Complications of Benchekroun vesicostomy in a spina bifida patient: severe stenosis requiring permanent suprapubic cystostomy, recurrent vesical calculi and abdominal hernia containing ileocystoplasty - a case report

Abstract

Introduction: In female patients with neuropathic bladder, the urethra is closed permanently in order to avoid urine leak. Then Benchekroun hydraulic ileal valve is attached to urinary bladder, thus providing a continent stoma for performing intermittent catheterisations.

Case presentation: We present a female patient with spina bifida who underwent Benchekroun continent vesicostomy in 1993. This patient developed severe stenosis of Benchekroun stoma and stones in urinary bladder. Dilatation of stoma and vesicolithotomy were carried out in 1995. Vesical calculi recurred; suprapubic cystolithotomy was performed in 1999. In March 2000, catheterisation of stoma was not possible and emergency suprapubic cystostomy was done. In April 2000, endoscopy was attempted through Benchekroun stoma. It was not possible to insert ureterorenoscope beyond two inches. The track was completely blocked. In November 2001, X-ray of abdomen showed several vesical calculi; suprapubic cystolithotomy was performed. In March 2005, this patient developed pain in abdomen. X-ray of abdomen showed a large vesical calculus. In June 2005, suprapubic catheter was removed and a cystoscope was introduced in to the bladder. Then electrohydraulic lithotripsy was performed. In 2007, this patient was concerned about the increasing swelling in lower abdomen. Computed tomography of abdomen revealed midline, lower abdominal wall hernia, which contained several loops of small bowel and ileal cystoplasty. The large hernia was uncomfortable and tender on coughing, but did not cause obstructive bowel symptoms. Surgical repair of hernia was considered. But this patient would require alternative way of urinary diversion because the current location of suprapubic catheter would almost lead to infection of prosthetic material used in reconstruction of the anterior abdominal wall. After discussing risks of operative procedures with patient and her husband, it was decided not to proceed with surgery.

Conclusion: This case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously, and patients should be informed of potential complications of surgical procedures some of which could be irreversible.

Figure 1

Cystogram, done on 06 October 1992, revealed a large capacity bladder. Bladder outline was smooth.

Figure 2

Cystogram, performed on 25 January 1994, showed marked dilatation of ileal segment (Benchekroun valve).

Figure 3

X-ray of abdomen, taken on 17 June 1999, showed several vesical calculi.

Figure 4

Histology of bladder biopsy (18 June 1999) revealed inflamed bladder mucosa showing non-keratinising squamous metaplasia (top left surface) with probable focal keratinising metaplasia (top centre) (H&E stain).

Figure 5

X-ray of abdomen, taken on 29 November 2001, showed several vesical calculi.

Figure 6

Histology of bladder mucosal biopsy (30 November 2001) showed extensive non-keratinising squamous metaplasia, including in von Brunn's nests, with probable focal keratinising metaplasia (top centre) (H&E stain).

Figure 7

X-ray of abdomen, taken on 22 June 2005, showed vesical calculi.

Figure 8

Axial computed tomography of abdomen, performed on 19 June 2007, revealed midline, lower abdominal wall hernia, whose neck measured 45 millimetres wide. Within the hernia, were several loops of small bowel and vesicostomy. (arrow).

Figure 9

Oblique sagittal reformat of computed tomography of abdomen, performed on 19 June 2007 revealed herniation of vesicostomy. (arrow).