Outcomes of continent catheterizable stomas for urinary and fecal incontinence: Comparison among different tissue options

Division of Paediatric Urology, Miami Children Hospital, Miami, Florida, USA.
BJU International (Impact Factor: 3.53). 05/2005; 95(7):1053-7. DOI: 10.1111/j.1464-410X.2005.05465.x
Source: PubMed


To retrospectively review the outcome of appendix, transverse tubularized intestine segments, caecal flap, gastric tube and others tissue options used as a continent stoma for urinary and fecal incontinence.
Between January 1993 and January 2003 we created 179 continent stomas to treat urinary and fecal incontinence in 135 patients (81 females and 54 males; mean age at surgery 13 years, 118, 87%, aged <17 years). We used either appendix (112), a short segment of bowel following the Yang-Monti technique (49), gastric augment single pedicle tube (eight), caecal flap (seven), Casale continent vesicostomy (two) and Meckel's diverticulum (one). Thirty-six patients had both urinary and fecal continent stomas created.
The mean follow-up for the appendix group was 46 months for the urinary stoma and 23 months for the Malone antegrade continent enema (MACE) stoma. Stoma-related complications occurred in 24 of 112 (21%) patients; there was complete channel fibrosis in five (4%). The mean follow-up for the Yang-Monti group was 38 months for the urinary and 59.2 months for the MACE stoma. There were stoma-related problems in 11 of 49 (22%) patients, with complete channel fibrosis in three (6%). Overall, in the long-term follow-up, there were stoma-related complications in 42 of 179 (23.5%) procedures.
Continent catheterizable stomas are a feasible and reliable method for treating urinary and fecal incontinence. Long-term success can be accomplished with appendix, transverse tubularized intestinal segments and caecal flaps, with similar complication rates in all groups. Surgeon preference and individual patient status should determine the surgical technique to be used.

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    • "Nevertheless, complications that occurred with cecostomy button placement and use are considered as minor complications because their management did not require surgery and were easy to treat. The MACE issues and complications are well known: traumatic catheterization and false passage, rare extravasation with peritonitis requiring immediate laparotomy [9], stoma stenosis requiring operative revision, and fecal leakage [10] [11]. "
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    ABSTRACT: This study evaluated the Trap-door button use (Cook Medical, Bloomington, IL) for antegrade enemas in children. Since 2002, patients with fecal incontinence or encopresis and constipation underwent percutaneous cecostomy under laparoscopy using a button. Technical details are described. Age at surgery, operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the button for less than 1 month were excluded from this evaluation. The survey concerned volume and frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment of the antegrade enemas in continence. Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11 syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and 3 sigmoidostomy button placements were successful with no intraoperative complication. The mean operative time was 25 minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-two parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL (mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes (mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6 needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery, only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder exstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were asked to give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt there had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good result, and 12 a very good result. The mean grade was 3.44 (17.2/20). A total of 3 patients had hypertrophic granulation tissue formation around the cecostomy button, and 12 had tiny leakage. Percutaneous placement of a cecostomy button under laparoscopic control is an easy and major complication-free procedure. The use of the Trap-door device by the patients or with the help of the parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.
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    ABSTRACT: Les traitements chirurgicaux des hyperactivités vésicales neurologiques sont réservés aux échecs des traitements médicaux, conservateurs. Le but de ces interventions est d’obtenir un réservoir vésical de bonne capacité qui se remplit à basse pression. Cela permet de diminuer les symptômes, de préserver le haut appareil urinaire et de diminuer les complications des vessies neurologiques. Plusieurs options thérapeutiques sont à décrire : les méthodes chirurgicales de dénervation vésicale, la détrusoromyomectomie, les entérocystoplasties avec ou sans dérivation urinaire continente et enfin les dérivations urinaires non continentes. Nous ne parlerons pas de la neuromodulation sacrée qui fera l’objet spécifiquement d’un article. Surgical treatment of neurogenic bladder hyperactivity is reserved for cases where conservative medical treatment has failed. The objective of such surgery is to obtain a bladder of adequate capacity, which fills at low pressure. This minimises symptoms, protects the upper urinary tract and reduces the complications of neurogenic bladder. There is a range of therapeutic options: surgical techniques for bladder denervation, detrusor myomectomy, enterocystoplasties with or without continent urinary diversion and, finally, non-continent urinary diversion procedures. We shall not discuss the technique of sacral neuromodulation, which will form the object of a separate article. Mots clésHyperactivité vésicale neurologique-Traitement chirurgical-Haut appareil urinaire-Vessie neurologique-Détrusoromyomectomie-Entérocystoplastie KeywordsNeurogenic vesical hyperactivity-Surgical treatment-Upper urinary tract-Neurogenic bladder-Detrusor myomectomy-Enterocystoplasty
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