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Vesicostomy for Neurogenic Bladder with Spina Bifida: Followup
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0022-5347/83/1304-0724$02.00/0 THE JOURNAL OF UROLOGY
Vol. 130, October
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
VESICOSTOMY FOR NEUROGENIC BLADDER WITH SPINA BIFIDA: FOLLOWUP HOWARD Mee. SNYDER, III, MIRIAM A. KALICHMAN, EDWARD CHARNEY JOHN W. DUCKETT
AND
From the Division of Urology, Department of Chi/,d Development and Rehabilitation, Chi/,dren's Hospital of Philadelphia, Philadelphia, Pennsylvania, and Rehabilitation Institute of Chicago, Chicago, Illinois
ABSTRACT
Of 260 patients being actively followed in a myelodysplasia clinic 48 have had a vesicostomy. Vesicostomy was done because of hydroureteronephrosis in 44 cases, infection in 3 and failure of clean intermittent catheterization in 1. Of the 48 patients 16 underwent closure of the vesicostomy, generally between ages 6 and 10 years, an age when the child is prepared to begin clean intermittent catheterization and is motivated to achieve continence. Two children underwent early vesicostomy closure because the bladder emptied adequately and neither has yet begun clean intermittent catheterization. Two children on clean intermittent catheterization are not acceptably continent. The remaining 12 patients are continent for at least 4 hours on clean intermittent catheterization, some with adjuvant drug therapy. No child has exhibited loss of bladder volume while diverted. Vesicostomy offers excellent temporary decompression of the urinary tract in children with spina bifida and neurogenic bladder, and has no long-term harmful effects on the bladder. During the last decade there has been a great increase in the use of vesicostomy in children with neurogenic bladders. i--4 The most common indication is failure of adequate bladder emptying with secondary hydroureteronephrosis with or without infection. By providing reliable effective bladder empyting, the upper tracts generally are well protected. While it is true that clean intermittent catheterization, when effectively performed, can achieve the same end, 5• 6 vesicostomy has the advantage of permitting the child to be cared for by family or personnel not trained in the technique of clean intermittent catheterization. The parent whose young child would be in diapers in any case, thus, is freed from the rather arduous demands of being available a minimum of 4 times a day for clean catheterization of the child. Additionally, vesicostomy is easily reversible, permitting closure of the bladder without sacrifice of significant bladder tissue. The technique advocated by Duckett minimizes the problem of stomal stenosis and bladder prolapse. 7 With increasing numbers of bladders diverted by vesicostomy, questions have been raised by some as to the effect of this form of bladder decompression on ultimate bladder volume. Can vesicostomy in the growing child result in a permanent loss of bladder volume? It has been our belief that permanent loss of bladder volume with urinary diversion either by vesicostomy or supravesical means is rare unless the diversion is accomplished at the time of severe infection in the bladder. In that situation fibrosis in the wall of an empty bladder may, indeed, permanently reduce its capacity. To review the long-term effect of vesicostomy on bladder volume we examined the long-term course of children with neurogenic bladders subject to vesicostomy, specifically focusing on those who had undergone closure. STUDY GROUP
Of 260 patients currently under active care in the myelodysplasia clinic of the Children's Hospital of Philadelphia 48 have had a vesicostomy. While this represents only a third of the vesicostomies done at this institution, it is a representative study population of myelodysplastic children. There were 35 girls and 13 boys. The age at vesicostomy was <6 months in 16, 6 months to 3 years in 20 and >3 years in 12. The primary Accepted for publication January 14, 1983.
indication for vesicostomy was hydroureteronephrosis, which was present in 44 cases. Of these children 7 had demonstrated reflux. This figure may be low, since not all children underwent voiding cystourethrography before vesicostomy. In 3 patients persistent infection that could not be controlled by oral agents led to vesicostomy. In 1 child with nephrogenic polyuria failure of adequate decompression by clean intermittent catheterization every 4 hours resulted in vesicostomy. Following vesicostomy the upper tracts showed improvement or stabilization of hydroureteronephrosis in 39 and 5, respectively, of the 48 patients (see figure). Only 1 child showed mild progression of unilateral hydroureteronephrosis after vesicostomy. In this case ureterovesical obstruction was corrected by vesicoureteral reimplantation with subsequent stabilization of the upper tract. Three children have had inadequate followup to judge the effect of vesicostomy on the upper urinary tract. While intermittent asymptomatic bacteriuria is not uncommon, only 2 children exhibited chronic bacteriuria and febrile urinary tract infections have been rare. Complications from the vesicostomy have been infrequent. Bladder calculi requiring removal occurred in 3 cases and none has recurred. F_'.our vesicostomies required 1 revision for either prolapse or stenosis, 1 child required 2 revisions and 1 stenotic vesicostomy is managed by intermittent catheterization of the stoma. Vesicostomy has been closed in 16 children. Closure is performed when the child expresses a desire to be dry and out of diapers, and has been taught clean intermittent self-catheterization. We prefer self-catheterization to promote independence of these often multiple handicapped children. The majority of children undergo closure between ages 6 and 10 years. There were 10 children in this age group when the vesicostomy was closed and 3 were > 10 years old. The remaining 3 patients underwent vesicostomy closure before age 6 years, including 2 in whom vesicostomy has been done in a bladder that, subsequently, was demonstrated to empty adequately spontaneously and 1, who was 2 years old and was placed on clean intermittent catheterization to facilitate orthopedic bracing. The duration of urinary diversion by vesicostomy ranged from 4 months to 10 years and averaged 6 years. Ancillary procedures performed at the time of vesicostomy closure consisted ofureterovesical reimplantation in 5 children,
724
veinc(Jst,)my shows good age 11 years.
including 1 for obstruction and 4 for reflux. No child has required bladder augmentation, although l has had a Scott genitourinary sphincter implanted. Followup of the 16 children with closed vesicostomies reveals that 12 are continent for at least 4 hours with clean intermittent catheterization. Of these 12 patients 7 require medication to assist in maintenance of continence. Two teenage girls have not achieved acceptable continence with clean intermittent catheterization despite bladder volumes between 280 and 290 cc. One has difficulty with clean intermittent catheterization because of severe orthopedic deformity and, accordingly, has undergone recently a successful continent vesicostomy using the appendix for a stoma on the abdominal wall for catheterization (Mitrofanoff procedure). 8 The other girl has undergone
a Marshall-Marchetti-Krantz procedure and is now u,,,w,,u."' further surgery to increase bladder outflow resistance. The 2 children who underwent ""s.,f'n
726
SNYDER AND ASSOCIATES
retardation is severe enough to interfere with clean intermittent catheterization. The other child has only a low normal intelligence but his mother refuses to have the vesicostomy closed. Additionally, 5 of the 9 patients have severe orthopedic deformities. None of these 5 children is able to ambulate. The management of all 9 has been considered to be simplified by a vesicostomy and, accordingly, it has been preserved. In none of the 9 children was an inadequate bladder capacity a consideration in the decision to maintain the cutaneous diversion. DISCUSSION
As in other studies, this review has again demonstrated that vesicostomy is an effective way of managing the nonemptying neurogenic bladder. Only 1 renal unit in the 44 patients with hydroureteronephrosis failed either to stabilize or improve. Significant infection was not a problem in any child with a vesicostomy. While 5 operative procedures were required for stomal stenosis or bladder prolapse and 3 children required removal of a bladder calculus, these were relatively minor operations and generally required a hospitalization of only 3 to 4 days. In the patient who is unsuitable for clean intermittent catheterization the vesicostomy can be maintained successfully for a long time. While fitting of an appliance to a vesicostomy is difficult, many of the patients who are maintained on longterm vesicostomy drainage are managed more easily with incontinence pads than a fitted appliance. This review has demonstrated that vesicostomy diversion is reversible without the loss of bladder volume. In this regard, vesicostomy diversion is similar to supravesical diversion. The undiversion experience reveals that the bladder rapidly redistends to its original pre-diversion volume after return of urine flow. We have been impressed that only when diversion is done during active infection in the bladder wall is a permanent loss of bladder volume likely to occur. This is most likely
due to the development of fibrosis in the wall of a decompressed bladder, which prevents its later expansion. No child in our series had this problem. While no patient in this study required bladder augmentation, this series is small and it is clear that in a large number of patients there will be an occasional child who has such a hypertonic small bladder that intestinal augmentation will be required to provide adequate bladder capacity. In summary, we continue to advocate vesicostomy for the temporary decompression of a neurogenic bladder with inadequate emptying. There is no evidence that this form of bladder diversion causes permanent bladder contracture or other harmful effect on the bladder. REFERENCES 1. Allen, T. D.: Vesicostomy for the temporary diversion of the urine
in small children. J. Urol., 123: 929, 1980. 2. Bruce, R. R. and Gonzales, E. T., Jr.: Cutaneous vesicostomy: a useful form of temporary diversion in children. J. Urol., 123: 927, 1980. 3. Cohen, J. S., Harbach, L. B. and Kaplan, G. W.: Cutaneous vesicostomy for temporary urinary diversion in infants with neurogenic bladder dysfunction. J. Urol., 119: 120, 1978. 4. Mandell, J., Bauer, S. B., Colodny, A. H. and Retik, A. B.: Cutaneous vesicostomy in infancy. J. Urol., 126: 92, 1981. 5. Kass, E. J., McHugh, T. and Diokno, A. C.: Intermittent catheterization in children less than 6 years old. J. Urol., 121: 792, 1979. 6. Plunkett, J. M. and Braren, V.: Clean intermittent catheterization in children. J. Urol., 121: 469, 1979. 7. Duckett, J. W., Jr.: Cutaneous vesicostomy in childhood. The Blocksom technique. Urol. Clin. N. Amer., 1: 485, 1974. 8. Mitrofanoff, P.: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir. Ped., 21: 297, 1980.
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0022-5347/83/1304-0724$02.00/0 THE JOURNAL OF UROLOGY
Vol. 130, October
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
VESICOSTOMY FOR NEUROGENIC BLADDER WITH SPINA BIFIDA: FOLLOWUP HOWARD Mee. SNYDER, III, MIRIAM A. KALICHMAN, EDWARD CHARNEY JOHN W. DUCKETT
AND
From the Division of Urology, Department of Chi/,d Development and Rehabilitation, Chi/,dren's Hospital of Philadelphia, Philadelphia, Pennsylvania, and Rehabilitation Institute of Chicago, Chicago, Illinois
ABSTRACT
Of 260 patients being actively followed in a myelodysplasia clinic 48 have had a vesicostomy. Vesicostomy was done because of hydroureteronephrosis in 44 cases, infection in 3 and failure of clean intermittent catheterization in 1. Of the 48 patients 16 underwent closure of the vesicostomy, generally between ages 6 and 10 years, an age when the child is prepared to begin clean intermittent catheterization and is motivated to achieve continence. Two children underwent early vesicostomy closure because the bladder emptied adequately and neither has yet begun clean intermittent catheterization. Two children on clean intermittent catheterization are not acceptably continent. The remaining 12 patients are continent for at least 4 hours on clean intermittent catheterization, some with adjuvant drug therapy. No child has exhibited loss of bladder volume while diverted. Vesicostomy offers excellent temporary decompression of the urinary tract in children with spina bifida and neurogenic bladder, and has no long-term harmful effects on the bladder. During the last decade there has been a great increase in the use of vesicostomy in children with neurogenic bladders. i--4 The most common indication is failure of adequate bladder emptying with secondary hydroureteronephrosis with or without infection. By providing reliable effective bladder empyting, the upper tracts generally are well protected. While it is true that clean intermittent catheterization, when effectively performed, can achieve the same end, 5• 6 vesicostomy has the advantage of permitting the child to be cared for by family or personnel not trained in the technique of clean intermittent catheterization. The parent whose young child would be in diapers in any case, thus, is freed from the rather arduous demands of being available a minimum of 4 times a day for clean catheterization of the child. Additionally, vesicostomy is easily reversible, permitting closure of the bladder without sacrifice of significant bladder tissue. The technique advocated by Duckett minimizes the problem of stomal stenosis and bladder prolapse. 7 With increasing numbers of bladders diverted by vesicostomy, questions have been raised by some as to the effect of this form of bladder decompression on ultimate bladder volume. Can vesicostomy in the growing child result in a permanent loss of bladder volume? It has been our belief that permanent loss of bladder volume with urinary diversion either by vesicostomy or supravesical means is rare unless the diversion is accomplished at the time of severe infection in the bladder. In that situation fibrosis in the wall of an empty bladder may, indeed, permanently reduce its capacity. To review the long-term effect of vesicostomy on bladder volume we examined the long-term course of children with neurogenic bladders subject to vesicostomy, specifically focusing on those who had undergone closure. STUDY GROUP
Of 260 patients currently under active care in the myelodysplasia clinic of the Children's Hospital of Philadelphia 48 have had a vesicostomy. While this represents only a third of the vesicostomies done at this institution, it is a representative study population of myelodysplastic children. There were 35 girls and 13 boys. The age at vesicostomy was <6 months in 16, 6 months to 3 years in 20 and >3 years in 12. The primary Accepted for publication January 14, 1983.
indication for vesicostomy was hydroureteronephrosis, which was present in 44 cases. Of these children 7 had demonstrated reflux. This figure may be low, since not all children underwent voiding cystourethrography before vesicostomy. In 3 patients persistent infection that could not be controlled by oral agents led to vesicostomy. In 1 child with nephrogenic polyuria failure of adequate decompression by clean intermittent catheterization every 4 hours resulted in vesicostomy. Following vesicostomy the upper tracts showed improvement or stabilization of hydroureteronephrosis in 39 and 5, respectively, of the 48 patients (see figure). Only 1 child showed mild progression of unilateral hydroureteronephrosis after vesicostomy. In this case ureterovesical obstruction was corrected by vesicoureteral reimplantation with subsequent stabilization of the upper tract. Three children have had inadequate followup to judge the effect of vesicostomy on the upper urinary tract. While intermittent asymptomatic bacteriuria is not uncommon, only 2 children exhibited chronic bacteriuria and febrile urinary tract infections have been rare. Complications from the vesicostomy have been infrequent. Bladder calculi requiring removal occurred in 3 cases and none has recurred. F_'.our vesicostomies required 1 revision for either prolapse or stenosis, 1 child required 2 revisions and 1 stenotic vesicostomy is managed by intermittent catheterization of the stoma. Vesicostomy has been closed in 16 children. Closure is performed when the child expresses a desire to be dry and out of diapers, and has been taught clean intermittent self-catheterization. We prefer self-catheterization to promote independence of these often multiple handicapped children. The majority of children undergo closure between ages 6 and 10 years. There were 10 children in this age group when the vesicostomy was closed and 3 were > 10 years old. The remaining 3 patients underwent vesicostomy closure before age 6 years, including 2 in whom vesicostomy has been done in a bladder that, subsequently, was demonstrated to empty adequately spontaneously and 1, who was 2 years old and was placed on clean intermittent catheterization to facilitate orthopedic bracing. The duration of urinary diversion by vesicostomy ranged from 4 months to 10 years and averaged 6 years. Ancillary procedures performed at the time of vesicostomy closure consisted ofureterovesical reimplantation in 5 children,
724
veinc(Jst,)my shows good age 11 years.
including 1 for obstruction and 4 for reflux. No child has required bladder augmentation, although l has had a Scott genitourinary sphincter implanted. Followup of the 16 children with closed vesicostomies reveals that 12 are continent for at least 4 hours with clean intermittent catheterization. Of these 12 patients 7 require medication to assist in maintenance of continence. Two teenage girls have not achieved acceptable continence with clean intermittent catheterization despite bladder volumes between 280 and 290 cc. One has difficulty with clean intermittent catheterization because of severe orthopedic deformity and, accordingly, has undergone recently a successful continent vesicostomy using the appendix for a stoma on the abdominal wall for catheterization (Mitrofanoff procedure). 8 The other girl has undergone
a Marshall-Marchetti-Krantz procedure and is now u,,,w,,u."' further surgery to increase bladder outflow resistance. The 2 children who underwent ""s.,f'n
726
SNYDER AND ASSOCIATES
retardation is severe enough to interfere with clean intermittent catheterization. The other child has only a low normal intelligence but his mother refuses to have the vesicostomy closed. Additionally, 5 of the 9 patients have severe orthopedic deformities. None of these 5 children is able to ambulate. The management of all 9 has been considered to be simplified by a vesicostomy and, accordingly, it has been preserved. In none of the 9 children was an inadequate bladder capacity a consideration in the decision to maintain the cutaneous diversion. DISCUSSION
As in other studies, this review has again demonstrated that vesicostomy is an effective way of managing the nonemptying neurogenic bladder. Only 1 renal unit in the 44 patients with hydroureteronephrosis failed either to stabilize or improve. Significant infection was not a problem in any child with a vesicostomy. While 5 operative procedures were required for stomal stenosis or bladder prolapse and 3 children required removal of a bladder calculus, these were relatively minor operations and generally required a hospitalization of only 3 to 4 days. In the patient who is unsuitable for clean intermittent catheterization the vesicostomy can be maintained successfully for a long time. While fitting of an appliance to a vesicostomy is difficult, many of the patients who are maintained on longterm vesicostomy drainage are managed more easily with incontinence pads than a fitted appliance. This review has demonstrated that vesicostomy diversion is reversible without the loss of bladder volume. In this regard, vesicostomy diversion is similar to supravesical diversion. The undiversion experience reveals that the bladder rapidly redistends to its original pre-diversion volume after return of urine flow. We have been impressed that only when diversion is done during active infection in the bladder wall is a permanent loss of bladder volume likely to occur. This is most likely
due to the development of fibrosis in the wall of a decompressed bladder, which prevents its later expansion. No child in our series had this problem. While no patient in this study required bladder augmentation, this series is small and it is clear that in a large number of patients there will be an occasional child who has such a hypertonic small bladder that intestinal augmentation will be required to provide adequate bladder capacity. In summary, we continue to advocate vesicostomy for the temporary decompression of a neurogenic bladder with inadequate emptying. There is no evidence that this form of bladder diversion causes permanent bladder contracture or other harmful effect on the bladder. REFERENCES 1. Allen, T. D.: Vesicostomy for the temporary diversion of the urine
in small children. J. Urol., 123: 929, 1980. 2. Bruce, R. R. and Gonzales, E. T., Jr.: Cutaneous vesicostomy: a useful form of temporary diversion in children. J. Urol., 123: 927, 1980. 3. Cohen, J. S., Harbach, L. B. and Kaplan, G. W.: Cutaneous vesicostomy for temporary urinary diversion in infants with neurogenic bladder dysfunction. J. Urol., 119: 120, 1978. 4. Mandell, J., Bauer, S. B., Colodny, A. H. and Retik, A. B.: Cutaneous vesicostomy in infancy. J. Urol., 126: 92, 1981. 5. Kass, E. J., McHugh, T. and Diokno, A. C.: Intermittent catheterization in children less than 6 years old. J. Urol., 121: 792, 1979. 6. Plunkett, J. M. and Braren, V.: Clean intermittent catheterization in children. J. Urol., 121: 469, 1979. 7. Duckett, J. W., Jr.: Cutaneous vesicostomy in childhood. The Blocksom technique. Urol. Clin. N. Amer., 1: 485, 1974. 8. Mitrofanoff, P.: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir. Ped., 21: 297, 1980.