Continent Urinary Diversion 

1. Concept

  • Continent diversion:
    • Ureterosigmoidostomy
      • Continence mechanism: anal sphincter
    • Orthotopic or neobladder diversion
      • Pouch: anastomosed to the native urethra
      • Continence mechanism: native striated urethral sphincter
    • Continent catheterizable diversion
      • Pouch: anastomosed to the catheterizable channel
      • Catheterizable channel:
        • enabling the pouch to be emptied
        • Continence mechanism: catheterizable channel
  • Continent diversion requires that most of the urinary bladder storage system should remain continent during the storage phase between catheterizations (commonly requires augmentation cystoplasty).

2. History

  • In 1852, Simon reported the first urinary diversion through the creation of ureterosigmoidostomies in a patient with bladder exstrophy [Simon 1852].
  • In 1950, Gilchrist described a urinary diversion in which a continent catheterizable neobladder was constructed [Gilchrist 1950]
  • In 1979, Kock developed an intussuscepted ileal nipple valve for continence mechanism [Kock 1978; Kock 1982]
  • In 1980, Mitrofanoff introduced a new method creating a continent catheterizable channel using appendix [Mitrofanoff 1980]
  • Later, various types of techniques developed for continent catheterizable channels. Today there are hundreds of combinations of stoma and catheterizable channels

3. Terminology

  • reservoir = pouch = storage system

4. Purpose of the Procedure

To overcome problems associated with urethral dysfunction

5. Indication and Contraindication

  • Indications
    • Patient able to perform CIC or that dependable assistance is available
  • Contraindications
    • Poor hand function for the intermittent catheterization
    • Bowel abnormalities: such as Crohn disease, severe irritable bowel syndrome
    • Poor renal function

6. Procedure

  • A continent catheterizable channel:
    • The appendix is used as the first choice (appendicovesicostomy) [Yang 1993] [Monti 1997]) [VIDEO]
    • The cutaneous stoma is commonly placed the in the umbilicus for cosmetic reasons.
  • Simultaneous procedures:
    • Augmentation cystoplasty: Continent urinary diversion is commonly combined since concomitant bladder pathology exists. However, continent catheterizable channel can be created in the native bladder.
    • Malone antegrade colonic enema (MACE) procedure: Since neuropathic lower urinary tract dysfunction usually combines bowel function (chronic constipation or fecal incontinence), this procedure is commonly combined [Malone 1990]

7. Technical Variants for Creating Continent Catheterizable Channel according to the Continence mechanism:

  • Native ileocaecal valve
  • Flap valve (Mitrofanoff principle): the most reliable type of continence mechanism
    • Mechanism: As the pouch fills up, the catheterizable channel is compressed between the mucosa and muscular backing of the bladder or reservoir. The fuller the bladder becomes, the more compression there is and the less chance of urine leakage.
    • Materials:
      • Retubularized ileovesicostomy (Yang-Monti procedure) [Monti 1997]: appendicovesicostomy.
      • Continent vesicostomy using tubularized bladder flap [VIDEO]
      • Tapered ileum [Figueroa 1994]
      • Ureter [Mor 1997] [Van Savage 1996]
        • greater risk of stomal stenosis
      • Others: stomach tube, fallopian tube or vas deferens
  • Flutter valves or nipple valve
    • Kock procedure
      • Procedure: The catheterizable channel is extended into the lumen of the pouch and fixed into position.
      • Mechanism: When the urine fills the pouch, it compresses the catheterizable channel circumferentially throughout its length of nipple in the pouch, thus maintaining continence. [VIDEO]
      • Disadvantages:
        • At least a 15% revision rate
        • Requires a significant length of small bowel
        • Over time, many tend to break down because permanent suture or staples cannot be used due to stone formation.
    • Benchekroun procedure:
      • Procedure: Intussusception of the ileum into itself.
      • Mechanism: As the pouch is filled, the urine compresses the intussuscepted segment so as to achieve continence.

8. Clinical Outcomes

Authors (Year)

Methods

Results

Comments

De Ganck J, Everaert K, Van Laecke E, Oosterlinck W, Hoebeke P. [BJU Int. 2002]

Mitrofanoff continent urinary diversion & MACE procedures.

53 patients incl. 27 spina bifida, 10 paraplegia, and 4 tetraplegia

stoma-related complications 36%: mostly stomal stenosis

median time to the first complication: 9 months

Women had more complications than men and umbilical stomas fared worse than those on the abdominal wall.

Most complications were relatively easy to treat: dilatation in 5, endoscopic incision in 1, re-anastomosis in 4, Y-V plasty in 7, a new channel in 2

The complication rate for continent small-diameter stoma is high. However, most complications are relatively easy to treat. Despite these complications, patient satisfaction remains high.

Cain MP, Casale AJ, King SJ, Rink RC. Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital. [J Urol. 1999]

various Mitrofanoff techniques to create a continent catheterizable stoma

Mean followup 2 years

100 patients incl. 69 neurogenic bladder

Appendicovesicostomy, Yang-Monti ileovesicostomy, Continent vesicostomy, Tapered ileal segment

Postoperative complications 20: stomal stenosis in 12

Continent vesicostomy was most prone to stomal problems (29%)

The Mitrofanoff procedure is a reliable technique for creating a continent catheterizable urinary stoma.

 

 

9. Complications

  • Early complications
    • ileus or bowel obstruction
    • ureter-bowel anastomotic leak
  • Late complications
    • Bowel-related (augmentation cystoplasty) complications:
      • Metabolic disturbances
      • Vitamin B-12 deficiency
      • Rupture of reservoir
    • Stoma-related complications: Stomal complications are extremely common whether CCU or MACE stomas requiring revision [Barqawi 2004]
      • Stenosis (24.5%)
      • Leakage (7.5%)
      • False passage (1.9%)
      • Breakdown (1.9%)
      • Total (35.8%)

9. Advantages

  • The patient can achieve continence.
  • high patient satisfaction rate
  • lack of the need for a urinary collection bag

10. Disadvantages

  • Complex surgery involving bowel
  • Potential of upper tract deterioration secondary to high-pressure storage

11. Current Significance

Summary

Effectiveness

Very effective to achieve low pressures and ease of catheterization

Safety

High rate of early and late complications

Ease of application

Difficult reconstructive surgery

Patient Comfort

Excellent if all goals are attained

Cost

Very expensive in the short term

12. Other Comments

  • As many patients who undergo continent urinary diversion also have severe constipation or fecal incontinence and fecal incontinence usually need diapers, it is reasonable to combine both urinary reconstruction procedures and Malone antegrade continent enema procedure (MACE).

Key Points of This Section

  • These reconstructive procedures are used when other treatment methods fail.
  • Other treatments are usually catheter drainage or CIC without pressure control.
  • These are difficult procedures a where the outcome is uncertain especially if one must achieve a low pressure system, closure of the urethra and construction of a continent catheterizable neourethra.

 

References

  • Barqawi A, de Valdenebro M, Furness PD 3rd, Koyle MA. Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas. BJU Int. 2004 Dec;94(9):1344-7.
  • Cain MP, Casale AJ, King SJ, Rink RC. Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital. J Urol. 1999 Nov;162(5):1749-52. 
  • De Ganck J, Everaert K, Van Laecke E, Oosterlinck W, Hoebeke P. A high easy-to-treat complication rate is the price for a continent stoma. BJU Int. 2002 Aug;90(3):240-3.             
  • Figueroa TE, Sabogal L, Helal M, Lockhart JL. The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results. J Urol. 1994 Jul;152(1):73-5. 
  • Gilchrist RK, Merricks JW, Hamlin HH, Rieger IT. Construction of a substitute bladder and urethra. Surg Gynecol Obstet. 1950 Jun;90(6):752-60.
  • Kock NG, Nilson AE, Nilsson LO, Norlen LJ, Philipson BM. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol. 1982 Sep;128(3):469-75.
  • Kock NG, Nilson AE, Norlen L, Sundin T, Trasti H. Changes in renal parenchyma and upper urinary tracts following urinary diversion via a continent ileum reservoir: an experimental study in dogs. Scand J Urol Nephrol 1978; 49 (Suppl):11–22.
  • Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet. 1990 Nov 17;336(8725):1217-8.
  • Mitrofanoff P. Cystostomie continent trans-appendiculaire dans le traitement des vessies neurologiques. Chir Ped 1980; 21:297.
  • Monti PR, Lara RC, Dutra MA, de Carvalho JR. New techniques for construction of efferent conduits based on the Mitrofanoff principle. Urology. 1997 Jan;49(1):112-5. 
  • Mor Y, Kajbafzadeh AM, German K, Mouriquand PD, Duffy PG, Ransley PG. The role of ureter in the creation of Mitrofanoff channels in children. J Urol. 1997 Feb;157(2):635-7.
  • Simon J. Ectopia vesical: Operation for dissecting the orifices of the ureters in the rectum, colon. Temporary success, death, autopsy. Lancet 1852;2:568–70.
  • Van Savage JG, Khoury AE, McLorie GA, Churchill BM. Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol. 1996 Nov;156(5):1794-7.
  • Yang WH. Yang needle tunneling technique in creating antireflux and continent mechanisms. J Urol. 1993 Sep;150(3):830-4.

Suggested Further Reading

  • Gonzalez R, Schimke CM. Strategies in urological reconstruction in myelomeningocele. Curr Opin Urol. 2002 Nov;12(6):485-90.
  • Stein R, Fichtner J, Thuroff JW. Urinary diversion and reconstruction. Curr Opin Urol. 2000 Sep;10(5):391-5.

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