Continent Catheterizable Channel Research Articles

Why are continent catheterizable channels continent? A stomal pressure profilometry feasibility study.

A continent catheterizable channel (CCC) may be a solution for patients with impaired bladder emptying and difficult transurethral access. Leakage of the CCC is a common complication. To prevent leakage, the pressure in the CCC has to be higher than the reservoir (bladder/pouch) pressure in at least one location. It has not been clearly defined through which mechanism(s) the CCC achieves continence. In this feasibility study, we measured the CCC pressure profile in adult patients with various types of CCC's with and without stomal leakage. Adult patients with a CCC on a (augmented) bladder or pouch who underwent a urodynamic investigation between January and March 2023 were included. Next to the standard urodynamic investigation, a continuous stomal pressure measurement (CSP) and stomal pressure profilometry with empty bladder (SPP-1) and with filled bladder (SPP-2) of the CCC were performed. A total of 17 patients were included. It was technically possible to perform SPP-1 and SPP-2 in all patients, and to measure the CSP in 16/17 patients. The median maximum stomal pressures in SPP-1 and SPP-2 were 112 (interquartile range [IQR], 76-140) cmH2O and 120 (IQR, 92-140) cmH2O, respectively. Nine patients had stomal leakage during the urodynamic investigation. In five patients, the detrusor leak point pressure (dLPP) was low (<20 cmH2O). A pressure peak at the beginning of SPP-2 was absent in all patients with stomal leakage at low dLPP. SPP and CSP measurement in CCCs are feasible. We found differences in SPP-2 between patients with and without leakage at low dLPP, indicative of a role of the intravesical tunnel in continence or high dLPP. The results of this study may improve our understanding of the physiology and dynamics of CCCs as well as the management of CCC-related complications.

Tubularized Bladder Flap as a Continent Catheterizable Channel in Adults

ObjectiveTo describe a modified, less invasive, surgical technique to create a continent catheterizable channel (CCC) in adults: the tubularized bladder flap (TBF). Materials and MethodsWe retrospectively reviewed records of patients in whom a TBF CCC was constructed at adult age between 2019 and 2023. We reported on demographics, operative outcomes, and 30-day and post-30-day complications. ResultsA total of 11 patients (10 female) were described. The median operative time was 96 (range 90-115) minutes in patients with only TBF creation. Estimated blood loss was <100cc in all patients. Within 30 days postoperatively, 6/11 (55%) patients developed a complication, all grade 1 Clavien Dindo. No bowel complications occurred (paralytic ileus, mechanical obstruction or leakage/perforation). Median follow-up was 25 (range 6-56) months. In 2/11 (18%) patients surgical revision for stenosis was done; 3/11 (27%) patients underwent surgical revision for stomal leakage. ConclusionsTBF as a means to create a CCC avoids intraperitoneal surgery, and bowel closure (appendicovesicostomy) or anastomosis (retubularized ileum). Postoperative bowel complications were not seen in any of our patients. Surgical revision rates for a TBF CCC appear to be comparable to other CCCs. Therefore, TBF could be considered in patients with sufficient bladder capacity as TBF is less invasive than other CCC techniques and avoids potential bowel complications.

Continent catheterizable urinary channels: Lessons for lifelong urological care from a comparative analysis of very long-term complications and revision-free survival of three different types.

Continent catheterizable channels (CCC) provide an alternative route to the bladder in both pediatric and adult patients. This study compared very long-term complications and revision-free survival of three different CCC techniques: appendicovesicostomy (AVS), ileum (Monti), and tubularized bladder flap (TBF). A retrospective cohort study was performed. Data from adult patients with CCC under surveillance at our academic tertiary referral urological center in 2020 and 2021 were collected. Both patients who acquired the CCC as a child and as an adult were included. The primary outcome was revision-free survival of the three CCC types. The secondary outcome was the prevalence of complications requiring surgical revision. Revisions were categorized as major (open subfascial or complete revisions) and minor (open suprafascial or endoscopic). We included 173 CCCs (AVS 90, Monti 51, TBF 32). Median follow-up was 12.4 years (4.8-18). Mean revision-free survival was 162 ± 13 months, with no significant difference between the three types. Ninety-two individual CCCs (53%) required surgical revision and a total of 157 surgical revisions were performed. Seventy CCCs (40%) required major surgical revision: AVS (27/90%-30%), Monti (31/51%-61%), TBF (12/32%-38%). Complications of CCCs are common; in this study with very long-term follow-up, more than half of CCCs required surgical revision. Revisions were more common in Monti channels compared with AVS and TBF. The mean revision-free survival of >13 years illustrates the sustained long-term durability of CCCs which is important in the lifelong urological care of this population with high life expectancy.

Classic Bladder Exstrophy Closure Without Osteotomy or Immobilization: An Exercise in Futility?

To review the outcomes of classic bladder exstrophy (CBE) closure without the use of osteotomy or lower extremity/pelvic immobilization. A prospectively maintained institutional approved exstrophy-epispadias complex database of 1487 patients was reviewed for patients with CBE who had undergone closure without osteotomy nor immobilization. All patients were referred to the authors' institution for reconstruction later in life or for failed closure. Of a total of 1016 CBE patients, 56 closure events were identified that met inclusion with a total of 47 unique patients. Thirty-eight closures were completed prior to 1990 (67.9%). Forty-five closure events developed eventual failure (45/56, 80.4%) (Table 1). Thirteen closure events were secondary closures (13/56, 23.2%). The primary closure failure rate was 83.7% (36/43) while the secondary closure failure rate was 69.2% (9/13). Failures were attributed to one or more of dehiscence, bladder prolapse, and vesicocutaneous fistula (25/45, 55.6%) (23/45, 51.1%) (6/45, 13.3%), respectively. Thirty-seven patients developed social continence (37/47, 78.7%), while only 8 patients developed spontaneous voided continence (7/47,17.0%) (Table 2). The most common methods of voiding were continent catheterizable channels (25/47, 53.2%) of which all were socially continent. These results illustrate the critical role osteotomy and postoperative immobilization can play in both primary and secondary exstrophy closure. While this is a historical case series, the authors believe that these results remain relevant to contemporary exstrophy surgeons.

Urological outcome with the use of salvage continent vesicostomy in pediatric reconstructive surgery. A single tertiary center experience

To report our experience and results in terms of complications, reoperation rate and urinary continence with the Salvage Continent Vesicostomy (SCV) technique in pediatric patients with history or need of enterocystoplasty and absent appendix. Retrospective review of all patients with a history of a continent catheterizable channel surgery performed in our institution between June 2016 and January 2022. Only patients with a SCV surgery with a minimum 6-month post operative follow up were included in this cohort and divided in group 1 (history of previous bladder augmentation) and group 2 (simultaneous bladder augmentation and SCV). Primary outcome of the study was to assess both continence and postoperative complication rates. Early complications were assessed using the Clavien-Dindo classification (I-V). Late complications were focused on the need of further subfascial revision. 84 patients with a history of a continent stoma creation surgery were identified. In 20 of them (12 males) a SCV was performed. The mean age at surgery was 10.38 (range 4.87-15.6) years and the median postoperative follow-up time was 32 (range 6-64) months. Eleven patients were included in Group 1, while 9 patients in Group 2. Early complications occurred in 4 patients (20%), two of them required a re-intervention (Clavien-Dindo IIIb). Stoma subfascial revision was further required in 2 patient (10%). Continence rate at last follow up was 95%. In our early experience, the salvage continent vesicostomy has proven to be a simple continent stoma technique with acceptable both continence and complication rates that can be used in selected patients with a history or need of bladder augmentation and absent appendix.

25 - Spiral-Monti in adults: The initial experience with a continent catheterizable channel

25 - Spiral-Monti in adults: The initial experience with a continent catheterizable channel

MP53-12 LONG-TERM FOLLOW-UP IN PATIENTS WITH CONTINENT URINARY AND FECAL CATHETERIZABLE STOMAS IN PEDIATRIC PATIENTS WITH NEUROGENIC BLADDER

You have accessJournal of UrologyCME1 Apr 2023MP53-12 LONG-TERM FOLLOW-UP IN PATIENTS WITH CONTINENT URINARY AND FECAL CATHETERIZABLE STOMAS IN PEDIATRIC PATIENTS WITH NEUROGENIC BLADDER Esteban Tresgallo, Mario Garcia, Marcos Perez-Brayfield, and Carla Marin Esteban TresgalloEsteban Tresgallo More articles by this author , Mario GarciaMario Garcia More articles by this author , Marcos Perez-BrayfieldMarcos Perez-Brayfield More articles by this author , and Carla MarinCarla Marin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Catheterizable stomas have revolutionized the management of neurogenic bladder. Long-term follow up is required due to high complication rates. There is concern with long term usage of the stoma during the transition to adulthood period. The aim of the study was to evaluate long-term functional outcomes and degree of satisfaction in pediatric patients and their caregivers after undergoing Continent Catheterizable Channel (CCC) and/or Malone Antegrade Continence Enema (MACE) procedure. METHODS: We retrospectively reviewed the charts of 32 pediatric patients who had undergone 53 CCC's between 2007 and 2022. Data was analyzed including indication, type of channel, and complications. Patients and caregivers were contacted via telephone and a survey assessing frequency of usage, presence of urinary/fecal incontinence, factors limiting or preventing channel use, and overall degree of satisfaction was conducted. This study was approved by our local IRB committee. RESULTS: 81% (26) patients had a Mitrofanoff channel and 19% (6) a Monti channel. 21 patients also underwent a concomitant MACE procedure. The average age at surgery was 10.4 years, ranging from 5-19 years. The average length of follow up was 6.9 years, with 9 patients followed for more than 10 years. 10 patients underwent revision surgery, 8 due to channel stenosis (5 sub-fascial, 3 supra-fascial). 90% of patients reported the CCC is still in use. In 65% of cases, it is the patient performing CIC. 6 reported incontinence through the CCC, which was mild in all cases. In terms of satisfaction, 84% reported to be “very satisfied” with the procedure/outcomes. In terms of the MACE procedure, 89% reported to still be using the channel and 78% of patients reported complete fecal continence. 3 patients underwent MACE revision due to stenosis (15%). The main performer of ACE is the patient in over 60% of cases and it takes on average 30-40 minutes to perform. 95% of patients reported to be “very satisfied” with the procedure. CONCLUSIONS: Continent catheterizable stomas are feasible and reliable in long term follow up. Despite a high revision rate (33%) associated with CCC, our data shows that functional outcomes and patient/caregiver satisfaction remain high even after transition into early adulthood. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e716 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Esteban Tresgallo More articles by this author Mario Garcia More articles by this author Marcos Perez-Brayfield More articles by this author Carla Marin More articles by this author Expand All Advertisement PDF downloadLoading ...

V12-06 PATIENT INFORMATION VIDEO: SURGERY FOR NEUROGENIC BLADDER

You have accessJournal of UrologyCME1 Apr 2023V12-06 PATIENT INFORMATION VIDEO: SURGERY FOR NEUROGENIC BLADDER Anne Cameron, Victoria Norausky, Lanre Aboderin, and Iryna Crescenze Anne CameronAnne Cameron More articles by this author , Victoria NorauskyVictoria Norausky More articles by this author , Lanre AboderinLanre Aboderin More articles by this author , and Iryna CrescenzeIryna Crescenze More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Many patients with neurogenic lower urinary tract dysfunction (NLUTD) fail conservative management with oral agents and bladder botulinum toxin and require surgical intervention to treat their neurogenic detrusor overactivity related incontinence or poor bladder compliance. Patients need reliable, easy to understand information to help guide their decision. METHODS: This video was created as part of the neurogenic bladder series encompassing multiple related topics for this patient population. All information is intended to be used by patients and their advocates as well as health care providers. Multiple clinician’s consensus were utilized to generate the information deemed essential for patients to understand these choices. RESULTS: This short video outlines bladder issues that would lead to a patient and their provider choosing surgery to treat intractable bladder symptoms. Conservative management with steady fluid intake, urinary tract infection prevention and regular catheterization are first discussed followed by oral agents and bladder injections to treat incontinence and or poor bladder compliance. The pathophysiology of neurogenic detrusor overactive and its consequences are also explained. Augmentation cystoplasty is reviewed in detail as well as continent catheterizable channels and urinary diversion. Important postoperative expectations and complications are discussed as well as long term follow up plans. CONCLUSIONS: This video provides patient appropriate information on NLUTD related bladder dysfunction and counselling on possible surgical options for treating this disorder when it is refractory to conservative, medical and injection treatments. Source of Funding: Craig Nielsen Foundation © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1066 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anne Cameron More articles by this author Victoria Norausky More articles by this author Lanre Aboderin More articles by this author Iryna Crescenze More articles by this author Expand All Advertisement PDF downloadLoading ...

False-positive urine pregnancy screening tests are uncommon in the hospital setting among patients with bowel-containing urinary tract reconstruction

False-positive urine pregnancy screening tests (UPST) have been reported among patients with bowel-containing urinary reconstruction (BCUR). However, the true frequency of such inaccurate results, which have been attributed to urinary mucous or other proteins interfering with or mimicking the binding of beta-HCG in the assay, is unknown in this population. We sought to determine the incidence of false-positive pregnancy screening tests among this patient population at our institution. Using existing databases of patients with spina bifida, bladder exstrophy, and genitourinary rhabdomyosarcoma, we identified female patients with BCUR who had UPST over a 10-year period as screening prior to procedures or imaging. Patient and test result information was recorded. A total of 120 patients with a history of BCUR were identified: 33 with spina bifida, 73 within the exstrophy-epispadias complex (EEC), and 14 with genitourinary rhabdomyosarcoma. Of this group, 46 patients (38%) had at least one UPST during the study period; 15 had 1 UPST, 6 had 2 UPSTs, 4 had 3 UPSTs, and 21 had greater than 3 UPSTs, for a total of 244 UPST in this cohort. UPSTs used at our institution included Sure-Vue brand and Alere brand (HCG sensitivity 20mIU/ml). Types of BCUR included ileal enterocystoplasty in 25 patients, colon enterocystoplasty in 6, stomach enterocystoplasty in 5, composite enterocystoplasty in 7, and continent catheterizable channel alone (e.g. Yang-Monti, appendicovesicostomy) in 3 patients. Of the 244 UPSTs in patients with BCUR, zero (0%) were positive. Despite reports in the literature that false-positive UPST are common among patients with bowel-containing urinary diversions, we found no positive UPST among patients with BCUR in the healthcare setting. False-positive UPST in the home setting may be due to variability in sensitivity thresholds, binding agents, technical errors in test technique, kit quality control, or other factors.

Complications of Continent Cutaneous Catheterizable Channel in Adult

Aim: To determine the frequency of postoperative complications related to continent cutaneous channel. Study Design: Descriptive study Place and duration of study: Department of Urology, Sindh Institute of Urology &amp; Transplantation, Karachi, Pakistan from 1st August 2019 to 30th November 2021 Methodology: One hundred and seven patients underwent continent catheterizable channel formation via Mitrofanoff principle were included. Each patient was followed in OPD up to 6 months post-procedure to assess the complications i.e. stomal stenosis, stomal incontinence and surgical site infection. Results: Mean age was 31.07±12.78 years. Out of 107 patients, 85(79.4%) were males while 22(20.6%) were females. Postop stenosis was found in 26(24.3%), incontinence in 3(2.8%) while surgical site infection was noted in 48(44.9%) patients. Conclusions: Surgical site infection is the most common postoperative complication that warrants attention followed by stenosis and incontinence. Keywords: Continent cutaneous channel, Mitrofanoff, Stomal stenosis, Stomal incontinence

Robot-Assisted vs. Open Appendicovesicostomy in Pediatric Urology: A Systematic Review and Single-Center Case Series.

IntroductionAppendicovesicostomy (APV) is the preferred choice of continent catheterizable channels in pediatric urology. The introduction of robot-assisted laparoscopic techniques has been correlated to superior cosmesis and convalescence and is now increasingly implemented for APV procedures. We aimed to perform a systematic review of the literature comparing open vs. robotic APV regarding possible differences in postoperative outcomes and to evaluate these findings with our own initial experiences with robotic APV compared to our previous open procedures.MethodsWe evaluated the first five patients undergoing robotic APV at our institution and compared 1-year outcomes with a consecutive series of 12 patients undergoing open APV. In a systematic literature review, we screened studies from PubMed, EMBASE, and CENTRAL comparing open and robotic APV in pediatric urology (current to December 2021) and performed meta-analyses on postoperative outcomes comparing the two groups and evaluated the grade of evidence.ResultsWe found significantly shortened postoperative length of stay in the robotic group (p = 0.001) and comparable 1-year complication rates in robotic vs. open APV patients. We systematically screened 3,204 studies and ultimately included three non-randomized studies comparing postoperative outcomes of robotic and open APV for quantitative analysis. The open and robotic approaches performed equally well regarding overall postoperative complications, surgical reintervention, and stomal stenosis. Two of the included studies reported comparable stomal continence rates and shortened postoperative length of stay in the robotic group, in agreement with the findings in our own series.ConclusionRobotic APV is equally safe to the conventional open approach with additional advantages in postoperative hospitalization length.

MP25-08 URINARY TRACT RECONSTRUCTION WITH ENTEROCYSTOPLASTY AFTER RADIATION FOR PELVIC CANCER

You have accessJournal of UrologyCME1 May 2022MP25-08 URINARY TRACT RECONSTRUCTION WITH ENTEROCYSTOPLASTY AFTER RADIATION FOR PELVIC CANCER Sender Herschorn, and Jenn Locke Sender HerschornSender Herschorn More articles by this author , and Jenn LockeJenn Locke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radiation (RT) for pelvic cancer may compromise the urinary tract. Reconstruction can be challenging especially at the time of surgical removal of the tumor. As an alternative to cystectomy, enterocystoplasty (EC) +/- ureteral reimplantation or continent catheterizable channel (CCC) brings the potential benefits of preserving the LUT. We report our experience in a series of patients, all of whom had RT, to assess outcomes and complications. METHODS: This is a retrospective case series of all post-RT patients who underwent EC to reconstruct the LUT between 1994 and 2021 from one institution. Complications and functional results were recorded. RESULTS: 36 patients (18 women,18 men) who had prior RT for treatment of advanced or recurrent pelvic cancer were identified. 10 patients, post chemo-RT for colorectal cancer, underwent immediate reconstruction after tumour excision, which included part of the bladder +/- ureter(s) (group 1) and 26 after RT for prostate (7), gynecologic (13), colorectal (5) and liposarcoma (1) had surgery due to RT complications (group 2). Mean age at surgery was 58 yrs (median 58.5; range 33-76). All patients underwent EC and 24 (67%) had simultaneous ureteral reimplants either into an afferent intestinal limb (17) or into the bladder (7) with 16 undergoing bilateral reimplants. Reimplants were done for obstruction due to tumor (group 1) or post-RT (group 2). 8 patients in group 2 had simultaneous CCC due to devastated urethras. The median postop length of stay (LOS) was 9 days (4-25) and was significantly shorter in group 2 vs. group 1; 8 (IQR 6-10) vs. 13 (IQR 10-14) (p=0.0039). No early (within 30 days) surgical reintervention was prompted by the LUT reconstruction. After a median follow-up of 38.5 mo. (range 2-195), 9 patients (29%) required reinterventions including 4 open operations (1 parastomal hernia, 1 vesicovaginal, 2 vesico-cutaneous fistulae), 2 ureteral intestinal anastomotic stricture dilations, and 3 endoscopic bladder stone removals. Reintervention rate was similar in the groups. Renal function was preserved. 23/28 non-stoma patients void spontaneously, 3 perform intermittent catheterization (IC), and 2 have indwelling catheters. 7/8 stoma patients do IC and one is awaiting persistent vesicocutaneous fistula repair with an indwelling catheter. At last follow-up, 32/36 patients considered their LUT management to be successful. CONCLUSIONS: Prior pelvic RT is not a contraindication to EC with or without ureteral reimplantation and/or CCC. Longer LOS was seen in the extirpative group. Acceptable functional outcomes and morbidity can be achieved. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e430 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sender Herschorn More articles by this author Jenn Locke More articles by this author Expand All Advertisement PDF DownloadLoading ...

Technical aspects and outcome review of continent catheterizable channels in the adult neurourologic population.

Multiple techniques for the creation of continent catheterizable channels have been reported. Several continence mechanisms have been used, including tunneled flap valves, nipple valves, and hydraulic valves. Moreover, several organs have been used, including the appendix, bowel, ureters, and bladders. In this review, we describe various techniques and their outcomes in the adult neuro-urological population. Compared to nipple valves, tunneled flap valves using the appendix and other organs are the most commonly performed procedures but have a higher number of reported complications when compared to nipple valves. Hydraulic valves have been largely abandoned due to disappointing long-term results.

Hemi-Kock Continent Stoma With Augmentation Cystoplasty: Modifications and Outcomes

ObjectiveTo evaluate the long-term outcomes and impact of surgical modifications on the need for secondary surgery of the Hemi-Kock continent catheterizable stoma, comprising a detubularized ileal segment with an attached stapled ileoileal intussusception of the catheterizable channel, in patients with complex lower urinary tract disorders. The technique may be used for augmentation in patients with reduced bladder capacity who require a continent catheterizable channel. Compared to the flap and ileocecal valve procedures, the hemi-Kock technique has not been widely adopted. Materials and MethodsThis is a retrospective case series including all patients who underwent a hemi-Kock catheterizable channel with cystoplasty from a single institution. Surgical technique and modifications in valve construction and tapering of the catheterizable limb are described. ResultsA total of 109 patients, with a median age of 38 years (range 18-72), underwent the procedure. At a mean of 10.4 years, 98 patients (90%) reported that they were managing with clean intermittent catheterization ± pads; 11 (10%) were failures. A total of 70 (64.2%) patients underwent secondary interventions with >60% performed endoscopically or under local anesthesia, mainly for bladder stones. Fourteen patients (12.8%) required valve revisions. However, the rate decreased from 18.2% (8/44) to 9.3% (6/65) following incorporation of the surgical modifications. ConclusionWe present the largest cohort to date of patients managed with a Hemi-Kock catheterizable channel and cystoplasty. Valve revision rate improved with surgical modifications. We demonstrate long-term durability and maintenance of stomal catheterization in the vast majority of patients.

Long-term usage pattern and satisfaction survey of continent catheterizable channels

We investigated the long-term usage pattern and satisfaction of continent catheterizable channels (CCCs). From 2005 to 2018, CCCs, including Mitrofanoff and antegrade continent enema (ACE) channels, were made in 67 patients (Mitrofanoff in 21 patients, ACE channels in 43 patients, and both in three patients) in our institution. An online survey was conducted for these patients in order to assess usage pattern, continent status, difficulty in usage, and patient satisfaction. Sixteen (66.7%) out of 24 patients with the Mitrofanoff channel and 39 (84.7%) out of 46 patients with the ACE channel completed the online survey. In the Mitrofanoff channel group, 10 (62.5%) patients had spina bifida, two (12.5%) had Hinman syndrome, one (6.3%) had posterior urethral valves, and three (18.8%) had urethral trauma or atresia. Additionally, the mean age of the patients at the time of surgery was 10.0 years, and the median follow-up duration was 10.9 years. All patients were using the Mitrofanoff channel to perform clean intermittent catheterization (CIC). Eleven patients (68.8%) had difficulty with catheterization, mostly at the stomal site. Most patients conducted CIC more than four times a day (13, 81.3%). Regarding urination status, seven patients (43.8%) responded that they were satisfied and nine (56.2%) responded they were neutral. In the ACE channel group, 35 patients (89.7%) had spina bifida, seven (17.9%) had cloacal anomalies, and 26 (66.7%) had anorectal malformations. The mean age of the patients at the time of surgery was 8.4 years, and the median follow-up period was 7.4 years. Two (5.1%) patients were no longer using their ACE channels, but 15 (38.5%) patients were still using their channels almost daily. Twenty-eight (71.8%) patients complained that performing enema was time-consuming, and seven (17.9%) patients reported pain when performing ACE and fecal incontinence. Most patients were satisfied with their defecation status (23, 59%), 15 (38.5%) were neutral, and one (2.6%) was dissatisfied. While most patients who had either Mitrofanoff or ACE channels were still using their channels effectively, approximately half of the patients with CCCs demonstrated neutral satisfaction with their current status; this shows a poor result compared to previous reports. Considering the results of our patient-based study, thorough explanations should be provided to patients who are candidates for Mitrofanoff and ACE procedures; additionally, the discomfort related to the procedures should be comprehensively assessed during follow-up consults.

Diagnosis, management and recurrence rates of Mitrofanoff polyps

Intraluminal polyps are a known complication following creation of a urinary continent catheterizable channel (Mitrofanoff). These polyps can lead to difficult catheterizations in addition to symptomatic bleeding. However, there is limited data available regarding management and outcomes of these polyps. We aim to describe clinical presentation and management of a large series of polyps occurring in a Mitrofanoff channel. We performed a retrospective review of all patients that were treated for polyps in a Mitrofanoff at our institution. Information was collected regarding presenting symptoms, management and recurrence rates of the polyps. A total of 24 patients were identified that fulfilled inclusion criteria. The majority of these polyps developed in channels composed of appendix (87%), while only 3 patients (13%) had polyps develop in an ileal composed channel. Thirteen (54%) of these polyps were incidentally diagnosed while 11 patients presented with a variety of symptoms such as difficulty in catheterization, bleeding with catheterization or both difficulty catheterizing and bleeding. For management of the polyps, a cystoscopy was performed and snaring the polyp with stone basket was performed in 37%, energy was applied to base to remove polyps in 33%, 16% were fulgurated and only 13% were left in situ. All procedures were performed under general anesthesia and all of the pathology was benign showing chronic inflammatory tissue. Eight polyps (33%) recurred after initial treatment. We did not observe an asymptomatic channel polyp convert to a symptomatic during our follow up period. Our experience has led us to not intervene on all asymptomatic Mitrofanoff polyps encountered during cystoscopy under assumption they will inevitably become symptomatic. Although we admit our follow up period may not be long enough to make this a universal declaration of best practice when any Mitrofanoff polyp is diagnosed. Endoscopic treatment was effective minimally invasive method to address the symptomatic polyp rather than excision and construction of new channel. This is the largest series to date of polyps developing in urinary continent catheterizable channels. The majority of these polyps were encountered incidentally however symptomatic polyps presented with difficulty with catheterizations. Symptomatic polyps can be managed endoscopically but recurrence of the polyp can occur.

Long-term urological and gynecological outcomes following complete primary repair in females with bladder exstrophy

Long-term continence outcomes in patients undergoing complete primary repair of exstrophy (CPRE) have shown that a subset of patients do not achieve continence until after puberty. We aim to update the continence outcomes as well as describe gynecological outcomes for females having undergone CPRE. This was a retrospective review between 1989 and 2019at a single institution. Inclusion criteria were females with classic bladder exstrophy who underwent CPRE. Exclusion criteria were variant diagnoses and age <4 years. Continence was defined as dry for ≥3h (volitional voiding or clean intermittent catheterization (CIC)). Partial continence was defined as minor stress incontinence or enuresis. Vaginal stenosis was evaluated in post-pubertal patients. Eighteen patients met inclusion criteria. Median age at last follow-up was 15.9 years (IQR 13.1, 18.4). All patients underwent primary closure <30 days of life (n=18). Subsequent procedures included bladder augmentation (n=4), continent catheterizable channel (n=7), bladder neck injections (n=12) and bladder neck reconstruction (n=12). Continence and partial continence were achieved in 6/18 (33.3%) and 9/18 (50.0%), respectively, with mean 3.2±2.5 continence procedures at 9.6 years (IQR 7.3, 15.2). Volitional voiding was seen in 11/18 (61.1%) and 7/18 (38.9%) performed CIC, with no significant difference in continence. Mean bladder capacity was 199ml±96 versus 90ml±29 in the volitional voiding versus CIC group (P=0.0047). Eleven women with median age of 18.0 years (IQR 15.2, 21.4) had recorded menarche: 6/11 (54.5%) patients reported painful/irregular menses, controlled with hormonal therapy. Six of 11 (54.5%) women had vaginal stenosis managed with vaginal dilation (n=2) or vaginoplasty (n=4). Three (27.3%) reported tampon use and penetrative intercourse. Overall, the majority of women who have undergone CPRE achieved complete or partial continence, though most required additional procedures and time to attain it. Additionally, volitional voiding was achievable. Bladder capacity was significantly lower in patients dependent on CIC. Most required medical or surgical interventions for gynecologic concerns post menarche. This study underscores the unique needs of girls and young women with bladder exstrophy and further supports the importance of close long-term urologic and gynecologic management throughout development.

Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels

Many patients with certain conditions require catheterizable channels for bladder and bowel management. There are a variety of accepted techniques for creating these channels; the split appendix technique enables the use of this organ for both procedures, obviating the need for more complex surgical procedures. Studies comparing outcomes across catheterizable channel types are limited. The aim of this study was to compare the urinary channel complication rates of the split appendix, intact appendix and transverse ileal tube (Monti) channels. We hypothesized that complication rates would be the same across all channel types. We retrospectively reviewed consecutive patients who underwent surgical creation of a urinary continent catheterizable channel. We recorded demographics, underlying diagnosis, body mass index, stoma location, surgical techniques, and surgical revisions. The primary outcome was complication (stenosis, leakage, or both) with or without surgical revision, and to compare the three different catheterizable channel types using time to event analysis. From January 2014-July 2018, 107 patients underwent creation of a continent catheterizable urinary channel; 86 (80.4%) patients also underwent simultaneous procedure for antegrade bowel management. The mean age was 7 years; 66 (60.8%) were females. Intact appendices were used in 46 (43.0%), Monti channel in 25 (23.4%), and split appendix technique in 36 (33.6%). The corresponding complication rates with or without surgical revision was 21.7%, 36.0%, and 47.2%, respectively. The only independent factor associated with increased risk of complication was the split appendix technique; these channels were more than twice as likely to require surgical revision with an adjusted hazard ratio of 2.32 (Table 4). The majority of revisions in all groups were skin level (58.3%). The most common indication for surgical revision was stenosis (55.6%). This analysis shows a statistically significant increase in risk of all complications, including an increase in need for surgical revision, in patients who underwent split appendix technique for simultaneous bladder and bowel catheterizable channels. This finding should be balanced with the fact that a bowel anastomosis is not required in cases where individuals need both a bowel and bladder catheterizable channel. This study is unique in its separation of split and intact appendix channels, and inclusion of patients experiencing complications that have not yet required surgical revision. Limitations of this study include its retrospective design, inclusion of a single institution, and the lack of consistency in documenting baseline appendiceal length. Split appendix catheterizable channels have a higher rate of channel complications than other techniques. The authors acknowledge that the split appendix technique has been proven feasible and effective, however recognize that it may not be appropriate for all patients and include counseling of the risks of its use.

EDITORIAL COMMENT

The primary goal of urologic management of people with spina bifida (SB), according to the Spina Bifida Association 2018 Guidelines, is to “maintain normal renal function throughout the lifespan.” The past 50 years have delivered astounding advancements towards this goa—the introduction of clean intermittent catheterization, use of antimuscarinic medications and onabotulinumtoxin, and the evolution of surgery from incontinent urinary diversion to continent reconstructions incorporating enterocystoplasty, continent catheterizable channels, and/or bladder outlet procedures.

Percutaneous cystolithotripsy in the reconstructed bladder of cloacal exstrophy: A case report

Background: Bladder stones are common after bladder augmentation. The management of bladder stones is challenging, especially in patients who underwent complex urinary tract reconstruction. Case Presentation: We report our experience of percutaneous cystolithotripsy after bladder neck closure, creation of a catheterizable channel, and ileal bladder augmentation in a girl with cloacal exstrophy. Conclusion: Percutaneous cystolithotripsy is a safe, effective, and minimally invasive treatment option for bladder stones after bladder neck closure and the creation of a continent catheterizable channel.