- Email: [email protected]
L Stent for Stomal Stenosis in Catheterizable Channels
L Stent for Stomal Stenosis in Catheterizable Channels Jennie J. Mickelson, Elizabeth B. Yerkes, Theresa Meyer, Bradley P. Kropp and Earl Y. Cheng* From the Division of Pediatric Urology, Children’s Memorial Hospital and Feinberg School of Medicine at Northwestern University, Chicago, Illinois, and University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Abbreviations and Acronyms MACE ⫽ Malone antegrade continent enema Study received institutional review board approval. * Correspondence: Division of Urology, Children’s Memorial Hospital, 2300 Children’s Pl., Box 24, Chicago, Illinois 60614 (telephone: 773880-4428; FAX: 773-880-3339; e-mail: echeng@ childrensmemorial.org).
Purpose: Stomal stenosis in patients with catheterizable channels can be a difficult problem that is managed by surgical revision or dilation. The L stent is a short, knotted catheter that lies flush with skin. The stent is used for any stomal narrowing, typically overnight for several days. The stent bridges the area of stenosis without passing into bowel or bladder lumen. We assessed whether the L stent is effective for preventing and managing stomal stenosis. Materials and Methods: We retrospectively reviewed the records of patients with catheterizable channels. A telephone survey and chart review were done to identify patients who required an L stent and those with stomal stenosis. Patient satisfaction was evaluated with Likert scale questions. Results: We identified 50 patients with a total of 66 catheterizable urinary and enteric channels. Eight patients with a total of 11 (17%) affected stomas had stomal stenosis. Seven of 8 patients used the L stent for management and 100% reported improvement in stenosis. Six of 7 patients used the stent or catheterization with topical betamethasone cream. Four of 7 patients used the L stent greater than 6 months postoperatively and 3 reported that stenosis occurred immediately postoperatively. All patients who used the L stent reported intermittent self-directed stent use as a prophylactic measure to prevent recurrence. Conclusions: Conservative management for stomal stenosis with an L stent is a simple, effective and well tolerated technique. This patient centered management significantly decreases the risk of surgical revision. Key Words: urinary diversion; urinary bladder, neurogenic; meningomyelocele; surgical stomas; postoperative complications
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www.jurology.com
CONTINENT urinary diversion is reported to improve quality of life, continence and renal outcomes.1 The advent of catheterizable channels such as Mitrofanoff appendicovesicostomy and MACE allowed patients significant choice over management for fecal and urinary continence.2 However, despite these channels offering patients the desired personal freedom associated with continence these surgical reconstructions are often complex and can have major and minor complications. A common
complication of catheterizable channels is stomal stenosis.2 The incidence of stomal stenosis in pediatric patients with a catheterizable channel is 5% to 57%3 with most reports in the literature citing a rate of around 15%.2– 6 Stomal stenosis can be a complicated problem that is often difficult to resolve. Commonly stomal stenosis is refractory to initial attempts at dilation, necessitating formal surgical revision. Patients with a catheterizable channel for urinary diversion usually have associate com-
0022-5347/09/1824-1786/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 182, 1786-1791, October 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.02.068
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
plicated medical problems and multiple comorbidities. As a result, the desire to treat the patients conservatively is paramount, reserving surgery until all other options are exhausted. Thus, the ability to manage stomal stenosis outside of the operative setting is a desired ideal. The L stent may represent a simple means of managing stomal stenosis nonoperatively. This stent allows passive dilation of the stenotic area without formal catheterization of the entire channel. The resultant decrease in the fibrotic nature of the scarred opening allows ease of catheter placement through the stoma. Concomitant use of the topical corticosteroid betamethasone may also be useful to improve scar tissue elasticity.7,8 Currently to our knowledge there is no reported literature on L stent use. We assessed whether the L stent is an effective means of managing stomal stenosis in patients with catheterizable channels.
MATERIALS AND METHODS After obtaining institutional review board approval we retrospectively reviewed the records of patients with catheterizable channels created at Children’s Memorial Hospital from January 2000 to July 2008. In these patients catheterizable channels were created by 3 pediatric urological surgeons. Patients were reviewed by telephone survey and chart review with the intent to identify those who had stomal stenosis and those who used an L stent for treatment. Stomal stenosis was defined as any narrowing at the skin level that created difficult catheterization. Patient satisfaction with this treatment was also evaluated with Likert scale questions. Figure 1 shows the phone survey performed. The L stent is made by tying a knot a few cm from the end of a catheter that the patient normally uses to catheterize the channel. This results in the catheter making an L shape at the end. The catheter is cut several cm proximal to the knot (fig. 2). The distal end of the L stent can be used to catheterize the proximal end of the catheterizable channel. The L stent goes through the stenotic area without going into the bladder or bowel lumen. The proximal end of the L stent lies flush with the skin, preventing distal migration into the distal portion of the catheterizable channel. The proximal end can be taped to the skin to secure it in place. The advantage of the L shape is that the catheter lies flush with the skin and is more comfortable for the patient (fig. 3). In addition, by not traversing into the bladder lumen the bladder is not irritated by an indwelling catheter. Patients are instructed to use the L stent at the first sign of stomal tightness. The L stent is inserted before going to sleep at night and removed in the morning. As an adjunct, 0.05% betamethasone cream can be used to coat the end of the L stent. All patients are advised to use the L stent with betamethasone when initializing treatment. Patients are instructed to use the L stent for 3 to 5 days or until tightness resolves. The duration of betamethasone use is patient dependent. Most patients use betametha-
1787
sone for 1 week with stent placement overnight. Patients are also instructed to use it as a prophylactic measure when recurrent tightness is noticed.
RESULTS Patient Characteristics A total of 22 males and 28 females were identified with a total of 66 urinary and enteric catheterizable channels, and adequate followup to allow study inclusion. Most patients had neurogenic bladder secondary to myelodysplasia (54%) or bladder exstrophy (18%). Table 1 lists the original patient diagnoses. A total of 16 patients (32%) had 2 catheterizable channels (urinary and enteric), 32 (64%) had a urinary catheterizable channel and 2 (4%) had a catheterizable enteric channel. Table 2 lists the reconstructions performed. A U or Vshaped flap technique was used to create the Mitrofanoff or MACE. L Stent Use Patient temporal details. Eight patients with a total of 11 affected stomas (17%) had stomal stenosis. Table 2 lists the reconstructions performed in patients with stomal stenosis. Median followup was 24 months (range 11 to 50). Of patients with stomal stenosis 7 (88%) used the L stent for management. One patient with stenosis did not use the stent and 1 male used serial catheter dilation of the stoma with betamethasone cream. Four of 7 patients (57%) used the L stent greater than 6 months postoperatively and 3 (43%) reported that stenosis developed less than 3 months postoperatively. 0.05% Betamethasone cream. Seven of 8 patients (87%) with stomal stenosis used topical 0.05% betamethasone cream. One male used the cream alone with catheter placement but did not use the L stent. The remaining patients coated the L stent in betamethasone cream before placing it in the stoma. Complications. One patient described some discomfort the first day of using the stent. Otherwise there were no reports of pain. One patient described bleeding with stent use in conjunction with betamethasone. After terminating betamethasone and continuing stent use there were no further bleeding problems. No other complications were noted. Although this was not asked formally in the survey, when asked about complications, no patients described problems with the stent falling out. Also, there were no reports of false passages created by the L stent. Prophylactic Use and Surgery All patients who used the L stent reported intermittent or ongoing self-directed stent use as a prophylactic measure to prevent recurrent stenosis. Pa-
1788
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
Figure 1. Pediatric stomal stenosis telephone survey
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
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Table 1. Diagnosis in patients with catheterizable channel
Figure 2. L stent
tients generally described intermittent L stent use, varying from nightly use 5 to 7 days per week to nightly use only once or twice every 2 to 4 weeks. Two patients also described initial daytime use between catheterizations when first using the stent. One patient (13%) required surgery for stomal revision. This patient, in whom keloids formed, underwent dilation under anesthesia, which failed, and subsequent stomal revision with a buccal graft inlay. This patient continued to use the L stent after revision approximately 1 to 4 times per week to prevent further stenosis. Patient Satisfaction With L Stent Overall satisfaction with the L stent as a treatment option for stomal stenosis was reported to be good or excellent according to telephone survey results. Patients reported increased perception of control over a difficult to manage problem. Patients perceived increased control over this problem due to the selfdirected nature of L stent use. Patients were content
Diagnosis
No. Pts (%)
Myelodysplasia Bladder exstrophy Cloacal exstrophy Spinal cord injury Sacral regression/agenesis VATER syndrome Anorectal malformation ⫹ neurogenic bladder Cerebral palsy Posterior urethral valves Spinal cord tumor
27 (54) 9 (18) 3 (6) 3 (6) 2 (4) 2 (4) 1 (2) 1 (2) 1 (2) 1 (2)
to initiate stent use when they noticed tightening of the stomal opening with catheterization. This selfstart therapy was a main reason that patients were most pleased with this management option. All patients would recommend this as a management plan in patients with a similar problem.
DISCUSSION Catheterizable channels are often a highly desirable option in patients desiring a continent catheterizable reservoir. The advent of the MACE and Mitrofanoff principles has allowed patients to undergo surgery to achieve urinary and fecal continence.2 Although these channels often provide patients with increased independence for genitourinary care, this complex reconstruction is associated with known complications.1– 6 Stomal stenosis is the most commonly reported problem associated with catheterizable channels. However, problems with stomal prolapse, false passage, fibrosis of the entire channel or stricture of the appendicovesical junction can also occur.3,5 The refractory nature of stomal stenosis, when it is unresponsive to initial dilation, can often generate significant stress for the patient and care provider since surgical revision is often needed to rectify this problem.
Figure 3. L stent. A, positioned for placement in appendicovesicostomy. B, in place in appendicovesicostomy
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L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
Table 2. Reconstruction in patients with catheterizable channel and stenosis incidence Reconstruction
No. Pts (%)
No. Stenosis (% total stomas)
Mitrofanoff Monti MACE
33 (50) 15 (23) 18 (27)
7 (11) 0 4 (6)
Totals
66 (100)
11 (17)
The 17% rate of stenosis in this review is consistent with that in previous published reports of the incidence of stomal stenosis in this patient population.2– 6 Most stomal stenosis is reported to occur within year 1 after surgery,5 which is also concordant with our experience in this series. When examining the time line of the incidence of stomal complications, it was found that MACE complications occurred several months earlier than Mitrofanoff channel complications. Although there was no statistically significant difference, it was postulated that the decreased daily frequency of catheterization associated with the MACE channel compared to that of appendicovesicostomy resulted in stenosis occurring earlier.2,5 It was suggested that twice daily catheterization of the MACE channel early in the postoperative period may alleviate MACE channel stomal stenosis.2,5 Although no higher incidence of stomal stenosis with MACE channels was reported, prior reviews of antegrade continent enemas showed a higher rate of stomal stenosis of around 30%.7 Similarly this study did not show a higher incidence of stomal stenosis in MACE channels compared to that of appendicovesicostomy (6% vs 11%). Despite conservative attempts to manage stomal stenosis with temporary catheter placement this often fails in the long term and surgical revision is usually needed.2–5 In this review all except 1 patient were successfully treated with an L stent. The patient who required surgical revision continued to use the L stent after revision due to persistent stenosis secondary to keloid scarring. Although it offers a nonsurgical solution to stomal stenosis, all patients required ongoing prophylactic use of the L stent. Whether this long-term prophylactic use is more effective and patient friendly than surgery in the long term is not clear. Followup in our study included 50 patients during 5 years (median 23 months). Results show that the L stent is effective and well tolerated in the long term and it need not be thought of as a temporizing measure before surgery. Of the patients 87% used 0.05% betamethasone cream with L stent placement or catheterization.
Corticosteroid cream has been used to improve the elasticity of scar tissue.8,9 Palmer et al described that betamethasone application clearly softened the scar to allow skin retraction of a phimotic foreskin in 11 of 14 patients.9 Several mechanisms have been postulated in regard to steroid cream improving scar elasticity.10 Palmer et al reviewed these methods, outlining the anti-inflammatory effects described by Monsour et al,10 the reduction of arachidonic and hydroxyeicosatetronic acids, increased superoxide dismutase activity and the anti-IgE mediated antiallergic effect.11–14 Although to our knowledge this was not previously reported as a treatment in patients with stomal stenosis, our study shows that 87% of patients used betamethasone as part of passive dilation with the L stent. One patient reported the complication of bleeding associated with steroid cream use, which resolved with stopping the betamethasone. This patient continued L stent dilation without the cream. Further prospective study is needed to elucidate the impact of betamethasone as an adjunct to L stent passive dilation. A lack of patient compliance with catheterization has been cited as a possible promoting factor for infection, stomal stenosis and the need for surgical revision.14 Our patients were highly satisfied with the L stent as treatment for stomal stenosis. In addition, all patients recommended the L stent as a good option in patients with a similar problem. Given this high patient satisfaction, the perception of patient control over the treatment modality and patient recommendation of this treatment option to other patients, it is predicted that compliance with this treatment for stenosis would be high. Although this was not studied prospectively in this review, patients report good compliance retrospectively and satisfaction with patient determined use of the L stent for prophylactic prevention of recurrent stenosis.
CONCLUSIONS Conservative management for stomal stenosis with an L stent is simple, effective and well tolerated in a complicated patient population. Cases with catheterizable channels are complex and the ability to manage stomal complications nonsurgically is desirable. Although stomal stenosis has been traditionally managed surgically, the L stent can obviate the need for surgical revision in patients with refractory stomal stenosis. This patient centered care decreases the risk of surgical revision for refractory stomal stenosis in patients with a catheterizable channel.
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
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REFERENCES 1. Rapoport D, Secord S and MacNeily A: The challenge of pediatric continent urinary diversion. J Pediatr Surg 2006; 41: 1113.
6. Narayanaswamy B, Wilcox DT, Cuckow PM et al: The Yang-Monti ileovesicostomy: a problematic channel. BJU Int 2001; 87: 861.
2. Barqawi A, De Valdenebro M, Furness PD et al: Lessons learned from stomal complications with cutaneous catheterizable continent stomas. BJU Int 2004; 94: 1344.
7. Calado AA, Macedo A Jr, Barroso U Jr et al: The Macedo-Malone antegrade continence enema procedure: early experience. J Urol 2005; 173: 1340.
3. Khoury AE, Van Savage JG, McLorie GA et al: Minimizing stomal stenosis in appendicovesicostomy using a modified umbilical stoma. J Urol 1996; 155: 2050. 4. Chulamorkodt NN, Estrada CR and Chaviano AH: Continent urinary diversion: 10-year experience of Shriners Hospitals for Children in Chicago. J Spinal Cord Med, suppl., 2004; 27: S84. 5. Thomas JC, Dietrich MS, Trusler L et al: Continent catheterizable channels and the timing of their complications. J Urol 2006; 176: 1816.
8. Radojicic ZI, Sava SV and Stojanoski K: Calibration and dilation with topical corticosteroid in the treatment of stenosis of neourethral meatus after hypospadias. BJU Int 2006; 97: 166. 9. Palmer JW, Elder JS and Palmer LS: The use of betamethasone to manage the trapped penis following neonatal circumcision. J Urol 2005; 174: 1577. 10. Monsour MA, Rabinovitch HH and Dean GE: Medical management of phimosis in children: our
experience with topical steroids. J Urol 1999; 162: 1162. 11. Hammarstrom S, Hamburg M, Duell EA et al: Glucocorticoid in inflammatory proliferative skin disease reduces arachidonic and hydroxyeicosatetaeonic acids. Science 1977; 197: 994. 12. Gavan N and Maibach H: Effect of topical corticosteroids on the activity of superoxide dismutase in human skin in vitro. Skin Pharmacol 1997; 10: 309. 13. Gronneberg R, Strandberg K, Staneheim G et al: Effect in man of anti-allergic drugs on the immediate and late phase cutaneous allergic reactions induced by anti-IgE. Allergy 1981; 36: 201. 14. Clark T, Pope JC IV, Adams MC et al: Factors that influence outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive procedures in children. J Urol 2002; 168: 1537.
EDITORIAL COMMENTS Stomal stenosis is an all too common problem in patients with urological reconstruction using catheterizable stomas (reference 2 in article). Stomal access in many patients is the only reliable way to allow bowel and/or bladder continence. Unfortunately the inability to access a bladder stoma can at times be a urological emergency. These authors not only present an inexpensive and simplistic way to treat stomal access issues, but also provide the option of self-directed use of this stent as a prophylactic measure to prevent recurrent stenosis. This selfdirected prophylactic measure is what I find most appealing about the L stent. The goal of most uro-
logical reconstruction is to enable self-care or family direct care to give the patient independence. The properly used L stent in this study most definitely avoided the 5 o’clock emergency visit in at least 1 or more patients. This effective and well tolerated prophylactic measure will surely find its way into my practice. It will give my patients more autonomy and hopefully keep my unplanned visits with them to a minimum.
This is a retrospective study of a satisfactory number of individuals, which allows adequate statistical analysis and has been done in a satisfactory way. Although we are all familiar with overnight catheterization of the urethra or abdominal channels, the idea of leaving a piece of catheter at the most affected area seems attractive and is well developed by the authors. A few times I have used a silicone catheter devised for hypospadias surgery with an adjustable holding piece (unpublished data) that replaces the knot mentioned by the authors. It is especially useful for overnight bladder channel catheterization.
The retrospective nature is the weak point of the study. The need for catheterizable channels is tending to increase since a growing number of surgeons use this type of procedure. A randomized, prospective study would be welcome to consolidate this method, which in my view has come to stay.
Peter D. Furness, III Rocky Mountain Pediatric Urology Denver, Colorado
Salvador Vilar C. Lima Department of Surgery/Urology Federal University of Pernambuco Recife, Brazil
Abbreviations and Acronyms MACE ⫽ Malone antegrade continent enema Study received institutional review board approval. * Correspondence: Division of Urology, Children’s Memorial Hospital, 2300 Children’s Pl., Box 24, Chicago, Illinois 60614 (telephone: 773880-4428; FAX: 773-880-3339; e-mail: echeng@ childrensmemorial.org).
Purpose: Stomal stenosis in patients with catheterizable channels can be a difficult problem that is managed by surgical revision or dilation. The L stent is a short, knotted catheter that lies flush with skin. The stent is used for any stomal narrowing, typically overnight for several days. The stent bridges the area of stenosis without passing into bowel or bladder lumen. We assessed whether the L stent is effective for preventing and managing stomal stenosis. Materials and Methods: We retrospectively reviewed the records of patients with catheterizable channels. A telephone survey and chart review were done to identify patients who required an L stent and those with stomal stenosis. Patient satisfaction was evaluated with Likert scale questions. Results: We identified 50 patients with a total of 66 catheterizable urinary and enteric channels. Eight patients with a total of 11 (17%) affected stomas had stomal stenosis. Seven of 8 patients used the L stent for management and 100% reported improvement in stenosis. Six of 7 patients used the stent or catheterization with topical betamethasone cream. Four of 7 patients used the L stent greater than 6 months postoperatively and 3 reported that stenosis occurred immediately postoperatively. All patients who used the L stent reported intermittent self-directed stent use as a prophylactic measure to prevent recurrence. Conclusions: Conservative management for stomal stenosis with an L stent is a simple, effective and well tolerated technique. This patient centered management significantly decreases the risk of surgical revision. Key Words: urinary diversion; urinary bladder, neurogenic; meningomyelocele; surgical stomas; postoperative complications
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www.jurology.com
CONTINENT urinary diversion is reported to improve quality of life, continence and renal outcomes.1 The advent of catheterizable channels such as Mitrofanoff appendicovesicostomy and MACE allowed patients significant choice over management for fecal and urinary continence.2 However, despite these channels offering patients the desired personal freedom associated with continence these surgical reconstructions are often complex and can have major and minor complications. A common
complication of catheterizable channels is stomal stenosis.2 The incidence of stomal stenosis in pediatric patients with a catheterizable channel is 5% to 57%3 with most reports in the literature citing a rate of around 15%.2– 6 Stomal stenosis can be a complicated problem that is often difficult to resolve. Commonly stomal stenosis is refractory to initial attempts at dilation, necessitating formal surgical revision. Patients with a catheterizable channel for urinary diversion usually have associate com-
0022-5347/09/1824-1786/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 182, 1786-1791, October 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.02.068
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
plicated medical problems and multiple comorbidities. As a result, the desire to treat the patients conservatively is paramount, reserving surgery until all other options are exhausted. Thus, the ability to manage stomal stenosis outside of the operative setting is a desired ideal. The L stent may represent a simple means of managing stomal stenosis nonoperatively. This stent allows passive dilation of the stenotic area without formal catheterization of the entire channel. The resultant decrease in the fibrotic nature of the scarred opening allows ease of catheter placement through the stoma. Concomitant use of the topical corticosteroid betamethasone may also be useful to improve scar tissue elasticity.7,8 Currently to our knowledge there is no reported literature on L stent use. We assessed whether the L stent is an effective means of managing stomal stenosis in patients with catheterizable channels.
MATERIALS AND METHODS After obtaining institutional review board approval we retrospectively reviewed the records of patients with catheterizable channels created at Children’s Memorial Hospital from January 2000 to July 2008. In these patients catheterizable channels were created by 3 pediatric urological surgeons. Patients were reviewed by telephone survey and chart review with the intent to identify those who had stomal stenosis and those who used an L stent for treatment. Stomal stenosis was defined as any narrowing at the skin level that created difficult catheterization. Patient satisfaction with this treatment was also evaluated with Likert scale questions. Figure 1 shows the phone survey performed. The L stent is made by tying a knot a few cm from the end of a catheter that the patient normally uses to catheterize the channel. This results in the catheter making an L shape at the end. The catheter is cut several cm proximal to the knot (fig. 2). The distal end of the L stent can be used to catheterize the proximal end of the catheterizable channel. The L stent goes through the stenotic area without going into the bladder or bowel lumen. The proximal end of the L stent lies flush with the skin, preventing distal migration into the distal portion of the catheterizable channel. The proximal end can be taped to the skin to secure it in place. The advantage of the L shape is that the catheter lies flush with the skin and is more comfortable for the patient (fig. 3). In addition, by not traversing into the bladder lumen the bladder is not irritated by an indwelling catheter. Patients are instructed to use the L stent at the first sign of stomal tightness. The L stent is inserted before going to sleep at night and removed in the morning. As an adjunct, 0.05% betamethasone cream can be used to coat the end of the L stent. All patients are advised to use the L stent with betamethasone when initializing treatment. Patients are instructed to use the L stent for 3 to 5 days or until tightness resolves. The duration of betamethasone use is patient dependent. Most patients use betametha-
1787
sone for 1 week with stent placement overnight. Patients are also instructed to use it as a prophylactic measure when recurrent tightness is noticed.
RESULTS Patient Characteristics A total of 22 males and 28 females were identified with a total of 66 urinary and enteric catheterizable channels, and adequate followup to allow study inclusion. Most patients had neurogenic bladder secondary to myelodysplasia (54%) or bladder exstrophy (18%). Table 1 lists the original patient diagnoses. A total of 16 patients (32%) had 2 catheterizable channels (urinary and enteric), 32 (64%) had a urinary catheterizable channel and 2 (4%) had a catheterizable enteric channel. Table 2 lists the reconstructions performed. A U or Vshaped flap technique was used to create the Mitrofanoff or MACE. L Stent Use Patient temporal details. Eight patients with a total of 11 affected stomas (17%) had stomal stenosis. Table 2 lists the reconstructions performed in patients with stomal stenosis. Median followup was 24 months (range 11 to 50). Of patients with stomal stenosis 7 (88%) used the L stent for management. One patient with stenosis did not use the stent and 1 male used serial catheter dilation of the stoma with betamethasone cream. Four of 7 patients (57%) used the L stent greater than 6 months postoperatively and 3 (43%) reported that stenosis developed less than 3 months postoperatively. 0.05% Betamethasone cream. Seven of 8 patients (87%) with stomal stenosis used topical 0.05% betamethasone cream. One male used the cream alone with catheter placement but did not use the L stent. The remaining patients coated the L stent in betamethasone cream before placing it in the stoma. Complications. One patient described some discomfort the first day of using the stent. Otherwise there were no reports of pain. One patient described bleeding with stent use in conjunction with betamethasone. After terminating betamethasone and continuing stent use there were no further bleeding problems. No other complications were noted. Although this was not asked formally in the survey, when asked about complications, no patients described problems with the stent falling out. Also, there were no reports of false passages created by the L stent. Prophylactic Use and Surgery All patients who used the L stent reported intermittent or ongoing self-directed stent use as a prophylactic measure to prevent recurrent stenosis. Pa-
1788
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
Figure 1. Pediatric stomal stenosis telephone survey
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
1789
Table 1. Diagnosis in patients with catheterizable channel
Figure 2. L stent
tients generally described intermittent L stent use, varying from nightly use 5 to 7 days per week to nightly use only once or twice every 2 to 4 weeks. Two patients also described initial daytime use between catheterizations when first using the stent. One patient (13%) required surgery for stomal revision. This patient, in whom keloids formed, underwent dilation under anesthesia, which failed, and subsequent stomal revision with a buccal graft inlay. This patient continued to use the L stent after revision approximately 1 to 4 times per week to prevent further stenosis. Patient Satisfaction With L Stent Overall satisfaction with the L stent as a treatment option for stomal stenosis was reported to be good or excellent according to telephone survey results. Patients reported increased perception of control over a difficult to manage problem. Patients perceived increased control over this problem due to the selfdirected nature of L stent use. Patients were content
Diagnosis
No. Pts (%)
Myelodysplasia Bladder exstrophy Cloacal exstrophy Spinal cord injury Sacral regression/agenesis VATER syndrome Anorectal malformation ⫹ neurogenic bladder Cerebral palsy Posterior urethral valves Spinal cord tumor
27 (54) 9 (18) 3 (6) 3 (6) 2 (4) 2 (4) 1 (2) 1 (2) 1 (2) 1 (2)
to initiate stent use when they noticed tightening of the stomal opening with catheterization. This selfstart therapy was a main reason that patients were most pleased with this management option. All patients would recommend this as a management plan in patients with a similar problem.
DISCUSSION Catheterizable channels are often a highly desirable option in patients desiring a continent catheterizable reservoir. The advent of the MACE and Mitrofanoff principles has allowed patients to undergo surgery to achieve urinary and fecal continence.2 Although these channels often provide patients with increased independence for genitourinary care, this complex reconstruction is associated with known complications.1– 6 Stomal stenosis is the most commonly reported problem associated with catheterizable channels. However, problems with stomal prolapse, false passage, fibrosis of the entire channel or stricture of the appendicovesical junction can also occur.3,5 The refractory nature of stomal stenosis, when it is unresponsive to initial dilation, can often generate significant stress for the patient and care provider since surgical revision is often needed to rectify this problem.
Figure 3. L stent. A, positioned for placement in appendicovesicostomy. B, in place in appendicovesicostomy
1790
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
Table 2. Reconstruction in patients with catheterizable channel and stenosis incidence Reconstruction
No. Pts (%)
No. Stenosis (% total stomas)
Mitrofanoff Monti MACE
33 (50) 15 (23) 18 (27)
7 (11) 0 4 (6)
Totals
66 (100)
11 (17)
The 17% rate of stenosis in this review is consistent with that in previous published reports of the incidence of stomal stenosis in this patient population.2– 6 Most stomal stenosis is reported to occur within year 1 after surgery,5 which is also concordant with our experience in this series. When examining the time line of the incidence of stomal complications, it was found that MACE complications occurred several months earlier than Mitrofanoff channel complications. Although there was no statistically significant difference, it was postulated that the decreased daily frequency of catheterization associated with the MACE channel compared to that of appendicovesicostomy resulted in stenosis occurring earlier.2,5 It was suggested that twice daily catheterization of the MACE channel early in the postoperative period may alleviate MACE channel stomal stenosis.2,5 Although no higher incidence of stomal stenosis with MACE channels was reported, prior reviews of antegrade continent enemas showed a higher rate of stomal stenosis of around 30%.7 Similarly this study did not show a higher incidence of stomal stenosis in MACE channels compared to that of appendicovesicostomy (6% vs 11%). Despite conservative attempts to manage stomal stenosis with temporary catheter placement this often fails in the long term and surgical revision is usually needed.2–5 In this review all except 1 patient were successfully treated with an L stent. The patient who required surgical revision continued to use the L stent after revision due to persistent stenosis secondary to keloid scarring. Although it offers a nonsurgical solution to stomal stenosis, all patients required ongoing prophylactic use of the L stent. Whether this long-term prophylactic use is more effective and patient friendly than surgery in the long term is not clear. Followup in our study included 50 patients during 5 years (median 23 months). Results show that the L stent is effective and well tolerated in the long term and it need not be thought of as a temporizing measure before surgery. Of the patients 87% used 0.05% betamethasone cream with L stent placement or catheterization.
Corticosteroid cream has been used to improve the elasticity of scar tissue.8,9 Palmer et al described that betamethasone application clearly softened the scar to allow skin retraction of a phimotic foreskin in 11 of 14 patients.9 Several mechanisms have been postulated in regard to steroid cream improving scar elasticity.10 Palmer et al reviewed these methods, outlining the anti-inflammatory effects described by Monsour et al,10 the reduction of arachidonic and hydroxyeicosatetronic acids, increased superoxide dismutase activity and the anti-IgE mediated antiallergic effect.11–14 Although to our knowledge this was not previously reported as a treatment in patients with stomal stenosis, our study shows that 87% of patients used betamethasone as part of passive dilation with the L stent. One patient reported the complication of bleeding associated with steroid cream use, which resolved with stopping the betamethasone. This patient continued L stent dilation without the cream. Further prospective study is needed to elucidate the impact of betamethasone as an adjunct to L stent passive dilation. A lack of patient compliance with catheterization has been cited as a possible promoting factor for infection, stomal stenosis and the need for surgical revision.14 Our patients were highly satisfied with the L stent as treatment for stomal stenosis. In addition, all patients recommended the L stent as a good option in patients with a similar problem. Given this high patient satisfaction, the perception of patient control over the treatment modality and patient recommendation of this treatment option to other patients, it is predicted that compliance with this treatment for stenosis would be high. Although this was not studied prospectively in this review, patients report good compliance retrospectively and satisfaction with patient determined use of the L stent for prophylactic prevention of recurrent stenosis.
CONCLUSIONS Conservative management for stomal stenosis with an L stent is simple, effective and well tolerated in a complicated patient population. Cases with catheterizable channels are complex and the ability to manage stomal complications nonsurgically is desirable. Although stomal stenosis has been traditionally managed surgically, the L stent can obviate the need for surgical revision in patients with refractory stomal stenosis. This patient centered care decreases the risk of surgical revision for refractory stomal stenosis in patients with a catheterizable channel.
L STENT FOR STOMAL STENOSIS IN CATHETERIZABLE CHANNELS
1791
REFERENCES 1. Rapoport D, Secord S and MacNeily A: The challenge of pediatric continent urinary diversion. J Pediatr Surg 2006; 41: 1113.
6. Narayanaswamy B, Wilcox DT, Cuckow PM et al: The Yang-Monti ileovesicostomy: a problematic channel. BJU Int 2001; 87: 861.
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EDITORIAL COMMENTS Stomal stenosis is an all too common problem in patients with urological reconstruction using catheterizable stomas (reference 2 in article). Stomal access in many patients is the only reliable way to allow bowel and/or bladder continence. Unfortunately the inability to access a bladder stoma can at times be a urological emergency. These authors not only present an inexpensive and simplistic way to treat stomal access issues, but also provide the option of self-directed use of this stent as a prophylactic measure to prevent recurrent stenosis. This selfdirected prophylactic measure is what I find most appealing about the L stent. The goal of most uro-
logical reconstruction is to enable self-care or family direct care to give the patient independence. The properly used L stent in this study most definitely avoided the 5 o’clock emergency visit in at least 1 or more patients. This effective and well tolerated prophylactic measure will surely find its way into my practice. It will give my patients more autonomy and hopefully keep my unplanned visits with them to a minimum.
This is a retrospective study of a satisfactory number of individuals, which allows adequate statistical analysis and has been done in a satisfactory way. Although we are all familiar with overnight catheterization of the urethra or abdominal channels, the idea of leaving a piece of catheter at the most affected area seems attractive and is well developed by the authors. A few times I have used a silicone catheter devised for hypospadias surgery with an adjustable holding piece (unpublished data) that replaces the knot mentioned by the authors. It is especially useful for overnight bladder channel catheterization.
The retrospective nature is the weak point of the study. The need for catheterizable channels is tending to increase since a growing number of surgeons use this type of procedure. A randomized, prospective study would be welcome to consolidate this method, which in my view has come to stay.
Peter D. Furness, III Rocky Mountain Pediatric Urology Denver, Colorado
Salvador Vilar C. Lima Department of Surgery/Urology Federal University of Pernambuco Recife, Brazil