People with tetraplegia, especially females often have difficulty performing clean intermittent catherization. In addition, females are more troubled by persistent incontinence. The surgical methods described in this section can result in the ability to self-catheterize, allowing the individual to benefit from intermittent rather than indwelling bladder catheterization, the latter being associated with a higher rate of complications. The mitrofanoff channel involves the use of an autologous tubular structure, usually the appendix, as a cutaneous catheterizable stoma. Implantation in the bladder via a submucosal tunnel provides continence to the conduit (Sylora et al. 1997). The stoma can be hidden in the umbilicus. While performed often in children, the procedure has less commonly been performed in adults. Long term followup is unknown, particularly with respect to the potential for malignancies. Karsenty et al. (2008) describes a similar procedure, performed in 13 patients with incontinence and inability to self-catheterize.
Ileal conduit diversion, another surgical approach more commonly performed in females, is also often considered for reasons of lack of manual dexterity or ease of care and convenience (Pazooki et al. 2006; Chartier-Kastler et al. 2002). This technique aims to establish low-pressure urinary drainage by diverting urine prior to entering the bladder and connecting the ureters to an external urinary collection system via a catheter passed through the ileal lumen. This procedure is sometimes conducted along with removal of the bladder as well (Chartier-Kastler et al. 2002; Kato et al. 2002).
Continent Catheterizable Stoma
Despite small sample sizes, the results of the above studies are very promising. High levels of continence, independence, and the ability to manage the bladder with intermittent catheterization are reported in all three studies. The stability of serum creatinine has implications for upper tract function (Karsenty et al. 2008). Hakenberg et al. (2001) reported safe urodynamic bladder storage pressures (20-44 mm H20) on patients that underwent appendicovesicostomy with cutaneous stoma. Participants in this study and the study by Sylora et al. (1997) were kept on anticholinergic medication, a consideration that ensures low pressure storage in those with persistent hyperreflexia and dyssynergia, and contributes to ongoing continence. Complications occur, most concerning of which are those requiring surgical procedures (pelvic abscess, bowel occlusion, stomal revision for stenosis). Larger sample sizes would be necessary to determine true incidence. Length of follow-up ranged from 20 – 44 months, which does not provide sufficiently long term safety and effectiveness data. However, given the importance of the clinical achievements (i.e., independent use of intermittent catheterization; continence) further study with larger sample sizes is warranted.
Incontinent Urinary Diversion
Ileal conduit diversion is another surgical procedure noted with some frequency in the literature. Chartier-Kastler et al. (2002) and Kato et al. (2002) have reported separate case series (N=33 and N=16 respectively) examining this approach. Chartier-Kastler et al. (2002) reported all patients became continent after initially being incontinent prior to surgery and Kato et al. (2002) reported that most patients were more satisfied with the procedure than their previous management method upon survey a few months after the operation. Both authors also reported several long-term complications (e.g., pyocystitis, suprapubic collection – genital secretions), chronic urethral leakage, acute pyelonephritis). However, it is uncertain if these high complication rates would be comparable in the event individuals had continued with their previous form of bladder management, as often surgical procedures are performed only if other more conservative methods are unsuccessful. Controlled trials (e.g., case control study design) would be beneficial to address this issue.
Colli & Lloyd (2011) evaluated a series of cases (N=35) involving bladder neck closure (BNC) which was paired with permanent suprapubic catheter (SPC) diversion as opposed to other forms of urinary diversion, such as ileovesicotomy or continent catheterizable stoma. Their results suggest that BNC in conjunction with SPC diversion offers urethral continence with a reasonable complication rate (17%). A straightforward operative approach without violation of the peritoneum, no need for enteric reconstruction, and possible reduction of bowel complications are additional advantages conferred by this technique. Specific disadvantages, such as a reduced likelihood of success in very low bladder capacity patients were noted.
Catheterizable abdominal stomas may increase the likelihood of achieving continence and independence in self-catherization, and may result in a bladder management program that offers more optimal upper tract protection.
Cutaneous ileal conduit diversion may increase the likelihood of achieving continence but may also be associated with a high incidence of various long-term complications.