Continent Catheterizable Stoma and Incontinent Urinary Diversion
People with tetraplegia, especially females, often have difficulty performing clean intermittent catheterization. In addition, females are more troubled by persistent incontinence. The surgical methods described in this section can result in the ability to self-catheterize, allowing the individual to benefit from intermittent rather than indwelling bladder catheterization, the latter being associated with a higher rate of complications. The mitrofanoff channel involves the use of an autologous tubular structure, usually the appendix, as a cutaneous catheterizable stoma. Implantation in the bladder via a submucosal tunnel provides continence to the conduit (Zommick et al. 2003; Sylora et al. 1997). The stoma can be hidden in the umbilicus. While performed often in children, the procedure has less commonly been performed in adults. Long term followup is reportedly good up to 60 months (Zommick et al. 2003, n=7; Hakenberg et al, 2001, n=4), but has not been reported with respect to the potential for malignancies. Karsenty et al. (2008) describes a similar procedure, performed in 13 patients with incontinence and inability to self-catheterize.
Ileal conduit diversion, another surgical approach more commonly performed in females, is also often considered for reasons of lack of manual dexterity or ease of care and convenience (Pazooki et al. 2006; Chartier-Kastler et al. 2002). This technique aims to establish low-pressure urinary drainage by diverting urine prior to entering the bladder and connecting the ureters to an external urinary collection system via a catheter passed through the ileal lumen. This procedure is sometimes conducted along with removal of the bladder as well (Chartier-Kastler et al. 2002; Kato et al. 2002). Peterson et al. (2012) observed that during the period from 1998 to 2005 in the USA, urinary diversion was used more frequently by older patients (>41 years, reliant on Medicare) than bladder augmentation as the treatment choice. But due to missing data (e.g., level of injury, failed previous bladder augmentation, renal function status, etc.), the reasons behind treatment choices are not completely understood.
Discussion
Continent Catheterizable Stoma
Despite small sample sizes, the results of the above studies are very promising. High levels of continence, independence, and the ability to manage the bladder with IC are reported in all three studies. The stability of serum creatinine has implications for upper tract function (Karsenty et al. 2008). Hakenberg et al. (2001) reported safe urodynamic bladder storage pressures (20-44 mm H20) in patients that underwent appendicovesicostomy with cutaneous stoma. Participants in this study and the study by Sylora et al. (1997) were kept on anticholinergic medication, a consideration that ensures low pressure storage in those with persistent hyperreflexia and dyssynergia, and contributes to ongoing continence. Complications occured most concerning of which were those requiring surgical procedures (i.e., pelvic abscess, bowel occlusion, stomal revision for stenosis). Larger sample sizes would be necessary to determine true incidence. Length of follow-up ranged from 20 to 44 months, which does not provide sufficient long-term safety and effectiveness data. However, given the importance of the clinical achievements (i.e., independent use of intermittent catheterization and continence), further study with larger sample sizes is warranted.
Incontinent Urinary Diversion
Ileal conduit diversion is another surgical procedure noted with some frequency in the literature. Chartier-Kastler et al. (2002) and Kato et al. (2002) have reported separate case series (N=33 and N=16 respectively) examining this approach. Chartier-Kastler et al. (2002) reported that all patients became continent after initially being incontinent prior to surgery. Kato et al. (2002) reported that most patients were more satisfied with the procedure than their previous management method upon survey a few months after the operation. Both authors also reported several long-term complications (e.g. pyocystitis, suprapubic collection with genital secretions, chronic urethral leakage, and acute pyelonephritis). However, it is uncertain if these high complication rates would be comparable in the event individuals had continued with their previous form of bladder management, as often surgical procedures are performed only if other more conservative methods are unsuccessful. Controlled trials (e.g. case control) would be beneficial to address this issue.
Colli and Lloyd (2011) evaluated a series of cases (n=35) involving bladder neck closure (BNC) which was paired with permanent SPC diversion as opposed to other forms of urinary diversion, such as ileovesicotomy or continent catheterizable stoma. Their results suggest that BNC in conjunction with SPC diversion offers urethral continence with a reasonable complication rate (17%). Additional advantages conferred by this technique include a straightforward operative approach without violation of the peritoneum, no need for enteric reconstruction, and possible reduction of bowel complications. Specific disadvantages were noted such as a reduced likelihood of success in very low bladder capacity patients.
Conclusion
There is level 4 evidence (from one case series and one pre-post study: Hakenberg et al. 2001; Sylora et al. 1997) that most individuals who receive catheterizable stomas become newly continent and can self-catheterize. It appears possible that this surgical intervention could protect upper tract function. Larger studies are needed to better evaluate true incidence of complications, and long-term bladder and renal outcome.
There is level 4 evidence (from two case series studies: Chartier-Kastler et al. 2002; Kato et al. 2002) that most individuals undergoing cutaneous ileal conduit (ileo-ureterostomy) diversion became newly continent and were more satisfied than with their previous bladder management method. Long-term follow-up demonstrated the presence of a high incidence of urological or renal complications.
