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.
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.
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.
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.