Incontinence Diversion: Ileovesicostomy and Conduit 

A. Ileovesicostomy

1. Concept

  • Cutaneous diversion at the level of the bladder: Ileovesicostomy and Conduit
  • Cutaneous diversion at the level of the ureter: Cutaneous ureterostomy (direct anastomosis of the ureters to the anterior abdominal wall)- this procedure is rarely performed today.
  • An alternative form of urinary management applied to patients with neurogenic bladder dysfunction who are either unable or unwilling to perform CIC or assisted catheterization.

2. History

  • In 1955, dog experiments in which the animal ’s native bladder was left in situ and connected to the skin surface by an intestinal conduit. [Smith 1955]
  • In 1957, first described by Cordonnier [Cordonnier 1957]
  • In 1994, modern concept of incontinent ileovesicostomy

3. Terminology

  • bladder chimney
  • Incontinent ileovesicostomy

4. Purpose of the Procedure

  • Provide low pressure urinary egress without a urteral anastomosis, leaving the bladder intact to protect the ureters

5. Indication

  • Failure of conservative treatment of neurogenic bladders, Intractable filling/storage or emptying failure, progressive hydronephrosis or recurrent urosepsis despite all means of therapy especially in quadriplegic patients with a high level of injury, patients with poor dexterity and poorly motivated patients
  • Severe urethral pathology (for example, urethral stricture, severe erosion, urethral diverticulum or urethrocutaneous fistula due to the prolonged urethral catheter indwelling)

6. Procedure

  • Isolation of a 15-20-cm segment of terminal ileum [VIDEO]
  • Anastomosis of the dome of the bladder and the proximal portion of the bowel
  • The distal portion of the ileum becomes the cutaneous stom

7. Clinical Outcomes

Authors (Year)

Methods

Results

Comments

Gauthier AR Jr, Winters JC.
(Neurourol Urodyn. 2003)

7 patients (5 male, 2 female; mean age, 33.7 yr) in quadriplegic neurogenic bladder

ileovesicostomy

urodynamic study

Mean follow-up 37.4 months.

No intraoperative complications.

Complications:
fascial stenosis requiring stoma revision (n = 1),
wound infection (n = 1),
postoperative ileus (n = 1).

Postoperatively, mean DLPP 16.7 cmH2O

High patient satisfaction

Ileovesicostomy is an effective method of urinary drainage in quadriplegic patients.

Detrusor leak point pressures were lowered, and upper tracts were preserved.

No long-term complications were encountered.

Gudziak MR, Tiguert R, Puri K, Gheiler EL, Triest JA. (Urology. 1999)

13 patients (mean age 43.2 years) with neurogenic bladder dysfunction incl. 8 SCI and 4 MS

Ileovesicostomy

Mean follow-up 23 months

 

No intraoperative complications

1 reoperation for stomal revision.

 

Mean bladder leak point pressure through the stoma 8.2cmH2O

Ileovesicostomy is a useful technique in the treatment of patients with neurogenic bladder unable to perform CIC.

It provides patients with a low-pressure urinary conduit that empties readily without an in dwelling catheter.

 

8. Advantages [Gudziak 1999]

  • less technically demanding
  • fewer postoperative complications associated
  • Compared with the ileal conduit:
    • Able to maintain collecting urine in the bladder, makes more natural way
    • No need for ureteral reimplantation: This makes preservation of original anatomic nonrefluxing mechanism at the ureterovesical junction.
    • Simplicity of surgical construction
    • Easier to reverse if newer methods of bladder management will be available in the future
  • Compared to other modalities:
    • Avoid danger to the urethral sphincter mechanism
    • Low pressure bladder
    • Ease of stomal appliance fitting
    • Applicable to female patients
    • Do not require an indwelling catheter or CIC

9. Disadvantages

  • bladder neck closure is usually needed
  • exposing patients to a major abdominal surgery
  • need for external collection device which impact on the body image and freedom of lifestyle

10. Current Significance

  • Ileovesicostomy may be used as the first choice in quadriplegic patients who are not able to CIC or do not have assistance available to do so [Gudziak 1999].

Summary

Effectiveness

About 80%

Safety

Requires bowel resection, periodic revision,

Ease of application

Technically easier than a loop and with less complications

Patient Comfort

Requires a bag, changes, sometimes urethral leakage

Cost

High, long period of hospitalization, extensive surgery

 

Key Points of This Section

  • Ileovesicostomy provides low pressure leakage of urine.
  • It is less complex than a loop or a continent diversion and does not require intermittent catheterization.
  • It has some problems: drainage, excessive mucous production occasional urethra urinary leakage.

 

B. Conduit Diversion

1. Concept

  • Cutaneous incontinent diversion above the level of the bladder below the kidney [VIDEO]

2. History

  • In 1937, Seifert described an incontinent urinary diversion performed by a jejunum conduit [Seifert 1937]
  • In 1950, first described by Bricker as a supravesical diversion and it soon became the most common form of urinary diversion [Bricker 1950].
  • In 1960, the colonic conduit with antireflux ureteric implantation was introduced in an attempt to preserve renal function [Turner-Warwick 1960]. Initial studies showed less renal damage with such a technique, however, this was not confirmed in later reports [Elder 1979; Husmann 1989].

3. Terminology

  • cutaneous diversion
  • ileoureterostomy
  • colonic conduit (when colon segment is used)
  • ileal conduit (when ileal segment is used)

4. Purpose of the Procedure

  • upper urinary tract protection
  • continence and perineal dryness
  • functional or social reasons

5. Indication

  • same as in the ileovesicostom

6. Procedure

  • A midline abdominal incision and obtaining an bowel segment from the small or large bowel
  • Both ureters were anastomosed to the proximal side of the bowel segment.
  • Distal part is brought to the skin to make the stoma.
  • It can be performed alone and in combination with simultaneous cystectomy.

7. Clinical Outcomes

Authors (Year)

Methods

Results

Comments

Chartier-Kastler EJ, Mozer P, Denys P, Bitker MO, Haertig A, Richard F. (Spinal Cord. 2002)

Retrospective review of
33 patients (19 women, 14 men) incl. 21 SCI and 4 MS

Mean follow-up was 48 months

Reviewed outcome and early and late complications

All problems related to catheters or incontinence had resolved.

All patients achieved perineal dryness.

There were no deaths or early re-operations.

36% peri-operative complication: ileus, ureteroileal anastomosis leak, sepsis

The ileal conduit procedure is a safe and well-tolerated procedure in neurologically impaired patients.

This procedure is suitable for most neurogenic patients with refractory lower urinary tract dysfunctions.

Pitts WR Jr, Muecke EC. (J Urol. 1979)

During the last 20 years 242 patients have undergone ileal conduit urinary diversion

11 % of the renal units showed damage after the ileal conduit

Poor long-term results with high rates of PN, renal scarring, stone formation and ureteral obstruction

There is a progressive risk of renal deterioration with increasing time and obstruction was its major cause.

 

Stein R, Wiesner C, Beetz R, Schwarz M, Thuroff JW. (Pediatr Nephrol. 2005)

Colonic conduit urinary diversion

56 patients

Average follow-up 21.8 years

 

Upper urinary tracts remained stable or improved 98%

Stoma revision 16%

Calculi formations 8%

For patients with chronic renal failure or who are unable to perform a catheterization of a continent stoma, the colonic conduit is a safe alternative in the long run.

Husmann DA, McLorie GA, Churchill BM. (J Urol. 1989)

25 patients undergoing urinary diversion with a nonrefluxing colonic conduit

Median followup of 12.7 years.

Renal scarring developed in 10% of the kidneys

Deterioration of the ureteroenteric anastomosis occurred in 22% of renal units due to the development of reflux or stricture. Of these kidneys 45% had scarring

 

 

8. Advantages

9. Disadvantages

  • late complication rate 19–86% [Graham 1982; Shapiro 1975]
    • Deterioration of the upper urinary tract and renal function
    • calculi formation
    • stoma stenosis
  • exposing patients to a major abdominal surgery: exposed to a considerable amount of complications

10. Current Significance

  • Although commonly employed in the past for the treatment of neurogenic voiding dysfunction, supravesical diversion is now rarely indicated in any patient with only voiding dysfunction.

Summary

Effectiveness

In  the short term very effective

Safety

High rate of serious complications with time, including ureteral and renal failure

Ease of application

Not easy surgery with relatively high early risks

Patient Comfort

Acceptable

Cost

Acceptable but late complications can be devastating and or untreatable.

 

References

  • Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am. 1950 Oct;30(5):1511-21.
  • Chartier-Kastler EJ, Mozer P, Denys P, Bitker MO, Haertig A, Richard F. Neurogenic bladder management and cutaneous non-continent ileal conduit. Spinal Cord. 2002 Sep;40(9):443-8.
  • Cordonnier JJ. Ileocystostomy for neurogenic bladder. J Urol. 1957 Nov;78(5):605-10.
  • Elder DD, Moisey CU, Rees RW (1979) A long-term follow-up of the colonic conduit operation in children. Br J Urol 51:462–465.
  • Gauthier AR Jr, Winters JC. Incontinent ileovesicostomy in the management of neurogenic bladder dysfunction. Neurourol Urodyn. 2003;22(2):142-6.
  • Graham AG (1982) Long-term results of ileal conduit diversion in children—a brighter picture? Br J Urol 54:632–634;
  • Gudziak MR, Tiguert R, Puri K, Gheiler EL, Triest JA. Management of neurogenic bladder dysfunction with incontinent ileovesicostomy. Urology. 1999 Dec;54(6):1008-11.
  • Husmann DA, McLorie GA, Churchill BM. Nonrefluxing colonic conduits: a long-term life-table analysis. J Urol. 1989 Nov;142(5):1201-3.
  • Pitts WR Jr, Muecke EC. A 20-year experience with ileal conduits: the fate of the kidneys. J Urol. 1979 Aug;122(2):154-7.
  • Schwartz SL, Kennelly MJ, McGuire EJ, Faerber GJ. Incontinent ileo-vesicostomy urinary diversion in the treatment of lower urinary tract dysfunction. J Urol. 1994 Jul;152(1):99-102.
  • Seifert L. Indikation und Operationstechnik der Darm-Siphon-Blase, ihrer Leistungsfähigkeit in Röntgenbild und Film. Zeitschr Urol 1937; 1:23–33.
  • Shapiro SR, Lebowitz R, Colodny AH. Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology. J Urol. 1975 Aug;114(2):289-95.
  • Smith GI, Hinman F Jr. The intussuscepted ileal cystostomy. J Urol. 1955 Feb;73(2):261-9.
  • Stein R, Wiesner C, Beetz R, Schwarz M, Thuroff JW. Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience Part III: Colonic conduit. Pediatr Nephrol. 2005 Apr 27 ; [Epub ahead of print]
  • Turner-Warwick RT. Colonic urinary diversion. Proc R Soc Med 1960; 53:56–58.

 

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