Last resort in devastated bladder outlet: bladder neck closure and continent vesicostomy--long-term results and comparison of different techniques

Abstract

Objectives: To compare surgical techniques and long-term outcomes in patients undergoing bladder neck closure (BNC) and continent vesicostomy for devastated bladder outlet.

Methods: A total of 17 patients who underwent BNC, omental interposition, and continent vesicostomy between 1994 and 2008 were analyzed. Indication for surgery was recurrent anastomotic stricture combined with postradical prostatectomy incontinence (n = 10), postvulvectomy (n = 1), and neurogenic bladder dysfunction (n = 6). Diversion was performed in 8 patients with normal bladder capacity (>300 mL in adults) through a Mitrofanoff appendicovesicostomy (n = 4) or ileal intussusception valve (n = 4). Simultaneous ileocecal bladder augmentation was performed in 9 patients with primarily reduced bladder capacity, and either the in situ embedded appendix (n = 4) or an ileal intussusception valve (n = 5) served as the continent outlet. The stoma was placed in the lower abdomen using the "butterfly technique" (n = 8) or in the umbilicus (n = 9).

Results: Medium follow-up was 68 months (range: 12-129). Primary BNC was successful in all patients and primary continence rate was 82%. Three patients (18%) suffered from continence failure, caused by reduced bladder capacity in 2 cases. The third patient presented with an iatrogenic destruction of his Mitrofanoff appendicovesicostomy. These patients were successfully reconstructed by ileocecal bladder augmentation with an ileal intussusception valve as the continent outlet. Four patients (23%) developed stomal stenosis (3/8 with an abdominal stoma and 1/9 with an umbilical stoma). Patients with simultaneous bladder augmentation had higher bladder capacity. No patients developed ureteral obstruction.

Conclusions: This technique is an effective, last resort treatment for patients with nonreconstructible bladder outlet.