- Email: [email protected]
Extravesical Implantation of a Continent Catheterizable Channel
Extravesical Implantation of a Continent Catheterizable Channel Brian A. VanderBrink,* Martin Kaefer, Mark P. Cain, Kirstan K. Meldrum, Rosalia Misseri and Richard C. Rink From the Division of Urology, Nationwide Children’s Hospital, Columbus, Ohio
Abbreviation and Acronym CCC ⫽ continent catheterizable channel Study received institutional review board approval. * Correspondence: Division of Urology, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, Ohio 43205 (telephone: 614-722-6625; fax: 614-722-6627; e-mail: brianvanderbrink@ yahoo.com).
Purpose: Extravesical ureteral reimplantation provides results equivalent to those of the open technique with the advantage of less postoperative morbidity from a large cystotomy. Surgical series describing the technique and efficacy of extravesical implantation of continent catheterizable channel are lacking. We reviewed our results to determine the efficacy of this technique with an emphasis on continence and the need for revision. Materials and Methods: We reviewed the records of 394 patients who underwent a bladder continent catheterizable channel procedure from 1999 to 2009. Operative records describing an extravesical technique were noted. Briefly, a 3 to 6 cm incision is made in the detrusor and seromuscular flaps are created. The continent catheterizable channel is laid in the tunnel and the flaps are brought anterior to the channel and sutured to each other. Fixation of the bladder wall to the abdominal wall preserves tunnel length and minimizes the risk of angulation. The type of continent catheterizable channel, stomal continence and the need for revision were recorded. Results: The extravesical implantation technique of a continent catheterizable channel was done in 84 of 394 patients (21%). The channel was an appendix in 47 cases and Monti ileovesicostomy in 37. Stomal continence was achieved in 79 of 84 cases (94%). At a mean followup of 45 months 22 patients (26%) required a total of 30 surgical revisions, of which most were skin level or endoscopic procedures at a mean of 26 months after channel creation. Conclusions: The extravesical technique for continent catheterizable channel implantation is effective. If intravesical surgery is not necessary, avoidance of a large cystotomy and longer operative time may expedite postoperative recovery when using an extravesical implantation technique to create a continent catheterizable channel. Key Words: urinary bladder, appendix, transplantation, catheterization, urinary continence
2572
www.jurology.com
NONSURGICAL and medical management strategies are the preferred initial therapies to treat and minimize morbidity resulting from urinary incontinence. In the population with neuropathy such as spina bifida or spinal cord injury there can be refractory cases and surgical intervention may then be appropriate to achieve urinary continence.1 In some patients
poor bladder outlet resistance may be responsible for urinary incontinence. Bladder neck reconstruction is often required, which may make catheterization via the native urethra difficult postoperatively. Mitrofanoff revolutionized urinary tract reconstruction with his description of appendicovesicostomy as a means to create a reliable bladder
0022-5347/11/1856-2572/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 185, 2572-2575, June 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.01.027
AND
RESEARCH, INC.
EXTRAVESICAL IMPLANTATION OF CONTINENT CATHETERIZABLE CHANNEL
2573
emptying alternative to the urethra.2 Since this seminal report, CCCs have been important components of the surgical armamentarium to plan reconstruction in these challenging circumstances. CCCs have been constructed from various tissues beside the appendix, including ureter, small or large bowel, stomach, preputial skin and vas deferens.3–7 The most common surgical technique for appendicovesicostomy involves creating a neohiatus in the bladder, which the appendix is passed through. Subsequently in a fashion to that of similar ureteroneocystostomy a submucosal tunnel is created of sufficient length to provide a reliable continence mechanism. The appendix is placed in this tunnel and an appendiceal mucosa-to-urothelium anastomosis is formed in the bladder. The contralateral end of the appendix is then brought up to the skin for stoma maturation. Extravesical ureteral reimplantation is a surgical technique with results equivalent to those of open intravesical reimplantation with the advantage of less postoperative morbidity.8 –10 Series describing the technique and efficacy of extravesical implantation of a CCC during urinary reconstruction are sparse.11,12 We reviewed our results using this technique in a large number of patients to determine its efficacy with an emphasis on the outcomes of stomal continence and any need for further revision.
METHODS Institutional review board approval was obtained, which allowed a retrospective review of the operative records of CCC creation at James Whitcomb Riley Hospital for Children from 1999 to 2009. Patients who underwent extravesical implantation were identified in this detailed review. Briefly, in our surgical technique step 1 is CCC creation. Appendix or reconfigured ileum is isolated or created, depending on the tissue used, via a lower midline incision. The contralateral side of the bladder from the site of CCC implantation is mobilized to allow adequate bladder mobility and properly align the implantation site. We prefer to implant the extravesical CCC in the anterolateral bladder wall for a number of reasons so that any potential future midline anterior cystotomy would be possible without cutting directly across the channel. If necessary, this route also allows clamshell or stellate detrusor incisions at metachronous augmentation cystoplasty, avoiding the need to reroute the CCC. A 3 to 6 cm detrusorotomy is outlined and formed (part A of figure). Seromuscular flaps are raised on either side of the incision to expose the underlying mucosa with the bladder distended to facilitate dissection (part B of figure). A hole is made in the bladder mucosa, where an enteric mucosa-to-urothelium anastomosis is formed. The seromuscular flaps are brought anterior to the CCC to provide the muscular backing for the reliable continence mechanism (part C of figure). We secure the tunnel to the posterior peritoneum and abdominal wall to preserve tunnel
Intraoperative photographs. A, proposed incision along exposed bladder anterolateral aspect with appendix isolated alongside on mesentery. B, seromuscular flaps are raised, allowing underlying bladder mucosa to bulge into trough. Created tunnel length is approximately 5 cm. C, completed extravesical CCC implantation after appendiceal anastomosis to urothelium and suturing of seromuscular flaps anterior.
length and minimize the risk of angulation while catheterizing the CCC. The stoma is created by anastomosis of a U-shaped skin flap to the apex of the spatulated portion of the CCC. No effort is made to conceal the mucocutaneous anastomosis since we believe that this may influence the risk of stomal stenosis. In all patients the underlying diagnosis causing urinary incontinence was recorded. All had been treated with medical therapy for a minimum of 12 months before surgical reconstruction. Age at surgery, followup after surgery, channel continence status and complications requiring additional anesthetics for treatment, ie difficult catheterization or stomal stenosis, were recorded.
RESULTS Of 394 children who underwent CCC creation during the study period 84 (21%) were identified in
2574
EXTRAVESICAL IMPLANTATION OF CONTINENT CATHETERIZABLE CHANNEL
whom an extravesical implantation technique was used. The CCC was appendix in 47 patients and reconfigured ileum (Monti) in 37. Mean ⫾ SD age at surgery was 12 ⫾ 6 years (range 3 to 26). Myelomeningocele was the most common diagnosis of the patients undergoing surgery (42 patients). The remaining patients had posterior urethral valves (11), spinal cord injury (9), cloacal anomaly and nonneurogenic bladder (4 each), prune-belly syndrome and epispadias-exstrophy complex (3 each), and cerebral palsy (1). Concomitant reconstructive procedures were performed in 48 patients, including a bladder outlet procedure in 25, bladder augmentation in 24, a Malone antegrade continence enema procedure in 19 and antireflux surgery in 8. Bladder outlet procedures consisted of an isolated bladder neck sling in 16 patients and bladder neck reconstruction in 5 while the remaining 4 underwent a sling procedure with bladder neck reconstruction. Antireflux surgical procedures consisted of endoscopic injection therapy in 4 patients and extravesical ureteral reimplantation in 3. One patient underwent open cross-trigonal ureteral reimplantation, which did not affect the CCC implant since CCC was implanted on the bladder anterolateral wall. Immediately after CCC creation 79 of 84 stomas (94%) achieved continence. All 5 incontinent stomas were salvaged by additional surgical procedures. Stomal incontinence was treated with endoscopic injection of dextranomer-hyaluronic acid in 4 of the patients with stomal incontinence. Success was achieved in half of them by a single injection and 3 of the 4 total injected patients. The remaining 2 patients with stomal incontinence underwent subfascial revision of the antireflux tunnel due to failed endoscopic treatment or delayed ileocystoplasty. The 2 patients who underwent open revision of the continence mechanism showed channel effacement due to the loss of seromuscular backing. These 2 channels were revised by the extravesical implantation technique. In 1 patient concomitant augmentation cystoplasty was done for a low capacity, poorly compliant bladder, which was thought to contribute to stomal incontinence. The 22 patients (26%) required a total of 30 surgical revisions during the mean 48-month followup. Mean time to revision in these patients was 26 ⫾ 24 months (range 4 to 103) after CCC creation. Reasons for channel revision were stomal stenosis in 9 patients, difficult catheterization in 6, stomal incontinence in 5, polyp excision in 1 and pain with bladder catheterization requiring rerouting of the intravesical portion of the appendicovesicostomy in 1. Of the 30 revisions 22 (73%) were outpatient procedures at the skin level or endoscopic and the remainder required a subfascial approach. We noted no influence
of umbilical vs lower abdominal stomal site on the incidence of surgical revision.
DISCUSSION CCC has become an important means to achieve urinary continence in the patient with incontinence. Traditional CCC implantation techniques involve an intravesical approach with the need for long cystotomy to provide adequate exposure and its attendant morbidity, such as spasm and hematuria. CCC implantation using an extravesical technique resulted in an excellent stomal continence rate and an effective conduit to empty the bladder. The 94% stomal continence rate and the 26% surgical revision rate for CCC in our series, exclusively using the extravesical implantation technique, compare favorably to outcomes reported by others using various surgical techniques. 3–18 A 22% surgical revision rate was reported in 199 ileovesicostomies performed in a 13-year period with a mean followup of 28 months.19 The basic tenets of reconstructive surgery, such as delicate tissue handling, preservation of blood supply and achievement of a tensionfree anastomosis, probably contribute more to successful and reproducible outcomes than the tissue composing the CCC. Preoperative assessment of bladder capacity, compliance and outlet resistance is essential to optimize the chance of a successful outcome in reconstructive surgery. Of the patients in this series 57% required additional procedures at extravesical CCC creation to attain the ultimate goal of total urinary and fecal continence. This resulted in varied operative times since the number of procedures varied in the series. Nevertheless, in the absence of an exclusive operative time for extravesical CCC creation it is our subjective opinion that the extravesical CCC implantation technique can be performed more rapidly than an intravesical implantation technique. This is not unexpected, given the decreased operative time needed to close the cystotomy. It is impossible to comment on any potentially decreased morbidity of an extravesical CCC implantation technique compared to an intravesical technique since we did not measure it in our study. The significant incidence of underlying neuropathic conditions in the patients and the administration of anticholinergics in all patients who underwent CCC creation made assessing any differences in morbidity between the 2 techniques challenging.
CONCLUSIONS The CCC extravesical implantation technique is effective and provides a reliable continence mechanism while avoiding a large cystotomy when in-
EXTRAVESICAL IMPLANTATION OF CONTINENT CATHETERIZABLE CHANNEL
travesical surgery is not planned. This could potentially minimize the postoperative morbidity of bladder spasms and hematuria, resulting in expedited convalescence. The surgical revision rate in
2575
the series was comparable to previously reported rates. Most revisions, when needed, were outpatient procedures done at the skin level or endoscopically.
REFERENCES 1. MacLellan DL: Management of pediatric neurogenic bladder. Curr Opin Urol 2009; 19: 407.
correct vesicoureteral reflux in children. J Urol 1987; 138: 947.
2. Mitrofanoff P: Trans-appendicular continent cystostomy in the management of the neurogenic bladder. Chir Pediatr 1980; 21: 297.
9. Ellsworth PI and Merguerian PA: Detrusorrhaphy for the repair of vesicoureteral reflux: comparison with the Leadbetter-Politano ureteroneocystostomy. J Pediatr Surg 1995; 30: 600.
3. Dykes EH, Duffy PG and Ransley PG: The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children. J Pediatr Surg 1991; 26: 535. 4. Monti PR, de Carvalho JR and Arap S: The Monti procedure: application and complications. Urology 2000; 55: 616.
10. Schwentner C, Oswald J, Lunacek A et al: LichGregoir reimplantation causes less discomfort than Politano-Leadbetter technique: results of a prospective, randomized, pain scale-oriented study in a pediatric population. Eur Urol 2006; 49: 388.
5. Mor Y, Kajbafzadeh AM, German K et al: The role of ureter in the creation of Mitrofanoff channels in children. J Urol 1997; 157: 635.
11. Perovic´ S, Sremcevic´ D, Milanovic´ D et al: Extravesical detrusor tunneling: a variant of antireflux procedure. Eur J Pediatr Surg 1996; 6: 216.
6. Borzi P and Gough DC: Pedicled gastric tube as a catheterising conduit. Eur Urol 1993; 24: 103.
12. Radojicic ZI, Perovic SV, Vukadinovic VM et al: Refluxing megaureter for the Mitrofanoff channel using continent extravesical detrusor tunneling procedure. J Urol 2005; 174: 693.
7. Perovic S: Continent urinary diversion using preputial penile or clitoral skin flap. J Urol 1996; 155: 1402. 8. Zaontz MR, Maizels M, Sugar EC et al: Detrusorrhaphy: extravesical ureteral advancement to
13. Cain MP, Dussinger AM, Gitlin J et al: Updated experience with the Monti catheterizable channel. Urology 2008; 72: 782.
14. Liard A, Séguier-Lipszyc E, Mathiot A et al: The Mitrofanoff procedure: 20 years later. J Urol 2001; 165: 2394. 15. Harris CF, Cooper CS, Hutcheson JC et al: Appendicovesicostomy: the Mitrofanoff procedure—a 15-year perspective. J Urol 2000; 163: 1922. 16. Kaefer M, Tobin MS, Hendren WH et al: Continent urinary diversion: the Children’s Hospital experience. J Urol 1997; 157: 1394. 17. Van Savage JG, Khoury AE, McLorie GA et al: Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol 1996; 156: 1794. 18. Pedraza R, Weiser A and Franco I: Laparoscopic appendicovesicostomy (Mitrofanoff procedure) in a child using the da Vinci robotic system. J Urol 2004; 171: 1652. 19. Nguyen HT, Passerotti CC, Penna FJ et al: Robotic assisted laparoscopic Mitrofanoff appendicovesicostomy: preliminary experience in a pediatric population. J Urol 2009; 182: 1528.
EDITORIAL COMMENT These authors report on 396 patients who underwent CCC creation. The channel was implanted in the anterolateral wall of the native bladder in 84 patients (21%), 26% required revision and a final continent stoma was achieved in 94%. This large series speaks to the technical expertise of the surgeons involved. Presumably in the other cases the CCC was implanted in the bowel augment. Other surgeons have preferred CCC implantation into the intestinal segment rather than the native bladder and achieved a comparable 87.5% success rate.1 In my opinion CCC implantation in the native bladder is preferable, provided that the bladder wall is relatively healthy. However, if the bladder is fibrotic and/or small, the surgeon should implant the CCC in the intestinal segment. For several years I have used the subserosal tunnel, as reported by Abol-Enein and Ghoneim.2 This
technique proved to be more reliable to create a valve mechanism than submucosal tunneling into the bowel. This method was applied in all of my recent patients with cloacal exstrophy who had an unhealthy bladder, of which most required augmentation, and in many of my other patients with a small capacity bladder requiring required enterocystoplasty. The basic principle in these cases is to create the shortest possible distance between the CCC as it exits the reservoir, and the stomal site, whether it is in the umbilicus or the skin of the iliac region. Moneer K. Hanna Department of Urology New York Presbyterian-Weill Cornell Medical Center New York, New York
REFERENCES 1. Franc-Guimond J and Gonzalez R: Effectiveness of implanting catheterizable channels into intestinal segments. J Pediatr Urol 2006; 2: 31. 2. Abol-Enein H and Ghoneim MA: Serous lined extramural ileal sleeve, a new continent urinary outlet. J Urol 1999; 161: 786.
Abbreviation and Acronym CCC ⫽ continent catheterizable channel Study received institutional review board approval. * Correspondence: Division of Urology, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, Ohio 43205 (telephone: 614-722-6625; fax: 614-722-6627; e-mail: brianvanderbrink@ yahoo.com).
Purpose: Extravesical ureteral reimplantation provides results equivalent to those of the open technique with the advantage of less postoperative morbidity from a large cystotomy. Surgical series describing the technique and efficacy of extravesical implantation of continent catheterizable channel are lacking. We reviewed our results to determine the efficacy of this technique with an emphasis on continence and the need for revision. Materials and Methods: We reviewed the records of 394 patients who underwent a bladder continent catheterizable channel procedure from 1999 to 2009. Operative records describing an extravesical technique were noted. Briefly, a 3 to 6 cm incision is made in the detrusor and seromuscular flaps are created. The continent catheterizable channel is laid in the tunnel and the flaps are brought anterior to the channel and sutured to each other. Fixation of the bladder wall to the abdominal wall preserves tunnel length and minimizes the risk of angulation. The type of continent catheterizable channel, stomal continence and the need for revision were recorded. Results: The extravesical implantation technique of a continent catheterizable channel was done in 84 of 394 patients (21%). The channel was an appendix in 47 cases and Monti ileovesicostomy in 37. Stomal continence was achieved in 79 of 84 cases (94%). At a mean followup of 45 months 22 patients (26%) required a total of 30 surgical revisions, of which most were skin level or endoscopic procedures at a mean of 26 months after channel creation. Conclusions: The extravesical technique for continent catheterizable channel implantation is effective. If intravesical surgery is not necessary, avoidance of a large cystotomy and longer operative time may expedite postoperative recovery when using an extravesical implantation technique to create a continent catheterizable channel. Key Words: urinary bladder, appendix, transplantation, catheterization, urinary continence
2572
www.jurology.com
NONSURGICAL and medical management strategies are the preferred initial therapies to treat and minimize morbidity resulting from urinary incontinence. In the population with neuropathy such as spina bifida or spinal cord injury there can be refractory cases and surgical intervention may then be appropriate to achieve urinary continence.1 In some patients
poor bladder outlet resistance may be responsible for urinary incontinence. Bladder neck reconstruction is often required, which may make catheterization via the native urethra difficult postoperatively. Mitrofanoff revolutionized urinary tract reconstruction with his description of appendicovesicostomy as a means to create a reliable bladder
0022-5347/11/1856-2572/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 185, 2572-2575, June 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.01.027
AND
RESEARCH, INC.
EXTRAVESICAL IMPLANTATION OF CONTINENT CATHETERIZABLE CHANNEL
2573
emptying alternative to the urethra.2 Since this seminal report, CCCs have been important components of the surgical armamentarium to plan reconstruction in these challenging circumstances. CCCs have been constructed from various tissues beside the appendix, including ureter, small or large bowel, stomach, preputial skin and vas deferens.3–7 The most common surgical technique for appendicovesicostomy involves creating a neohiatus in the bladder, which the appendix is passed through. Subsequently in a fashion to that of similar ureteroneocystostomy a submucosal tunnel is created of sufficient length to provide a reliable continence mechanism. The appendix is placed in this tunnel and an appendiceal mucosa-to-urothelium anastomosis is formed in the bladder. The contralateral end of the appendix is then brought up to the skin for stoma maturation. Extravesical ureteral reimplantation is a surgical technique with results equivalent to those of open intravesical reimplantation with the advantage of less postoperative morbidity.8 –10 Series describing the technique and efficacy of extravesical implantation of a CCC during urinary reconstruction are sparse.11,12 We reviewed our results using this technique in a large number of patients to determine its efficacy with an emphasis on the outcomes of stomal continence and any need for further revision.
METHODS Institutional review board approval was obtained, which allowed a retrospective review of the operative records of CCC creation at James Whitcomb Riley Hospital for Children from 1999 to 2009. Patients who underwent extravesical implantation were identified in this detailed review. Briefly, in our surgical technique step 1 is CCC creation. Appendix or reconfigured ileum is isolated or created, depending on the tissue used, via a lower midline incision. The contralateral side of the bladder from the site of CCC implantation is mobilized to allow adequate bladder mobility and properly align the implantation site. We prefer to implant the extravesical CCC in the anterolateral bladder wall for a number of reasons so that any potential future midline anterior cystotomy would be possible without cutting directly across the channel. If necessary, this route also allows clamshell or stellate detrusor incisions at metachronous augmentation cystoplasty, avoiding the need to reroute the CCC. A 3 to 6 cm detrusorotomy is outlined and formed (part A of figure). Seromuscular flaps are raised on either side of the incision to expose the underlying mucosa with the bladder distended to facilitate dissection (part B of figure). A hole is made in the bladder mucosa, where an enteric mucosa-to-urothelium anastomosis is formed. The seromuscular flaps are brought anterior to the CCC to provide the muscular backing for the reliable continence mechanism (part C of figure). We secure the tunnel to the posterior peritoneum and abdominal wall to preserve tunnel
Intraoperative photographs. A, proposed incision along exposed bladder anterolateral aspect with appendix isolated alongside on mesentery. B, seromuscular flaps are raised, allowing underlying bladder mucosa to bulge into trough. Created tunnel length is approximately 5 cm. C, completed extravesical CCC implantation after appendiceal anastomosis to urothelium and suturing of seromuscular flaps anterior.
length and minimize the risk of angulation while catheterizing the CCC. The stoma is created by anastomosis of a U-shaped skin flap to the apex of the spatulated portion of the CCC. No effort is made to conceal the mucocutaneous anastomosis since we believe that this may influence the risk of stomal stenosis. In all patients the underlying diagnosis causing urinary incontinence was recorded. All had been treated with medical therapy for a minimum of 12 months before surgical reconstruction. Age at surgery, followup after surgery, channel continence status and complications requiring additional anesthetics for treatment, ie difficult catheterization or stomal stenosis, were recorded.
RESULTS Of 394 children who underwent CCC creation during the study period 84 (21%) were identified in
2574
EXTRAVESICAL IMPLANTATION OF CONTINENT CATHETERIZABLE CHANNEL
whom an extravesical implantation technique was used. The CCC was appendix in 47 patients and reconfigured ileum (Monti) in 37. Mean ⫾ SD age at surgery was 12 ⫾ 6 years (range 3 to 26). Myelomeningocele was the most common diagnosis of the patients undergoing surgery (42 patients). The remaining patients had posterior urethral valves (11), spinal cord injury (9), cloacal anomaly and nonneurogenic bladder (4 each), prune-belly syndrome and epispadias-exstrophy complex (3 each), and cerebral palsy (1). Concomitant reconstructive procedures were performed in 48 patients, including a bladder outlet procedure in 25, bladder augmentation in 24, a Malone antegrade continence enema procedure in 19 and antireflux surgery in 8. Bladder outlet procedures consisted of an isolated bladder neck sling in 16 patients and bladder neck reconstruction in 5 while the remaining 4 underwent a sling procedure with bladder neck reconstruction. Antireflux surgical procedures consisted of endoscopic injection therapy in 4 patients and extravesical ureteral reimplantation in 3. One patient underwent open cross-trigonal ureteral reimplantation, which did not affect the CCC implant since CCC was implanted on the bladder anterolateral wall. Immediately after CCC creation 79 of 84 stomas (94%) achieved continence. All 5 incontinent stomas were salvaged by additional surgical procedures. Stomal incontinence was treated with endoscopic injection of dextranomer-hyaluronic acid in 4 of the patients with stomal incontinence. Success was achieved in half of them by a single injection and 3 of the 4 total injected patients. The remaining 2 patients with stomal incontinence underwent subfascial revision of the antireflux tunnel due to failed endoscopic treatment or delayed ileocystoplasty. The 2 patients who underwent open revision of the continence mechanism showed channel effacement due to the loss of seromuscular backing. These 2 channels were revised by the extravesical implantation technique. In 1 patient concomitant augmentation cystoplasty was done for a low capacity, poorly compliant bladder, which was thought to contribute to stomal incontinence. The 22 patients (26%) required a total of 30 surgical revisions during the mean 48-month followup. Mean time to revision in these patients was 26 ⫾ 24 months (range 4 to 103) after CCC creation. Reasons for channel revision were stomal stenosis in 9 patients, difficult catheterization in 6, stomal incontinence in 5, polyp excision in 1 and pain with bladder catheterization requiring rerouting of the intravesical portion of the appendicovesicostomy in 1. Of the 30 revisions 22 (73%) were outpatient procedures at the skin level or endoscopic and the remainder required a subfascial approach. We noted no influence
of umbilical vs lower abdominal stomal site on the incidence of surgical revision.
DISCUSSION CCC has become an important means to achieve urinary continence in the patient with incontinence. Traditional CCC implantation techniques involve an intravesical approach with the need for long cystotomy to provide adequate exposure and its attendant morbidity, such as spasm and hematuria. CCC implantation using an extravesical technique resulted in an excellent stomal continence rate and an effective conduit to empty the bladder. The 94% stomal continence rate and the 26% surgical revision rate for CCC in our series, exclusively using the extravesical implantation technique, compare favorably to outcomes reported by others using various surgical techniques. 3–18 A 22% surgical revision rate was reported in 199 ileovesicostomies performed in a 13-year period with a mean followup of 28 months.19 The basic tenets of reconstructive surgery, such as delicate tissue handling, preservation of blood supply and achievement of a tensionfree anastomosis, probably contribute more to successful and reproducible outcomes than the tissue composing the CCC. Preoperative assessment of bladder capacity, compliance and outlet resistance is essential to optimize the chance of a successful outcome in reconstructive surgery. Of the patients in this series 57% required additional procedures at extravesical CCC creation to attain the ultimate goal of total urinary and fecal continence. This resulted in varied operative times since the number of procedures varied in the series. Nevertheless, in the absence of an exclusive operative time for extravesical CCC creation it is our subjective opinion that the extravesical CCC implantation technique can be performed more rapidly than an intravesical implantation technique. This is not unexpected, given the decreased operative time needed to close the cystotomy. It is impossible to comment on any potentially decreased morbidity of an extravesical CCC implantation technique compared to an intravesical technique since we did not measure it in our study. The significant incidence of underlying neuropathic conditions in the patients and the administration of anticholinergics in all patients who underwent CCC creation made assessing any differences in morbidity between the 2 techniques challenging.
CONCLUSIONS The CCC extravesical implantation technique is effective and provides a reliable continence mechanism while avoiding a large cystotomy when in-
EXTRAVESICAL IMPLANTATION OF CONTINENT CATHETERIZABLE CHANNEL
travesical surgery is not planned. This could potentially minimize the postoperative morbidity of bladder spasms and hematuria, resulting in expedited convalescence. The surgical revision rate in
2575
the series was comparable to previously reported rates. Most revisions, when needed, were outpatient procedures done at the skin level or endoscopically.
REFERENCES 1. MacLellan DL: Management of pediatric neurogenic bladder. Curr Opin Urol 2009; 19: 407.
correct vesicoureteral reflux in children. J Urol 1987; 138: 947.
2. Mitrofanoff P: Trans-appendicular continent cystostomy in the management of the neurogenic bladder. Chir Pediatr 1980; 21: 297.
9. Ellsworth PI and Merguerian PA: Detrusorrhaphy for the repair of vesicoureteral reflux: comparison with the Leadbetter-Politano ureteroneocystostomy. J Pediatr Surg 1995; 30: 600.
3. Dykes EH, Duffy PG and Ransley PG: The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children. J Pediatr Surg 1991; 26: 535. 4. Monti PR, de Carvalho JR and Arap S: The Monti procedure: application and complications. Urology 2000; 55: 616.
10. Schwentner C, Oswald J, Lunacek A et al: LichGregoir reimplantation causes less discomfort than Politano-Leadbetter technique: results of a prospective, randomized, pain scale-oriented study in a pediatric population. Eur Urol 2006; 49: 388.
5. Mor Y, Kajbafzadeh AM, German K et al: The role of ureter in the creation of Mitrofanoff channels in children. J Urol 1997; 157: 635.
11. Perovic´ S, Sremcevic´ D, Milanovic´ D et al: Extravesical detrusor tunneling: a variant of antireflux procedure. Eur J Pediatr Surg 1996; 6: 216.
6. Borzi P and Gough DC: Pedicled gastric tube as a catheterising conduit. Eur Urol 1993; 24: 103.
12. Radojicic ZI, Perovic SV, Vukadinovic VM et al: Refluxing megaureter for the Mitrofanoff channel using continent extravesical detrusor tunneling procedure. J Urol 2005; 174: 693.
7. Perovic S: Continent urinary diversion using preputial penile or clitoral skin flap. J Urol 1996; 155: 1402. 8. Zaontz MR, Maizels M, Sugar EC et al: Detrusorrhaphy: extravesical ureteral advancement to
13. Cain MP, Dussinger AM, Gitlin J et al: Updated experience with the Monti catheterizable channel. Urology 2008; 72: 782.
14. Liard A, Séguier-Lipszyc E, Mathiot A et al: The Mitrofanoff procedure: 20 years later. J Urol 2001; 165: 2394. 15. Harris CF, Cooper CS, Hutcheson JC et al: Appendicovesicostomy: the Mitrofanoff procedure—a 15-year perspective. J Urol 2000; 163: 1922. 16. Kaefer M, Tobin MS, Hendren WH et al: Continent urinary diversion: the Children’s Hospital experience. J Urol 1997; 157: 1394. 17. Van Savage JG, Khoury AE, McLorie GA et al: Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol 1996; 156: 1794. 18. Pedraza R, Weiser A and Franco I: Laparoscopic appendicovesicostomy (Mitrofanoff procedure) in a child using the da Vinci robotic system. J Urol 2004; 171: 1652. 19. Nguyen HT, Passerotti CC, Penna FJ et al: Robotic assisted laparoscopic Mitrofanoff appendicovesicostomy: preliminary experience in a pediatric population. J Urol 2009; 182: 1528.
EDITORIAL COMMENT These authors report on 396 patients who underwent CCC creation. The channel was implanted in the anterolateral wall of the native bladder in 84 patients (21%), 26% required revision and a final continent stoma was achieved in 94%. This large series speaks to the technical expertise of the surgeons involved. Presumably in the other cases the CCC was implanted in the bowel augment. Other surgeons have preferred CCC implantation into the intestinal segment rather than the native bladder and achieved a comparable 87.5% success rate.1 In my opinion CCC implantation in the native bladder is preferable, provided that the bladder wall is relatively healthy. However, if the bladder is fibrotic and/or small, the surgeon should implant the CCC in the intestinal segment. For several years I have used the subserosal tunnel, as reported by Abol-Enein and Ghoneim.2 This
technique proved to be more reliable to create a valve mechanism than submucosal tunneling into the bowel. This method was applied in all of my recent patients with cloacal exstrophy who had an unhealthy bladder, of which most required augmentation, and in many of my other patients with a small capacity bladder requiring required enterocystoplasty. The basic principle in these cases is to create the shortest possible distance between the CCC as it exits the reservoir, and the stomal site, whether it is in the umbilicus or the skin of the iliac region. Moneer K. Hanna Department of Urology New York Presbyterian-Weill Cornell Medical Center New York, New York
REFERENCES 1. Franc-Guimond J and Gonzalez R: Effectiveness of implanting catheterizable channels into intestinal segments. J Pediatr Urol 2006; 2: 31. 2. Abol-Enein H and Ghoneim MA: Serous lined extramural ileal sleeve, a new continent urinary outlet. J Urol 1999; 161: 786.