, nor require the formation of a new stoma and channel. Patients are able to adapt easily to clean intermittent catheterization through a channel they are already familiar with for their prior antegrade enemas.

CONCLUSION

In select patients, surgeons should consider the MACEtrofanoff procedure to avoid the added morbidity of further bowel mobilization.

Diagnosis, management and recurrence rates of Mitrofanoff polyps

BACKGROUND

Intraluminal polyps are a known complication following creation of a urinary continent catheterizable channel (Mitrofanoff). These polyps can lead to difficult catheterizations in addition to symptomatic bleeding. However, there is limited data available regarding management and outcomes of these polyps. We aim to describe clinical presentation and management of a large series of polyps occurring in a Mitrofanoff channel.

METHODS

We performed a retrospective review of all patients that were treated for polyps in a Mitrofanoff at our institution. Information was collected regarding presenting symptoms, management and recurrence rates of the polyps.

RESULTS

A total of 24 patients were identified that fulfilled inclusion criteria. The majority of these polyps developed in channels composed of appendix (87%), while only 3 patients (13%) had polyps develop in an ileal composed channel. Thirteen (54%) of these polyps were incidentally diagnosed while 11 patients presented with a variety of symptoms such as difficulty in catheterization, bleeding with catheterization or both difficulty catheterizing and bleeding. For management of the polyps, a cystoscopy was performed and snaring the polyp with stone basket was performed in 37%, energy was applied to base to remove polyps in 33%, 16% were fulgurated and only 13% were left in situ. All procedures were performed under general anesthesia and all of the pathology was benign showing chronic inflammatory tissue. Eight polyps (33%) recurred after initial treatment.

DISCUSSION

We did not observe an asymptomatic channel polyp convert to a symptomatic during our follow up period. Our experience has led us to not intervene on all asymptomatic Mitrofanoff polyps encountered during cystoscopy under assumption they will inevitably become symptomatic. Although we admit our follow up period may not be long enough to make this a universal declaration of best practice when any Mitrofanoff polyp is diagnosed. Endoscopic treatment was effective minimally invasive method to address the symptomatic polyp rather than excision and construction of new channel.

CONCLUSIONS

This is the largest series to date of polyps developing in urinary continent catheterizable channels. The majority of these polyps were encountered incidentally however symptomatic polyps presented with difficulty with catheterizations. Symptomatic polyps can be managed endoscopically but recurrence of the polyp can occur.

Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels

INTRODUCTION

Many patients with certain conditions require catheterizable channels for bladder and bowel management. There are a variety of accepted techniques for creating these channels; the split appendix technique enables the use of this organ for both procedures, obviating the need for more complex surgical procedures. Studies comparing outcomes across catheterizable channel types are limited.

OBJECTIVE

The aim of this study was to compare the urinary channel complication rates of the split appendix, intact appendix and transverse ileal tube (Monti) channels. We hypothesized that complication rates would be the same across all channel types.

STUDY DESIGN

We retrospectively reviewed consecutive patients who underwent surgical creation of a urinary continent catheterizable channel. We recorded demographics, underlying diagnosis, body mass index, stoma location, surgical techniques, and surgical revisions. The primary outcome was complication (stenosis, leakage, or both) with or without surgical revision, and to compare the three different catheterizable channel types using time to event analysis.

RESULTS

From January 2014-July 2018, 107 patients underwent creation of a continent catheterizable urinary channel; 86 (80.4%) patients also underwent simultaneous procedure for antegrade bowel management. The mean age was 7 years; 66 (60.8%) were females. Intact appendices were used in 46 (43.0%), Monti channel in 25 (23.4%), and split appendix technique in 36 (33.6%). The corresponding complication rates with or without surgical revision was 21.7%, 36.0%, and 47.2%, respectively. The only independent factor associated with increased risk of complication was the split appendix technique; these channels were more than twice as likely to require surgical revision with an adjusted hazard ratio of 2.32 (Table 4). The majority of revisions in all groups were skin level (58.3%). The most common indication for surgical revision was stenosis (55.6%).

DISCUSSION

This analysis shows a statistically significant increase in risk of all complications, including an increase in need for surgical revision, in patients who underwent split appendix technique for simultaneous bladder and bowel catheterizable channels. This finding should be balanced with the fact that a bowel anastomosis is not required in cases where individuals need both a bowel and bladder catheterizable channel. This study is unique in its separation of split and intact appendix channels, and inclusion of patients experiencing complications that have not yet required surgical revision. Limitations of this study include its retrospective design, inclusion of a single institution, and the lack of consistency in documenting baseline appendiceal length.

CONCLUSION

Split appendix catheterizable channels have a higher rate of channel complications than other techniques. The authors acknowledge that the split appendix technique has been proven feasible and effective, however recognize that it may not be appropriate for all patients and include counseling of the risks of its use.

Pelvic organ prolapse in a woman with previous mitrofanoff operation: Management of a case

Mitrofanoff operation or vesico-appendicostmy is a continent conduit operation performed for intractable incontinence. The long-term complications reported in the literature are related to the stoma. Pelvic organ prolapse among women who have undergone this surgery is not reported earlier. A woman of 27 years of age presented with uterovaginal prolapse. She had sustained bladder neck transection following a road traffic accident at 16 years of age. The same was primarily repaired but incontinence had remained. Many standard operations for incontinence were performed. Finally, Mitrofanoff operation was carried out 9 years back because of persisting intractable incontinence. She got married and had two uneventful vaginal deliveries 5 and 2 years back. There was supravaginal elongation of the cervix with a rectocele. After counseling Fothergills operation with laparoscopic ligation was performed. The challenges and details of the management of the case are highlighted.

Managing intractable incontinence from a Yang-Monti channel in a case of enterocystoplasty with bladder neck closure - Challenges and a modified surgical technique

Incontinence in the Mitrofanoff principle varies between 2% and 40% and is a challenging problem to treat. Incontinence is even more when a Yang-Monti channel is used with simultaneous enterocystoplasty, probably due to ineffective submucosal tunneling owing to the inferior quality of bowel mucosa. Here, we report the management options of such problems along with a novel surgical technique.

Endourological management of multiple large bladder calculi over eroded mesh in an adult with augmented bladder and catheterisable continent appendicovesicostomy

Migration of abdominal wall mesh in an augmented bladder is a rarely encountered complication leading to formation of bladder stones causing recurrent urinary tract symptoms. The usual management of this condition involves either open surgical or a percutaneous approach for removal of the stone and migrated portion of mesh. Diagnosis of a migrated mesh is usually made intraoperatively during cystolitholapaxy. Appropriate management results in symptomatic improvement. Endoscopic management through catheterisable continent appendicovesicostomy has not been described to manage this challenging condition. To the best of our knowledge, we describe herewith the first report of endoscopic management of a large bladder stone formed over migrated mesh which involved removal of migrated mesh with holmium laser via a Mitrafanoff.

A right colon pouch with a novel efferent channel concept: long-term results of the Turin pouch

PURPOSE

To report stoma stenosis rates and efferent channel (EC) complications at long term follow-up for Turin pouch (TP).

METHODS

This is a retrospective analysis of the prospectively maintained database of patients who underwent TP between March 2006 and May 2018. The TP is a U-shaped right colon pouch. The EC was conceived by the tubularization of 5 cm of the colon wall with the use of a stapler and sutured to the skin (EC-cutaneostomy). The ureters are sutured separately to the last 10 cm of ileum before the ileocecal valve. In literature, catheterization problems have been described on average in 20.3% of patients and stoma stenosis in 19.5% of the patients with flap valve systems.

RESULTS

Thirty-eight consecutive patients underwent a TP procedure. The median age was 55 years (IQR: 52-60). Median operative time was 201 min (IQR: 170-210), median reconstructive time was 61 min (IQR: 55-65) and the blood loss was 244 ml (IQR: 150-300) and 4 patients (10.5%) needed blood transfusions. The median follow-up was 52 months (IQR: 37-92). Complete 24h continence was achieved in 34 (89%) patients. Seven (18.4%) patients reported difficulties in EC catheterization and 4 (10.5%) patients had stoma stenosis. This study is limited by the relatively small number of patients.

CONCLUSION

In relation to similar systems, the TP seems to offer comparatively good functional results but EC and stoma complications were lower than other pouch variants in literature.

Medical Management of Neurogenic Bladder for Children and Adults: A Review

Neurogenic bladder is a chronic condition affecting patients of all ages with significant medical and quality of life implications. Goals of treatment consist of protection of the upper urinary tract and promotion of reliable urinary continence. Successful management involves medications and most often bladder drainage via clean intermittent catheterization. This article reviews current literature on medical management to achieve goals of treatment.