Facebook Twitter YouTube

16919

Utilizing a Serosal-Trough for Fashioning a Continent Catheterizable Stoma: Technique and Outcomes

Sunday, October 21, 2012: 3:06 PM
Grand Ballroom B (Hilton Riverside)
Nima Baradaran, MD1, Andrew A. Stec, MD2, Angela Gupta, MD1, Michael A. Keating, MD, FAAP3 and John P. Gearhart, MD, FAAP1, (1)Pediatric Urology, Johns Hopkins University School of Medicine, Baltimore, MD, (2)Urology, Medical University of South Carolina, Charleston, SC, (3)Division of Pediatric Urology, Walt Disney Pavilion at Florida Hospital for Children, Orlando, FL

Purpose: To evaluate the efficacy and potential complications of the serosal-trough (ST) technique for the implantation of a continent catheterizable stoma (CCS) during enterocystoplasty in children with bladder exstrophy.

Methods: Using an IRB-approved departmental database, children with bladder exstrophy, born after 1990 were selected and patients, who underwent urinary diversion with a CCS created with the ST technique, were identified. Demographic characteristics, as well as the eventual clinical outcomes, were retrospectively reviewed.

Results: A total of 135 patients with urinary diversion were identified, of whom 26(13 males) had CCS implantation using the ST technique. Patients included 14 classic exstrophies, 10 cloacal exstrophies, and 2 epispadias. The appendix and tapered ileum was utilized for creation of CCS in 11 and 15 cases respectively. The median age at creation of CCS was 10.7 years (range: 4.4 17.4). At the time of CCS creation, 21 patients underwent initial enterocystoplasty, 4 had repeat augmentations, and 1 had a CCS on a previously augmented bladder. Ileum (average length 18cm) was used in 24/25 augmentations and was selected due to lack of redundant sigmoid in 52% of cases and intraoperative surgeon preference in the remaining. In one case of cloacal exstrophy, a hindgut remnant was utilized. In 24(92%) cases, initial CCS resulted in complete continence of the catheterizable channel. After median 2.5 years(range: 0.2 7.5) of follow-up all patients are dry via intermittent catheterization. The CCS failed at postoperative months 6 and 21 and required complete revision in two cases. The details of the procedure are illustrated in figures 1 and 2.

Conclusion: Utilizing a serosal-trough to provide a strong backing for a catheterizable channel is an excellent option when a channel must be placed in ileum, hindgut, or in an area of an augment where muscular backing is not available. This technique provides a reliably catheterizable tunnel, durable continence mechanism and good success rate when creating a CCS in combination with a urinary diversion.

Figure 1:

Figure-1.jpg

Two parallel longitudinal incisions only on the serosa are made to expose the underlying mucosa (A). The two incisions are caudally joined forming a U-shaped incision. Tacking sutures help to fan out the serosal layer and define the limits of the trough (B, C).

Figure 2:

Figure-2.jpg

The tabularized conduit is placed on the newly created trough (E, F). Tacking sutures are used to wrap the trough, covering the new continent catheterizable stoma with over 5:1 ratio in length to width. Pulling the sutures too hard may cause over compression of the catheterizable stoma and compromise the function of the conduit (G). The catheterizable stoma is attached to the reservoir with an end-to-end anastomosis and then the stoma is matured on the abdominal wall.