Mitchell's Detrusor Wrap-Around Bladder Neck (Dwbn), Ileocystoplasty, and the Extramural Serous-Lined Continent Outlet: An Optimal Triad

Abstract

Purpose Providing continence for children with non compliant bladder and low detrusor leak point pressure secondary to neuropathic dysfunction or bladder exstrophy is a challenging task. A one stage reconstruction triad is presented. Material and Methods Between May 2005 to July 2008, 21 patients underwent DWBN, ileocystoplasty, and extramural serous lined tunnel as continent outlet in one stage. Patients included 15 boys and 6 girls with mean age of 7.6 years. Nine patients had previous complete repair of bladder exstrophy, 4 had staged repair and 8 had neuropathic bladder dysfunction. The ileum was fashioned in the shape of U in 4, S in 13, and W in 4. The appendix was used in 17 and Monti was used in 4. Neo umbilicus was constructed for the outlet in 13. In all patients the continent outlet was located in the umbilicus or a neo-umbilicus. Results Mean follow-up duration was 19 months (range 4-39). Early postoperative complications included prolonged ileus in 1 and urine leak in 1 and both were conservatively managed. Vesicoureteral reflux persisted in 13/21 (62%) patients. All patients were completely dry on CIC except 1. The leakge was through the urethra and was successfully managed by macroplastique injection at the bladder neck. No patient leaked through the continent outlet. Stomal stenosis was encountered in 2 patients with neo-umbilicus and both had stomal revision. No patient had bladder stones or perforation during follow-up. Conclusions Children with urinary incontinence secondary to the combination of a non-compliant bladder and sphincteric deficiency could be optimally managed with this triad. The DWBN provides optimal bladder neck reconstruction. The extramural serous-lined technique has the advantages of a leak-proof continent outlet, ease of catheterization through a straight channel, and the orthotopic position of the outlet in the umbilicus/neo-umbilicus in all patients.