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Continent Catheterizable Stoma and Incontinent Urinary Diversion

People with tetraplegia, especially females, often have difficulty performing clean intermittent catherization. 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.

Table 17 Continent Catheterizable Stoma and Incontinent Urinary Diversion

Author Year

Country
Score
Research Design
Total Sample Size

MethodsOutcome
Continent Catheterizable Stoma
Karsenty et al. 2008

France

Pre-Post

N=13

Population: Mean age: 42 yr; Gender: males=2, females=11; Level of injury: cervical=5, thoracic=5, sacral=1. cauda equina=1 other=1; All were unable to self catheterize. Mean time post-injury=12.2 yr; Mean follow-up=44 mo.

Intervention: Individuals underwent a novel procedure involving a cutaneous continent diversion composed of an abdominal continent stoma combined with enterocystoplasty which was used to facilitate self-catheterization.

Outcome Measures: Complications, continence, catheterization difficulties, functional bladder capacity and serum creatinine.

1.     Complications included postoperative infections (5 urinary, 2 pulmonary) and 1 pelvic abscess and 1 small bowel occlusion both requiring surgery

2.     In all individuals, the catheterizable stoma was continent, but 3 females had stress leakage through native urethra, 2 requiring secondary bladder neck closure.

3.     All individuals could self catheterize.

4.     An increase from 180ml to 540ml was seen in functional bladder capacity from pre to post surgery.

5.     No change in serum creatinine was seen post surgery.

Sylora et al. 1997

USA

Pre-Post

N=7

Population: Age Range19 to 44 yr; Gender: males=4, females=3; Level of injury: tetraplegia=7. All individuals had adequate bladder capacity and were on anticholinergics

Intervention: Individuals underwent Mitrofanoff umbilical apendicovesicostomy with appendix or ileum. F/U 5–20 mo.

Outcome Measures: Bladder capacity, continence, complications.

1.     No significant changes were seen in bladder capacity.

2.     All individuals were continent.

3.     Complications included transient stress urinary incontinence which resolved spontaneously (n=1) and stomal revision (n=1).

Hakenberg et al. 2001

Germany

Case Series

N=5

Population: Mean age: 31 yr; Gender: males=1, females=4; Level of injury: tetraplegia=5; Mean time post-injury=22 mo. F/U 21–40 mo. All individuals on anticholinergics both pre and post surgery.

Intervention: Individuals underwent appendicovesicostomy and a cutaneous stoma was placed in the lower right abdominal quadrant.

Outcome Measures: Independent clean intermittent catheterization (IC), stomal stenosis, urinary tract infections, satisfaction.

1.     All individuals were able to independently perform clean IC and were continent.

2.     Stomal stenosis did not occur.

3.     2 individuals experienced urinary tract infections once, and 1 individual had repeated occurrences.

4.     3 out of 5 individuals were highly satisfied with the results.

5.     Post-op bladder compliance 20–44 mm H20.

 

 

Incontinent Urinary Diversion
Perrouin-Verbe et al. 2016

France

Pre-Post

N=29

Population: Median age: 35 yr; Gender: males=7, females=22; Level of injury: cervical=17, thoracic=10, lumbar=2; Median time post-injury: 9 yr.

Intervention: Individuals unable to perform intermittent self-catheterization through the native urethra received continent cutaneous urinary diversion with a concomitant supratrigonal and augmentation enterocystoplasty.

Outcome Measures: Postoperative complications, duration of hospitalization, long-term complications, urethral continence, antimuscarinics, onabotulinum toxin A, detrusor overactivity, low bladder compliance, maximal cystometric capacity, maximal detrusor pressure, creatinine clearance, upper urinary tract dilation, quality of life.

1.     During the first mo post-surgery, there were three minor complications, two major complications and no deaths.

2.     The overall complication rate was 44.8% and the total reoperation rate was 24.1%.

3.     Compared to before surgery, the number of participants with urethral incontinence (p=0.013), using antimuscarinics, using onabotulinum toxin A, with detrusor overactivity (p=0.0006), with low bladder compliance (p=0.05), and upper urinary tract dilation significantly decreased.

4.     There was a significant increase for the median maximal cystometric capacity (p=0.021), a significant decrease for maximal detrusor pressure (p=0.05), and no significant difference in creatinine clearance.

5.     Urethral continence was achieved in 96% of participants and quality of life was improved in 90%.

Craven & Etchells 1998 Australia

Pre-Post

N=27

Population: SCI individuals with ileostomy, colostomy, or urostomy.

Intervention: No intervention – chart review

Outcome Measures: Questionnaire for physical, psychological, quality of life (QoL) and lifestyle effects after surgery.

1.     11 individuals underwent urostomy (Indications: chronic UTI in all, 1 recurrent calculi, 3 hydronephrosis)

2.     Three individuals required cyctectomy, while a fourth was advised to get one

3.     Although 27 charts reviewed only 18 individuals located to complete the questionnaire:

·       Bowel and bladder management greatly improved in most cases, resulting in improved QoL for these individuals.

·       Positive psychological effects.

4.     Long-term impact on renal health not assessed.

Peterson et al. 2012

USA

Case Series

N=3051

Population: Ileal loop urinary diversion=1919, Bladder augmentation=1132; Mean age: 40 yr.

Intervention: Review of individuals’ information undergoing either ileal loop urinary diversion or bladder augmentation.

Outcome Measures: Sociodemographic characteristics and care settings.

1.     Individuals who had ileal loop diversions were older than those who received bladder augmentation (mean age of 46 versus 34 yr p<0.001).

2.     Ileal loop diversion individuals were most likely to have Medicare as the primary payer, whereas private insurance was used most among bladder augmentation (p<0.001).

3.     Individuals were more likely to get bladder augmentation at teaching institutions than those at non-teaching institutions (42% versus 23%; p<0.001).

4.     Ileal loop diversions required longer LOS and used more healthcare resources than bladder augmentation. More likely to be discharged to home healthcare (37.0% versus 23.6%; p<0.001).

 

Colli & Lloyd 2011

USA

Case Series

N=35

Population: Mean age: 44.7yr (range=25-78yr); Gender: male=11, female=24; mean LOS=4.1 d; Etiology of injury: SCI=77, MS=5, Cerebrovascular accident=3; Abdominal BNC=31; Transvaginal bladder neck closure=4; Mean follow up=27 mo

Intervention: Bladder neck closure (BNC)

Outcome Measures: Renal functions measure, complication rate.

1.     Indications for BNC included: severe urethral erosion (80%), decuitus ulcer (40%), urethrocutaneous fistula (11%), and severe incontinence (9%). Most individuals reported multiple indications for surgery.

2.     Overall, the complications rate was 16.7%.

Zommick et al. 2003

USA

Case Series

N=21

Population: Age Range 17-51 yr; Gender: males=12, females=9; Level of injury=Cervical Spine.

Intervention: Review of charts, and individuals contacted by independent reviewer to determine satisfaction and quality of life (QoL) after lower urinary tract reconstruction.

Outcome Measures: Visual Analogue Scale measuring satisfaction, nonvalidated QoL questionnaires.

1.     68% reported improved QoL after bladder reconstruction.

2.     Satisfaction was high in most individuals (8 ≥ out of 10), with lower ratings relating to complications that arose.

Chartier-Kastler et al. 2002

France

Case Series

N=33

Population: MS (N=4), CP (N=3), Myelitis (N=3), Other (N=2), SCI (N=21): Mean Age=40.6 years; Gender: males=14, females=19; Level of injury: cervical=32, thoracic=25, C1-T10=14, T11-L1=6, below L2=1; Severity of injury: complete, incomplete; Mean follow-up=48 months.

Intervention: Follow-up evaluation of those having cutaneous ileal conduit (ileo-ureterostomy) diversion.

Outcome Measures: IVU, serum creatinine, cystoscopy, urine cultures and pre/post incidence of UTIs, visual analog individual satisfaction. Collected at follow-up as indicated above.

1.     No statistical comparisons reported

2.     Initial surgery was successful. All individuals became continent after initially being incontinent prior to surgery.

3.     Of 17 with pre-op hydronephrenosis, 10 showed a decrease or disappearance.

4.     12 individuals developed one or more complications during follow-up. 4 early complications and 13 late complications.

5.     Most prevalent long-term complications were pyocystitis (4–3 requiring cystectomy), pyelonephritis (4) and urethral leak (2).

6.     Satisfaction survey indicated none regretted surgery (9.1±2.8 out of 10).

Kato et al. 2002

Japan

Case Series

N=16

Population: SCI: Mean Age=46years; Gender: males=13, females=3; Level of injury: tetraplegia; Mean follow-up time=8.7years.

Intervention: Follow-up evaluation of those having ileal conduit formation.

Outcome Measures: Review of charts (deaths, complications, subjective statements of satisfaction, serum creatinine where completed)

1.     No statistical comparisons reported

2.     Serum creatinine remained stable

3.     3 subjects died (constrictive ileus, unknown, septicemia associated with UTIs) during the follow-up period.

4.     5/16 individuals had calculus formation in the upper urinary tract; 3 had severe UTI’s as a result

5.     8 subjects of 13 in whom a bladder was initially preserved sustained a pyocyst.

6.     5 experienced calculus formation in the upper urinary tract, 3 of these having severe UTIs as a result.

7.     Most individuals were more satisfied with procedure than previous management method upon survey a few months after operation (no long-term follow-up on this issue).

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.

Catheterizable abdominal stomas may increase the likelihood of achieving continence and independence in self-catherization, and may result in a bladder management program that offers more optimal upper tract protection.

Cutaneous ileal conduit diversion may increase the likelihood of achieving continence but may also be associated with a high incidence of various long-term complications.