The etiology of voiding dysfunction in these patients included neurogenic bladder secondary to Eagle-Barrett syndrome (n = 2), Noonan syndrome (n = 1), Lennox-Gastaut syndrome (n = 1), and Spina bifida (n = 2; 1 patient with prior gastrocystoplasty and 1 patient with prior ileocystoplasty). A complete listing of patient demographics and outcomes is in Table 1. The median patient age at the time of surgery was 8 (interquartile range [IQR] 12) years, and there were 3 males and 3 females. The four patients without Eagle-Barrett syndrome had fluorodynamic estimated bladder capacities of 250, 410, 380, and 202 mL.
This study describing the continent catheterizable vesicostomy, using solely native bladder tissue, offers an additional surgical modality to the myriad of approaches that bypass the urethra for long-term bladder drainage. With modest follow-up, our initial case series demonstrates that the procedure is safe, feasible, and without episodes of channel incontinence between catheterizations. The indications for continent catheterizable vesicostomy are similar to other modalities (ie, Mitrofanoff or Monti procedure), in that the patients or caregivers should be capable and willing to perform catheterization 4-6 times per day via the umbilical stoma. Secondly, the patient\’s bladder capacity should be large enough to facilitate tubularization of a bladder flap cephalad to the umbilicus without compromising remaining bladder capacity. In our initial experience, cephalad traction at the dome of the bladder to delineate the length of tubularized flap necessary to reach the level of the umbilicus (Fig. 1A) has demonstrated sufficient capability to perform a continent catheterizable vesicostomy. Finally, for patients who require use of the GW788388 for a MACE procedure, continent catheterizable vesicostomy avoids the necessity of using a segment of bowel (ie, for a Monti procedure).
Appendicovesicostomy, introduced by Mitrofanoff in 1980, remains the preferred method for the creation of a catheterizable stoma. The appendix provides an adequate blood supply, stoma shape, lumen, and auto-lubrication, making it an ideal conduit. However, the required use of the appendix is a disadvantage for children in which the appendix is not available, including those patients requiring concurrent MACE procedure, as seen in our patient population. Many modified techniques have been developed on the basis of the Mitrofanoff principle, whichdescribes a continence mechanism based on a positive-pressure gradient between the channel lumen and the urinary reservoir. The most prominent is the Monti ileovesicostomy, first described in 1997. Additionally, Wedderburn et al and Kajbafzadeh and Chubak reported results using a modified technique to divide the appendix for simultaneous vesicostomy and antegrade continence enema. However, in addition to being technically challenging, this technique requires an appendix of adequate length, limiting its use.
Only a few techniques have been proposed that solely use bladder tissue for the formation of a catheterizable channel. Cain et al described a continent vesicostomy consisting of a 2-3 cm extravesical channel and a 3 cm intravesical mucosal channel. After opening the bladder in the midline, a U-shaped incision is made at the bladder dome to provide tissue for the extravesical channel, while mucosa elevated from the bladder interior wall forms the intravesical portion. The continence mechanism is derived from detrusor muscle closure over the mucosal tunnel to create flap-valve continence. However, despite excellent continence rates, in a 100 patient study performed at a single institution, this technique was found to have higher rates of stenosis requiring surgical intervention or reconstruction compared to appendicovesicostomy and Monti procedures.
Based on an incidental finding of continence in an epithelized neobladder-cutaneous fistula in a male infant with bladder extrophy, Yang et al developed the vesicocutaneous fistula. Operatively, a 0.5-cm cystotomy is made and the outer muscle layer of the bladder wall is secured to Scarpa\’s fascia and the skin to create a near-continent fistula. The bladder mucosa is not fixed to the skin, differentiating this technique from traditional vesicostomy. With limited follow-up, patients with vesicocutaneous fistulae suffered minimal complications, as only 1 out of 6 patients required surgical revision for stomal stenosis following noncompliance with regular catheterization. Additionally, only 1 patient suffered from occasional enuresis, suggesting that vesicocutaneous fistula may have acceptable continence rates.