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Continent Cutaneous Urinary Diversion in Children: Experience With Charleston Pouch I
Continent Cutaneous Urinary Diversion in Children: Experience With Charleston Pouch I N. K. Bissada, M. M. Abdallah, I. Aaronson and H. M. Hammouda From the Arkansas Children’s Hospital and University of Arkansas for Medical Sciences, Little Rock, Arkansas (NKB, MMA), Medical University of South Carolina, Charleston, South Carolina (IA), and Assuit University Hospital, Assuit, Egypt (HMH)
Purpose: Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children. Materials and Methods: A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and longterm functional status. Results: Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory. Conclusions: Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable. Key Words: urinary diversion; urinary reservoirs, continent; bladder exstrophy; spinal dysraphism; bladder, neurogenic
ontinent urinary diversion not incorporating the bladder is seldom used in children. Potential indications include following cystectomy for genitourinary malignancy, and occasionally in cases of bladder exstrophy, cloacal anomalies or neurogenic bladder.1 Creation of a stable, reliable, continent, easily catheterizable valve is essential for construction of a continent cutaneous urinary reservoir.2 As early as 1950 Gilchrist introduced the principle of using the ileocecal valve and an antiperistaltic segment of distal ileum as a continence mechanism. The ileocecal valve and the terminal ileum were tapered and plicated by Rowland and Kropp to provide a competent outlet for the Indiana pouch.3 The efferent limb was stapled to create a smooth and readily catheterizable stoma.3,4 In 1993 Bissada used the unaltered or minimally altered in situ appendix to create the continent mechanism.5,6 The urinary reservoir was formed from detubularized distal ileum, cecum and ascending colon. The procedure was called the Charleston pouch.
MATERIALS AND METHODS
C
Patients A total of 17 children (8 boys and 9 girls) with a mean age of 10.2 years (range 6 to 16) underwent continent cutaneous urinary diversion (Charleston pouch I) at 3 university hospitals between 1989 and 2005. Indications for diversion were bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). All patients had failed standard reconstructive surgery or conservative treatment before being considered for continent urinary diversion. Pouch Construction and Ureteral Implantation Patients received mechanical bowel preparation and a preoperative loading dose of antibiotics. The technique of Charleston pouch I has been described previously.5,7 The reservoir is constructed from segments of terminal ileum and ascending colon. The appendix is used as the continent outlet. The appendix is calibrated and gently dilated if necessary. Leak point pressure is tested. If no leakage occurs at an approximate pressure of 80 cm H2O, the continence mechanism is considered adequate.8 If LPP is low, the appendicocolic junction is reinforced by 1 or 2 partial purse string sutures.
Submitted for publication June 14, 2006. Study received institutional review board approval.
0022-5347/07/1771-0307/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
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Vol. 177, 307-311, January 2007 Printed in U.S.A. DOI:10.1016/j.juro.2006.08.143
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The colon and ileum are completely detubularized by incision along the antimesenteric border (see figure). Each organ is formed into an inverted U-shaped pouch, and the pouches are approximated with continuous absorbable suture. Two techniques were used for ureteral reimplantation, with either a submucosal tunnel or serous lined tunnel being created.9 The choice of ureteral reimplantation by submucosal tunnel or serous lined tunnel depended on surgeon preference. Early in the series use of submucosal tunnel was the standard. After popularization of the serous lined tunnel technique it was used in most patients. Single-J ureteral stents were used to drain the kidneys during the postoperative period. Each stent is secured to the colonic mucosa close to the anastomosis using 4-zero chromic
suture. A 20Fr Malecot catheter is left as a cecostomy for adequate drainage during the early postoperative period. Lastly, the 2 intestinal pouches are approximated with 3-zero polyglycolic acid suture on a Keith needle to establish a large globular pouch. Stoma Construction The stoma was created at the umbilicus. The operative technique has been reported previously.10 A 2.5 cm triangular skin flap is raised to the right of the umbilicus with a medial apex and lateral base. A 1 cm core of the umbilical scar medial to the triangular skin flap is excised down to the peritoneum. The appendix is then passed through the created defect. The appendix is spatulated for 1 cm and oriented so that the spatulation is on the right side opposite the skin flap. The triangular skin flap is then sutured to the spatulated appendix. The remaining edges are anastomosed to the surrounding skin. The pouch is catheterized several times to ensure easy catheterization. Postoperative Care Parenteral fluids were maintained until adequate bowel function resumed. Ureteral catheters were removed on 2 successive days (usually postoperative days 8 and 9). Draining tubes were removed after ensuring no urinary leakage occurred after removal of the ureteral catheters (usually day 10). Patients were discharged home with the cecostomy tube and the appendix stenting catheter, and were advised to irrigate the pouch daily. Followup Patients returned at about 5 to 6 weeks postoperatively. A pouchogram and upper tract studies were obtained. The tubes were removed and the families were further instructed on proper stoma catheterization techniques and general care of the pouch, including irrigation and trouble shooting. Patients were seen at 3 months and then every 6 months thereafter. History was recorded with special attention to continence status, and frequency and ease of catheterization. Family and patient satisfaction was assessed. Continence status was defined as no leakage between scheduled catheterizations. Patients were examined with emphasis on the condition of the stoma. Blood samples were obtained for chemical analysis and vitamin B12. Urine was obtained for urinalysis and culture. RESULTS Postoperative stay was 9 to 14 days (mean 10). Patients generally recovered adequate bowel function at 5 to 6 days postoperatively. One patient with neurogenic bladder and ventriculoperitoneal shunt had peritonitis requiring replacement of the shunt. Mean followup was 87.5 months (range 12 to 140). Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14).
Charleston pouch. A, folding of pouch and ureteral implantation using serous lined tunnels. B, final shape of pouch and outlet.
Continence and Family/Patient Satisfaction One patient was lost to followup. The remaining patients were dry with a mean catheterizing interval of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Patients were advised to moderate fluid intake and abstain from caffeinated drinks. They became
CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after catheter removal and others at 3 to 12 months before pouch maturation. At that time patients and families were comfortable with catheterization and expressed general satisfaction. When asked, some parents and older children indicated that they would recommend the procedure to others. Upper Tract Evaluation Ultrasound and/or other upper tract studies demonstrated no deterioration of the upper urinary system in this group of patients. No patient experienced clinical pyelonephritis. Biochemical and Metabolic Evaluation Serum creatinine ranged from 0.4 to 1.2 mg/dl. It remained stable in the majority of patients, improved in 2 (12%) and increased in 1 (6%). Serum vitamin B12 remained in the normal range in all patients. Late Complications Three patients (18%) had pouch stones. Open lithotomy was necessary in 1 of these patients, who had poor compliance and different care givers, with no irrigation of the pouch. He underwent removal of stones 3 times. Endoscopic lithotripsy was used in the remaining 2 patients. No patient experienced clinical pyelonephritis or clinical acidosis. No patient had bladder perforation. One boy with neurogenic bladder had intermittent diarrhea. DISCUSSION Continent cutaneous diversion not incorporating the bladder is seldom used in children. However, there are some indications that require such intervention, including post-cystectomy cases, cases where exstrophy surgery has failed or the bladder is not suitable for construction, and occasionally cases of neurogenic bladder. In these patients CCD is one of the options that may be offered. In this study we evaluated the use of a form of CCD (Charleston pouch I) in children. The Charleston pouch procedure entails construction of a urinary reservoir from an isolated segment of the small and large bowel. The continence mechanism uses the vermiform appendix.11 The ureters are reimplanted in a submucosal or a serous lined tunnel. In our series stone formation rate was 18%, which is comparable to the 18% to 52% rate in patients with bladder augmentation.12 No case of bladder perforation was recorded in this group. Undoubtedly, with longer experience perforations and stomal complications will be encountered.12,13 It is also conceivable that by using the unaltered or minimally altered appendix as the continent outlet the LPP can be predetermined intraoperatively, thus, allowing a safety valve for leakage when pressure increases beyond a certain level. In fact, adjusting the LPP is intended to provide adequate but not perfect continence. This approach has obvious advantages in children in whom leakage may occur when the reservoir is not evacuated at recommended intervals, thus, minimizing the potential for catastrophic rupture. In the Mainz pouch experience with 32 children no bladder perforations were reported.1 Lemelle et al reported a
309
3.4% rate of perforation with augmented bladder.12 In a Scandinavian study reservoir perforation rate was reported as 1.5%.14 Metcalfe et al reported no significant difference between ileum, stomach and cecal segments with regard to rate of perforation.13 We did not observe stomal stenosis in this group of children. However, this complication occurs in 7% to 24% of children with appendiceal stoma.15 Mean patient age in our series was 9.5 years, which is slightly less than that reported by Baird et al (12.9).16 Barqawi et al reported a significantly higher proportion of postpubertal patients (older than 12 years) undergoing revision of the stoma compared to younger patients (p ⬍0.05).17 A similar experience to ours is that of the Mainz pouch.1 In this technique the reservoir is formed of composite ileal and colonic segments. The outlet is formed of either the distal ileum or the appendix, which is folded and embedded into a submucosal tunnel in the proximal colon. In the Charleston pouch the unaltered or minimally altered appendix is used as the continent outlet. We believe that the native unaltered or minimally enforced appendicocolic junction is adequate for continence. The LPP is measured intraoperatively.8 In patients with inadequate LPP simple reinforcement as described can be accomplished quickly. This approach simplifies the procedures, obviates the need for implanting the appendix, minimizes the potential for affecting the blood supply and may contribute to the ease of catheterization. The exact role of CCD in children remains to be defined. It is clearly applicable following cystectomy for genitourinary malignancy.18 In patients with bladder exstrophy who are candidates for cystectomy CCD may be considered if repair of bladder exstrophy has failed or is not applicable. Some patients with complications from ureterosigmoidostomy are also candidates. Continent cutaneous diversion is rarely considered in patients with NB, such as those with spina bifida or spinal cord injuries. Moore et al indicated that in patients with spina bifida continence is associated with better self-concept, and incontinent girls are at higher risk for poor self-esteem.19 Accordingly, it may be argued that CCD is a reasonable alternative to performing multiple procedures, such as a combination of bladder augmentation, bladder neck surgery and ureteral reimplantation. Although there is no standardized definition of continence, it seems that continence rates with CCD compare favorably to those after bladder augmentation. Barqawi et al17 reported a 92% continence rate with CCD. Similarly, Abd-el-Gawad et al reported an 84% continence rate, with complete satisfaction in their patients.14 Finally, Stein et al reported a 97% continence rate at the latest followup in patients with an embedded appendix as the continence mechanism.1 In this limited experience a satisfactory continence rate was noted with the Charleston pouch I after 1 to 12 months of maturation.
CONCLUSIONS We report our experience using the Charleston pouch I as a form of CCD. This approach provided preservation of the upper urinary tract and satisfactory continence rates while allowing leakage when catheterization was not performed at recommended intervals.
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Abbreviations and Acronyms CCD ⫽ continent cutaneous diversion LPP ⫽ leak point pressure
REFERENCES 1.
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3. 4.
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6. 7.
8.
9.
10.
11.
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18.
Stein R, Wiesner C, Beetz R, Pfitzenmeier J, Schwarz M and Thuroff JW: Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience. Part II: continent cutaneous diversion using the Mainz pouch I. Pediatr Nephrol 2005; 20: 926. Abol-Enein H, Salem M, Mesbah A, Abdel-Latif M, Kamal M, Shabaan A et al: Continent cutaneous ileal pouch using the serous lined extramural valves. The Mansoura experience in more than 100 patients. J Urol 2004; 172: 588. Rowland RG and Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 1994; 152: 2247. Bejany DE and Politano VA: Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir. J Urol 1998; 140: 491. Bissada NK: New continent ileocolonic urinary reservoir: Charleston pouch with minimally altered in situ appendix stoma. Urology 1993; 41: 524. Hammouda H: Charleston pouch with in-situ appendix and concealed umbilical stoma. Afr J Urol 2003; 9: 176. Hull GW and Bissada NK: The Charleston pouch: a continent urinary diversion using the in-situ appendix. Curr Surg Tech Urol 1997; 10: 1. Bissada NK and Marshall I: Leak point pressure use for intraoperative adjustment of the continence mechanism in patients undergoing continent cutaneous urinary diversion. Urology 1998; 52: 790. Abol-Enein H and Ghoneim MA: A novel uretero-ileal reimplantation technique: the serous lined extramural tunnel. A preliminary report. J Urol 1994; 151: 1193. Bissada NK: Favorable experience with a simple technique to create a concealed umbilical stoma. J Urol 1998; 159: 1174. Bissada NK: Continent cutaneous diversion using the ileocecal bowel segment. In: Current Genitourinary Cancer Surgery, 2nd ed. Edited by ED Crawford and S Das. Baltimore: Williams & Wilkins 1997; p 414. Lemelle JL, Guillemin F, Aubert D, Guys JM, Lottmann H, Lortat-Jacob S et al: A multicenter evaluation of urinary incontinence management and outcome in spina bifida. J Urol 2006; 175: 208. Metcalfe PD, Casale AJ, Kaefer MA, Misseri R, Dussinger AM, Meldrum KK et al: Spontaneous bladder perforations: a report of 500 augmentations in children and analysis of risk. J Urol 2006 175: 1466. Abd-el-Gawad G, Abrahamsson K, Hanson E, Norlen L, Sillen U, Sixt R et al: Evaluation of Kock urinary reservoir function in children and adolescents at 3–10 years’ follow-up. Scand J Urol Nephrol 1999; 33: 149. Harris CF, Cooper CS, Hutcheson JC, Snyder HM 3rd: Appendicovesicostomy: the mitrofanoff procedure—a 15-year perspective. J Urol 2000; 163: 1922. Baird AD, Frimberger D and Gearhart JP: Reconstructive lower urinary tract surgery in incontinent adolescents with exstrophy/epispadias complex. Urology 2005; 66: 636. Barqawi A, de Valdenebro M, Furness PD 3rd and Koyle MA: Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas. BJU Int 2004; 94: 1344. Rigamonti W, Iafrate M, Milani C, Capizzi A, Bisogno G, Carli M et al: Orthotopic continent urinary diversion after radical
19.
cystectomy in pediatric patients with genitourinary rhabdomyosarcoma. J Urol 2006; 175: 1092. Moore C, Kogan BA and Parekh A: Impact of urinary incontinence on self-concept in children with spina bifida. J Urol 2004; 171: 1659.
EDITORIAL COMMENT The authors report their experience with ileocecal reservoirs in 17 children. What distinguishes this reservoir from the Mainz pouch is use of the appendix not embedded into a submucosal tunnel. The authors believe that the unaltered or “minimally” enforced appendicocolic junction is adequate for providing continence. However, they do not clearly mention in the text the number of patients in whom the appendix was, in fact, embedded, “minimally enforced” or not embedded at all. We routinely practice this concept of embedding the efferent channel by seromuscular stitches in urinary and colonic stomas.1,2 Interestingly, in an ex vivo experimental model we showed that the angulation of the tube against the reservoir, rather than the extension of the serous lined tunnel itself, is the main factor responsible for continence.3 In the context of the present article if the majority of patients had undergone this embedding step, this technique would be similar to the well established Mainz pouch. Antonio Macedo, Jr. Federal University of São Paulo São Paulo, Brazil 1.
Macedo A Jr and Srougi M: A continent catheterizable ileumbased reservoir. BJU Int 2000; 85: 160. 2. Calado AA, Macedo A Jr, Barroso U Jr, Netto JM, Liguori R, Hachul M et al: The Macedo-Malone antegrade continence enema procedure: early experience. J Urol 2005; 173: 1340. 3. Vilela M, Macedo A Jr, Furtado G, Koh I, Poli L, Garrone G et al: How continent are catheterizable urinary and colonic stomas? An ex-vivo experimental model. BJU Int, suppl., 2003; 91: 5.
REPLY BY AUTHORS The Charleston pouch relies on the unaltered or minimally enforced appendix as the continent catheterizable outlet. We perform appendiceal LPP measurement and if adequate no enforcement is required (reference 8 in article). If the LPP is low the appendicocolic junction is enforced by placing 1 or 2 partial purse-string polypropylene sutures at the junction to coapt the lumen and enhance the anti-leakage mechanism. In every case this was adequate to keep the LPP above 70 to 80 cm H2O. Thus, the appendix is not embedded nor is there any angulation of the tube against the reservoir. The Charleston pouch has been used since 1989 and the technique has been described in several publications (references 5, 6, 7 and 11 in article).1–5 Our article and the prior publications illustrate the technical details. We also emphasize that the anti-incontinence mechanism in the Charleston pouch is meant to be adequate but not perfect. This imperfection allows the pouch to leak when catheterization schedules are not adhered to by noncompliant patients. The obvious advantage is in children who often have periods of
CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN noncompliance when leakage occurs and, therefore, they are less likely to experience a potentially catastrophic increase in pouch pressure. 1.
2.
Bissada NK: Characteristics and utility of the in-situ appendix as a continent catheterizable stoma for continent urinary diversion in adults. J Urol 1993; 150: 151. Bissada NK: Experience with the Charleston Pouch continent urinary diversion. Contemp Urol 1995; 7: 4752.
3.
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Marshall IY, and Bissada NK: Study of the unaltered in-situ appendix as a native continence mechanism. J Investig Surg 1995; 8: 147. 4. Bissada NK and Marshall IY: Towards construction of an ideal continent urinary diversion: the Charleston pouch with an in-situ appendix. Scand J Urol Nephrol 1992; 142: 150. 5. Hammouda H, Gaafour AA, Sayed MA and Abouella HA: Urodynamic features of Charleston pouch versus modified neobladder. Egypt J Urol 2005; 87.
Purpose: Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children. Materials and Methods: A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and longterm functional status. Results: Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory. Conclusions: Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable. Key Words: urinary diversion; urinary reservoirs, continent; bladder exstrophy; spinal dysraphism; bladder, neurogenic
ontinent urinary diversion not incorporating the bladder is seldom used in children. Potential indications include following cystectomy for genitourinary malignancy, and occasionally in cases of bladder exstrophy, cloacal anomalies or neurogenic bladder.1 Creation of a stable, reliable, continent, easily catheterizable valve is essential for construction of a continent cutaneous urinary reservoir.2 As early as 1950 Gilchrist introduced the principle of using the ileocecal valve and an antiperistaltic segment of distal ileum as a continence mechanism. The ileocecal valve and the terminal ileum were tapered and plicated by Rowland and Kropp to provide a competent outlet for the Indiana pouch.3 The efferent limb was stapled to create a smooth and readily catheterizable stoma.3,4 In 1993 Bissada used the unaltered or minimally altered in situ appendix to create the continent mechanism.5,6 The urinary reservoir was formed from detubularized distal ileum, cecum and ascending colon. The procedure was called the Charleston pouch.
MATERIALS AND METHODS
C
Patients A total of 17 children (8 boys and 9 girls) with a mean age of 10.2 years (range 6 to 16) underwent continent cutaneous urinary diversion (Charleston pouch I) at 3 university hospitals between 1989 and 2005. Indications for diversion were bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). All patients had failed standard reconstructive surgery or conservative treatment before being considered for continent urinary diversion. Pouch Construction and Ureteral Implantation Patients received mechanical bowel preparation and a preoperative loading dose of antibiotics. The technique of Charleston pouch I has been described previously.5,7 The reservoir is constructed from segments of terminal ileum and ascending colon. The appendix is used as the continent outlet. The appendix is calibrated and gently dilated if necessary. Leak point pressure is tested. If no leakage occurs at an approximate pressure of 80 cm H2O, the continence mechanism is considered adequate.8 If LPP is low, the appendicocolic junction is reinforced by 1 or 2 partial purse string sutures.
Submitted for publication June 14, 2006. Study received institutional review board approval.
0022-5347/07/1771-0307/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
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Vol. 177, 307-311, January 2007 Printed in U.S.A. DOI:10.1016/j.juro.2006.08.143
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CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN
The colon and ileum are completely detubularized by incision along the antimesenteric border (see figure). Each organ is formed into an inverted U-shaped pouch, and the pouches are approximated with continuous absorbable suture. Two techniques were used for ureteral reimplantation, with either a submucosal tunnel or serous lined tunnel being created.9 The choice of ureteral reimplantation by submucosal tunnel or serous lined tunnel depended on surgeon preference. Early in the series use of submucosal tunnel was the standard. After popularization of the serous lined tunnel technique it was used in most patients. Single-J ureteral stents were used to drain the kidneys during the postoperative period. Each stent is secured to the colonic mucosa close to the anastomosis using 4-zero chromic
suture. A 20Fr Malecot catheter is left as a cecostomy for adequate drainage during the early postoperative period. Lastly, the 2 intestinal pouches are approximated with 3-zero polyglycolic acid suture on a Keith needle to establish a large globular pouch. Stoma Construction The stoma was created at the umbilicus. The operative technique has been reported previously.10 A 2.5 cm triangular skin flap is raised to the right of the umbilicus with a medial apex and lateral base. A 1 cm core of the umbilical scar medial to the triangular skin flap is excised down to the peritoneum. The appendix is then passed through the created defect. The appendix is spatulated for 1 cm and oriented so that the spatulation is on the right side opposite the skin flap. The triangular skin flap is then sutured to the spatulated appendix. The remaining edges are anastomosed to the surrounding skin. The pouch is catheterized several times to ensure easy catheterization. Postoperative Care Parenteral fluids were maintained until adequate bowel function resumed. Ureteral catheters were removed on 2 successive days (usually postoperative days 8 and 9). Draining tubes were removed after ensuring no urinary leakage occurred after removal of the ureteral catheters (usually day 10). Patients were discharged home with the cecostomy tube and the appendix stenting catheter, and were advised to irrigate the pouch daily. Followup Patients returned at about 5 to 6 weeks postoperatively. A pouchogram and upper tract studies were obtained. The tubes were removed and the families were further instructed on proper stoma catheterization techniques and general care of the pouch, including irrigation and trouble shooting. Patients were seen at 3 months and then every 6 months thereafter. History was recorded with special attention to continence status, and frequency and ease of catheterization. Family and patient satisfaction was assessed. Continence status was defined as no leakage between scheduled catheterizations. Patients were examined with emphasis on the condition of the stoma. Blood samples were obtained for chemical analysis and vitamin B12. Urine was obtained for urinalysis and culture. RESULTS Postoperative stay was 9 to 14 days (mean 10). Patients generally recovered adequate bowel function at 5 to 6 days postoperatively. One patient with neurogenic bladder and ventriculoperitoneal shunt had peritonitis requiring replacement of the shunt. Mean followup was 87.5 months (range 12 to 140). Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14).
Charleston pouch. A, folding of pouch and ureteral implantation using serous lined tunnels. B, final shape of pouch and outlet.
Continence and Family/Patient Satisfaction One patient was lost to followup. The remaining patients were dry with a mean catheterizing interval of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Patients were advised to moderate fluid intake and abstain from caffeinated drinks. They became
CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after catheter removal and others at 3 to 12 months before pouch maturation. At that time patients and families were comfortable with catheterization and expressed general satisfaction. When asked, some parents and older children indicated that they would recommend the procedure to others. Upper Tract Evaluation Ultrasound and/or other upper tract studies demonstrated no deterioration of the upper urinary system in this group of patients. No patient experienced clinical pyelonephritis. Biochemical and Metabolic Evaluation Serum creatinine ranged from 0.4 to 1.2 mg/dl. It remained stable in the majority of patients, improved in 2 (12%) and increased in 1 (6%). Serum vitamin B12 remained in the normal range in all patients. Late Complications Three patients (18%) had pouch stones. Open lithotomy was necessary in 1 of these patients, who had poor compliance and different care givers, with no irrigation of the pouch. He underwent removal of stones 3 times. Endoscopic lithotripsy was used in the remaining 2 patients. No patient experienced clinical pyelonephritis or clinical acidosis. No patient had bladder perforation. One boy with neurogenic bladder had intermittent diarrhea. DISCUSSION Continent cutaneous diversion not incorporating the bladder is seldom used in children. However, there are some indications that require such intervention, including post-cystectomy cases, cases where exstrophy surgery has failed or the bladder is not suitable for construction, and occasionally cases of neurogenic bladder. In these patients CCD is one of the options that may be offered. In this study we evaluated the use of a form of CCD (Charleston pouch I) in children. The Charleston pouch procedure entails construction of a urinary reservoir from an isolated segment of the small and large bowel. The continence mechanism uses the vermiform appendix.11 The ureters are reimplanted in a submucosal or a serous lined tunnel. In our series stone formation rate was 18%, which is comparable to the 18% to 52% rate in patients with bladder augmentation.12 No case of bladder perforation was recorded in this group. Undoubtedly, with longer experience perforations and stomal complications will be encountered.12,13 It is also conceivable that by using the unaltered or minimally altered appendix as the continent outlet the LPP can be predetermined intraoperatively, thus, allowing a safety valve for leakage when pressure increases beyond a certain level. In fact, adjusting the LPP is intended to provide adequate but not perfect continence. This approach has obvious advantages in children in whom leakage may occur when the reservoir is not evacuated at recommended intervals, thus, minimizing the potential for catastrophic rupture. In the Mainz pouch experience with 32 children no bladder perforations were reported.1 Lemelle et al reported a
309
3.4% rate of perforation with augmented bladder.12 In a Scandinavian study reservoir perforation rate was reported as 1.5%.14 Metcalfe et al reported no significant difference between ileum, stomach and cecal segments with regard to rate of perforation.13 We did not observe stomal stenosis in this group of children. However, this complication occurs in 7% to 24% of children with appendiceal stoma.15 Mean patient age in our series was 9.5 years, which is slightly less than that reported by Baird et al (12.9).16 Barqawi et al reported a significantly higher proportion of postpubertal patients (older than 12 years) undergoing revision of the stoma compared to younger patients (p ⬍0.05).17 A similar experience to ours is that of the Mainz pouch.1 In this technique the reservoir is formed of composite ileal and colonic segments. The outlet is formed of either the distal ileum or the appendix, which is folded and embedded into a submucosal tunnel in the proximal colon. In the Charleston pouch the unaltered or minimally altered appendix is used as the continent outlet. We believe that the native unaltered or minimally enforced appendicocolic junction is adequate for continence. The LPP is measured intraoperatively.8 In patients with inadequate LPP simple reinforcement as described can be accomplished quickly. This approach simplifies the procedures, obviates the need for implanting the appendix, minimizes the potential for affecting the blood supply and may contribute to the ease of catheterization. The exact role of CCD in children remains to be defined. It is clearly applicable following cystectomy for genitourinary malignancy.18 In patients with bladder exstrophy who are candidates for cystectomy CCD may be considered if repair of bladder exstrophy has failed or is not applicable. Some patients with complications from ureterosigmoidostomy are also candidates. Continent cutaneous diversion is rarely considered in patients with NB, such as those with spina bifida or spinal cord injuries. Moore et al indicated that in patients with spina bifida continence is associated with better self-concept, and incontinent girls are at higher risk for poor self-esteem.19 Accordingly, it may be argued that CCD is a reasonable alternative to performing multiple procedures, such as a combination of bladder augmentation, bladder neck surgery and ureteral reimplantation. Although there is no standardized definition of continence, it seems that continence rates with CCD compare favorably to those after bladder augmentation. Barqawi et al17 reported a 92% continence rate with CCD. Similarly, Abd-el-Gawad et al reported an 84% continence rate, with complete satisfaction in their patients.14 Finally, Stein et al reported a 97% continence rate at the latest followup in patients with an embedded appendix as the continence mechanism.1 In this limited experience a satisfactory continence rate was noted with the Charleston pouch I after 1 to 12 months of maturation.
CONCLUSIONS We report our experience using the Charleston pouch I as a form of CCD. This approach provided preservation of the upper urinary tract and satisfactory continence rates while allowing leakage when catheterization was not performed at recommended intervals.
310
CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN
Abbreviations and Acronyms CCD ⫽ continent cutaneous diversion LPP ⫽ leak point pressure
REFERENCES 1.
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3. 4.
5.
6. 7.
8.
9.
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11.
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Stein R, Wiesner C, Beetz R, Pfitzenmeier J, Schwarz M and Thuroff JW: Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience. Part II: continent cutaneous diversion using the Mainz pouch I. Pediatr Nephrol 2005; 20: 926. Abol-Enein H, Salem M, Mesbah A, Abdel-Latif M, Kamal M, Shabaan A et al: Continent cutaneous ileal pouch using the serous lined extramural valves. The Mansoura experience in more than 100 patients. J Urol 2004; 172: 588. Rowland RG and Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 1994; 152: 2247. Bejany DE and Politano VA: Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir. J Urol 1998; 140: 491. Bissada NK: New continent ileocolonic urinary reservoir: Charleston pouch with minimally altered in situ appendix stoma. Urology 1993; 41: 524. Hammouda H: Charleston pouch with in-situ appendix and concealed umbilical stoma. Afr J Urol 2003; 9: 176. Hull GW and Bissada NK: The Charleston pouch: a continent urinary diversion using the in-situ appendix. Curr Surg Tech Urol 1997; 10: 1. Bissada NK and Marshall I: Leak point pressure use for intraoperative adjustment of the continence mechanism in patients undergoing continent cutaneous urinary diversion. Urology 1998; 52: 790. Abol-Enein H and Ghoneim MA: A novel uretero-ileal reimplantation technique: the serous lined extramural tunnel. A preliminary report. J Urol 1994; 151: 1193. Bissada NK: Favorable experience with a simple technique to create a concealed umbilical stoma. J Urol 1998; 159: 1174. Bissada NK: Continent cutaneous diversion using the ileocecal bowel segment. In: Current Genitourinary Cancer Surgery, 2nd ed. Edited by ED Crawford and S Das. Baltimore: Williams & Wilkins 1997; p 414. Lemelle JL, Guillemin F, Aubert D, Guys JM, Lottmann H, Lortat-Jacob S et al: A multicenter evaluation of urinary incontinence management and outcome in spina bifida. J Urol 2006; 175: 208. Metcalfe PD, Casale AJ, Kaefer MA, Misseri R, Dussinger AM, Meldrum KK et al: Spontaneous bladder perforations: a report of 500 augmentations in children and analysis of risk. J Urol 2006 175: 1466. Abd-el-Gawad G, Abrahamsson K, Hanson E, Norlen L, Sillen U, Sixt R et al: Evaluation of Kock urinary reservoir function in children and adolescents at 3–10 years’ follow-up. Scand J Urol Nephrol 1999; 33: 149. Harris CF, Cooper CS, Hutcheson JC, Snyder HM 3rd: Appendicovesicostomy: the mitrofanoff procedure—a 15-year perspective. J Urol 2000; 163: 1922. Baird AD, Frimberger D and Gearhart JP: Reconstructive lower urinary tract surgery in incontinent adolescents with exstrophy/epispadias complex. Urology 2005; 66: 636. Barqawi A, de Valdenebro M, Furness PD 3rd and Koyle MA: Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas. BJU Int 2004; 94: 1344. Rigamonti W, Iafrate M, Milani C, Capizzi A, Bisogno G, Carli M et al: Orthotopic continent urinary diversion after radical
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EDITORIAL COMMENT The authors report their experience with ileocecal reservoirs in 17 children. What distinguishes this reservoir from the Mainz pouch is use of the appendix not embedded into a submucosal tunnel. The authors believe that the unaltered or “minimally” enforced appendicocolic junction is adequate for providing continence. However, they do not clearly mention in the text the number of patients in whom the appendix was, in fact, embedded, “minimally enforced” or not embedded at all. We routinely practice this concept of embedding the efferent channel by seromuscular stitches in urinary and colonic stomas.1,2 Interestingly, in an ex vivo experimental model we showed that the angulation of the tube against the reservoir, rather than the extension of the serous lined tunnel itself, is the main factor responsible for continence.3 In the context of the present article if the majority of patients had undergone this embedding step, this technique would be similar to the well established Mainz pouch. Antonio Macedo, Jr. Federal University of São Paulo São Paulo, Brazil 1.
Macedo A Jr and Srougi M: A continent catheterizable ileumbased reservoir. BJU Int 2000; 85: 160. 2. Calado AA, Macedo A Jr, Barroso U Jr, Netto JM, Liguori R, Hachul M et al: The Macedo-Malone antegrade continence enema procedure: early experience. J Urol 2005; 173: 1340. 3. Vilela M, Macedo A Jr, Furtado G, Koh I, Poli L, Garrone G et al: How continent are catheterizable urinary and colonic stomas? An ex-vivo experimental model. BJU Int, suppl., 2003; 91: 5.
REPLY BY AUTHORS The Charleston pouch relies on the unaltered or minimally enforced appendix as the continent catheterizable outlet. We perform appendiceal LPP measurement and if adequate no enforcement is required (reference 8 in article). If the LPP is low the appendicocolic junction is enforced by placing 1 or 2 partial purse-string polypropylene sutures at the junction to coapt the lumen and enhance the anti-leakage mechanism. In every case this was adequate to keep the LPP above 70 to 80 cm H2O. Thus, the appendix is not embedded nor is there any angulation of the tube against the reservoir. The Charleston pouch has been used since 1989 and the technique has been described in several publications (references 5, 6, 7 and 11 in article).1–5 Our article and the prior publications illustrate the technical details. We also emphasize that the anti-incontinence mechanism in the Charleston pouch is meant to be adequate but not perfect. This imperfection allows the pouch to leak when catheterization schedules are not adhered to by noncompliant patients. The obvious advantage is in children who often have periods of
CONTINENT CUTANEOUS URINARY DIVERSION IN CHILDREN noncompliance when leakage occurs and, therefore, they are less likely to experience a potentially catastrophic increase in pouch pressure. 1.
2.
Bissada NK: Characteristics and utility of the in-situ appendix as a continent catheterizable stoma for continent urinary diversion in adults. J Urol 1993; 150: 151. Bissada NK: Experience with the Charleston Pouch continent urinary diversion. Contemp Urol 1995; 7: 4752.
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Marshall IY, and Bissada NK: Study of the unaltered in-situ appendix as a native continence mechanism. J Investig Surg 1995; 8: 147. 4. Bissada NK and Marshall IY: Towards construction of an ideal continent urinary diversion: the Charleston pouch with an in-situ appendix. Scand J Urol Nephrol 1992; 142: 150. 5. Hammouda H, Gaafour AA, Sayed MA and Abouella HA: Urodynamic features of Charleston pouch versus modified neobladder. Egypt J Urol 2005; 87.