DIFFERENT TYPES OF CONTINENT CATHETERIZABLE URINARY STOMAS ADVANTAGES AND DISADVANTAGES

Abstract

The history of continent cutaneous diversion dates back to 1908 whenVerhoogen and Makkas used the excluded ileocecal segment as a reservoir and the appendix as an outlet valve. Indications of continent cutaneous urinary diversion are Pelvic malignancies as Invasive bladder cancer and gynecologic malignancies, Non Malignant Indications include neurogenic bladder, Bladder extrophy-Epispadias complex,complicated recurrent cases of urethral stricture and Conversion to continent cutaneous diversion. Renal and hepatic insufficiencies are absolute contraindications. Relative contraindications are age above 70 years old, multiple sclerosis, quadriplegic individuals, frail, mentally impaired patients andimpaired intestinal function. Many types of reservoirs are described and classified according to the bowel segment used in; ileo-colonic reservoirs depending on the ileo-cecal valve as a continent mechanism (Glichrist pouch, Mainz pouch I, Indiana pouch, Florida pouch, Miami Pouch and Penn Pouch), Ileal Reservoir (Kock pouch, Hemi Kock procedure and double T-pouch),Gastric reservoirs and Colonic reservoirs(Mainz-pouch III). There are four Principles of construction of continent outlet: Anti-peristaltic ileal segment, Passive tubular resistance mechanism, Pressure equilibrium principle, the flap valve principle. Many Types of continent outlet are described: Ileal Nipple Valve, Serous lined Extramural Valve, Plicated Terminal Ileum (Indiana Type Outlet), Appendix outlet and Mitrofanoff principlewhich considered one of the most important techniquesin CCD many authorsdescribedalternatives to the appendix as (the ureter, fallopian tubes, gastric tube, tapered ileum, continent vesicostomy and large bowel tube),Hydraulic Ileal Valve (Benchekroun technique)which is no longer practiced due to high failure rate, Monti technique with its modifications as full monti, spiral monti. Selection of the stomal site is the most important factor for success.There are two favorite sites for stomal location which are at the umbilicus and in the lower quadrant of the abdomen through the rectus bulge and below the bikini line. Stomal application to the skin has several modalities: Flush stoma,Nipple stoma, Y-V Plasty stoma and VQZ plasty stoma; the latteris the most cosmetic and has the lowest risk of stenosis. Continence is the challenging goal of CCD. Serous lined extramural tunnel reported the highest continence success rate of all the above mentioned types of continence (up to 100%continence) followed by Mitrofanoff appendix stoma (93%) then ileal nipple valve(87%). The existing literature does not support the assumption that continent reconstruction provides higher QOL than ileal conduit diversion.So ileal conduit is still the gold standard technique for urinary diversion. The preservation of renal function is both the ultimate goal and an essential prerequisite of successful intestinal urinary diversion. No or minimal impairment of the kidney function had been reported with continent urinary diversion. The growing number of techniques described for achieving continence in urinary reconstruction indicates that a universally applicable procedure with low complication rates has not yet evolved. Complications related to the upper tract are Ureterointestinal stenosis or stricture which is the most serious complications inherent to urinary diversion, the overall incidence of anastomotic stricture after urinary diversion is 3% to 9 % and Pouchoureteral reflux. Complications related to the pouch arerupture of the pouch (rare), urinary tract infection 56-71%, excessive mucous secretion and Stone formation. Complications related to the stoma are Parastomal hernia (0-5%),stomal stenosis and difficult catheterization ( 4 years follow up reports 1-2% incidence with appendix , 3–6%plicated tubes and 9 % withintussuscepted valves), incontinence (5.8% with intussuscepted ileal nipple valves, 3% with a tunneled appendix, and 0.6% with stapled plicated ileocecal valves), urine retention whichrepresents a true emergency, stomal Prolapse; a one of the most common complications, parastomal pyoderma gangrenosum and parastomal varices in hepatic patients. Complications of the intestinal anastomosis are fistulas (fecal and urinary with mortality rate 2%), sepsis and other infectious complications(The overall septicemia rate after radical cystectomy is currently 3.6% with a 17% mortality rate), bowel obstruction (5%withcolonic reservoirs, 10% with gastric and ileal reservoirs), hemorrhage(a rare complication), intestinal stenosis and pseudo-obstruction (Ogilvie’s syndrome). Metabolic complications including;complications following exclusion of intestinal segment (diarrhea, lipid malabsorption and vitamin B12 deficiency), complications due to urine storage in intestinal reservoirs (Hyperchloremic metabolic acidosis, Hypokalemia, hypocalcaemia,Hypomagnesaemia and Ammoniagenic encephalopathy), bone disease (osteomalacia), altered sensorium (due to magnesium deficiency, drug intoxication, or ammoniagenic encephalopathy), abnormal drug absorption and carcinogenesis.