Catheterizable Stoma Research Articles

Robotic Assisted Surgery in Pediatric Urology

Robotic assistance may permit more generalized development of laparoscopic reconstruction in pediatric urological procedures such as pyeloplasty and anti-reflux surgery. The relatively slow adaptation of laparoscopic techniques in reconstructive pediatric urology appears to be due to the challenges of efficient and accurate laparoscopic suturing. This review summarizes the current robotic options available for pediatric urological applications, the means of utilization, and early experience. The most commonly available robotic system is the daVinci® (Intuitive Surgical, Mountain View, California) with its EndoWrist technology that permits highly accurate and precise manipulation for laparoscopic dissection, tissue handling,and suturing. The system is large and costly in its current version, but has demonstrated its efficiency and potential in a wide variety of adult applications and now with pediatric uses. Most procedures performed have been transperitoneal, due to the large size of the instruments (12-mm camera port and two 8-mm working ports) and have included pyeloplasty, pyelolithotomy, extravesical anti-reflux procedures, and continent catheterizable stoma using appendix (Mitrofanoff). These procedures have largely been identical to those performed using conventional laparoscopy, and newer procedures will need to develop unique algorithms to take full advantage of the robotic system. Potential applications are numerous and this development is likely to contribute significantly to minimally invasive pediatric urology.

The Gastrostomy Button as a Catheterizable Urinary Stoma: A Pilot Study

We assessed the impact of the gastrostomy button used as a catheterizable urinary stoma on the infection, encrustation and erosion rates, and quality of life in a series of 19 patients. Patients were selected as candidates for the button based on multichannel urodynamic studies that confirmed an areflexic neurogenic bladder. At study enrollment each patient completed a quality of life questionnaire based on a visual analog scale. If the patient had a preexisting indwelling suprapubic tube, it was replaced with a button. If no preexisting suprapubic tube was present, one was inserted. The button was then inserted approximately 1 month later after an adequate tract was established. For 1 year the patient underwent cystoscopy with urine culture every 2 months for a total of 6 times. Symptomatic infections were treated but asymptomatic colonization was not. A quality of life questionnaire was completed at each visit. Of the 19 patients 10 had failure, necessitating button removal. These failures were due to an excessive suprapubic distance from skin to bladder, which prevented adequate button fit. All patients in whom the button remained showed significant improvements in quality of life. The colonization rate was 100% but the rate of symptomatic infections was low. The incidence of bladder stones was zero and the rate of encrustation was low. When used as a catheterizable stoma to treat areflexic neurogenic bladder, a gastrostomy button is a safe, effective option for these patients. The rate of symptomatic infections is low, the risk of bladder stone formation is minimal and erosion was not observed in properly sized button insertions. The current limiting factor is the length of the button compared with the patient suprapubic measurement (length from skin to bladder). Each patient reported that quality of life with the button was significantly better than prior to button placement.

Continent catheterizable urinary conduit constructed from defunctionalized colon

The authors describe a technique for construction of a continent catheterizable stoma from distal defunctionalized colon in a patient with imperforate anus, urethral atresia, and sacral agenesis.

Transvaginal Sling Suspension of Bladder Neck in Female Patients With Neurogenic Sphincter Incontinence

Many surgical options exist to enhance bladder neck closing pressure in women. Most procedures are relatively large with a success rate of between 70% and 90%. Sling procedures with the sling placed between the anterior vaginal wall and bladder neck cause a risk of traumatic lesions of the bladder neck at operation and of postoperative erosion of the sling into the urethra. We evaluated the results of surgical treatment for neurogenic pelvic floor paralysis in girls with spina bifida by transvaginal rectus abdominis sling suspension. Between 1991 and 2001 we treated 24 girls with a pubovaginal sling placed through the vagina. Patient age at operation was 1 to 17 years (mean 9). After identification of the bladder neck and anterior vaginal wall 2 small holes were made into the vagina left and right of the bladder neck. The sling was taken through these holes and fixed to the contralateral pubic bone. The sling procedure has been combined with ileocystoplasty, auto-augmentation, a continent catheterizable stoma and ureteral reimplantation when needed. Of the 24 patients 19 were dry after the initial procedure and 3 others became dry after a total of 4 additional injections of a bulking agent into the bladder neck via suprapubic needle introduction under transurethral endoscopic guidance. A patient underwent bladder neck closure after a vesicovaginal fistula developed from the ileal bladder and another primarily elected bladder neck closure for persistent urinary incontinence. No infectious complications occurred that were related to the procedure. Clean intermittent catheterization was possible in all patients. Transvaginal sling suspension is safe, relatively easy to perform and cost-effective compared with most alternative procedures. It appears to be as successful as other more complicated procedures to achieve urinary continence in girls with spina bifida.

Outcome of Continence Procedures in the Pediatric Patient: A Single Institutional Experience

Achieving continence remains a major goal in the treatment of children with neurogenic and/or anatomical voiding dysfunction. We reviewed our experience with continence procedures in pediatric lower urinary tract reconstruction. We reviewed the records of all pediatric patients who underwent continence procedures at our institution since July 1993. We reviewed the diagnosis, type of primary reconstructive procedure, concomitant procedure(s) and initial success rate. In cases of primary failure we noted the type of secondary continence procedure performed and the ultimate success rate. Success was defined as dry intervals of at least 4 hours when the patient was compliant with a catheterization or voiding regimen. Primary continence procedures were performed in 43 cases and secondary procedures were performed in 6 for a total of 49 continence procedures. The diagnoses included myelomeningocele in 22 patients, exstrophy in 12, epispadias in 3, bilateral single system ureteral ectopia in 3 and spinal cord injury in 3. A total of 32 primary procedures were performed concomitantly with or were preceded by bladder augmentation with creation of a catheterizable stoma. The remaining 11 patients underwent a continence procedure only. The diagnosis in these 11 patients was exstrophy in 5, epispadias in 3, with spinal cord injury in 2 and myelomingocele in 1. Mean followup was 35 months (range 1 to 95). Initial continence procedures included Young-Dees-Leadbetter bladder neck repair in 14 cases, of which 11 (79%) were initially successful, a urethral sling in 9 with 7 initial successes (78%), bladder neck division and closure in 7 with all successful (100%), collagen in 5 with 1 success (20%), other urethral lengthening procedure (eg Pippi Salle or Kropp) in 4 with 3 successes, (75%), combined urethral sling and Young-Dees-Leadbetter in 2 with 1 success (50%), and an artificial sphincter and fascial wrap in 1 each, which were successful. Of the 6 secondary procedures performed for primary failure collagen was injected in 4 and the bladder neck was divided and closed in 2. All were successful. Various lower urinary tract procedures can be performed to achieve successful continence in the pediatric population. At our institution all procedures had a reasonable success rate except primary collagen injection. Collagen injection and bladder neck division/closure proved to be reliable secondary procedures in cases of primary failure.

Conservative Management of an Intraperitoneal Rupture of an Augmentation Cystoplasty and Continent Urinary Diversion in an Adult

Augmentation cystoplasty has been used extensively during the last 50 years as a surgical means of increasing the storage capacity of the bladder, particularly in patients with neurogenic bladder dysfunction. Perforation of the augmented bladder has been reported infrequently. CASE REPORT A 27-year-old woman with spina bifida had undergone surgery for neurogenic bladder dysfunction and intractable incontinence 8 years previously. The bladder was bivalved and augmented with a detubularized ileocecal segment, the urethra was disconnected, the bladder neck was closed and a continent catheterizable stoma was produced using the intussuscepted ileocecal valve and an ileal conduit. The patient was managed with clean intermittent self-catheterization and had been continent and well until presentation. After arising from bed, sudden onset of right abdominal pain developed exacerbated by movement and coughing. The patient also noticed oliguria. On examination the abdomen was distended with rebound tenderness on the right side. Computerized tomography (CT) revealed multiple fluid collections throughout the abdomen and pelvis. A total of 20 ml cloudy yellow fluid was aspirated from below the liver. Creatinine concentration in this fluid was 1.76 mmol/l consistent with urine, and Candida glabrata was cultured. A catheter was inserted through the stoma to achieve free drainage of the augmented bladder, and a cystogram showed no definite intra-abdominal leak. However, delayed CT cystography demonstrated some extravasation of contrast material into the right pelvic collection 2 hours after intravesical injection of contrast medium and clamping of the catheter (fig. 1). A 10Fr pigtail drain was inserted percutaneously into the urinoma inferior to the right lobe of the liver and 750 ml urine was drained. The patient was managed with an indwelling catheter on free drainage and monitored closely. The pain improved, the drain was removed when drainage had stopped on postoperative day 6 and the patient was discharged home with the catheter indwelling. Repeat CT of the abdomen 4 weeks later displayed almost complete resolution of the intraabdominal fluid and no leak (fig. 2). The indwelling catheter was removed and intermittent self-catheterization was resumed. At 3 months the patient was well and she remained continent with clean intermittent self-catheterization.

Spontaneous Regression of Cystic Dysplasia of the Testis

A 9-year-old boy with left multicystic dysplastic kidney and the VATER (vertebral defects, imperforate anus, tracheoesophageal fistula, and radial and renal dysplasia) syndrome presented with an enlarging left testis, and negative serum -fetoprotein and -human chorionic gonadotropin. Because construction of a catheterizable stoma was planned, the patient underwent exploration rather than ultrasound. The left testis, including the rete testis, was cystic and measurement with calipers showed a size of 2.4 1.9 1.5 cm. (4.9 cc). Due to lesion proximity to the epididymis the testis was not biopsied but replaced in the scrotum. At age 9 years 8 months scrotal ultrasound showed that the left testis was 5 times larger than the right testis, that is 7.2 versus 1.3 cc according to the Lambert formula (fig. 1). At age 10 years 4 months testis volumes had increased to 8.8 and 1.9 cc, respectively. At age 11 years 8 months the left testis was 9.4 cc but the right had also enlarged to 4.8 cc. The areas of cystic dysplasia had completely resolved and were replaced by normal appearing parenchyma (fig. 2). At age 13 years the left testis was 8.7 cc and the right testis was 6.7 cc without evidence of recurrent cysts.

Surgical management of the neurogenic bladder and bowel

Spina bifida and myelodysplasia are associated with neurogenic abnormalities of the bladder and bowel function. All children with myelodysplasia require an evaluation of their urinary tract with ultrasound and urodynamics to confirm normal bladder and kidney function. Patients with anatomical and functional abnormalities require treatment, the mainstay being intermittent catheterization and anticholinergic medication. The treatment goals for patients with a neurogenic bladder are the preservation of the upper urinary tract, bladder and bowel continence, independence, autonomy, and facilitation of self-esteem. A minority of children will not respond to conservative therapy and will ultimately require surgical intervention. This review will discuss the surgical options for bladder augmentation, bladder neck reconstruction and closure, as well as the methods for the creation of continent catheterizable stomas. The timing, indications, and description for each procedure will be addressed. Finally, the antegrade continence enema procedure will be described for the management of refractory fecal incontinence.

Use of A Monti Channel For Administration of Antegrade Continence Enemas

Use of A Monti Channel For Administration of Antegrade Continence Enemas

Continent vesicostomy in the absence of the appendix: three methods in 16 children

Objectives. To review our experience with three methods of continent vesicostomy and to examine the morbidity and long-term outcome of each method. In the absence of an appendix, the surgical options for constructing continent vesicostomies include the use of the ureter, retubularized ileum, or stomach, a Benchekroun valve, or creation of a continent stoma from the reservoir itself. Methods. Between 1984 and 1999, 16 children, 14 with neurogenic bladder, 1 with cloacal malformation, and 1 with valve bladder, required access to their continent reservoir other than the urethra. The appendix was unavailable in all, either because it had been removed surgically at an earlier date or it had been used for an antegrade continent enema procedure. Eighteen continent vesicostomies were performed in 16 children. In 5 children, a Benchekroun valve was constructed. Two were subsequently replaced by tapered small bowel. In 7 children, a segment of small bowel was harvested, retubularized, and reimplanted in the reservoir in a submucosal or seromuscular tunnel. In 6 children, a flap of bowel forming the reservoir was raised, tubularized, and then a Nissen valve was constructed. Results. The early results of the Benchekroun valve were satisfactory; however, the results with long-term follow-up were disappointing because 4 of 5 children developed stomal stenoses and one subsequent valve perforation. One of the 5 children continued to do well 6 years postoperatively. The 7 children in whom a segment of small bowel was retubularized (Monti procedure) continued to do well and to catheterize their stomas without difficulty. At last follow-up, 1 child was awaiting collagen implant of her bladder neck for urinary incontinence. Five of the 6 children with a Nissen valve were doing well 1 to 8 years postoperatively. One child did well initially, but was lost to follow-up 1 year later. Conclusions. The appendix is the preferred conduit for a catheterizable stoma. In its absence, our experience with the Benchekroun valve was disappointing. The retubularized ileum provided an excellent and reliable alternative to the appendix and is preferable if the bladder capacity is marginal. The Nissen valve constructed out of the reservoir has the advantage of avoiding intraperitoneal dissection and the use of additional small bowel. The two latter methods appear to be reliable in the long-term and are viable options when the appendix is not available.

Surgical reconstruction of exstrophy-epispadias complex: analysis of 13 patients.

Because exstrophy-epispadias complex is uncommon and satisfactory surgical reconstruction outcomes are difficult to achieve, the surgical repairs by one surgeon (PS) were analysed over a 14-year period. Retrospective analysis was performed on 13 patients with the complex who underwent surgery between January 1986 to August 2000. Cosmesis and continence were evaluated. Complications including wound dehiscence and urethrocutaneous fistula were reported. Of six patients with classical exstrophy who underwent functional bladder closure, all had good cosmesis except one who had partial dehiscence. Four patients with isolated epispadias had satisfactory cosmesis. Urethrocutaneous fistula was found in one boy in the classical exstrophy group. Continence was achieved in three out of four patients who had bladder neck reconstruction. One girl whose bladder neck was severely obstructed after functional bladder closure, had continent catheterizable stoma. Functional bladder closure yielded satisfactory cosmetic outcome. Bladder neck reconstruction made the patient dry in 75% of cases.

APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADE CONTINENCE ENEMA

To assess outcomes after the antegrade continence enema procedure, we present our results with an ileal segment or the appendix in children with severe bowel dysfunction. A retrospective review of 45 children who had undergone the creation of a continent cecostomy for severe chronic constipation and fecal incontinence was performed. The appendix was used to create the continent cecostomy in 28 patients (group 1) and ileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendiceal Mitrofanoff neourethra, including continent catheterizable stoma, the appendix was split and used for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39 (87%) patients and total continence 31 (69%). No significant difference was noted in the rate of continence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 patients in group 1 and 3 group 2. Complications that required reoperation related to the continent cecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2 (p >0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who had previously undergone colostomy for intractable constipation who were undiverted at the time of the creation of continent cecostomy. Both were continent postoperatively. There were 3 patients, including those 2 who presented with chronic severe constipation of unclear etiology, who underwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently required total colectomy. The creation of a continent cecostomy for antegrade continence enema is a successful management option in children with debilitating fecal incontinence, and may enable undiversion of an existing colostomy. The appendix and ileal segment are viable options for the procedure, with no significant difference noted in continence or complication rates.

A technique of bladder neck closure combining prostatectomy and intestinal interposition for unsalvageable urethral disease.

We describe a technique of bladder neck detachment and augmented closure incorporating total prostatectomy and urinary diversion in men with complex bladder and urethral pathology due to fistula, radiation and neurogenic dysfunction. We retrospectively reviewed the records of 5 men 38 to 61 years old who presented with unsalvageable urethral pathology, including prostate cancer in 2. All 5 patients underwent radical prostatectomy and augmented bladder neck closure with creation of a continent catheterizable stoma in 4 and chimney diversion in 1. Bladder neck closure was performed with interposition of an ileocecal patch in 4 cases and sigmoid colon in 1. At a mean followup of 6 months no fistula, recanalization or urinoma developed. Delayed complications included stomal stenosis, stomal incontinence requiring collagen injection and rupture of the augmented bladder in 1 case each. The 2 men with prostate cancer had undetectable prostate specific antigen. Prostatectomy facilitated mobilization of the bladder neck away from the urethral pathology and interposition of an intestinal segment at the bladder neck allowed healing. In addition to cases of complicated urethrovesical pathology, this technique may have applications in salvage prostatectomy after pelvic irradiation for carcinoma.

A TECHNIQUE OF BLADDER NECK CLOSURE COMBINING PROSTATECTOMY AND INTESTINAL INTERPOSITION FOR UNSALVAGEABLE URETHRAL DISEASE

We describe a technique of bladder neck detachment and augmented closure incorporating total prostatectomy and urinary diversion in men with complex bladder and urethral pathology due to fistula, radiation and neurogenic dysfunction. We retrospectively reviewed the records of 5 men 38 to 61 years old who presented with unsalvageable urethral pathology, including prostate cancer in 2. All 5 patients underwent radical prostatectomy and augmented bladder neck closure with creation of a continent catheterizable stoma in 4 and chimney diversion in 1. Bladder neck closure was performed with interposition of an ileocecal patch in 4 cases and sigmoid colon in 1. At a mean followup of 6 months no fistula, recanalization or urinoma developed. Delayed complications included stomal stenosis, stomal incontinence requiring collagen injection and rupture of the augmented bladder in 1 case each. The 2 men with prostate cancer had undetectable prostate specific antigen. Prostatectomy facilitated mobilization of the bladder neck away from the urethral pathology and interposition of an intestinal segment at the bladder neck allowed healing. In addition to cases of complicated urethrovesical pathology, this technique may have applications in salvage prostatectomy after pelvic irradiation for carcinoma.

THE ULTIMATE CHALLENGE OF CLOACAL EXSTROPHY

Our review addresses the various system abnormalities associated with cloacal exstrophy and revisits the question of gender assignment. Gender assignment decisions and psychological aspects of gender issues have become the "ultimate challenge." Exploration of gender identity, gender role behavior and sexual orientation has just begun. A comprehensive literature review was performed with all world literature regarding the current management of cloacal exstrophy. Research focused on management principles, outcomes and documentation of concurrent anomalies. We also describe original research evaluating gender identity in our own series of patients raised as girls to illustrate the challenge of treatment and augment the available literature, which is scant. Abnormalities of the vertebral column ranged from hemivertebra to myelomeningocele. With magnetic resonance imaging, the incidence of spinal dysraphism approached 100% and cord tethering was also more frequently recognized. For children with the short bowel syndrome, advances in antibiotic usage, and parenteral and enteral nutrition have increased the survival rate and reduced morbidity. A neurological component has been recognized for bladder function, bladder neck continence, lower extremity function and erectile capacity. Mitrofanoff-type reconstruction with bladder neck closure and continent catheterizable stoma dramatically increased continence. Diminutive or absent penis has been documented in 30% of males, and no documentation of paternity exists. The majority of females have bicornuate uterus. However, ovaries and tubes were generally normal. No reports of proven fertility exist. The strategy and timing of surgery relating to gender assignment remain controversial. A desperate need exists for research focusing on gender development and quality of life. Until that time, a cautious watchful approach may be most appropriate as our patients with cloacal exstrophy mature into adulthood.

Spiral small-bowel tube as an alternative to the appendix for a catheterizable stoma.

Spiral small-bowel tube as an alternative to the appendix for a catheterizable stoma.

Application of the Mitrofanoff principle for intermittent self-catheterization in quadriplegic patients

Objectives. Patients with cervical spinal cord lesions have impaired hand function, which often prohibits clean intermittent self-catheterization (CIC), especially in female patients. Enabling these patients to perform CIC gives them control of their bladder management and can improve their quality of life considerably. We have used an appendicovesicostomy to provide easy access for CIC in such patients. Methods. Five patients (4 women, 1 man) with a mean age of 31 years (range 20 to 52) and a mean duration of the cervical cord lesion of 22 months (range 7 to 37) underwent appendicovesicostomy. Three patients were young victims of motor vehicle accidents, 1 patient had a progressive rheumatoid arthritic disorder, and 1 patient had a complex functional paraplegia syndrome and underwent bladder augmentation at the same time. Results. The surgical procedure with the creation of a catheterizable stoma in the right lower abdominal quadrant was successful in all cases but was complicated by mechanical ileus in the patient with simultaneous bladder augmentation. All patients learned to perform independent CIC with continuing anticholinergic medication. Stomal stenosis did not occur in any of the 5 patients, and urinary tract infections occurred once in 2 patients and repeatedly in 1 patient. Three of 5 patients have been enabled by independent bladder management to achieve occupational rehabilitation. Conclusions. Appendicovesicostomy is a suitable procedure in patients with cervical spinal cord lesions who are otherwise unable to perform independent CIC. The creation of a catheterizable abdominal stoma enables these patients to gain independent control of their bladder management. However, caution in patient selection is advisable as probably the best results are achieved in highly motivated, younger patients with traumatic cervical cord lesions.

Catheter knotting in a catheterizable urinary reservoir

An 11-year-old boy with bladder extrophy was treated ultimately with an ileocystoplasty and a catheterizable stoma. In attempting to drain his bladder via intermittent catheterization, the catheter became lodged. This case details the surgical treatment of a knotted catheter in an urinary reservoir. J Pediatr Surg 36:516-517. Copyright © 2001 by W.B. Saunders Company.

A technique for constructing an umbilicus and a concealed catheterizable stoma.

A technique for constructing an umbilicus and a concealed catheterizable stoma.

URODYNAMIC EVALUATION AND LONG-TERM RESULTS OF THE ORTHOTOPIC GASTRIC NEOBLADDER IN MEN

Orthotopic neobladders are most commonly formed from colon and/or small bowel segments. However, after excellent results were reported in children, we constructed gastric neobladders in select men who had undergone cystectomy. Although gastric neobladders in adults have been reported to have decreased capacity, to our knowledge neither long-term followup nor urodynamic parameters have been reported in these patients. Gastric neobladder was performed in 8 patients following cystectomy for malignancy in 7 and undiversion in 1. Average followup was 43 months and all patients underwent urodynamic evaluations an average of 9.1 months after surgery. Patients also completed an incontinence questionnaire. The gastric neobladder group was compared to a similar group of patients who underwent neobladder construction from either small bowel (Kock/Hautmann/Studer) or ileocecal segments (Mainz). The gastric neobladder group had significantly reduced mean bladder capacity compared to the ileal or ileocecal neobladder group (309 versus 551 cc, respectively, t = 0.001), while compliance was similarly decreased (27 versus 59 cc/cm. H2O, respectively, t = 0.04). Incontinence rates were greater in the gastric neobladder group (63%) compared to the ileal or ileocecal neobladder group (8% to 23%, t = 0.02). Complication rates were comparable. Revision or removal was required in 3 (38%) patients for severe incontinence, intractable dysuria and ureterogastric anastomotic stricture, respectively. Adult gastric neobladders as currently constructed are associated with poor urodynamic parameters and high incontinence rates. Routine use of gastric neobladders in adults is not recommended. They may be appropriate, especially as composites, in select cases such as renal failure or inadequate bowel length. The reasons for success in some patients and not in others are unknown.