Continent Catheterizable Stoma

Karsenty et al. 2008
France
Downs & Black score=17
Pre-Post
N=13

Population: Mean age = 42 yrs; Gender: males = 2, females = 11; Level of injury: cervical = 5, thoracic = 5, sacral =1. cauda equina = 1 other = 1; All were unable to self catheterize.  Mean time since injury = 12.2 yrs; Mean follow-up = 44 months.
Treatment: Patients underwent a novel procedure involving a cutaneous continent diversion composed of an abdominal continent stoma combined with enterocystoplasty was used to facilitate self-catheterization.
Outcome Measures: Complications, continence, catheterization difficulties, functional bladder capacity and serum creatinine.

• Complications included postoperative infections (5 urinary, 2 pulmonary) and 1 pelvic abscess and 1 small bowel occlusion both requiring surgery
• In all patients, the catheterizable stoma was continent, but 3 females had stress leakage through native urethra, 2 requiring secondary bladder neck closure.
• All patients could self catheterize.
• An increase from 180ml to 540ml was seen in functional bladder capacity from pre to post surgery.
• No change in serum creatinine was seen post surgery.

Hakenberg et al. 2001
Germany
Downs & Black score=16
Case series
N=5

Population: Mean age = 31 yrs; Gender: males = 1, females = 4; Level of injury: tetraplegia = 5; Mean time since injury = 22 months. F/U 21 – 40 months.  All patients on anticholinergics both pre and post surg.
Treatment: Patients underwent appendicovesicostomy and a cutaneous stoma was placed in the lower right abdominal quadrant.
Outcome Measures: Independent CIC, Stomal stenosis, urinary tract infections, satisfaction.

• All patients were able to independently perform CIC and were continent.
• Stomal stenosis did not occur
• 2 patients experienced urinary tract infections once, and 1 patient had repeated occurrences.
• 3 out of 5 patients were highly satisfied with the results.
• Post-op bladder compliance 20 – 44 mmH20

Sylora et al. 1997
USA
Downs & Black score=15
Pre-Post
N=7

Population: Age = 19 to 44 yrs; Gender: males = 4, females = 3; Level of injury: tetraplegia = 7. All patients had adequate bladder capacity and were on anticholinergics
Treatment: Patients underwent Mitrofanoff umbilical apendicovesicostomy with appendix or ileum. F/U 5 – 20 months
Outcome Measures: Bladder capacity, continence, complications.

• No significant changes were seen in bladder capacity.
• All patients were continent.
• Complications included:
• 1 patient had transient stress urinary incontinence which resolved spontaneously.
• 1 patient required stomal revision.

Incontinent Urinary Diversion

Chartier-Kastler et al. 2002
France
Downs & Black score=14
Case Series
N=33

Population: MS (N=4), CP (N=3), Myelitis (N=3), Other (N=2), SCI (N=21): Mean Age = 40.6 yrs; Gender: males = 14, females = 19; Level of injury: cervical = 32, thoracic = 25, C1-T10 = 14, T11-L1 = 6, below L2 = 1; Severity of injury: complete, incomplete; Mean follow-up = 48 months.
Treatment: Follow-up evaluation of those having cutaneous ileal conduit (ileo-ureterostomy) diversion.
Outcome Measures: IVU, serum creatinine, cystoscopy, urine cultures and pre/post incidence of UTIs, visual analog patient satisfaction. Collected at follow-up as indicated above.

• No statistical comparisons reported
• Initial surgery was successful. All patients became continent after initially being incontinent prior to surgery.
• Of 17 with pre-op hydronephrenosis, 10 showed a ↓ or disappearance.
• 12 patients developed one or more complications during follow-up. 4 early complications and 13 late complications.
• Most prevalent long-term complications were pyocystitis (4 – 3 requiring cystectomy), pyelonephritis (4) and urethral leak (2).
• Satisfaction survey indicated none regretted surgery (9.1±2.8 out of 10).

Kato et al. 2002
Japan
Downs & Black score=11
Case Series
N=16

Population: SCI: Mean Age = 46 yrs; Gender: males = 13, females = 3; Level of injury: tetraplegia; Mean follow-up time = 8.7 yrs.
Treatment: Follow-up evaluation of those having ileal conduit formation.
Outcome Measures: Review of charts (deaths, complications, subjective statements of satisfaction, serum creatinine where completed)

• No statistical comparisons reported
• Serum creatinine remained stable
• 3 subjects died (constrictive ileus, unknown, septicemia associated with UTIs) during the follow-up period.
• 5/16 patients had calculus formation in the upper urinary tract; 3 had severe UTI’s as a result
• 8 subjects of 13 in whom a bladder was initially preserved sustained a pyocyst.
• 5 experienced calculus formation in the upper urinary tract, 3 of these having severe UTIs as a result.
• Most patients were more satisfied with procedure than previous management method upon survey a few months after operation (no long-term follow-up on this issue).

Craven & Etchells 1998 Australia
Downs & Black score=8
Case Series
N=27

Population:  SCI patients with ileostomy, colostomy, or urostomy.
Treatment:  No treatment – chart review
Outcome Measures: Questionnaire for physical, psychological, and lifestyle effects after surgery.

• 11 patients underwent urostomy (Indications: chronic UTI in all, 1 recurrent calculi, 3 hydronephrosis) 
• Three patients required cyctectomy, while a fourth was advised to get one
• Although 27 charts reviewed only 18 patients located to complete the questionnaire:
• Bowel and bladder management greatly improved in most cases, resulting in improved quality of life for these patients.
• Positive psychological effects.
• Long-term impact on renal health not assessed.