Impact of the antireflux implantation's site for continent cutaneous urinary diversion: Native bladder versus enterocystoplasty

Abstract

Introduction: In patients who cannot perform intermittent self-catheterization via the urethra, continent cutaneous urinary diversion (CCUD) represents a valuable alternative, often associated with enterocystoplasty (EC). The CCUD is created using the appendix or the ileum, which can be implanted into the native bladder (NB) or the EC using various surgical techniques. This study aimed to evaluate postoperative outcomes and functional results of CCUD according to these two surgical approaches.

Materials and methods: We conducted a retrospective, single-center study that included patients who underwent CCUD creation between 1991 and 2020. Clinical characteristics were compared using Fisher's exact test and the Mann-Whitney test. Postoperative complications were analyzed using Kaplan-Meier survival curves and compared using the Log-rank test.

Results: A total of 94 patients were included (60 children, 34 adults): 74 (79 %) CCUD were implanted into the native detrusor (NB group), and 20 (21 %) onto the anterior wall of the enterocystoplasty (EC group). Early complications occurred on average at 7.5 days [7-11.5], with an overall rate of 5 %. Forty patients (42 %) experienced at least one long-term complication (e.g., leakage, stenosis, kinks), with no significant difference between groups. Survival analysis revealed no significant difference in overall surgical revisions (NB: 42 %, EC: 46 %; p = 0.51) or endoscopic revision. However, the EC group had significantly more frequent subfascial revision procedures (p = 0.005) and less frequent superficial stoma revision (p = 0.02), but this was not significant on multivariate analysis. At the end of follow-up (median: 12 years [7-21]), 82 % of patients remained continent (NB: 83 %, EC: 75 %).

Discussion: A short and straight abdominal segment of the CCUD appears to reduce complication rates, as recommended by the technique involving implantation into a detrusor flap. However, preservation of the native bladder may contribute to persistent overactivity. The study is limited by its low external validity and the heterogeneity of patient characteristics, which may reduce statistical power. Nevertheless, the results reflect a real-life experience with a complex and uncommon surgical procedure.

Conclusion: Implantation of the conduit into the native bladder seems to be associated with better long-term continence outcomes and fewer subfascial revisions despite multiple confounding factors. Further studies are needed to refine surgical techniques and reduce complications.

Keywords: Continent cutaneous urinary diversion; Enterocystoplasty; Mitrofanoff; Monti; Neurogenic bladder.