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18091

Predictive Factors for Stomal Incontinence Following Creation of a Continent Catheterizable Channel

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Duong D. Tu, M.D., Abhishek Seth, M.D., Carlos A. O. Buchalla, Joseph G. Borer, M.D., Stuart B. Bauer, M.D., Alan B. Retik, M.D. and Carlos R. Estrada Jr., M.D., Department of Urology, Children's Hospital Boston, Harvard Medical School, Boston, MA

Purpose

Children with bladder dysfunction from a variety of causes often require intermittent catheterization (IC) to empty. Creation of a continent catheterizable channel (CCC) offers several advantages including increased independence and the ability to catheterize without transfer for wheelchair-dependent children. However, urinary incontinence from the channel can occur and is distressing to patients and families; risk factors for these developments have not been clearly delineated.  Our study aims to identify predictive risk factors for stomal incontinence following creation of a CCC.

Methods

We conducted a retrospective review of patients who underwent creation of an appendicovesicostomy or a Monti-Yang CCC at our institution over the past 2 years. Data recorded included demographics, surgical details, continence status, and results of urodynamic testing.  Data were analyzed using Fisher’s exact test and a p-value of <0.05 was considered significant.

Results

52 children (47% female) were included in the study.  Mean age was 16 years (range 4-41 yrs).  32 (62%) had an appendicovesicostomy, and 20 (38%) a Monti-Yang channel.  Pre-operative diagnosis included: spina bifida (20), exstrophy/epispadias (15), cloacal malformation (3), sacral agenesis (2), valve bladder (4), pelvic neurofibromatosis (3), conjoined twin (1), spinal cord injury (3), and Hinman-Allen syndrome (1).  11/52 (21%) patients had stomal incontinence at a mean follow-up of 15 months.  Of these, 1 (1/32, 3%) had an appendicovesicostomy and 10 (10/20, 50%) had a Monti-Yang channel (p=0.0007).  Incontinence was noted at a mean 3.8 mos following surgery (range 0-16 mos).  In the Monti-Yang cohort, we examined possible predictive factors for incontinence, including age, pre-operative diagnosis, urodynamic parameters, surgical technique and postoperative management.  The patients with stomal incontinence were significantly older (mean 21.2 ± 9.0yrs vs. 13.7 ± 5.4yrs, p=0.0375).  Pre-operative diagnosis was not a significant predictor of stomal incontinence (p=0.99). Pre-operative urodynamic parameters including bladder capacity (p=0.47), maximum detrusor pressure (p=0.41), or overactivity (p=0.475) were also not significant.  Likewise, intraoperative factors such as insertion site of the channel, catheter size over which the bowel segment was tubularized, and whether a concomitant bladder augmentation was performed were non-significant predictors (p=0.99).  Postoperative management parameters including frequency of IC (p=0.18) and catheter size (p=0.99) were also not predictive.

Conclusion

Patients who undergo creation of an appendicovesicostomy have significantly higher rates of stomal continence compared to those with a Monti-Yang catheterizable channel. The only significant predictor of stomal incontinence was age. No other pre-, intra- or postoperative factors were found to be predictive of stomal incontinence, making risk stratification difficult. Patients and families should be counseled accordingly.