Catheterizable Channel Creation Research Articles

MP18-13 IS INDOCYANINE GREEN SUPERIOR TO SURGEON’S SUBJECTIVE ASSESSMENT WHEN CREATING A CATHETERIZABLE CHANNEL? DEVELOPMENT OF A STANDARDIZED PROTOCOL

You have accessJournal of UrologyCME1 Apr 2023MP18-13 IS INDOCYANINE GREEN SUPERIOR TO SURGEON’S SUBJECTIVE ASSESSMENT WHEN CREATING A CATHETERIZABLE CHANNEL? DEVELOPMENT OF A STANDARDIZED PROTOCOL Amanda Raines, Jennifer Ahn, Nicolas Fernandez, Mark Cain, Byron Joyner, Kathleen Kieran, Margarett Shnorhavorian, and Paul Merguerian Amanda RainesAmanda Raines More articles by this author , Jennifer AhnJennifer Ahn More articles by this author , Nicolas FernandezNicolas Fernandez More articles by this author , Mark CainMark Cain More articles by this author , Byron JoynerByron Joyner More articles by this author , Kathleen KieranKathleen Kieran More articles by this author , Margarett ShnorhavorianMargarett Shnorhavorian More articles by this author , and Paul MerguerianPaul Merguerian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While we know blood supply to catheterizable channels is important to their long term success, there is currently no objective means to assess perfusion. Indocyanine green has a well established use in the evaluation of bowel perfusion, however, use has not been reported in catheterizable channels. Our aims were to develop a standardized protocol for using ICG in the creation of catheterizable channels and establish perfusion patterns of the channels. METHODS: A standardized protocol for the use of ICG in catheterizable channel creation was developed in an adaptive process in this single institution pilot study. Stryker’s SPY PHI system and SPY-QP quantification system were used. SPY-QP allowed for quantification of ICG uptake in the channel relative to healthy bowel. The standardized protocol is described in figure 1. RESULTS: ICG was used in the creation of 3 new appendicovesicostomies and 1 channel revision. Overall, perfusion to the channel decreased with increasing mobilization, but degree of decrease varied between patients. The median ICG uptake went from 85.5% immediately after stapling the appendix to 63.5% when examining the subfascial channel after maturing and 27% at the stoma. In the one revision, ICG clearly delineated an area of poor perfusion in the distal channel after complete mobilization of the channel off the skin and fascial attachments. CONCLUSIONS: The standardized protocol for use in catheterizable channels was successfully implemented. In the channel revision, ICG clearly delineated the area of distal hypoperfusion after channel takedown. ICG can provide surgeons with an objective assessment of channel perfusion rather than relying on subjective assessment alone. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e228 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Raines More articles by this author Jennifer Ahn More articles by this author Nicolas Fernandez More articles by this author Mark Cain More articles by this author Byron Joyner More articles by this author Kathleen Kieran More articles by this author Margarett Shnorhavorian More articles by this author Paul Merguerian More articles by this author Expand All Advertisement PDF downloadLoading ...

Catheterizable channel creation for neurogenic bladder: Comparison of the robotic and open approaches

Catheterizable channel creation for neurogenic bladder: Comparison of the robotic and open approaches

Evaluating the role for regional analgesia in children with spina bifida: a retrospective observational study comparing the efficacy of regional versus systemic analgesia protocols following major urological surgery

IntroductionRegional techniques are a key component of multimodal analgesia and help decrease opioid use perioperatively, but some techniques may not be suitable for all patients, such as those with spina...

Long-term Follow-up of Patients With Cerebral Palsy Undergoing Catheterizable Channel Creation Without Concurrent Bladder Augmentation

To characterize long-term outcomes for adults with cerebral palsy who have undergone catheterizable channel creation without concurrent bladder augmentation. Retrospective review was conducted of patients who underwent catheterizable channel creation without augmentation by the senior author. Variables of interest included development of de novo neurogenic detrusor overactivity, change in continence, escalation in therapy, and upper tract changes. Descriptive statistics were conducted using t-tests and chi-squared tests as appropriate. Nine patients were followed for an average of 70 months. Prior to surgery two patients were on regular clean intermittent catheterization (CIC), six were not on CIC, and one was on occasional CIC. Patients not on CIC preoperatively were more likely to develop de novo neurogenic detrusor overactivity (83% vs 0%, P=.02), and have statistically significant decreases in average compliance (P=.04 vs P=.31). They were also more likely to require escalation in bladder therapy (83% vs 50%) and have worsening of incontinence (67% vs 0%), though these did not reach statistical significance (P=.34, 0.1). Five patients underwent repeat urodynamics an average of 46 months after initial postoperative study because of persistent urgency - 4 of 5 had stable urodynamic findings and one demonstrated >50% reduction in compliance and capacity. Adults with cerebral palsy who are not on CIC prior to creation of a catheterizable channel are at high risk for development of de novo neurogenic detrusor overactivity and decrease in bladder compliance. Prophylactic augmentation should be considered in this group.

Pregnancy and Delivery in Women with Lower Urinary Tract Reconstruction: A National Multicenter Retrospective Study from the French-Speaking Neuro-Urology Study Group (GENULF) and the Neuro-Urology Committee of the French Association of Urology.

Management of pregnancy and delivery in women with lower urinary tract reconstruction is challenging and the currently available literature is insufficient to guide clinical practice. We report pregnancy and delivery outcomes in this specific population. We conducted a national multicenter retrospective study (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation enterocystoplasty, catheterizable channel creation and/or artificial urinary sphincter implantation. Maternal and fetal complications during pregnancy and delivery were reported, as well as postpartum functional outcomes, according to the delivery mode. The chi-square test and Student's t-test were used to compare categorical and continuous variables, respectively. Overall 32% of reported pregnancies were complicated by febrile urinary tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% of deliveries. Delivery mode (p=0.293) and multiparity (p=0.572) had no impact on urinary continence. In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women.

Presentation and Management Patterns of Lower Urinary Tract Symptoms in Adults Due to Rare Inherited Neuromuscular Diseases

ObjectiveTo describe the urologic sequalae of several rare congenital neuromuscular diseases. MethodsWe retrospectively reviewed medical records at Gillette Specialty Healthcare (2014-2018) of patients presenting to urology clinic with lower urinary tract symptoms and select rare congenital diseases: muscular dystrophy, spinal muscular atrophy, and Rett syndrome. ResultsMuscular dystrophies (n = 19) are X-linked myogenic disorders characterized by progressive muscle wasting and weakness. Men present to the urologist at variable ages, typically with complaints of functional incontinence and normal cystometrograms; we manage them with oral anticholinergic medications, condom catheter, or suprapubic catheter.Spinal muscular atrophy (n = 6) is a rare autosomal recessive disease characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem leading to progressive muscle weakness and atrophy. Patients typically present with nephrolithiasis and urinary retention in late adolescence/early adulthood, but timing varies. Filling cystometrograms have been normal. We allow passive retention with intermittent catheterization and creation of catheterizable channels, when indicated.Rett syndrome (n = 5) is a rare, noninheritable genetic condition affecting females characterized by a brief period of normal development followed by loss of speech and purposeful hand use; there are characteristic behaviors. Patients present in early adulthood with complaints of urinary retention. We manage retention with permissive retention or sphincter chemodenervation. ConclusionSeveral congenital neuromuscular conditions can cause lower urinary tract symptoms when these individuals become adults. We have discussed the clinical characteristics and management of select neurogenic and myogenic bladder conditions seen in adults with congenital conditions.

Augmentation cystoplasty in the patient with neurogenic bladder.

To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries. PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB. AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel. Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Bladder changes after catheterizable channel creation in adults with cerebral palsy who are in chronic urinary retention

Cerebral palsy (CP) is characterized by motor impairments as a result of brain injury during development. Patients can have neurogenic bladder dysfunction and are often unable to catheterize through their native urethra. Catheterizable channel (CC) creation can facilitate clean intermittent catheterization (CIC). We have observed that patients with large capacity, low-pressure bladders can develop de novo neurogenic detrusor overactivity (NDO) postoperatively. We sought to better characterize this finding. We reviewed the charts of patients 17 years or older with CP seen between 2006 and 2017. Patients undergoing creation of any type of CC without augmentation cystoplasty, due to adequate storage on pre-operative urodynamics (UDS), were included. Pre- and post-operative UDS were reviewed. Frequency of incontinence and use of anticholinergics or intravesical injections of onabotulinum toxin A (Btx) were reviewed. Eight patients with CP underwent CC creation without augmentation. Preoperatively, six of eight patients were in chronic retention with two others performing CIC. Following CC creation, patients in retention required additional NDO management with anticholinergics, mirabegron, or onabotulinumtoxin A. Among those with complete UDS data, 67% demonstrated lower maximum cystometric capacity postoperatively. Median follow-up was 25 months. CC creation facilitates CIC in adults with CP who are in chronic retention due to pseudodyssynergia. Despite preoperative UDS suggesting an adequate capacity, low-pressure bladder, such patients often manifest de novo NDO and worsening incontinence upon initiation of CIC after surgery. These findings should be considered when determining whether to perform augmentation at the time of CC in adults with CP.

PD48-07 BLADDER CHANGES AFTER CATHETERIZABLE CHANNEL CREATION IN ADULTS WITH CEREBRAL PALSY WHO ARE IN CHRONIC URINARY RETENTION PRE-OPERATIVELY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Transitional Urology & GU Congenitalism1 Apr 2018PD48-07 BLADDER CHANGES AFTER CATHETERIZABLE CHANNEL CREATION IN ADULTS WITH CEREBRAL PALSY WHO ARE IN CHRONIC URINARY RETENTION PRE-OPERATIVELY Vikram Narayan, Ronak Gor, Jenna Katorski, and Sean Elliott Vikram NarayanVikram Narayan More articles by this author , Ronak GorRonak Gor More articles by this author , Jenna KatorskiJenna Katorski More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2311AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cerebral palsy (CP) is characterized by motor impairments as a result of injury to the brain during development. These patients are often unable to self-catheterize through their native urethra due to fine motor impairments and muscle spasticity of the limbs & pelvic floor. Chronic retention can be alleviated with catheterizable channel (CC) creation. But, we have observed that some patients with large capacity, low-pressure bladders who are in chronic urinary retention due to pseudodyssynergia pre-operatively, develop de novo neurogenic detrusor overactivity (NDO) post-operatively. We sought to better characterize this finding. METHODS We retrospectively reviewed the charts of 8 patients 17 years of age or older with a diagnosis of CP who underwent surgical creation of CC without an augmentation cystoplasty in 2011-2017. We have limited augmentation cystoplasty to those CP patients (n=11) with poor bladder compliance, refractory NDO or small bladder capacity; these are not the focus of this study. Pre-operative and post-operative UDS were reviewed, where available. Clinical data, including frequency of incontinence, use of anti-cholinergics, and need for intravesical injections of onabotulinum toxin A before and after surgery were reviewed. Descriptive summaries were tabulated. RESULTS All 8 patients had low detrusor pressures and bladder volumes of at least 250 mL (mean 528 mL) on UDS before surgery. Seven of these patients had severe CP based on the Gross Motor Function Classification System (GMFCS), with a grade of either IV or V, and one was grade III. Pre-operatively, 6 of 8 patients were in chronic retention. These patients all reported worsening incontinence post-operatively. Before surgery, 5 of 8 patients were managed with either anticholinergics or intravesical onabotulinum toxin A. Following CC creation, all patients who were previously in chronic retention required NDO management with either additional anticholinergics, intravesical onabotulinum, or mirabegron. Among those with complete UDS data (6/8 patients), 67% demonstrated lower maximum cystometric capacity post-operatively, with an average volume loss of 88.5 ±81.2 mL (SD). Median follow-up was 25 months. CONCLUSIONS Catheterizable channel creation facilitates CIC in adults with severe CP who are in chronic retention due to psuedodyssynergia. However, despite pre-operative UDS that demonstrate a large capacity, low pressure bladder, such patients often manifest diminished bladder capacities and new NDO upon initiation of CIC after surgery. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e963 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Vikram Narayan More articles by this author Ronak Gor More articles by this author Jenna Katorski More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Bladder perforation after augmentation cystoplasty: Determining the best management option

Delayed bladder perforation is a well-described complication after augmentation cystoplasty. Although the frequency, risk factors, and diagnostic challenges are well documented, discussions regarding management strategies are sparse. We evaluated our experience of managing augmented bladder perforation to interrogate the hypothesis that non-operative management can be used effectively. We retrospectively evaluated the management of 10 patients with augmented bladder perforations over a 16-year period (Jan 2000-Jan 2016). Patients who demonstrated clinical deterioration, severe peritonitis, or extensive extravasation on imaging underwent exploratory laparotomy and primary closure. Clinically stable patients with minimal extravasation were managed non-operatively with maximal bladder drainage, and those with loculated fluid collections in feasible locations for drainage underwent an image-guided percutaneous drain placement. Underlying diagnoses included four patients with myelomeningocele, three with sacral agenesis, two with spinal cord injuries, and one with bladder exstrophy. Three of the four patients with myelomeningocele had concomitant ventriculoperitoneal shunts. Six patients had continent catheterizable channel creation and two patients had bladder neck reconstructions during the original operation. Four patients were managed with exploratory laparotomy and primary closure. Among the six patients managed non-operatively, three underwent image-guided drain placement in addition to maximal bladder drainage. Four patients developed re-perforation. Two of the four surgically managed patients developed re-perforation. Two of the three patients managed only with maximal bladder drainage developed re-operation. None of the patients managed non-operatively with drain placement suffered from re-perforation. Four perforation episodes were alcohol-related, two occurred after high-impact sporting activity, and two patients reported non-compliant catheterization. Non-operative management with maximal bladder drainage and selective image-guided drain placement can be successfully deployed in clinically stable patients with limited extravasation. Ensuring low intraluminal detrusor pressures and empty bladder with maximal drainage is critical for spontaneous sealing of the perforation site. Exploratory laparotomy and primary closure remains our approach for those presenting with clinical deterioration or significant extravasation on imaging. The majority of our perforations and re-perforation episodes seemed to stem from preventable behavioral risk factors. Our findings support the hypothesis that non-operative management with maximal bladder drainage and image-guided drain placement can be effective in stable patients with limited extravasation.

Reconstructive techniques for creation of catheterizable channels: tunneled and nipple valve channels.

Cutaneous catheterizable channels allow for continent bladder emptying when an alternate route is desired. The goals of channel creation in the neurogenic bladder population are successful urine elimination, renal preservation, continence and lastly cosmesis. In addition to a particular surgeon’s comfort and experience with a given procedure, individual patient factors such as medical comorbidities, anatomic factors, and occupational function should be central to the selection of a surgical approach. An ideal channel is one that is short, straight, and well supported by associated blood supply and surrounding adventitia, so as to minimize difficulty with catheterization. Two types of channel continence mechanisms are discussed at length in this review—the tunneled channel, and the nipple valve. The appendicovesicostomy (Mitrofanoff), and reconfigured ileum (Yang-Monti) are both tunneled channels. The ileocecal valve is a commonly used nipple valve and provides continence when reinforced. The continent catheterizable ileal cecocystoplasty (CCIC) is an example of this channel technique. This method couples a tapered ileal limb as a catheterizable channel, the ileocecal valve as the continence mechanism, and the cecum and ascending colon as a bladder augmentation. While this procedure has higher perioperative complications relative to a simple tunneled channel, it has increased channel length flexibility and is also coupled with a bladder augment, which is completely performed using one bowel segment. Continent channel creation in adults can improve quality of life and minimize morbidity associated with neurogenic bladder. However, the decision to proceed with creation of a catheterizable channel should be made only after careful consideration of the patient’s medical comorbidities, physical abilities social support, and surgeon experience.

Long-Term Followup and Time to Event Outcome Analysis of Continent Catheterizable Channels

Creation of a continent catheterizable channel has facilitated the treatment of patients undergoing lower urinary tract reconstruction. We present outcomes and complications of a single center series of continent catheterizable channels followed out to 15 years. We retrospectively reviewed medical records of all children who underwent continent catheterizable channel (Mitrofanoff and Monti) between 1992 and 2007. Collected data included age, underlying diagnosis, associated procedures, stoma site, conduit type (appendix or reconfigured bowel), time to complications and need for subsequent surgical revisions. We identified 71 girls and 98 boys who underwent surgery at a mean age of 7.5 years (range 6 months to 22 years) and were subsequently followed for a mean of 5.8 years (8 months to 15 years). Underlying diagnoses included neurogenic bladder (36% of patients), bladder exstrophy (25%), epispadias (6%) and posterior urethral valves (6%). Concurrent procedures were conducted in 71% of cases, including augmentation (35%) and bladder neck plasty (22%) or closure (8%). Surgical revision was performed in 39% of patients, including stomal revision (18%), redo operation (8%), bulking agent injection (8%) and prolapse correction (4%). Although an initial peak was followed by a relatively stable complication-free period, delayed problems were detected on long-term followup. No statistically significant differences in complication rates were noted when comparing use of appendix and reconfigured bowel or different stoma locations. Despite an initial decrease in complications soon after continent catheterizable channel creation, late problems appeared on long-term evaluation. In our experience no specific factor predicted the likelihood of complications. Nevertheless, despite the need for surgical revision, good functional outcomes were evidenced in this series.

Long-term followup and outcome of continent catheterizable vesicocstomy using the Rink modification.

Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.

Long-Term Followup and Outcome of Continent Catheterizable Vesicostomy Using the Rink Modification

Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.