Laparoscopic Ileovesicostomy and Augmentation

In the past three decades, clean intermittent catheterization proposed by Lapides has been accepted by the urologic community as an excellent method of management of the neurogenic bladder that fails to empty (8). However, this option may not be applicable for some patients such as those without manual dexterity and without assistance from care givers. In these cases, options may include the use of chronic indwelling urethral or suprapubic catheter or urinary diversion. Chronic catheter placement is frequently associated with complications including stone formation, tissue erosion, frequent infection and malignancy; therefore, it is uncommonly used as first-line definitive management (9). Urinary diversion, which traditionally takes the form of an ileal conduit involving ureteral reimplantation, may lessen the risk for catheter-associated problems. However, a different set of problems such as urinary reflux and ureteral obstruction may arise (10).

Incontinent ileovesicostomy providing low-pressure urinary storage and drainage was first introduced in 1994 to address the problems associated with conventional incontinent urinary diversions (11). Without ureteral mobilization or reimplantation, it decreases the operative time and avoids the risk for ureteral complications. Preserving the ureterovesical junction, it maintains the antireflux mechanism and prevents pyocys-tis formation. Furthermore, it does not require the use of any catheter or foreign material, either intermittently or chronically. These advantages, together with excellent renal function preservation and the low rate of complications, have been confirmed by several recent reports with long-term follow-up. In fact, ileovesicostomy has been recommended as a better alternative to all other types of incontinent urinary diversion (12-14).

Prior to our publication in 2002, all ileovesicostomy procedures described were performed in the conventional, open manner. Similar to augmentation, the major surgical components of ileovesicostomy included the following: (i) bladder mobilization with cystotomy creation, (ii) harvesting of a well-vascularized bowel segment, (iii) establishment of bowel-to-bowel anastomosis with closure of the mesenteric window, and (iv) performance of full-thickness, mucosa-to-mucosa ileovesical anastomosis in a tension-free, watertight manner. Using the laparoscopic approach described below, we have been able to accomplish all these steps in four patients to date and use this technique as a primary approach to ileovesicostomy formation.

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