Catheterizable Channel Research Articles

Prevention of ventriculoperitoneal shunt complications after intraperitoneal urological surgeries

PurposeTo evaluate perioperative management for the prevention of postoperative shunt infection and malfunction after intraperitoneal urological surgery in patients with myelodysplasia and a ventriculoperitoneal shunt. MethodsFrom 2005 to 2015, 20 consecutive patients with myelodysplasia and a ventriculoperitoneal shunt who underwent intraperitoneal urological surgeries were managed with the same perioperative regimen. Intraperitoneal surgeries involved opening gastrointestinal tracts, including bladder augmentation by enterocystoplasty, creating continent catheterizable channels and Malone antegrade continent enema. We compared results with those from seven previous reports regarding postoperative shunt complications, surgical histories of previous shunt revisions, management of bacteriuria before surgery preoperative bowel preparation, antibiotic regimens, and duration of indwelling drain. ResultsOf 20 patients, 18 received prior shunt revisions, and 14 had positive urine culture before surgery that was managed with oral antibiotics. Thirteen patients underwent bladder augmentation with ileum, and one underwent augmentation with sigmoid colon. Nineteen patients underwent Malone antegrade continent enema using the appendix. All parenteral antibiotics were stopped on postoperative day 2.5. Mean duration of indwelling peritoneal drain was 2.7days. Mean follow-up period was 59.8months. Neither postoperative shunt infections nor intraperitoneal shunt malfunctions were recognized during follow-up period. ConclusionsThis is the first study to evaluate postoperative ventriculoperitoneal shunt complications in patients with myelodysplasia who underwent intraperitoneal urological surgeries with a specific perioperative regimen. Shunt complications are greatly reduced by rigorous perioperative management, including preoperative control of bacteriuria, appropriate administration of prophylactic antibiotics, and early removal of intraperitoneal drains. Levels of evidenceThe type of study: Case series with no comparison group, IV.

Long-term outcomes of the Kropp and Salle urethral lengthening bladder neck reconstruction procedures

The Kropp and Salle procedures have shown good short-term outcomes for managing neuropathic urinary incontinence. However, few studies have assessed their long-term results. This study aimed to evaluate the long-term outcomes of Kropp and Salle procedures, including: dryness, secondary interventions for incontinence or complications, upper urinary tract changes, and use of urethral catheterizations. Consecutive patients undergoing Kropp and Salle procedures at the present institution (1983-2012) were retrospectively reviewed. Patients with <1-year follow-up or prior bladder neck (BN) continence procedures were excluded. Data were collected on postoperative dryness per urethra at 4-hourly and 3-hourly intervals, secondary interventions, lab tests, and imaging. Non-parametric tests were used for statistical analysis. Thirty-eight patients had Kropp (K: 30 boys) and 12 had Salle procedures (S: 8 boys). Patients underwent surgery at similar median ages (K: 7.4 vs S: 8.7 years old, P=0.51) and had similar median follow-up (6.9 vs 10.3 years, P=0.10). Most patients had myelomeningocele, a prior/concomitant bladder augmentation (K: 73.7%, S: 58.3%) and catheterizable channel (K: 81.6%, S: 50.0%). Differences in all outcomes between Kropp and Salle procedures were statistically non-significant. The majority of patients did not have additional BN procedures for dryness (K: 84.2%, S: 66.7%). Of this group, K: 81.3% and S: 75.0% were dry for ≥4h, K: 93.8% and S: 87.5% were dry for ≥3h between catheterizations (Table). Of the minority of patients who underwent additional BN procedures for dryness (K: 15.8%, S: 33.3%), most achieved dryness for ≥4h (K: 66.7%, S: 100%) and ≥3h (100% for both). Among patients without an initial catheterizable channel, 57.1% had one subsequently created after a Kropp procedure, and 33.3% after a Salle. Among patients without bladder augmentation, approximately half underwent delayed augmentation (K: 50.0%, S: 40.0%). Ultimately, most patients required a secondary intervention under anesthesia for incontinence or complications (K: 79.0%, S: 66.7%). Few patients developed worsening hydronephrosis, vesicoureteral reflux or renal function (K: 2.6%, S: 0.0%). At the end of follow-up, few patients catheterized per urethra (K: 10.5%, S: 33.3%). This was a retrospective study without urodynamic data. Originating from a tertiary center, the results may not apply to other clinical settings. At the present institution the Kropp and Salle procedures attained similar dryness in 75-81% at 4-hourly intervals and 88-94% at 3-hourly intervals without additional BN procedures. Few patients required subsequent BN procedures to achieve dryness. However, the overall need for secondary procedures during long-term follow-up was high for both procedures.

Commentary to “Effect of postoperative weight gain on the risk of channel revision following continent catheterizable urinary channel surgery”

Commentary to “Effect of postoperative weight gain on the risk of channel revision following continent catheterizable urinary channel surgery”

Perioperative and long-term surgical complications for the Indiana pouch and similar continent catheterizable urinary diversions

This article summarizes recent evidence describing perioperative and long-term surgical complications of the Indiana pouch and similar continent catheterizable urinary diversions. The perioperative morbidity and long-term complications are better defined in recent literature describing the Indiana and similar pouches. Both perioperative and long-term surgical complications for the Indiana and similar pouches are extremely variable between studies, but ranges between 1-32% and 6-69%, respectively. Significant perioperative surgical risks include bowel leak, deep wound and organ space infection, ureteral leak and/or stenosis, and death. Common long-term surgical risks include: ureteral stenosis, problems with the catheterizable (efferent) channel, and the treatment of pouch or other urinary calculi. Perioperative and long-term surgical complications have only recently been reported in a consistent manner for continent catheterizable urinary diversions. Understanding perioperative and long-term surgical complications allows for comparison of studies and more importantly allows surgeons to provide accurate information about complications and risk to patients.

Effect of baseline obesity and postoperative weight gain on the risk of channel revision following continent catheterizable urinary channel surgery

Prior studies suggest that obese patients are at increased risk for complications following continent catheterizable urinary (CCU) channel surgery. We hypothesized that postoperative weight gain increases the risk of channel angulation, difficulty catheterizing, and possible channel perforation requiring subfascial revision. The purpose of this study was to evaluate whether baseline obesity or becoming overweight/obese postoperatively was associated with a greater risk of subfascial revision. We reviewed retrospectively an institutional database of patients who underwent CCU channel surgery between the ages of ≥2 and <20 years from January 1990 to May 2013, excluding those with continent urinary reservoirs, continent vesicostomies, and those without body mass index (BMI) data. We collected data on patient/procedure characteristics, baseline/most recent BMI, and subfascial revision(s). We used Cox proportional hazard multivariable regression to assess the association of being overweight/obese at baseline (≥85% BMI) with time to first subfascial revision, and Fisher's exact test to compare rates of subfascial revision between those who became overweight/obese and those who did not. Of the patients, 328/501 (65.5%) had baseline and post-baseline BMI data available: 53.4% male, 90.6% white, median age 7.4 years; median follow-up 76.4 months. Of the 328 patients, 38 (11.6%) had subfascial revisions. Baseline BMI data were available for 378 patients, and, of these, 130 (34.4%) were overweight/obese at baseline. Overweight/obese patients were more likely to undergo umbilical Monti (10% vs. 8.1%), non-umbilical spiral Monti (33.8% vs. 13.7%), and spiral umbilical Monti channels (13.8% vs. 7.3%) versus normal/underweight patients (p<0.0001). From a multivariable Cox proportional hazard model controlling for age, BMI category, diagnosis, and ambulatory status, the hazard of subfascial revision for spiral umbilical Monti channels was 2.1× that of other channels (hazard ratio (HR) 2.1 [95% CI 1.2-3.8], p=0.01). Fifty-one out of 328 patients (15.6%) became overweight/obese postoperatively, with 7.8% having a subfascial revision vs. 12.3% of those whose weight category decreased or remained stable (p=0.3) (Table 1). Patients who were overweight/obese at baseline were more likely to have channels constructed that are at the highest risk of subfascial revision. Patients who became overweight/obese postoperatively were not at greater risk of subfascial revision. Limitations include potential bias because of differential follow-up and inaccuracy of BMI percentile as a measurement of obesity.

20 years experience with appendicovesicostomy in paediatric patients: Complications and their re-interventions.

To evaluate the long-term outcome of appendicovesicostomies and to present the frequency and timing of complications needing re-intervention. In this retrospective study we included patients in whom an appendicovesicostomy was created at our institution between 1993 and 2011. Patients with a follow-up less than 1 year were excluded. Patient characteristics and conduit-related complications requiring re-intervention were collected. One hundred and twenty-eight patients were included with mean age at initial surgery of 10.1 ± 3.9 years. Two thirds of the children had underlying neurogenic disease. The mean follow-up was 10.1 ± 4.8 years. All but one patient continued to use the catheterizable channel. Re-intervention for conduit-related complications was necessary in 32.0% of the patients. A second, third, and fourth re-intervention was required in respectively 10.9%, 2.3%, and 1.6%. The commonest complications were cutaneous/fascial stenosis in 14.8%, stenosis at conduit-bladder level in 9.4%, and stomal incontinence in 6.3% of the patients. The most performed re-interventions were stoma revision (in 16.4% of the patients), conduit revision (10.2%), and dilatation of a stenotic tract (4.7%). 63.3% of the re-interventions was superficial and/or endoscopic. The peak incidence of re-interventions was in the 1st year after conduit construction and decreased yearly. Our study gives an overview of patients and their conduits developing from prepubertal children to young adults. During a mean follow-up of 10.1 years, roughly one third of the patients needed a re-intervention. We conclude that an appendicovesicostomy is an effective and durable treatment for whom transurethral clean intermittent catheterization is not feasible. Neurourol. Urodynam. 36:1325-1329, 2017. © 2016 Wiley Periodicals, Inc.

Does endoscopy of difficult to catheterize channels spare some patients from formal open revision?

Patients with continent catheterizable channels (CCC) may develop difficulty catheterizing postoperatively. In complex cases, endoscopic evaluation with indwelling catheter placement may be indicated, but the risk factors for subsequent formal channel revision are not well defined. The purpose of this study was to determine the risk factors for formal channel revision after attempted endoscopic management of difficulty catheterizing. We performed an IRB-approved retrospective review of pediatric (<21 years old) patients undergoing CCC construction at our institution from 1999 to 2014 to identify patients who underwent endoscopy for difficulty catheterizing. Fisher's Exact test was used for categorical data and Mann-Whitney U test for continuous variables to examine the association between endoscopic intervention and subsequent formal revision. Sixty-three of 434 patients (14.5%) underwent at least one endoscopy for reported difficulty catheterizing their CCC, with 77.8% of these requiring additional intervention during endoscopy (catheter placement, dilation, etc.). Of these, almost half with functioning channels (43.5%, 27/62) were managed successfully with endoscopy without formal revision; six (22.2%) of whom underwent more than one endoscopy. These 27 patients continued to catheterize well at a median follow-up of 3.2 years (interquartile range 2.0-6.0). Patients requiring revision had a median of 1.7 years between CCC creation and first endoscopy, versus 1.6 years in those who were not revised (p=0.60). There was no statistically significant difference between revised and non-revised channels in terms of patient age at CCC creation, underlying patient diagnosis, status of bladder neck, stomal location, or channel type (p≥0.05) (see Table). Approximately half of our patients did not require a formal channel revision after endoscopic management. We did not identify any specific risk factors for subsequent formal revision of a CCC. We recommend performing at least one endoscopic evaluation for those with difficulty catheterizing prior to proceeding with formal open revision.

V10-12 ROBOTIC BLADDER NECK CLOSURE AND MITROFANOFF

You have accessJournal of UrologyRobotics – Benign Disease1 Apr 2016V10-12 ROBOTIC BLADDER NECK CLOSURE AND MITROFANOFF Gregory Murphy and Joseph Wagner Gregory MurphyGregory Murphy More articles by this author and Joseph WagnerJoseph Wagner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Complex urologic reconstruction may be required after morbid cancer operations. Well documented advantages of robotic surgery can be utilized during these reconstructive cases including shorter hospital stay and improved cosmesis. This video demonstrates a robotic bladder neck closure and appendicovesicostomy after radical vaginectomy and urethrectomy in a female with vulvar melanoma. METHODS Our patient is a 72 year old female with vulvar melanoma requiring a radical vaginectomy, urethrectomy and inguinal node dissection by the gynecologists. We performed a concomitant robotic bladder neck closure and Mitrofanoff catheterizable channel. RESULTS Operative time was 368 minutes, of which 204 minutes was robotic time. Estimated blood loss was 200 mL. The patient had an uncomplicated hospital course and was discharged on post-operative day #3. Three weeks after surgery she was taught to catheterize her Mitrofanoff. She is doing well 4 months after surgery without evidence of disease or incontinence. CONCLUSIONS Robotic bladder neck closure and Mitrofanoff are safe and effective means to treat patients after morbid vaginal cancer operations. It offered this patient continence while providing quick recovery and optimal cosmesis. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e949 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Gregory Murphy More articles by this author Joseph Wagner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Continent Catheterizable Vesicostomy: An Alternative Surgical Modality for Pediatric Patients With Large Bladder Capacity

To present a modified technique and early outcomes of a continent catheterizable vesicostomy in pediatric patients with either flaccid neurogenic bladder or intractable voiding dysfunction and large capacity bladder. Six patients underwent the procedure from October 2014 to December 2015. A 4-cm Pfannenstiel incision was made, avoiding intraperitoneal dissection. After adequate mobilization, a 2-cm vertical flap at the dome of the bladder was identified and tubularized over a 12Fr catheter with 4-0 vicryl suture. The tubularized flap was then intussuscepted into the bladder with four 4-0 polydioxanone sutures, creating a continent mechanism. The catheterizable channel was then tunneled to the umbilicus, the channel ostomy matured, and the cystotomy closed in two layers. The median patient age was 8 (interquartile range [IQR] 12) years. All patients had urinary dysfunction requiring drainage from etiologies that included Eagle-Barrett syndrome (n = 2), Noonan syndrome (n = 1), Lennox-Gastaut syndrome (n = 1), and Spina bifida (n = 2). Median hospital length of stay was 8 (IQR 3) days. One patient had a superficial wound infection treated with antibiotics, and 1 patient required balloon dilation of the catheterizable channel at 3 months postoperatively, secondary to difficulty self-catheterizing. Five patients were successfully self-catheterizing at last follow-up. Median follow-up was 6 (IQR 5) months and there were no intra- or perioperative complications. Continent catheterizable vesicostomy is a novel technique for urinary drainage in patients with large bladder capacity that spares use of the appendix or ileum. Early results are encouraging, providing a catheterizable channel through the umbilicus without urinary leakage between catheterization.

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.

Perioperative and Short-Term Outcomes of Robotic vs Open Bladder Neck Procedures for Neurogenic Incontinence

Complex urological reconstruction may be facilitated by the improved magnification and dexterity provided by a robotic approach. Minimally invasive surgery also has the potential advantages of decreased length of stay and improved convalescence. We reviewed perioperative and short-term outcomes between robot-assisted and open bladder neck sling/repair with catheterizable channel in patients with neurogenic bladder. We performed an institutional review board approved retrospective chart review of all patients who underwent open or robotic bladder neck reconstruction without augmentation cystoplasty for refractory urinary incontinence between 2010 and 2014. Age at surgery, operative time, length of stay, complications within 30 days of surgery and future continence procedures (injection of bladder neck/catheterizable channel, additional bladder neck surgery, botulinum toxin A injection) were compared between the groups. A total of 45 patients underwent bladder neck reconstruction (open in26, robotic in 19) with a mean follow up of 2.8 years. There was no difference in preoperative urodynamics, age at surgery or length of stay (median 4 days in each group, p >0.9). Operative time was significantly longer in the robotic group (8.2 vs 4.5 hours, p <0.001). Three patients (16%) undergoing robotic and 3 (12%) undergoing open surgery had a complication within 30 days (p >0.9). Of patients undergoing open repair 14 (56%) underwent 23 subsequent surgeries for incontinence. By comparison, 8 patients undergoing robotic repair (42%) underwent 12 additional procedures (p = 0.5). Although a robotic approach may take longer to perform, it does not result in increased complications or length of stay, or worsened continence outcomes.

Evaluation and Management of Failed Bladder Reconstructions

Bladder reconstructions are commonly performed in patients with neurogenic bladders with a high rate of complications. We seek to help guide the evaluation and management of these complications by reviewing the available data. Augmentation cystoplasty and concomitant procedures such as continent catheterizable channels, bladder neck closure, and bladder neck sling can provide long-term solutions for patients with poorly compliant, high-pressure bladders or refractory detrusor overactivity. While these techniques improve symptoms and protect against upper tract deterioration, patients are exposed to new risks including bladder perforation, increased malignancy rates, urolithiasis, surgical failures, and persistent symptoms. The overall rate of reoperation is high. Evaluation with urodynamics and endoscopy, when indicated, remain critical tools to protect this patient population. Use of clean intermittent catheterization has helped popularize bladder reconstructive surgery, but a strict regimen is required to minimize postoperative risks in the long term. Additionally, various surgical techniques can be utilized to manage complications after bladder reconstruction, and concurrent use of anticholinergics and onabotulinum toxin injections can further mitigate these reconstructive failures. Bladder reconstruction can provide excellent long-term solutions, but patients are at a high risk of long-term complications. Appropriate patient counseling, close follow-up, and timely evaluation are crucial in managing the long-term complications of bladder reconstruction surgery.

Bladder stones after bladder augmentation are not what they seem

Bladder and renal calculi after bladder augmentation are thought to be primarily infectious, yet few studies have reported stone composition. The primary aim was to assess bladder stone composition after augmentation, and renal stone composition in those with subsequent nephrolithiasis. The exploratory secondary aim was to screen for possible risk factors for developing infectious stones. Patients treated for bladder stones after bladder augmentation at the present institution between 1981 and 2012 were retrospectively reviewed. Data were collected on demographics, surgeries and stone composition. Patients without stone analysis were excluded. Stones containing struvite, carbonate apatite or ammonium acid ureate were classified as infectious. The following variables were analyzed for a possible association with infectious bladder stone composition: gender, history of cloacal exstrophy, ambulatory status, nephrolithiasis, recurrent urea-splitting urinary tract infections, first vs recurrent stones, timing of presentation with a calculus, history of bladder neck procedures, catheterizable channel and vesicoureteral reflux. Fisher's exact test was used for analysis. Of the 107 patients with bladder stones after bladder augmentation, 85 met inclusion criteria. Median age at augmentation was 8.0 years (follow-up 10.8 years). Forty-four patients (51.8%) recurred (14 multiple recurrences, 143 bladder stones). Renal calculi developed in 19 (22.4%) patients with a bladder stone, and 10 (52.6%) recurred (30 renal stones). Overall, 30.8% of bladder stones were non-infectious (Table). Among patients recurring after an infectious bladder stone, 30.4% recurred with a non-infectious one. Among patients recurring after a non-infectious stone, 84.6% recurred with a non-infectious one (P = 0.005). Compared with bladder stones, renal stones were more likely to be non-infectious (60.0%, P = 0.003). Of patients with recurrent renal calculi after an infectious stone, 40.0% recurred with a non-infectious one. No clinical variables were significantly associated with infectious stone composition on univariate (≥0.28) or bivariate analysis (≥0.36). This study had several limitations: it was not possible to accurately assess adherence with bladder irrigations, and routine metabolic evaluations were not performed. The findings may not apply to patients in all clinical settings. While stone analysis was available for 3/4 of the stones, similar rates of incomplete stone analyses have been reported in other series. In patients with bladder augmentation, 1/3 of bladder stones and >1/2 of renal stones were non-infectious. Furthermore, an infectious stone does not imply an infectious recurrent stone and no known clinical variables appear to be associated with stone composition, suggesting that there is a possible metabolic component in stone formation after bladder augmentation.

Overcoming Obesity and a Short Appendix in the Creation of Continent Catheterizable Stomas. Preliminary Outcomes of the “Casella-Ost Procedure”

To describe a novel method of using a bladder flap to partially span the distance between the bladder and abdominal wall when creating a concealed catheterizable channel. We retrospectively identified 3 patients in whom we performed this reconstruction and report our surgical technique and their outcomes at 23, 27, and 32 months. There were no immediate operative complications and all patients continue to catheterize without difficulty. Two patients reported mild stomal stress incontinence, which resolved with Ditropan in one case, and was not bothersome enough to desire additional treatment in the second. Incorporation of the bladder flap allows for a shorter proximal limb (appendix or tubularized ileum), improving ease of catheterization in addition to providing a surface where a tunneled, nonrefluxing anastomosis between the proximal limb and bladder can be easily performed. Long-term follow-up and greater patient numbers are needed, nonetheless, we have not seen this approach described in the literature and feel that it is an important reconstructive option to be considered when creating a continent catheterizable diversion.

Neophalloplasty to congenital aphallia using two transverse skin-flaps: An alternative approach

Penile agenesis is a rare congenital abnormality with an incidence of 1 in 30 million births. We want to demonstrate in this video a new technique of neophalloplasty based on two transverse skin flaps from lower abdominal wall. The patient was placed into a prone position; the urethral meatus was found inside the rectum, 2 cm from the anal border. An Anterior Sagittal Transrectal Approach (ASTRA) approach was performed; the urethra was isolated and repositioned as a perineal urethrostomy. We created the neophallus based on two flaps, each measuring 7 × 3 cm. After incision, flaps were rotated 90° and sutured to each other creating the neophallus. We also created a Mitrofanoff channel to secure bladder emptying in cases of urethrostomy stricture. The patient had an uneventful immediate postoperative evolution, but later showed some degree of penile retraction. He voids preferably through the urethrostomy and his mother uses the Mitrofanoff once a day. The current follow-up is 18 months. We acknowledge limited clinical experience with this technique. However, the same principle has been used to create catheterizable urinary channels, with favorable results and longer follow-up. The use of transverse skin flaps might be an interesting alternative for neophalloplasty in aphallia.

Long-term outcomes of catheterizable continent urinary channels: What do you use, where you put it, and does it matter?

Appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) are commonly used catheterizable channels with similar outcomes on short-term follow-up. Their relative long-term results have not been previously published. Our goal was to assess long-term durability of APV and Monti channels in a large patient cohort. In this retrospective cohort study, we retrospectively reviewed consecutive patients ≤21 years old undergoing APV and Monti surgery at our institution (1990-2013). We collected data on demographics, channel type, location, continence and stomal and subfascial revisions. Kaplan-Meier survival and Cox proportional hazards analysis were used. Of 510 patients meeting inclusion criteria, 214 patients had an APV and 296 had a Monti (50.5% spiral Monti). Median age at surgery was 7.4 years for APV (median follow-up: 5.7 years) and 8.7 years for Monti (follow-up: 7.7 years). Stomal stenosis, overall stomal revisions and channel continence were similar for APV and Monti (p ≥ 0.26). Fourteen APVs (6.5%) had subfascial revisions compared to 49 Montis (16.6%, p = 0.001). On survival analysis, subfascial revision risk at 10 years for APV was 8.6%, Monti channels excluding spiral umbilical Monti: 15.5% and spiral umbilical Monti: 32.3% (p < 0.0001, Figure). On multivariate regression, Monti was 2.09 times more likely than APV to undergo revision (p = 0.03). The spiral Monti to the umbilicus, in particular, was 4.23 times more likely than APV to undergo revision (p < 0.001). Concomitant surgery, gender, age and surgery date were not significant predictors of subfascial revision (p ≥ 0.17). Stomal location was significant only for spiral Montis. Our study has several limitations. Although controlling for surgery date was a limited way of adjusting for changing surgical techniques, residual confounding by surgical technique is unlikely, as channel implantation technique was typically unrelated to channel type. We did not include complications managed conservatively or endoscopically. In addition, while we did not capture patients who were lost to follow-up, we attempted to control for this through survival analysis. We demonstrate, durable long-term results with the APV and Monti techniques. The risk of channel complications continues over the channel's lifetime, with no difference in stomal complications between channels. At 10 years after initial surgery, Monti channels were twice as likely to undergo a subfascial revision (1 in 6) than APV (1 in 12). The risk is even higher in for the spiral umbilical Monti (1 in 3).

PD11-06 DURABILITY OF REVISION SURGERY FOR STENOSIS OF CATHETERIZABLE CHANNELS IN ADULTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion II1 Apr 2015PD11-06 DURABILITY OF REVISION SURGERY FOR STENOSIS OF CATHETERIZABLE CHANNELS IN ADULTS Travis Pagliara, Daniel Liberman, Jeremy Myers, John Stoffel, and Sean Elliott Travis PagliaraTravis Pagliara More articles by this author , Daniel LibermanDaniel Liberman More articles by this author , Jeremy MyersJeremy Myers More articles by this author , John StoffelJohn Stoffel More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1095AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The incidence of stenosis of continent catheterizable channels varies by channel type (e.g. Mitrofanoff vs. Monti vs. tapered ileal limb) and patient factors. Up to 55% of channels will require intervention for stenosis; intervention is usually a dilation but for recurrent stenosis revision surgery may be required. We sought to describe the strategies of surgical revision for catheterizable channel stenosis and their outcomes. METHODS We retrospectively reviewed the charts of 74 adult patients who underwent catheterizable channel revision or replacement from 2000 to 2014 for stomal stenosis or difficult catheterization. The primary outcome was continued ability to catheterize the channel post-operatively without surgical dilation or revision. Secondary outcomes included channel continence and post-operative complications. Revisions were classified into the following strategies: revision above the rectus fascia, below the fascia, or channel replacement. RESULTS Revision approaches included 42% above the fascia, 30% below the fascia, and 28% channel replacement. Patients with congenital etiology of neurogenic bladder were more likely than other patients to undergo more complicated revisions (p=0.012). Channel patency was achieved in 65% at a median 34 months post-revision procedure; there was no difference by revision strategy (p=0.104). Severe stomal incontinence occurred in 3.2% after above the fascia repairs, 22.7% after below the fascia repairs and 14.3% after channel replacement (p=0.111). Surgical complications occurred in 28.4%; almost all were Clavien 1-2 and there was no difference by revision strategy (p=0.293). CONCLUSIONS Surgical revision for continent channel stenosis can be performed with good rates of durable patency. Patency rates are similar across surgical strategies of revision. Those with congenital neuropathic bladder require more complex revisions. Severe post-operative channel incontinence is not uncommon. We present our management algorithm based on length of stenosis, the amount of redundant channel available for reconstruction, and the presence or lack of a continence mechanism prior to intervention (Figure 1). © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e253 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Travis Pagliara More articles by this author Daniel Liberman More articles by this author Jeremy Myers More articles by this author John Stoffel More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Does augmentation cystoplasty with continent reconstruction at a young age increase the risk of complications or secondary surgeries?

Lower urinary tract reconstruction with augmentation cystoplasty (AC) is an effective strategy for achieving urinary continence in children with neurogenic or severely compromised bladder. We compared complications and need for secondary surgeries in children 3-5 years of age undergoing AC with continent reconstruction to those ≥ 6 years old. Medical charts of children undergoing AC with continent urinary diversion between 2003 and 2011 were reviewed. Complications and secondary surgeries were analyzed according to patient age. Patient demographics, etiology of bladder dysfunction, bowel segment used, and concomitant procedures were also assessed. One hundred and eight children underwent AC with continent urinary diversion. Mean age at augmentation was 8.5 years (range 3-20). Twenty-eight children (25.9%) were 3-5 years old and 80 (74.1%) were ≥ 6 years. Mean follow-up was 6.93 years (range 1.6-10 years). Bowel segment used included ileum in 59 (54.6%), sigmoid in 33 (30.6%), cecum in 4 (3.7%) and composite in 12 (11.1%). Major complications included bowel obstruction in 6 (5.6%), bladder perforation in 3 (2.8%) and fistula in 2 (1.9%). There was no difference in major complications based on bowel segment utilized (p = 0.804, OR 0.894) or age (p = 0.946, OR 0.969). Fifty children (46.3%) required no additional surgeries; the remaining 58 underwent 137 procedures post-augmentation. Surgeries included urolithiasis management (58/137, 42.3%), appendicovesicostomy revision including stoma revision or redo for persistent leakage between catheterizations in (34/137, 24.8%), bladder neck procedures (26/137, 19%) and revision of MACE (19/137, 13.9%) [Figure]. Incidence of stones in patients 3-5 years (32.1%) was not significantly different than children ≥ 6 years of age (25%, p = 0.463, OR 0.704). Mean number of secondary surgeries for those 3-5 years was 1.21 ± 1.34, which was not statistically different than those ≥ 6 (1.3 ± 1.82, p = 0.154). Children with myelomeningocele (MMC) were statistically more likely to require secondary surgeries than those with other bladder pathology (p = 0.01). Augmentation enterocystoplasty with cutaneous continent catheterizable channel is performed both to protect the upper urinary tract and afford the patient the option of social continence. Continent lower urinary tract reconstruction has been proven technically feasible and safe in preschool-aged children however, the ideal age for augmentation remains unknown. Urolithiasis accounted for over 40% of additional procedures in our series, with 26.9% of patients requiring one or more surgeries for stone disease. The incidence of stone disease in patients 3-5 years of age at the time of augmentation was comparable to that seen in older children. The overall need for additional post-augment procedures was not influenced by patient age or bowel segment utilized, however children with MMC were significantly more likely to require future surgeries than those with a different underlying etiology of bladder dysfunction. Our study has several limitations that warrant mention. Children with neurogenic bladder represent a heterogeneous population, and their surgical outcomes are inherently influenced by underlying disease processes and severity. Complications and secondary surgeries were assessed; however success rates were not evaluated in the current study. Patient and caregiver adherence with CIC and daily bladder irrigation was not assessed; whether noncompliance affected complication rates (i.e. stone formation) is unknown. Whether performed at a young or older age, families must be adequately counseled regarding the daily management responsibilities and potential risks associated with lower urinary tract reconstruction including bladder augmentation. Augmentation with continent urinary diversion in selected patients 3-5 years of age confers complication and secondary surgery risk equal to that observed in their older counterparts.

Assessing Health Related Benefit after Reconstruction for Urinary and Fecal Incontinence in Children: A Parental Perspective

We sought to evaluate health related benefit in children undergoing surgical reconstruction for urinary and fecal incontinence from a parental perspective. A health related benefit instrument was mailed to the parents or guardians of 300 consecutive patients who had undergone reconstruction for urinary and/or fecal incontinence at our institution between 1997 and 2011. We assessed parent reported health related benefit using the validated Glasgow Children's Benefit Inventory and satisfaction with 6 supplemental questions. One-sample t-tests as well as exploratory univariate and multivariate linear regressions were performed for statistical analysis. Response rate was 40.0% at a mean of 5.5 years (range 0.6 to 13.8) after reconstruction. Spina bifida was the most common primary diagnosis (48 patients, 56.5%). Mean total Glasgow Children's Benefit Inventory score and subscores for each domain were positive, indicating an improved health related benefit after reconstruction (all p <0.0001). Certain patients, possibly based on diagnosis and gender, may particularly benefit from reconstruction (p ≤0.04). Parents believed that the bladder augmentation and/or urinary continent catheterizable channel most changed the life of their child but that achievement of stool continence was most important to themselves. Only 17 families (16.2%) required more than 1 month to become comfortable with catheterizations, and 69 patients (68.8%) required less care or no assistance with daily activities after reconstruction. Only 2 parents (1.9%) would be unwilling to consent to the procedure again. We observed moderate parental satisfaction and parent reported improvement in health related quality of life for children undergoing surgical reconstruction for urinary and fecal incontinence.

Santosh PGI pouch: A new innovation in urinary diversion.

IntroductionTo know the feasibility and outcome of the Santosh PGI pouch as a new innovative technique of continent cutaneous diversion (CCD) following cystectomy.Material and methodsTwelve patients (eleven with carcinoma of the bladder and one with an exstrophy of the bladder) underwent CCD using the Santosh PGI pouch after cystectomy. A 50-cm segment of terminal ileum was isolated 15-20 cm proximal to the ileocecal junction. The ileal segment was folded into the form of an ‘S’ configuration. On the antimesenteric border three longitudinal incisions were performed of about 7 cm in length. The terminal 8 cm portion of the distal part of the pouch was used for creating the intussuscepted nipple valve. Demucosalization of the interior of the nipple, fixing the nipple valve with the serosa of the pouch wall and wrapping of the catheterizable channel with a pouch wall for providing continence was done. The uretero-pouch anastomosis was done using the serosal lined tunnel technique. The catheterizable channel was brought out through the right rectus muscle.ResultsMedian follow-up of the patients was 13.5 months. No significant complications were noted in the pouch reconstruction. Duration of the pouch reconstruction was around 75-110 min. Postoperatively, one patient had a UTI and another had paralytic ileus on the follow-up. All patients were doing regular CIC with acceptable continence of up to 400 ml. No ureteroileal anastomotic stricture or difficulty in catheterizing the pouch was seen.ConclusionsThe Santosh PGI pouch, which is a type of CCD, is technically feasible, easy to reconstruct with acceptable continence and offers minimal morbidity.