Continent Catheterizable Stoma Research Articles

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 ...

Artificial urinary sphincter in congenital neuropathic bladder: Very long-term outcomes.

Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter. A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected. An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra. The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients.

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.

Giant Prostatic Calculi: A Novel Use of the Ultrasonic Lithoclast

Introduction: A 51-year-old man with neurogenic bladder secondary to spina bifida had been managed with clean intermittent catheterization (CIC) his entire life. The patient subacutely developed difficulty performing CIC for several months, so a suprapubic tube was placed. Computed tomography scan obtained during a hospitalization for urosepsis revealed large stones in the prostatic urethra eroding into his prostate circumferentially. These stones were obstructing entrance of catheters into his bladder. Given his history of urosepsis and desire to resume CIC, the patient was taken to the operating room for attempted endoscopic treatment of these stones. Materials and Methods: Given the large stone burden and challenging location unsuitable for an Ellik evacuator, the stones were treated using ultrasonic lithotripsy rather than laser lithotripsy. The rigid nephroscope was blindly advanced to the bulbar urethra using the obturator. Ultrasonic lithotripsy and evacuation was then performed under direct observation using the Boston Scientific Swiss Lithoclast Select™. Results: All stones were cleared. The patient was admitted overnight for observation and discharged in the morning with his Foley catheter in place. There were no postoperative complications or readmissions. At 4 weeks, his Foley catheter was removed. He was still unable to perform CIC secondary to the large prostatic cavity that remained. The patient will undergo transurethral resection of the prostate to create more continuous anatomy through which catheters can traverse without the aid of a wire or direct observation. Another option offered but declined was creation of a continent catheterizable stoma. Conclusions: Ultrasonic lithotripsy is feasible for use in the prostatic urethra. In this case, it facilitated complete and efficient treatment of large prostatic urethral stone burden that would have otherwise required a more invasive procedure, such as simple prostatectomy. It is important to keep this equipment in the urologist's armamentarium for use in this nontraditional clinical scenario. No competing financial interests exist. Runtime of video: 4 mins 10 secs Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: This music (Clair de Lune by Debussy) was obtained from YouTube and is not copyrighted material.

Case - Unique complication of continent catheterizable stoma after bariatric surgery.

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Pelvic fracture urethral injuries associated with rectal injury: a review of acute and definitive urologic and bowel management with long term outcomes.

Pelvic fracture urethral injuries (PFUI) with simultaneous rectal lacerations are unique rarely reported injuries. This paper serves to define our management, outcomes and make recommendations to improve the care of these patients. We retrospectively reviewed all patients with a PFUI and concurrent rectal injury treated from 1990-2018, initial surgical treatments, along with definitive surgical repair were reviewed. Statistical analysis considered P values <0.05 as significant. Eighteen patients were identified; median follow-up post injury is 4 years, range 1-12 years. Injuries that impacted urologic care included concurrent bladder neck lacerations (BNL) in 50% (9/18) and concurrent neurologic injuries in 28% (5/18). In the nine patients with a simultaneous BNL, 44% (4/9) underwent a primary sutured anastomotic repair of the BNL and urethra, 33% (3/9) underwent primary closure of the bladder neck and SPT drainage and 23% (2/9) had primary repair of BNL with urethral realignment. Continued urinary extravasation through the BN despite the initial surgery resulted in life threating pelvic sepsis in 56% (5/9) versus 0% (0/9) in the patients without a bladder neck laceration, P=0.012. Long term follow up revealed, 22% (2/9) are currently voiding per urethra, neither are continent, one with chronic diaper dependent incontinence, one with stress incontinence. Urinary continence was eventually obtained in 44% (4/9) with either closure of the bladder neck and creation of a continent catheterizable stoma (3 pts) or with cystectomy and creation of an Indiana pouch (1 pt), 33% (3/9) were managed with eventual cystectomy and an enteric urinary conduit. In the nine patients with no concurrent bladder neck injury all were managed with a suprapubic tube placement and consideration for a delayed urethral reconstruction. Delayed end to end urethroplasties were performed in 67% (6/9). Eighty-three percent (5/6) are continent, 50% (3/6) are voiding per urethra without sequale, 33% (2/6) developed recurrent urethral strictures, one was treated with a single DVIU and has retrained urethral patency, at four years post treatment, one is on daily intermittent catheterization to maintain patency. Stress incontinence is noted in 17% (1/6). Due to concurrent neurologic injuries 33% (3/9) of these pts did not undergo further attempt at repair and have been managed with a long-term suprapubic tube. PFUI with simultaneous rectal lacerations have significant comorbid injuries, especially, concurrent bladder neck lacerations and neurologic injuries that affect the urologic prognosis. In patients with a concurrent BNL we recommend initial intervention include primary lower urinary tract reconstruction with simultaneous proximal urinary diversion to help prevent the complication of persistent urinary extravasation with resultant pelvic sepsis.

Worsening disability status in multiple sclerosis predicts urologic complications.

Multiple sclerosis (MS) causes voiding dysfunction and might predispose to urologic complications. However, long-term complications and risk factors for complications are unknown. We aim to assess long-term changes in voiding function and to determine risk factors for urologic complications during MS follow-up. We analyzed the records of MS patients and recorded baseline and follow-up voiding symptoms, urodynamic (UDS) findings, Expanded Disability Status Scale (EDSS), serum blood studies, imaging, and complications. T test and Chi-square test were used to determine statistical significance using a two-tailed p value < 0.05. We assessed complication-free survival using Kaplan-Meier curves and performed multiple variable Cox proportional hazard models to estimate hazard ratios predicting complications for various independent variables. 126 women and 35 men with MS were followed for a median of 9.7years (IQR 4.3-13). Mean age at MS diagnosis was 36.7 with a mean EDSS of 3.2. During follow-up, EDSS progressed to a mean of 5.5. In addition, at least one complication occurred in 60.2% and major complications were present in 16.7%. After multivariable analysis, EDSS progression ≥ 2.0 (p = 0.003), follow-up EDSS ≥ 6.0 (p = 0.01), use of intermittent catheterization (p < 0.001) and urinary reconstruction with continent catheterizable stoma (p = 0.009) were significantly related to an increased hazard for any complications. Upper tract changes and other major complications were uncommon. Complications were related to MS progression, resultant increase in total disability, and the need for intervention to maintain functional continence. Lower tract infections occurred more frequently in patients with the need for catheterization.

Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study

For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children. A research ethics board-approved retrospective review was performed to assess peri-operative outcomes amongpediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann-Whitney U test were used to determine statistical significance. Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8-14.0) and 9.9 years (4.2-14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n=3, 20.0%; n=9, 47.4%). The median follow-up period was 25.9 (IQR 7.7-47.2) months and 28.0 (IQR 13.0-53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes. Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS. Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.

Urinary Continence Outcomes in Classic Bladder Exstrophy: A Long-Term Perspective.

We investigated surgical approaches to urinary incontinence and long-term continence outcomes after successful bladder reconstruction in a heterogeneous patient population with classic bladder exstrophy. We hypothesized that while most patients will achieve urinary continence after surgery, only a select group will void volitionally per urethra. An institutional database of 1,323 patients with exstrophy-epispadias complex was reviewed for patients with classic bladder exstrophy who underwent successful bladder closure and a subsequent continence procedure between 1975 and 2017. Procedures included bladder neck reconstruction, bladder neck reconstruction with augmentation cystoplasty or continent catheterizable stoma, and bladder neck closure with continent catheterizable stoma. Cloacal exstrophy, epispadias and variant exstrophy cases were excluded from analysis. Continence at last followup was defined as a dry interval of 3 or more hours without nighttime leakage. Those patients with more than 3 months of followup were assessed. Overall 432 patients underwent successful bladder closure (primary 71.5%, repeat 28.5%) and a urinary continence procedure. At last followup 162 (37%) underwent bladder neck reconstruction, 76 (18%) underwent bladder neck reconstruction with augmentation cystoplasty or continent catheterizable stoma, 173 (40%) underwent bladder neck closure with continent catheterizable stoma and 18 underwent other procedures. Median followup from the first continence procedure was 7.2 years (IQR 2.3-13.7). Continence was assessed in 350 patients. After isolated bladder neck reconstruction 91 of 142 patients were continent (64%, 95% CI 56-72). After bladder neck closure with continent catheterizable stoma 124 of 133 patients evaluated were continent (93%, 95% CI 87-97). Most patients with classic bladder exstrophy require multiple reconstructive procedures to achieve continence. Only about 25% of patients are expected to void normally per urethra without reliance on catheterization or urinary diversion.

Turner-Warwick scrotal drop back procedure as a revision perineal urethrostomy

Stomal stenosis post perineal urethrostomy (PU) is a common problem. Management options for patients with PU stomal stenosis include dilatation, buccal mucosal augmentation of stoma, PU revision, and continent catheterizable stoma. In the present case, Turner-Warwick scrotal drop back procedure was performed as revision PU.

Feasibility and Early Outcomes of Continent Catheterizable Stomas Using Cecal/Colon and Ileum for Children with Fecal Incontinence as an Alternative to Appendicular Malone Antegrade Continence Enema

Feasibility and Early Outcomes of Continent Catheterizable Stomas Using Cecal/Colon and Ileum for Children with Fecal Incontinence as an Alternative to Appendicular Malone Antegrade Continence Enema

Use of a Modified Continent Ileovesicostomy in Adults with Prior Enterocystoplasty

Background/Aims: To describe our initial experience with a novel modification of the Mitrofanoff conduit technique utilizing the Yang-Monti ileovesicostomy and the serosa lined extramural tunnel of the T-pouch to create a continent catheterizable stoma in patients with a prior enterocystoplasty. Methods: A 14 cm segment of bowel was harvested, and the distal 4 cm was divided and reconfigured utilizing the Yang-Monti technique. The remaining segment was folded into a U and secured with a serosal basting stitch. Half of the Yang-Monti tube is laid in the trough of the U-shaped segment and secured. Next, the U-shaped segment was incised along the anti-mesenteric border for the length of the tube. The newly created flaps adjacent to the tube was then laid over the tube and sutured together completing the serosa lined tunnel. The entire patch was anastomosed to a cystostomy through the previous enterocystoplasty. Finally, the proximal end of the tube was brought through the umbilicus and matured as a stoma. Results: Two patients with prior enterocystoplasties underwent the procedure described above. At follow-up of 18 and 24 months, both patients reported excellent continence. To date, there have been no revisions or significant complications. Conclusion: The construction of continent catheterizable stoma in adults with prior history of enterocystoplasty presents many technical challenges. The combination of the Yang-Monti ileovesicostomy and the extramural tunnel of the T-pouch provides an effective option for creating a continent catheterizable stoma in adults with prior history of enterocystoplasty.

Lessons learned from the management of adults who have undergone augmentation for spina bifida and bladder exstrophy: Incidence and management of the non-lethal complications of bladder augmentation.

The present review provides clinical insights and makes recommendations regarding patient management garnered by the long-term follow up of patients undergoing enteric bladder augmentation for the management of congenital anomalies. A prospectively maintained database on 385 patients that have experienced an enteric bladder augmentation, using either the ileum or colon, was reviewed. Evaluations included methods used to prevent bladder calculi formation and recurrence, the incidence and etiology of renal calculi development, the incidence and treatment of vitamin B12 deficiency, and the complications and need for surgical revisions for continent catheterizable stomas. A significantly increased risk for continent catheterizable stomal complications occurred after Monti-Yang tube formation, 70% (21/30 patients), compared with appendicovesicostomy, 41% (27/66 patients), P = 0.008. Both procedures had significantly more complications than continent catheterizable stomas using tapered ileum with a reinforced ileal-cecal valve, 21% (13/63 patients), P < 0.0001 and P < 0.013, respectively. Approximately 50% of the patient population developed a body mass index ≥30 during adulthood. The onset of obesity resulted in significantly more complications developing in patients with a Monti-Yang tube (87%; 13/15 patients) or appendicovesicostomy (55%; 18/33 patients) compared with a tapered ileum with a reinforced ileal-cecal valve (27%, 8/30 patients), P < 0.00015 and P < 0.025, respectively, with a median follow-up interval of 16 years, range 10-25 years. Long-term follow-up evaluations on patients undergoing an enteric bladder augmentation are necessary to prevent the long-term sequela of this procedure. The key to improving patient prognosis is the nutritional management of the patient as they mature, especially if a continent abdominal stoma is going to be carried out.

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.

MP80-03 BLADDER MANAGEMENT AND MECHANISM OF INJURY IN MALE AND FEMALE CERVICAL SPINAL CORD PATIENTS: A RETROSPECTIVE REVIEW

USC Institute of Urology Results • A total of 303 men and 86 women with average age at time of injury 39 and 40, respectively, were evaluated • Table 1 depicts bladder management by gender • Diversions performed included augment (10 men, 2 women); continent catheterizable stoma (2 men); and ileovesicostomy (1 male) • Table 2 depicts mechanism of injury by gender • Auto accidents (MVA) and gunshot wounds (GSW) listed separately from other trauma

Using a serosal trough for fashioning a continent catheterizable stoma: technique and outcomes

Using a serosal trough for fashioning a continent catheterizable stoma: technique and outcomes

Long-Term Outcomes of Augmentation Enterocystoplasty with a Catheterizable Channel in the Adult Neurogenic Population

Augmentation enterocystoplasty with a continent catheterizable stoma is a common approach to refractory neuropathic bladder, incontinence and end-stage bladder disease that aims to provide a large capacity, low-pressure reservoir and continent stoma. The goal is to not only to prevent renal deterioration, but also provide the patient with an improved quality of life. Several recent studies, reviewed in this chapter, have assessed the long-term outcomes of these procedures, demonstrating durable improvement in bladder capacity, bladder compliance, continence and quality of life. The long-term complications of the surgery include stomal complications such as stenosis and prolapse, channel related complications leading to difficult catheterization, bladder stones, recurrent urinary tract infections, bladder rupture, metabolic derangement and in very rare cases, malignant transformation. Successful surgery and good outcomes depend on proper patient selection, surgeon and center experience with the procedure, and close follow-up.

A Modification to Augmentation Cystoplasty With Catheterizable Stoma for Neurogenic Patients: Technique and Long-term Results

To evaluate the use of a modified Indiana continent urinary reservoir, the Indiana augmentation cystoplasty (IAC), for patients with neurogenic bladder (NGB). NGB with incontinence can be devastating for patients with neurologic illness. Augmentation cystoplasty with a continent catheterizable stoma creates a continent, low-pressure storage system, with catheterizable cutaneous stoma, leading to decreased urinary tract morbidity and increased quality of life. Retrospective chart review of the IAC procedure in a single center from 1993 to 2010 was performed and included subjects with NGB and minimum 1-year follow up. Patients' demographics, NGB diagnosis, surgery details, urodynamic findings, concurrent operations, complications, and continence outcomes were recorded. Thirty-four patients met the inclusion criteria. Mean age at time of surgery was 39.8 years. Neurologic diagnoses included multiple sclerosis (n = 12), spina bifida (n = 9), and spinal cord injury (n = 14). Concurrent surgeries included: bladder neck closure (n = 3), pubovaginal sling (n = 4), hysterectomy (n = 3), artificial urinary sphincter (n = 1), and cystolithotomy (n = 1). Mean estimated blood loss was 461.8 mL. Short-term postoperative complications were prolonged ileus (n = 2), wound infection (n = 1), and transfusion (n = 1). Median follow-up was 31 months. Long-term complications occurred in 15 (44.1%) patients: recurrent urinary tract infections (n = 4), pyelonephritis (n = 1), pelvic abscess (n = 1), seroma (n = 1), bladder stones (n = 2), and stomal revision in (n = 4). All patients were continent at latest follow-up. This modification of the Indiana continent urinary reservoir is an excellent surgical option providing a low-pressure reservoir with a reliable continence mechanism and easily catheterizable stoma, with few complications or need for reoperation.

Editorial Comment

This paper very nicely reviews the authors' experience with the Indiana augmentation cystoplasty (IAC) for patients with neurogenic bladder (NGB). Thirty-four patients underwent reconstruction, all of whom were unable to self-catheterize per their native urethra for a variety of reasons. In addition, 6 patients underwent a concomitant procedure (bladder neck closure, sling or artificial urinary sphincter [AUS]) to address an incompetent outlet. There are a variety of techniques (eg, Mitrofanoff, Monti, and T-limb) to construct a continent urinary stoma. There is no “best option” and surgeons should choose the technique with which they are most comfortable. The authors' comfort with this technique is evident, with a very acceptable rate of stoma revision and outstanding continence. A Modification to Augmentation Cystoplasty With Catheterizable Stoma for Neurogenic Patients: Technique and Long-term ResultsUrologyVol. 80Issue 2PreviewTo evaluate the use of a modified Indiana continent urinary reservoir, the Indiana augmentation cystoplasty (IAC), for patients with neurogenic bladder (NGB). NGB with incontinence can be devastating for patients with neurologic illness. Augmentation cystoplasty with a continent catheterizable stoma creates a continent, low-pressure storage system, with catheterizable cutaneous stoma, leading to decreased urinary tract morbidity and increased quality of life. Full-Text PDF

237 RECONSTRUCTION OF COMPLEX RECTOURETHRAL FISTULAS WITH THE INTENT OF PRESERVING ORTHOTOPIC BOWEL AND BLADDER FUNCTION

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery III1 Apr 2012237 RECONSTRUCTION OF COMPLEX RECTOURETHRAL FISTULAS WITH THE INTENT OF PRESERVING ORTHOTOPIC BOWEL AND BLADDER FUNCTION Ty Higuchi, Yuka Yamaguchi, Ryan Mori, Hadley Wood, and Kenneth Angermeier Ty HiguchiTy Higuchi Cleveland, OH More articles by this author , Yuka YamaguchiYuka Yamaguchi Cleveland, OH More articles by this author , Ryan MoriRyan Mori Cleveland, OH More articles by this author , Hadley WoodHadley Wood Cleveland, OH More articles by this author , and Kenneth AngermeierKenneth Angermeier Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.292AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Complex rectourethral fistulas (RUF) present a daunting challenge for the reconstructive urologist due to poor tissue quality, cavitation, and tissue fixation with loss of planes of dissection. In patients wishing to avoid urinary and fecal diversion, surgical repair requires careful preoperative evaluation, tissue interposition and possibly formal urethral reconstruction. We reviewed our experience with reconstruction of complex RUFs. METHODS We retrospectively reviewed patients undergoing reconstruction of complex RUFs with the intent of preserving orthotopic bowel and bladder function from 2004 to 2011. RUFs were related to one or more ablative therapies for prostate cancer (XRT, brachy or cryotherapy), surgical complication (salvage prostatectomy, large fistula) or previous failed repair(s). All patients underwent fecal diversion prior to surgery. Transperineal RUF repair was performed with urethral fistula closure or urethral reconstruction, primary rectal repair and gracilis muscle interposition. RESULTS Thirty patients were identified and the etiology of the RUF was 13 ablative therapy, 7 combination ablative therapy, 3 complex surgical and 7 previously failed repair(s). Median age was 64 years (range 36-75) at the time of RUF repair. Primary closure of the urethral defect was performed in 50% (15/30), buccal mucosal patch in 23% (7/30) and excision of the fistula and unhealthy tissue with primary urethral anastomosis in 27% (8/30). At a median follow-up of 10.4 months (range 1.3 - 44.6), 93% (28/30) of the patients achieved closure with 1 repair. Both failures were combined ablative fistulas. One recurred 1 mo after colostomy closure and had a successful second repair of the urethra with permanent colostomy. The second developed 1 mo after ileostomy closure and has closed with repeat fecal diversion. Overall, bowel diversion was closed in 80% (24/30) of patients with 3 awaiting closure, 1 not a candidate due to ongoing colitis and the two failed repairs. In patients who have completed their reconstruction, 2 patients required DVIU for recurrent stricture, 1 had a suprapubic tube for recalcitrant stricture, 5 had AUS of which 1 had multiple infections and eventually was managed with bladder neck closure and continent catheterizable stoma. CONCLUSIONS Complex RUFs can be closed with a high success rate and restoration of orthotopic bowel and bladder function in the majority of patients. Long term studies are required to determine the durability of these repairs. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e97-e98 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ty Higuchi Cleveland, OH More articles by this author Yuka Yamaguchi Cleveland, OH More articles by this author Ryan Mori Cleveland, OH More articles by this author Hadley Wood Cleveland, OH More articles by this author Kenneth Angermeier Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...