The continent vesicostomy

The Continent Vesicostomy By Keith M. Schneider, Reginald S. Ewing, and Richard D. Signer N A PREVIOUS

COMMUNICATION,’ we reported on the creation of a continent vesicostomy using an intussuscepted anterior bladder flap tube. I This procedure was performed on ten dogs and was successful in producing continence in eight. Emptying of the bladder was accomplished by intermittent unsterile catheterization of the stoma. This report presents the results of postoperative x-ray, blood, and urine studies, and indicates a technical modification of the original procedure. MATERIALS

AND

METHODS

The flap is created on the anterior aspect of the bladder with the base of the flap either at the cephalad or caudad portion of the bladder. The dimensions of the flap have been altered to 5.0 cm at the base, 9.0 cm in length, and 3.0 cm at the apex. Formerly, we converted this flap into a tube which was then intussusthis valve is created cepted into the bladder lumen, creating a “valve.” Currently, by folding the flap before converting it into a tube. This has allowed us to be more precise in the extent of the intussusception and has minimized the manipulation of tissue. After the flap is fashioned, a fold, measuring 2 cm in length, is made at the base. This is fixed by three 2-O chromic catgut sutures that are inserted through both walls of the fold and tied to approximation (Fig, 1A). The tube is constructed in three layers over a No. IO catheter. The initial layer approximates the mucous membrane with a running lock stitch of 3-O chromic catgut. (Fig. IB). The muscular layer is closed with 3-O Tevdek sutures which extend through the muscle of the adjacent bladder wall, locking the intussusception in place. (Fig. 1C) The outer mucosal closure is completed with a running locked 3-O chromic catgut suture. (Fig. 1D) This last suture is continued on to the defect in the anterior wall of the bladder. The anterior wall closure is completed with approximation of the outer muscle layer with 330 Tevdek. POSTOPERATIVE

STUDIES

Blood studies in the experimental animals include blood urea nitrogen, creatinine, carbon dioxide-combining power, and routine electrolyte determinations (Table 1). All of these studies have remained normal throughout the followup periods which now vary from 2 to 6 mo in individual animals. Bacteriologic studies reveal that bacteriuria has been present in all animals, Cultures done at biweekly intervals have indicated growth of E. coli, Proteus, Klehsiella, or Enterococcus. Appropriate antibiotic therapy has been instituted From

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Medicine,

Division

Bronx.

Addressfor reprint Ea.stche.cter Road. cc) 1975 bv Prune

Journal

of Pediatric

of

Pediatric

Surgery.

Depurrmmt

o/’ .Sur,g:grrl~. Albert

Eimtein

College

of

N. I’. requests:

Bronx.

Keith

M. Schneider,

M.D..

Alberr

Einstein

College of Medic,inr.

1,925

:V.Y. 10461

& Stratton. Surgery, Vol.

Inc.

10.

No.

2 (Apd).

1975

221

SCHNEIDER,

222

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SCHNEIDER,

EWING,

AND

SIGNER

Fig. 2. Negative filling defect of in ception within bladder.

for the duration of the study. Sterile catheterization of the dogs proved impractical. Radiologic studies include excretory urography and cystography. None of the dogs has shown evidence of upper urinary tract dilatation. With cystography we were able to demonstrate reflux in only one animal. This was unilateral and not associated with upper tract dilatation. The negative filling defect of the intussusception within the bladder lumen was frequently visualized. (Fig. 2) After catheterization of the stoma, there was little or no retention of radiopaque material. One animal was sacrificed 3 mo after operation. Another dog died of an overdose of anesthesia during the cystogram. This intussusception suture line had opened; however, the valve remained competent. CONCLUSION

The creation of a competent bladder valve is technically feasible. These valves have remained competent for the duration of the study except in three animals in which marked overdistention of the bladder resulted in temporary leakage from the stoma. Postoperative studies have indicated no progressive damage to the upper urinary tract despite the persistence of bacteriuria in the animals subjected to unsterile catheterization. The role of the continent vesicostomy in the management of the human neurogenic bladder remains to be evaluated. REFERENCE I. Schneider

KM,

Ewing RS, Signer

RD: A continent

vesicostomy.

Urology

3: 654-656,

1974