Leak point pressure use for intraoperative adjustment of the continence mechanism in patients undergoing continent cutaneous urinary diversion

Abstract

Objectives. Failure of the continence mechanism is the most common cause of unsatisfactory results and the need for revision in patients with continent cutaneous urinary diversion. We believed that incontinence in these patients could be eliminated or minimized by using the concept of leak point pressure intraoperatively to make appropriate adjustments and thus ensure adequate continence postoperatively. Methods. The appropriate ileocolonic bowel segment for continent urinary diversion was isolated. Whenever the appendix was available, the unaltered or minimally altered appendicocolic junction was used for continence. In the absence of an appendix, the tapered distal ileum and reinforced ileocecal valve were used. Intraoperative leak point pressure (pressure at which leakage occurs) was measured before detubularization using a simple standing column manometer and arterial line tubing. Whenever leakage occurred at pressure less than 75 to 80 cm H 2O, adjustment of the continence mechanism was performed and leak point pressure measurement was repeated to ensure adequate continence. Results. Seventy-seven patients had long-term follow-up (30 to 100 months). These included 41 in whom the native appendix was used and 36 in whom the terminal ileum and ileocecal valves were used. Adjustment of the continence mechanism was required in 32 of the 41 patients in whom the native appendicocolic junction was used and in all 36 patients in whom the tapered ileum and ileocecal valve were used. After adjustment, all patients attained leak pressures over 80 cm H 2O. At the last follow-up visit, all 77 patients were continent on intermittent catheterization every 3.5 to 6 hours. None has required revision of the continence mechanism. Conclusions. Intraoperative measurement of leak point pressure is valuable in predicting the need for adjusting the continence mechanism and eliminating or substantially minimizing the need for subsequent revision.