Continent Catheterizable Stomal Reservoirs

When continent catheterizable stomal reservoirs is desired, preoperative preparation and patient selection parallels that of their open counterparts. First and foremost, patients must be motivated and intact cognitively and physically, without restrictions imposed by neurologic injury or neurodegenerative disorders that would impair coordination necessary for clean intermittent catheterization.

Mitrofanoff Urinary Stoma

Many of the reports of appendicovesicostomy urinary diversion are found in the pediatric population, and are comprised largely of lap-assisted procedures affording initial appendiceal and cecal mobilization, followed by lower abdominal incisions for urinary reconstruction. Jordan and Winslow, who performed the procedure in a 15-year-old girl with bilateral ectopic ureteroceles and an obliterated bladder neck, described laparoscopic appendicovesicostomy in 1993. Open assistance was required to fashion the appendiconeocystostomy. Van Savage and Slaughenhoupt later described a similar lap-assisted approach to appendicovesicostomy in three obese women, with laparoscopic mobilization of the appendix and right colon, and a Pfannensteil incision for construction of the urinary diversion. Hedican et al. described the use of laparoscopy in eight patients (mean age, 13.4 years) requiring either an ileal or appendiceal Mitrofanoff, with or without an antegrade continent enema in eight patients with neurogenic bladder and bowel. A lower abdominal incision was used for part of the reconstructive procedure. Cadeddu and Docimo reported a similar series of 11 pediatric patients with neurogenic bladder and bowel in 1999, where laparoscopic-assisted approach was again utilized. A continent urinary diversion was created in seven of these patients through a Pfannenstiel or low mid-line incision, including appendiceal, tapered ileal, or sigmoid Mitrofanoff urinary stoma positioned at the umbilicus.

The first two completely intracorporeal case reports of laparoscopic appendi-covesicostomy were reported almost simultaneously. In April 2004, Pedraza et al. reported their success with the DaVinci robotic system, with a four-port transperitoneal approach. Although total operative time was six hours, the anastomosis took 25 minutes. The patient was discharged on postoperative day 4. One month later, Casale and colleagues reported the feasibility of pure laparoscopic appendicovesicostomy. The case involved a four-year old girl with the VATER malformation and associated neurogenic bladder. A four-port transperitoneal approach was also used; total operative time was 198 minutes, and the patient was discharged home on the third postoperative day.

There is little doubt, considering the technical feasibility of a wide range of techniques that have been demonstrated, that the laparoscopic or open-assisted approach will be extended to the many variations of cutaneous continent urinary diversions not mentioned herein.

The debate between pure laparoscopy and open assistance continues.

Other Procedures

Pomel and Castaigne recently reported laparoscopic hand-assisted Miami pouch in a 45-year-old woman following anterior pelvic exenteration. The initial cervical cancer invaded into the bladder. The patient underwent combined chemotherapy and radiation, resulting in total incontinence secondary to a vesicovaginal fistula, with residual local disease. A five-port transperitoneal approach was used, and following anterior pelvic exenteration the right colon, terminal ileum, and cecum were mobilized laparoscopically. The Miami pouch was created though a 4-cm mini laparotomy incision. The ileal conduit portion was sutured to the umbilicus. Total operative time was six hours.

Gill and coworkers reported a laparoscopic radical cystectomy and Indiana pouch urinary diversion with a continent, catheterizable stoma. Orthotopic neoblad-der was not advised due to prostatic urethral tumor involvement. The pouch was created extracorporeally by exteriorizing the ileocecal segment through a 2-3 cm extension of a right pararectus port incision. In contrast to open-assisted techniques for ileal conduit urinary diversions in which the ureters are commonly delivered through the incision with the bowel segment to perform the anastomosis, the pouch was reintroduced into the abdomen and subsequent ureteroileal anastomoses were performed intracorporeally. The continent stoma was created at the umbilicus. Total operative time was seven hours with 300 mL blood, and the patient was discharged after six days.

There is little doubt, considering the technical feasibility of a wide range of techniques that have been demonstrated, that the laparoscopic or open-assisted approach will be extended to the many variations of cutaneous continent urinary diversions not mentioned herein.

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