The Utility of Serous Lined Extramural (SLEM) Conduit Implantation in Pediatric Augmentation Cystoplasty with Continent Diversion

Abstract

Purpose During Ileocystoplasty with continent diversion, inherent anatomical and pathological abnormalities involving the bladder template, available conduit length, compression spinal deformities and obesity can preclude the effective construction of an adequate vesical submucosal antireflux mechanism and/or hinder putting an easily accessible abdominal stoma for the child. We present an extrapolation of Abol-Einein & Ghoneim's SLEM antireflux principle utilized in adult orthotopic bladder substitution to conduit implantation in select group of candidate children in an attempt to overcome these difficulties. Material and Methods Nineteen patients (8 boys and 11 girls, age range 5-16 years, median 9) with bladder exstrophy (9/19), myelodysplasia (7/19), urethral valves (2/19), and post repair of persistent cloaca (1/19) underwent ileocystoplasty with utilization of either the appendix (10/19) or a Monti (9/19) as a Mitrofanoff channel. The latter was received into the intestinal portion of the augment in a SLEM tunnel with its stomal end brought through the abdominal wall at an easily accessible site for the child. Results Median follow up was 24 months (13-47). The stoma was positioned at a neo-umbilicus in all exstrophy patients, in the epigastrium in 3 obese patients with spinal deformities, in the left iliac fossa in 2 left-handed patients and at the umbilicus in 5. Easy catheterization with adequate emptying was initially achieved in 14/19 (74%). Stomal stenosis developed in 5/19 (26%) of which 2/5 responded to dilatation and 3/5 to a skin level revision. None developed a stricture at the conduit trunk nor at its proximal end. Eighteen patients (95%) were CIC continent by end of followup. Conclusions The SLEM principle creates an effective and durable antireflux mechanism. Its versatility allows overcoming the problem of an inadequate or hostile bladder template, meanwhile, the conduit length sparing effect provides more liberty in placing easily accessible stomata in myelodysplastic patients with severe spinal deformities and obesity.