**3.7 Outcomes**

284 Urinary Incontinence

described for the anastomosis between the conduit and the skin aiming to avoid stomal stenosis. They include V-flaps, tubular skin flaps and V-quadrilateral-Z flaps. Ideally, the conduit should be as short and straight as possible in order to avoid kinking. On the other hand, there must be no tension to the anastomosis [21-24]. Optimal drainage should be maintained post operatively. This is best accomplished with a combination of suprpubic

Conduit Foley catheter is removed 3 to 6 weeks after surgery. Suprapubic cystostomy is clamped and CIC is initialized. Cystostomy may be unclamped at the end of catheterization. Once the patient is familiar with CIC technique cystostomy is definitively removed [3,12,15].

In 1993, Yang described the transversal tubularization of two previously detubularized intestinal ileal segments [25]. This technique, however, was only popularized in 1997 by

The Monti conduit became a very important option especially in patients who are candidates for a catheterizable channel but have already undergone apendicectomy

The most important aspect for the length of the channel is the width of the abdominal wall, which should be measured in advance with the aid of a long needle [25]. The conduit short arm must be equivalent to this length. It is important to keep in mind that the diameter of the intestinal loop and not its length is the factor that is going to determine the conduit final length [27]. To obtain a longer conduit, two ileal detubularized tubes in sequence may be

In order to avoid complications secondary to malabsorption of vitamin B12 the final 15 cm of the ileum are spared [27]. A 2-2.5 cm long intestinal segment is isolated along with its vascular pedicle. This length will allow the passage of a 16F catheter. Intestine is opened longitudinally and the distance from the incision to the mesentry should be equal to the one anticipated for the conduit short arm. The segment is then tubularized transversally over a

Double conduits can be made of 4-5 cm of intestinal segment. Four sutures (2 at each end of the segment, one at the mesentry and the other at the anti mesenteric border) allow adequate traction and division of the intestinal loop. The two segments are incised 5 mm from the mesentry border and sutured together by the short arm with separate sutures to avoid stenosis. Tubularization is carried out in the same fashion as for single conduits. The centrifuge circulation guarantees proper perfusion and allow tailoring of the distal ends of

The reservoir should be anchored to the deep surface of the abdominal wall immediately adjacent to the point where the channel was implanted in order to provide stability, avoid reservoir migration and conduit kinking. As mentioned for the Mitrofanoff procedure, a Foley catheter should be placed at the end of the procedure through the conduit associated

catheterisation and a cathter through the channel.

Monti et al. who described its use in dogs [26].

12-14F catheter using absorbable suture [26,27,28].

the conduit in case it is too long [27].

with a suprapubic cystostomy [26].

**3.5 Yang-Monti** 

[12,15,19,26].

**3.6 Surgical technique** 

anastomosed [26].

The risk for some early complications is common to any abdominal surgical intervention involving the urinary and gastrointestinal tracts: bleeding, infection, ileus, intestinal and urinary fistulas, intestinal obstruction, conduit ischemia, abscess, pyelonephritis and sepsis are included [1,14].

Long term follow up series show results for both Mitrofanoff and Monti interventions exceeding 90% continence rates. Sahadevan et al. reported a self-reported continence rate of 89% with a mean follow up time of 126 months [30]. Incontinence may occur through the urethra or the conduit [20,21,31,12-14,17,27-29,32-34].

Continent Urinary Diversions in Non Oncologic Situations: Alternatives and Complications 287

reported rates of 11% [47] and 23% of problems related to catheterization of retubularized intestinal tubes [27]. Management may involve a simple Foley catheter placement for a few

Narayanaswamy et al. also found an incidence of conduit stenosis at the bladder implant of 6% for appendix and 8% for Monti tubes. Stomal stenosis occurred in 15% vs. 16% comparing appendix and Monti, respectively [46]. Landau et al. reported on a retrospective series comparing different techniques for stoma confection: umibilical flap, tubularized skin

Problems suspected to be related to conduit patency should be evaluated using an endoscopic approach or performing a conduitogram. This will allow differentiation between stenosis, pouching or kinking. Definitive treatment may vary from calibration to conduit or stoma surgical revision [3,18,48]. D'Ancona and Miyaoka presented an innovative option for salvage treatment of stomal stenosis that fails more conservative approaches such as dilatations and corticosteroid injections and traditional surgical revisions. In patients in whose stoma was placed in the lower abdomen and had the umbilicus preserved they used an umbilical grafting to reestablish conduit superficial patency. Although follow up was

In cases where urine leakage happens the valvular mechanism may be defective, the reservoir pressure may be excessively high, or both. Urodynamic study is key to establish the diagnosis [36]. If a high pressure-reservoir is diagnosed bladder augmentation may be considered. On the other hand, if the valve mechanism is the issue a submucosal injection of a bulking agent or surgical revision making the tunnel longer may solve the problem [26].

Most conduit complications will occur within 2 years from surgery, but even initially stable channels are susceptible to complications and must be reassessed throughout patients'

Calculi formation and urinary tract infection have a fairly high incidence in continent reservoir patients and may vary from 26-32% and 19-63%, respectively [47,50]. They may be facilitated by mucus formation in patients who undergo bladder augmentation and by the position in which the tube is implanted into the bladder (anteriorly placed tubes drain with lower efficacy than those positioned posteriorly) [51]. Patient compliance with CIC

Table 1 compiles comparatively the complication rates between Mitrofanoff and Monti

**Mitrofanoff Monti Author** 

6% 8% Narayanaswamy et al. 2001

Bulking agents have conflicting results with reported success rates up to 71% [49].

flap and TVZ flap. Stenosis rates were 25%, 45% and zero, respectively [23].

weeks or a surgical resection of the pouches [3].

short (up to 6 months) results were promising [48].

execution may also influence these complication rates [18].

Table 1. Surgical complications and incidence rates

Overall 19% 60% Welk et al. 2008

Difficulty to catheterise 27% 60% Narayanaswamy et al. 2001

Stomal stenosis 15% 16% Narayanaswamy et al. 2001 Calculi formation 26-32% 26-32% Clark et al. 2002; Duckett et al. 1993 Urinary Tract Infection 19-63% 19-63% Clark et al. 2002; Duckett et al. 1993

lifetime [18].

channels (Table 1).

implant

Channel stenosis at bladder

Most reports comparing the two types of channel did not show differences in continence rates when comparing site of conduit implantation into the native bladder versus bowel [21,35].

Whenever there is an indication for occlusion or reinforcement of the bladder neck resistance different procedures may be considered including a "tight" sling, periurethral bulking agents injection, or bladder neck closure. In a retrospective study, De Troyer et al. [36] compared bladder neck closure with reconstructive procedures aiming to reinforce the bladder outlet resistance in a pediatric population showing a higher continence rate in the former, with no increase in morbidity (such as stone formation and stomal stenosis) or relationship with augmentation procedures. The authors highlight the need for concern when considering a bladder neck closure as access to the reservoir and to the upper urinary tract may become more difficult [36].

In Yang's original study, two main areas of elevated pressure were identified: bladder submucosal tunnel and the segment crossing the abdominal wall. Under Valsalva maneuver simultaneous pressure onto the conduit and the reservoir occurs, but not in the area through the abdominal wall [25]. As such, continence is highly dependent on the submucosal tunnel.
