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The Continent Vesicostomy: Clinical Experiences in the Adult
Vol. 117, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
THE CONTINENT VESICOSTOMY: CLINICAL EXPERIENCES IN THE ADULT KEITH M. SCHNEIDER, ROBERTO E. REID
AND
BERNARD FRUCHTMAN
From the Departments of Surgery and Urology, The Albert Einstein College of Medi.cine and Montefiore Hospital and Medi.cal Center, Bronx, New York
ABSTRACT
During a 2-year period continent vesicostomy has been attempted in 17 adults and a continent stoma has been achieved in all but 4 patients. Operative morbidity is low and there has been no operative mortality. Definition of precise indications and contraindications must await further experience but this operative procedure seems to be a useful alternative in the management of neurogenic bladder and incontinence. In 1974 we reported on a new operative procedure for urinary diversion. 1 The continent vesicostomy involves a valvelike intussusception from an anterior wall bladder flap, which communicates with a stoma on the anterior abdominal wall. Findings in the experimental animal were encouraging enough to undertake a clinical evaluation. Continent vesicostomies now have been performed on 17 adults. Herein we evaluate our clinical experience during the last 2 years. CLINICAL MATERIAL
Nineteen procedures have been performed on 17 patients. The 11 women and 6 men ranged in age from 19 to 84 years. Followup has been from 2 to 26 months, with a mean of 13.5 months. No patient has been lost to followup. Indications for the operation were neurogenic bladders in 15 cases and a decompensated bladder secondary to advanced prostatism and post-prostatectomy incontinence in 2. Seven patients had traumatic paraplegia, 2 of whom were considered to have lower motor neuron lesions. Four women had multiple sclerosis. Pernicious anemia and diabetes were the etiologies in 1 patient each. In 2 patients the cause of the neurogenic bladder was undetermined but resulted in a large capacity hypotonic bladder (table 1).
TABLE
1. Diagnosis in 17 patients undergoing continent vesicostomy No. Pts.
Neurogenic bladder: Spastic bladder (paraplegia), 5 Lower motor region (paraplegia), 2 Multiple sclerosis, 4 Pernicious anemia, 1 Diabetes, 1 Unknown, 2 Decompensated bladder secondary to advanced prostatism and post-prostatectomy incontinence Total
TECHNIQUE
The surgical technique has undergone essential modifications, which have improved our clinical results. 2 A major factor in constructing a continent valve is the maintenance of an intussusception of adequate length against the hydrostatic pressure of the bladder. A technical error in early patients was the use of absorbable sutures, coapting the muscle in the wall of the intussusception. Early dissolution of these sutures allowed dehiscence and/or reduction of the intussusception before fibrosis had secured the intussusception in place sufficiently. We now use non-absorbable sutures for this critical step in the operative procedure (fig. 1). Two factors not sufficiently appreciated during the initial operations were the importance of the length of the intussusception and the need for prolonged catheter diversion. The intussusception now is constructed so that it is at least 3.0 or, preferably, 4.0 cm. in length. Suprapubic and stomal catheter diversion is maintained for 6 weeks to avoid hydrostatic pressure reduction of the intussusception until healing has taken place (fig. 2). A bladder capacity of 200 cc or more is required. In those individuals with low bladder outlet resistance a technique for closure of the bladder neck was required to prevent urethral leakage. This additional step was required in 5 patients. Accepted for publication September 10, 1976. 571
15
2 17
Patients are discharged from the hospital in 2 weeks and are readmitted 4 weeks later. The suprapubic tube is removed, followed in 2 or 3 days by removal of the stomal tube. Intermittent stomal catheterization is started at 2-hour intervals and gradually increased to 6-hour periods. RESULTS
A successful continent vesicostomy has been constructed in 13 patients. These 13 patients included all 4 with multiple sclerosis and 4 of 7 with traumatic paraplegia. Patients catheterize themselves in the sitting or supine position with 14 to 18F catheters. Catheterization intervals range from 3 to 8 hours. Some leakage through the stoma occurred in most patients for 1 or 2 weeks after the catheter is withdrawn. We are uncertain as to the cause of this temporary leakage. The presence of a catheter in the stoma for 6 weeks may compromise temporarily the contractility of the intussusception. Cystoscopy in patients in whom the bladder neck had not been closed revealed a well formed nipple within the bladder lumen (fig. 3). The longest followup is 26 months. The nipple persists and still is functioning in this patient. Bladder neck closure has been successful in 4 of 5 cases. There have been 4 failures to achieve a continent vesicostomy. However, 2 cases in the successful group required a second procedure, necessitated by reduction of the intussusception after the initial operation. In these patients absorbable sutures were used for the initial operation and non-absorbable sutures were used for the second and successful operation (table 2). In 2 patients, 1 with diabetes and 1 with traumatic quadriplegia, failure was associated with necrotizing fasciitis. Two other failures, both in paraplegics, were the result ofreduction of the intussusception. In all 4 patients intermittent stomal catheterization was suspended and the stoma was closed spontaneously. Bladder calculi developed in 2 patients, while stomal stenosis was noted in 2 others. The bladder calculi were secondary to extruded non-absorbable sutures and were removed transu-
572
SCHNEIDER, REID AND FRUCHTMAN
Fm. 3
!
f
;(
TABLE
2. Results of continent vesicostomy in 17 patients No. Pts. 13 4
Good Failure*
* Failures were caused by wound infection and disruption in 2 cases, and because of absorbable sutures in 2.
Fm. 1. Reprinted with permission2
Fm. 2. Reprinted with permission2
rethrally. The stomal stenosis has responded to intermittent dilatation. One patient had reflux in 1 ureter during a bout of cystitis but the upper tract has remained normal. Another 39-year-old paraplegic had a staghorn calculus that required an operation 2 years after the continent vesicostomy. All other patients have normal upper tracts without reflux, including 1 patient with reflux who had unilateral ureteral reimplantation at the time of the continent vesicostomy. Bacteriuria has been present intermittently in all but 2 patients. However, clinical cystitis has occurred in only 3 of our cases. DISCUSSION
Current techniques for urinary diversion are less than ideal. Complications range in severity from embarrassing appliance leakage to upper tract deterioration. The continent vesicostomy preserves the capacity of the bladder to function as a
reservoir, maintains the intact ureterovesical junctions and requires no external appliance. The procedure offers the patient and physician an alternative to ileal or sigmoid loops and to intermittent urethral catheterization. A large number of patients and longer followup are necessary before the ultimate value of the continent vesicostomy can be determined. We believe that we are justified in proposing this operation to patients in whom intermittent urethral catheterization has failed or has been refused, making them candidates for upper tract diversion. In addition, the procedure seems to be indicated for unmanageable incontinence, particularly in the female patient for whom a suitable external appliance has not been devised. Intermittent catheterization through an abdominal stoma, instead of per urethram, may be more compatible with the prospects of returning the patient to an active and involved social life. More precise indications and contraindications for the continent vesicostomy must await further experience. However, it would seem that the patient with a large capacity neurogenic bladder who is unable to empty it well is the ideal candidate. The decompensated or hypotonic bladder does not require bladder neck closure, which offers the advantage of a totally reversible procedure. If continence is not achieved the stoma will close when catheterization is stopped. CONCLUSION
The continent vesicostomy seems to be a useful alternative procedure to the usual urinary diversion and intermittent urethral catheterization. While the ultimate role of this procedure awaits further clinical experience initial results indicate its usefulness in selected patients. REFERENCES
1. Schneider, K. M., Ewing, R. S. and Signer, R. D.: Continent vesicostomy. Urology, 3: 654, 1974. 2. Schneider, K. M., Reid, R. E., Fruchtman, B. and Ewing, R. S: Continent vesicostomy-surgical technique. Urology, 6: 741, 1975.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
THE CONTINENT VESICOSTOMY: CLINICAL EXPERIENCES IN THE ADULT KEITH M. SCHNEIDER, ROBERTO E. REID
AND
BERNARD FRUCHTMAN
From the Departments of Surgery and Urology, The Albert Einstein College of Medi.cine and Montefiore Hospital and Medi.cal Center, Bronx, New York
ABSTRACT
During a 2-year period continent vesicostomy has been attempted in 17 adults and a continent stoma has been achieved in all but 4 patients. Operative morbidity is low and there has been no operative mortality. Definition of precise indications and contraindications must await further experience but this operative procedure seems to be a useful alternative in the management of neurogenic bladder and incontinence. In 1974 we reported on a new operative procedure for urinary diversion. 1 The continent vesicostomy involves a valvelike intussusception from an anterior wall bladder flap, which communicates with a stoma on the anterior abdominal wall. Findings in the experimental animal were encouraging enough to undertake a clinical evaluation. Continent vesicostomies now have been performed on 17 adults. Herein we evaluate our clinical experience during the last 2 years. CLINICAL MATERIAL
Nineteen procedures have been performed on 17 patients. The 11 women and 6 men ranged in age from 19 to 84 years. Followup has been from 2 to 26 months, with a mean of 13.5 months. No patient has been lost to followup. Indications for the operation were neurogenic bladders in 15 cases and a decompensated bladder secondary to advanced prostatism and post-prostatectomy incontinence in 2. Seven patients had traumatic paraplegia, 2 of whom were considered to have lower motor neuron lesions. Four women had multiple sclerosis. Pernicious anemia and diabetes were the etiologies in 1 patient each. In 2 patients the cause of the neurogenic bladder was undetermined but resulted in a large capacity hypotonic bladder (table 1).
TABLE
1. Diagnosis in 17 patients undergoing continent vesicostomy No. Pts.
Neurogenic bladder: Spastic bladder (paraplegia), 5 Lower motor region (paraplegia), 2 Multiple sclerosis, 4 Pernicious anemia, 1 Diabetes, 1 Unknown, 2 Decompensated bladder secondary to advanced prostatism and post-prostatectomy incontinence Total
TECHNIQUE
The surgical technique has undergone essential modifications, which have improved our clinical results. 2 A major factor in constructing a continent valve is the maintenance of an intussusception of adequate length against the hydrostatic pressure of the bladder. A technical error in early patients was the use of absorbable sutures, coapting the muscle in the wall of the intussusception. Early dissolution of these sutures allowed dehiscence and/or reduction of the intussusception before fibrosis had secured the intussusception in place sufficiently. We now use non-absorbable sutures for this critical step in the operative procedure (fig. 1). Two factors not sufficiently appreciated during the initial operations were the importance of the length of the intussusception and the need for prolonged catheter diversion. The intussusception now is constructed so that it is at least 3.0 or, preferably, 4.0 cm. in length. Suprapubic and stomal catheter diversion is maintained for 6 weeks to avoid hydrostatic pressure reduction of the intussusception until healing has taken place (fig. 2). A bladder capacity of 200 cc or more is required. In those individuals with low bladder outlet resistance a technique for closure of the bladder neck was required to prevent urethral leakage. This additional step was required in 5 patients. Accepted for publication September 10, 1976. 571
15
2 17
Patients are discharged from the hospital in 2 weeks and are readmitted 4 weeks later. The suprapubic tube is removed, followed in 2 or 3 days by removal of the stomal tube. Intermittent stomal catheterization is started at 2-hour intervals and gradually increased to 6-hour periods. RESULTS
A successful continent vesicostomy has been constructed in 13 patients. These 13 patients included all 4 with multiple sclerosis and 4 of 7 with traumatic paraplegia. Patients catheterize themselves in the sitting or supine position with 14 to 18F catheters. Catheterization intervals range from 3 to 8 hours. Some leakage through the stoma occurred in most patients for 1 or 2 weeks after the catheter is withdrawn. We are uncertain as to the cause of this temporary leakage. The presence of a catheter in the stoma for 6 weeks may compromise temporarily the contractility of the intussusception. Cystoscopy in patients in whom the bladder neck had not been closed revealed a well formed nipple within the bladder lumen (fig. 3). The longest followup is 26 months. The nipple persists and still is functioning in this patient. Bladder neck closure has been successful in 4 of 5 cases. There have been 4 failures to achieve a continent vesicostomy. However, 2 cases in the successful group required a second procedure, necessitated by reduction of the intussusception after the initial operation. In these patients absorbable sutures were used for the initial operation and non-absorbable sutures were used for the second and successful operation (table 2). In 2 patients, 1 with diabetes and 1 with traumatic quadriplegia, failure was associated with necrotizing fasciitis. Two other failures, both in paraplegics, were the result ofreduction of the intussusception. In all 4 patients intermittent stomal catheterization was suspended and the stoma was closed spontaneously. Bladder calculi developed in 2 patients, while stomal stenosis was noted in 2 others. The bladder calculi were secondary to extruded non-absorbable sutures and were removed transu-
572
SCHNEIDER, REID AND FRUCHTMAN
Fm. 3
!
f
;(
TABLE
2. Results of continent vesicostomy in 17 patients No. Pts. 13 4
Good Failure*
* Failures were caused by wound infection and disruption in 2 cases, and because of absorbable sutures in 2.
Fm. 1. Reprinted with permission2
Fm. 2. Reprinted with permission2
rethrally. The stomal stenosis has responded to intermittent dilatation. One patient had reflux in 1 ureter during a bout of cystitis but the upper tract has remained normal. Another 39-year-old paraplegic had a staghorn calculus that required an operation 2 years after the continent vesicostomy. All other patients have normal upper tracts without reflux, including 1 patient with reflux who had unilateral ureteral reimplantation at the time of the continent vesicostomy. Bacteriuria has been present intermittently in all but 2 patients. However, clinical cystitis has occurred in only 3 of our cases. DISCUSSION
Current techniques for urinary diversion are less than ideal. Complications range in severity from embarrassing appliance leakage to upper tract deterioration. The continent vesicostomy preserves the capacity of the bladder to function as a
reservoir, maintains the intact ureterovesical junctions and requires no external appliance. The procedure offers the patient and physician an alternative to ileal or sigmoid loops and to intermittent urethral catheterization. A large number of patients and longer followup are necessary before the ultimate value of the continent vesicostomy can be determined. We believe that we are justified in proposing this operation to patients in whom intermittent urethral catheterization has failed or has been refused, making them candidates for upper tract diversion. In addition, the procedure seems to be indicated for unmanageable incontinence, particularly in the female patient for whom a suitable external appliance has not been devised. Intermittent catheterization through an abdominal stoma, instead of per urethram, may be more compatible with the prospects of returning the patient to an active and involved social life. More precise indications and contraindications for the continent vesicostomy must await further experience. However, it would seem that the patient with a large capacity neurogenic bladder who is unable to empty it well is the ideal candidate. The decompensated or hypotonic bladder does not require bladder neck closure, which offers the advantage of a totally reversible procedure. If continence is not achieved the stoma will close when catheterization is stopped. CONCLUSION
The continent vesicostomy seems to be a useful alternative procedure to the usual urinary diversion and intermittent urethral catheterization. While the ultimate role of this procedure awaits further clinical experience initial results indicate its usefulness in selected patients. REFERENCES
1. Schneider, K. M., Ewing, R. S. and Signer, R. D.: Continent vesicostomy. Urology, 3: 654, 1974. 2. Schneider, K. M., Reid, R. E., Fruchtman, B. and Ewing, R. S: Continent vesicostomy-surgical technique. Urology, 6: 741, 1975.