Continent Ileocecal Augmentation Cystoplasty

Spinal Cord (1998) 36, 246 ± 251 1998 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/98 $12.00 http://www.stockton-press.co.uk/sc Continent ileocecal augmentation cystoplasty Mark A Sutton1, John L Hinson2, Kevin G Nickell3 and Timothy B Boone4 Scott Department of Urology, Baylor College of Medicine and the Veterans Aairs Spinal Cord Injury Unit, Houston, Texas, USA Objectives: To evaluate the use of the ileocecal bowel segment for bladder augmentation in a select group of patients who need a low pressure, high capacity urinary storage mechanism and a continent, catheterizable, cutaneous stoma that, because of their physical limitations, is easier to catheterize than their native urethra. Methods: We reviewed records of 23 continent ileocecal augmentation cystoplasties performed over the last 5 years. The goals of the operation, patient selection criteria, pre-operative evaluation, operative technique, and post- operative evaluation with results were studied. Results: Twenty-three patients underwent the procedure with the average follow-up being 26.9 months (range 3 ± 67 months). Bladder capacity was increased by an average of 276.8 milliliters (ml). No metabolic problems have been detected, and 95% (22/23 patients) are continent via their urethra and stoma. Conclusions: This unique modi®cation of the Indiana continent urinary reservoir is not technically dicult to create and is relatively free of complications. The bladder capacity is greatly increased and post-operative continence rates are excellent. Finally, the quality of life for these patients has been signi®cantly improved by their ability to access the augmented bladder independently via an abdominal stoma. Keywords: continent ileocecal augmentation; neuropathic bladder; cystoplasty Introduction Urinary incontinence can be a devastating problem for to create the ideal augmentation cystoplasty procedure patients and their caretakers, especially when a have been used. The Indiana continent urinary coexisting neurological disorder limits the patient's reservoir and its subsequent modi®cations2 have ability to manage their urinary tract independently. enjoyed widespread success since the initial descrip- Failure of pharmacological therapy and problems with tion of the reservoir in 1987.3 Sarsody described the urethral access to perform self-catheterization represent technique of ileocecocystoplasty with a continent common dilemmas to the clinician trying to protect catheterizable stoma in 1992.4 His recent follow-up upper urinary tract function and restore continence. reported excellent results in eight patients followed for One possible option when this dilemma occurs is the almost 3 years.5 We report similar results in 23 continent urinary diversion. patients followed for a mean of 26.9 months. In the The ®rst continent urinary diversion is attributed to present study, we used a modi®cation of the Indiana Simon in 1852 when he performed a ureterorectal continent urinary reservoir technique in a distinct anastomosis in a patient with a bladder extrophy.1 patient population. We review the patient character- Since that initial pioneering eort there has been istics and operative goals, describe the operative steady progress in the eort to create a reliable technique, and report our outcomes with this continent urinary diversion. Concomitantly, a gradual procedure. evolution has occurred in re®ning the optimal technique in bladder augmentation. Various segments Materials and methods of bowel, ureter, and even autoaugmentation in order Between December 1990 and May 1996, 23 patients underwent continent ileocecal augmentation cysto- Correspondence: Timothy B Boone 1Resident, Scott Department of Urology, Baylor College of Medicine, plasty. The patient population included eight females Houston, Tx. and 15 males. Sixteen patients had spinal cord injuries 2Fellow, Neurourology and Urodynamics, Scott Department of and four had multiple sclerosis as the cause of the Urology, Baylor College of Medicine, Houston, Tx USA. neuropathic bladders. One had `non-neurogenic neuro- 3Fellow, Neurourology and Urodynamics, Scott Department of Urology, Baylor College of Medicine, Houston, Tx, USA. genic' voiding dysfunction with loss of detrusor 4Assistant Professor, Scott Department of Urology, Baylor College of compliance and hydronephrosis. The remaining two Medicine, Houston, Tx, USA patients had urethral loss, one secondary to urethral Continent ileocecal augmentation cystoplasty MA Sutton et al 247 necrosis and the other due to a large bladder neck tenia in an anti-mesenteric fashion in preparation for ®stula that had not responded to several attempts at its anastomosis with the bladder. The urethral closure repair. The average age of the patients was 42.2 years or pubovaginal sling usually is completed prior to (range 26 ± 64 years). isolation of the bowel segment. Urethral closure in the The goal of the augmentation was to create a large female is completed from above and below to assure a capacity, low pressure, compliant reservoir (4300 ml). multi-layer closure. The sling is fashioned from rectus It required a reliable continence mechanism both to fascia, suspended on prolene sutures, placed at the the stoma and to an easily catheterizable cutaneous bladder neck, and utilized for functional closure of the stoma that oered easier access than the native urethra. urethra. In our study, 19 of the 23 patients required The bladder is then opened transversely along its the surgery both to augment their bladder capacity anterior surface, and the detubularized right colon is and to create a continent, catheterizable, cutaneous sewn to the opened bladder (Figure 1). A suprapubic stoma (Table 1, Group 1). The remaining four patients tube is placed through the native bladder prior to required the surgery mainly for the continent stoma complete closure. The augmentation is then ®lled to needed particularly because of urethral trauma or check for leaks and pressure is applied to the because of their inability to catheterize their native augmentation with the drainage tubes clamped to urethras (Table 1, Group 2). assess continence of the eerent limb. A 14F stomal Among the selection criteria were that the patients catheter is placed to drain the bladder and ensure easy have a life expectancy of more than 1 year, have passage through the eerent limb into the newly- manual dexterity sucient to perform the catheteriza- augmented bladder. A ¯ush right lower quadrant tion of the abdominal stoma, have a strong motivation stoma is created according to Rowland's previously to be `bag free', have adequate renal and bowel described technique.3 Finally, a closed suction drain is function, and have physical/social limitations that placed in the pelvis. We routinely use gastrostomy made catheterization via the native urethra dicult tubes in this patient population because of concomi- and/or impossible. If high grade vesicoureteral re¯ux tant neurogenic bowel dysfunction. was present, then ureteral reimplantation was per- Postoperatively, irrigation of the pouch is begun on formed in the same setting. Anti-incontinence proce- the ®rst post-operative day to prevent mucous buildup. dures to the urethra were performed concomitantly in A pouch-o-gram is performed after a week to 10 days, 11 of the 23 patients: seven urethral closures, three and the drain is removed if no leak is demonstrated pubovaginal sling procedures, and one collagen and the drain output is less than 50 ml/day. Assuming injection. Finally, one patient underwent a concurrent adequate return of bowel function, the patient is right nephrectomy secondary to non-function of that discharged with the suprapubic tube and plugged kidney. stomal catheter in place and the gastrostomy tube, Preoperative evaluation included a detailed history clamped, and in place. Irrigation through the and physical examination designed to assess the suprapubic tube is done at home approximately four patients' goals and level of function, routine blood times daily. At 3 weeks postoperatively, the patient chemistry evaluation, an upper tract study, a barium returns to the oce, where the stomal catheter is enema in patients with a history of gastrointestinal removed and the suprapubic tube is clamped. Self- disease, and a ¯ourourodynamics study. The decision catheterization is then taught, with the catheterization regarding either urethral closure or functional bladder time schedule at ®rst being every 2 to 3 h and neck closure (pubovaginal sling) was based on both gradually increasing to every 4 to 6 h. The history and ¯ourourodynamic ®ndings. Patients with suprapubic tube is removed after the patient is able neuropathic bladders who complained of preoperative to catheterize the stoma independently for 1 week. incontinence and those in whom an open bladder neck and incontinence were demonstrated on video studies underwent either urethral closure or pubovaginal sling, Case example depending on gender and surgeon's preference. The SC is a 48-year-old female with a history of multiple enterostomal therapy service and occupational therapy sclerosis (MS) for 21 years. Over the past several years service counseled patients on self-catheterization and she has developed debilitating urgency and urge marked their stomal site pre-operatively. All patients incontinence (voiding small volumes every 1 ± 2 h and had to demonstrate the manual dexterity necessary to using 8 ± 10 pads/day). These eects were seen despite perform the self-catheterization technique.

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