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Cystostomy Button for Bladder Drainage in Children
Cystostomy Button for Bladder Drainage in Children I. Milliken, N. P. Munro and R. Subramaniam* From the Department of Pediatric Urology (IM, RS) and the Department of Urology (NPM), St. James’s University Hospital, Leeds, United Kingdom
Purpose: The “button” enteral feeding systems are widely used as a gastrostomy. We describe our use of this device to facilitate bladder drainage in children. Materials and Methods: We prospectively reviewed all patients who underwent insertion of a cystostomy button between 2002 and 2005. Indications and complications were analyzed. Results: A total of 17 children (8 female, 9 male) with a mean age of 7.1 years underwent insertion of a cystostomy button during the 4-year period. Mean followup was 16 months (range 2 to 40). Cases selected included those with a neuropathic bladder, prune belly syndrome, previous major bladder neck surgery and those unsuitable for Mitrofanoff stoma formation. Complications included 1 wound infection treated with antibiotics. Four children had leakage from the cystostomy site that was successfully treated with a change in button size, and 14 buttons remain in situ. Conclusions: Button cystostomy is a safe and effective form of bladder drainage in children. It is a good alternative to standard suprapubic drainage and it gives children an improved quality of life. Key Words: bladder, drainage, cystostomy
hildren with many underlying conditions require bladder drainage to protect the upper tracts. Historically, different methods of bladder drainage have been used. The least invasive is clean intermittent selfcatheterization while the most common surgical method is vesicostomy. The placement of a suprapubic catheter is used in many circumstances as a temporary method of bladder drainage. We performed insertion of a cystostomy button as an alternative form of suprapubic drainage in children and review our preliminary results here.
C
MATERIALS AND METHODS Between 2002 and 2005 children requiring bladder drainage were considered for placement of a cystostomy button. Through a mini Pfannenstiel incision the rectus muscle was split and the bladder identified and mobilized (fig. 1). The bladder was opened using diathermy between stay sutures. A button measuring device allowing the surgeon to gauge the length of button required was inserted. It was then replaced with a button of suitable length and its balloon inflated with 5 ml sterile water. We found a 14Fr Mic-Key button (Kimberly-Clark/Ballard, Roswell, Georgia) to be the most suitable (fig. 2). The skin was closed around the button and apposed with steristrips. The bladder could be emptied as required using the tubing for the Mic-Key button, which is simply attached and allows free drainage. The procedure was covered with 3 doses of intravenous gentamicin (7.5 mg/kg) and all patients then remained on prophylactic antiStudy received department and institutional guidelines and review committee approval. * Correspondence: Department of Paediatric Urology, Level 4 Gledhow Wing, Nephrology Secretary Office, St. James University Hospital, Beckett’s St., Leeds LS9 7TF United Kingdom (telephone: ⫹44 113 2064840; FAX: ⫹44 113 2066634).
0022-5347/07/1786-2604/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
biotics. Buttons were routinely changed every 3 months either on the ward or in the community by a urology nurse specialist. RESULTS In the 4 years from 2002 to 2005 there were 17 children (8 female, 9 male) with a mean age of 7.1 years for whom placement of a cystostomy button was considered suitable as an alternative form of bladder drainage. Four children with a neuropathic bladder who had initially been treated with CISC were offered the button to improve quality of life. These children all had a primary button placed using the technique described. One child with prune belly syndrome had a previous vesicostomy but this had caused problems with urinary retention due to a stricture and a button was therefore inserted as an alternative form of drainage. One child with the DIDMOAD syndrome (a hereditary condition characterized by multiple symptoms including Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness, also known as the Wolfram syndrome) was obese and partially blind. A Mitrofanoff stoma was considered unsuitable in this case and, therefore, a button was inserted. Two further children refused to consent to a Mitrofanoff stoma, 1 with a history of posterior urethral valves and 1 with spina bifida. The latter patient did consent to bladder augmentation but declined the Mitrofanoff procedure. Ileocystoplasty was performed and a suprapubic catheter initially left in situ. This was later changed to a button for 6 months, although it was subsequently removed when the child was happy with CISC. One child born with a cloaca underwent ileocystoplasty and a Yang-Monti procedure. However, a kink in the Monti tube prevented successful CISC. A button was inserted be-
2604
Vol. 178, 2604-2606, December 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.08.031
CYSTOSTOMY BUTTON FOR BLADDER DRAINAGE IN CHILDREN
2605
tions. One child had a history of posterior urethral valves and poor renal function. A baby born with megacystis microcolon syndrome required an ileostomy, and a cystostomy button was inserted simultaneously to facilitate bladder drainage while she awaits further treatment. All buttons were inserted into the bladder as previously described. All procedures were successful and uneventful, with a mean followup of 16 months (range 2 to 40). Complications in our series include 1 case of wound infection which responded to antibiotics. Urine culture was negative but wound swab grew staphylococcus aureus, and was treated with flucloxacillin. Four children had significant leakage after the insertion period. One settled with time while the others required the button to be changed to a shorter length and tighter fit once the tract was well established. None of the children requiring a shorter button had any further problems with leakage or stoma erosion. There were no children with lithiasis. All patients, especially the older children, believed the button gave them an improved quality of life. However, this was not formally assessed. Of the 17 buttons 3 have now been removed as many of them were used as a temporary measure. DISCUSSION Adequate bladder drainage can be achieved with CISC, the use of a suprapubic catheter or a surgical vesicostomy. For those who do not have a sensate urethra, CISC remains an excellent option. Complications are rare but include hematuria, urethral erosion and strictures, creation of false passages, and epididymitis.1 Suprapubic catheters are excellent for short-term use. However, this can be restrictive for patients as they must carry around excess tubing and a bag. The skin site surrounding a catheter can be problematic with encrustation or infection. Cutaneous vesicostomy is a safe and simple method of surgical bladder drainage in children with obstructed or dysfunctional lower urinary tracts. While they are usually used as a temporary measure until continent reconstruction is achieved, some children end up with vesicostomies for an extended period.2 Children with low pressure storage need regular drainage to protect the upper tracts and would be a safe group for consideration for cystostomy button insertion.
FIG. 1. Bladder is mobilized through small Pfannenstiel incision and stay sutures applied. A, bladder is opened just enough to insert measuring device to gauge button size required. B, appropriate size button is inserted, balloon is inflated with 5 ml water and then bladder can be drained as required.
cause revision of the Monti conduit was declined by the patient. Three children who underwent major bladder neck reconstruction had a button inserted postoperatively to facilitate bladder drainage, cycling and training. One child had previous surgery for a pelvic rhabdomyosarcoma and again had a button inserted as a temporary measure while he learned CISC. Two children with bilateral hydronephrosis and severe vesicoureteral reflux had a button inserted to aid bladder emptying. Of these children 1 had a previous vesicostomy but after closure had further problems with urinary infec-
A
B
FIG. 2. A, components of Mic-Key button. B, baby girl with megacystis microcolon syndrome has ileostomy, and cystostomy button helps to drain bladder intermittently.
2606
CYSTOSTOMY BUTTON FOR BLADDER DRAINAGE IN CHILDREN
To our knowledge we report the first series of inserting a button in children, primarily for bladder drainage. Two previous reports described button placement to replace a vesicostomy3 or suprapubic catheter.4 The button was initially described in 1984 as a gastrostomy for enteral feeding, and has shown to have a high patient and parent satisfaction level.5 The silicone button is held at skin level with internal wings or in more recent designs with a balloon filled with water. There is no excessive tubing attached to the skin and, therefore, it appears to be cosmetically superior to standard gastrostomy tubes. The buttons come in a variety of sizes and are measured to fit each patient. One advantage is the ability to change the buttons on a ward or in a home setting without the need for a general anesthetic. The Mic-Key buttons are held in place with a balloon filled with water and can be easily removed and reinserted, although as a result they are more prone to misplacement. This is only a problem during the early postoperative period when an immature tract may close over. With gastrostomy buttons the formation of excess granulation tissue can be problematic, but we did not encounter this problem in our series.6 The use of a gastrostomy button in the bladder was initially described in 1996 by de Badiola et al using a Bard® Button.3 The technique allowed for clinical and urodynamic evaluation before vesicostomy closure in 3 children, 1 with prune belly syndrome and 2 with cloacal anomalies. The button was inserted just before vesicostomy closure to evaluate bladder emptying, compliance, continence and changes to the upper tracts during several weeks. In the 4 weeks that these buttons were used they reported no urinary infection, encrustation or lithiasis, and bladder function during this temporary occlusion was predictive of future bladder function. In 2003 Bennett et al from Cincinnati reviewed 19 adult patients with neurogenic bladder, and specifically looked at infection, encrustation and erosion rates and quality of life.4 Although all patients reported an improvement in quality of life, only 9 completed the study due to problems with button
length. Six urinary infections were seen in 3 patients with a mean followup of 19 months and none of the 9 patients who completed the study had erosions at skin level. Cystostomy buttons allow bladder training and cycling by the introduction of a clamp and release program. They are cosmetically acceptable and allow children to maintain a more normal lifestyle without always having a bag attached. Thus, they can go swimming. CONCLUSIONS This preliminary study suggests a cystostomy button should be considered to facilitate bladder drainage in the short and long-term in appropriately selected patients.
Abbreviations and Acronyms CISC ⫽ clean intermittent self-catheterization REFERENCES 1.
Wyndaele JJ and Maes D: Clean intermittent self-catheterization: a 12-year followup. J Urol 1990; 143: 906. 2. Hutcheson JC, Cooper CS, Canning DA, Zderic SA and Snyder HM 3rd: The use of vesicostomy as permanent urinary diversion in the child with myelomeningocele. J Urol 2001; 166: 2351. 3. de Badiola FI, Denes ED, Ruiz E, Smith C, Bukowski T and Gonzalez R: New application of the gastrostomy button for clinical and urodynamic evaluation before vesicostomy closure. J Urol 1996; 156: 618. 4. Bennett SG, Bennett S and Bell TE: The gastrostomy button as a catheterizable urinary stoma: a pilot study. J Urol 2003; 170: 832. 5. Gauderer MW, Picha GJ and Izant RJ Jr: The gastrostomy “button”– a simple, skin-level, nonrefluxing device for longterm enteral feedings. J Pediatr Surg 1984; 19: 803. 6. Freeman JK: Experience with a new technique of primary gastrostomy button placement in association with the Nissen fundoplication. Pediatr Surg Int 1998; 13: 451.
Purpose: The “button” enteral feeding systems are widely used as a gastrostomy. We describe our use of this device to facilitate bladder drainage in children. Materials and Methods: We prospectively reviewed all patients who underwent insertion of a cystostomy button between 2002 and 2005. Indications and complications were analyzed. Results: A total of 17 children (8 female, 9 male) with a mean age of 7.1 years underwent insertion of a cystostomy button during the 4-year period. Mean followup was 16 months (range 2 to 40). Cases selected included those with a neuropathic bladder, prune belly syndrome, previous major bladder neck surgery and those unsuitable for Mitrofanoff stoma formation. Complications included 1 wound infection treated with antibiotics. Four children had leakage from the cystostomy site that was successfully treated with a change in button size, and 14 buttons remain in situ. Conclusions: Button cystostomy is a safe and effective form of bladder drainage in children. It is a good alternative to standard suprapubic drainage and it gives children an improved quality of life. Key Words: bladder, drainage, cystostomy
hildren with many underlying conditions require bladder drainage to protect the upper tracts. Historically, different methods of bladder drainage have been used. The least invasive is clean intermittent selfcatheterization while the most common surgical method is vesicostomy. The placement of a suprapubic catheter is used in many circumstances as a temporary method of bladder drainage. We performed insertion of a cystostomy button as an alternative form of suprapubic drainage in children and review our preliminary results here.
C
MATERIALS AND METHODS Between 2002 and 2005 children requiring bladder drainage were considered for placement of a cystostomy button. Through a mini Pfannenstiel incision the rectus muscle was split and the bladder identified and mobilized (fig. 1). The bladder was opened using diathermy between stay sutures. A button measuring device allowing the surgeon to gauge the length of button required was inserted. It was then replaced with a button of suitable length and its balloon inflated with 5 ml sterile water. We found a 14Fr Mic-Key button (Kimberly-Clark/Ballard, Roswell, Georgia) to be the most suitable (fig. 2). The skin was closed around the button and apposed with steristrips. The bladder could be emptied as required using the tubing for the Mic-Key button, which is simply attached and allows free drainage. The procedure was covered with 3 doses of intravenous gentamicin (7.5 mg/kg) and all patients then remained on prophylactic antiStudy received department and institutional guidelines and review committee approval. * Correspondence: Department of Paediatric Urology, Level 4 Gledhow Wing, Nephrology Secretary Office, St. James University Hospital, Beckett’s St., Leeds LS9 7TF United Kingdom (telephone: ⫹44 113 2064840; FAX: ⫹44 113 2066634).
0022-5347/07/1786-2604/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION
biotics. Buttons were routinely changed every 3 months either on the ward or in the community by a urology nurse specialist. RESULTS In the 4 years from 2002 to 2005 there were 17 children (8 female, 9 male) with a mean age of 7.1 years for whom placement of a cystostomy button was considered suitable as an alternative form of bladder drainage. Four children with a neuropathic bladder who had initially been treated with CISC were offered the button to improve quality of life. These children all had a primary button placed using the technique described. One child with prune belly syndrome had a previous vesicostomy but this had caused problems with urinary retention due to a stricture and a button was therefore inserted as an alternative form of drainage. One child with the DIDMOAD syndrome (a hereditary condition characterized by multiple symptoms including Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness, also known as the Wolfram syndrome) was obese and partially blind. A Mitrofanoff stoma was considered unsuitable in this case and, therefore, a button was inserted. Two further children refused to consent to a Mitrofanoff stoma, 1 with a history of posterior urethral valves and 1 with spina bifida. The latter patient did consent to bladder augmentation but declined the Mitrofanoff procedure. Ileocystoplasty was performed and a suprapubic catheter initially left in situ. This was later changed to a button for 6 months, although it was subsequently removed when the child was happy with CISC. One child born with a cloaca underwent ileocystoplasty and a Yang-Monti procedure. However, a kink in the Monti tube prevented successful CISC. A button was inserted be-
2604
Vol. 178, 2604-2606, December 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.08.031
CYSTOSTOMY BUTTON FOR BLADDER DRAINAGE IN CHILDREN
2605
tions. One child had a history of posterior urethral valves and poor renal function. A baby born with megacystis microcolon syndrome required an ileostomy, and a cystostomy button was inserted simultaneously to facilitate bladder drainage while she awaits further treatment. All buttons were inserted into the bladder as previously described. All procedures were successful and uneventful, with a mean followup of 16 months (range 2 to 40). Complications in our series include 1 case of wound infection which responded to antibiotics. Urine culture was negative but wound swab grew staphylococcus aureus, and was treated with flucloxacillin. Four children had significant leakage after the insertion period. One settled with time while the others required the button to be changed to a shorter length and tighter fit once the tract was well established. None of the children requiring a shorter button had any further problems with leakage or stoma erosion. There were no children with lithiasis. All patients, especially the older children, believed the button gave them an improved quality of life. However, this was not formally assessed. Of the 17 buttons 3 have now been removed as many of them were used as a temporary measure. DISCUSSION Adequate bladder drainage can be achieved with CISC, the use of a suprapubic catheter or a surgical vesicostomy. For those who do not have a sensate urethra, CISC remains an excellent option. Complications are rare but include hematuria, urethral erosion and strictures, creation of false passages, and epididymitis.1 Suprapubic catheters are excellent for short-term use. However, this can be restrictive for patients as they must carry around excess tubing and a bag. The skin site surrounding a catheter can be problematic with encrustation or infection. Cutaneous vesicostomy is a safe and simple method of surgical bladder drainage in children with obstructed or dysfunctional lower urinary tracts. While they are usually used as a temporary measure until continent reconstruction is achieved, some children end up with vesicostomies for an extended period.2 Children with low pressure storage need regular drainage to protect the upper tracts and would be a safe group for consideration for cystostomy button insertion.
FIG. 1. Bladder is mobilized through small Pfannenstiel incision and stay sutures applied. A, bladder is opened just enough to insert measuring device to gauge button size required. B, appropriate size button is inserted, balloon is inflated with 5 ml water and then bladder can be drained as required.
cause revision of the Monti conduit was declined by the patient. Three children who underwent major bladder neck reconstruction had a button inserted postoperatively to facilitate bladder drainage, cycling and training. One child had previous surgery for a pelvic rhabdomyosarcoma and again had a button inserted as a temporary measure while he learned CISC. Two children with bilateral hydronephrosis and severe vesicoureteral reflux had a button inserted to aid bladder emptying. Of these children 1 had a previous vesicostomy but after closure had further problems with urinary infec-
A
B
FIG. 2. A, components of Mic-Key button. B, baby girl with megacystis microcolon syndrome has ileostomy, and cystostomy button helps to drain bladder intermittently.
2606
CYSTOSTOMY BUTTON FOR BLADDER DRAINAGE IN CHILDREN
To our knowledge we report the first series of inserting a button in children, primarily for bladder drainage. Two previous reports described button placement to replace a vesicostomy3 or suprapubic catheter.4 The button was initially described in 1984 as a gastrostomy for enteral feeding, and has shown to have a high patient and parent satisfaction level.5 The silicone button is held at skin level with internal wings or in more recent designs with a balloon filled with water. There is no excessive tubing attached to the skin and, therefore, it appears to be cosmetically superior to standard gastrostomy tubes. The buttons come in a variety of sizes and are measured to fit each patient. One advantage is the ability to change the buttons on a ward or in a home setting without the need for a general anesthetic. The Mic-Key buttons are held in place with a balloon filled with water and can be easily removed and reinserted, although as a result they are more prone to misplacement. This is only a problem during the early postoperative period when an immature tract may close over. With gastrostomy buttons the formation of excess granulation tissue can be problematic, but we did not encounter this problem in our series.6 The use of a gastrostomy button in the bladder was initially described in 1996 by de Badiola et al using a Bard® Button.3 The technique allowed for clinical and urodynamic evaluation before vesicostomy closure in 3 children, 1 with prune belly syndrome and 2 with cloacal anomalies. The button was inserted just before vesicostomy closure to evaluate bladder emptying, compliance, continence and changes to the upper tracts during several weeks. In the 4 weeks that these buttons were used they reported no urinary infection, encrustation or lithiasis, and bladder function during this temporary occlusion was predictive of future bladder function. In 2003 Bennett et al from Cincinnati reviewed 19 adult patients with neurogenic bladder, and specifically looked at infection, encrustation and erosion rates and quality of life.4 Although all patients reported an improvement in quality of life, only 9 completed the study due to problems with button
length. Six urinary infections were seen in 3 patients with a mean followup of 19 months and none of the 9 patients who completed the study had erosions at skin level. Cystostomy buttons allow bladder training and cycling by the introduction of a clamp and release program. They are cosmetically acceptable and allow children to maintain a more normal lifestyle without always having a bag attached. Thus, they can go swimming. CONCLUSIONS This preliminary study suggests a cystostomy button should be considered to facilitate bladder drainage in the short and long-term in appropriately selected patients.
Abbreviations and Acronyms CISC ⫽ clean intermittent self-catheterization REFERENCES 1.
Wyndaele JJ and Maes D: Clean intermittent self-catheterization: a 12-year followup. J Urol 1990; 143: 906. 2. Hutcheson JC, Cooper CS, Canning DA, Zderic SA and Snyder HM 3rd: The use of vesicostomy as permanent urinary diversion in the child with myelomeningocele. J Urol 2001; 166: 2351. 3. de Badiola FI, Denes ED, Ruiz E, Smith C, Bukowski T and Gonzalez R: New application of the gastrostomy button for clinical and urodynamic evaluation before vesicostomy closure. J Urol 1996; 156: 618. 4. Bennett SG, Bennett S and Bell TE: The gastrostomy button as a catheterizable urinary stoma: a pilot study. J Urol 2003; 170: 832. 5. Gauderer MW, Picha GJ and Izant RJ Jr: The gastrostomy “button”– a simple, skin-level, nonrefluxing device for longterm enteral feedings. J Pediatr Surg 1984; 19: 803. 6. Freeman JK: Experience with a new technique of primary gastrostomy button placement in association with the Nissen fundoplication. Pediatr Surg Int 1998; 13: 451.