title: Using a serosal trough for fashioning a continent catheterizable stoma: technique and outcomes.
abstract: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Continent urinary diversion with bladder augmentation is an established method of providing urinary continence in children with bladder exstrophy, who are not suitable candidates or have a failed bladder neck reconstruction. Sub-mucosal implantation of the tubularized catheterizable stoma (usually the appendix) into the reservoir, with backing typically provided by either the bladder musculature or colonic taenia, is safe and highly effective in these children. In some cases of classic bladder exstrophy and in the majority of patients with cloacal exstrophy, the ileum is used for enterocystoplasty and therefore there is no taenia to back the implanted catheterizable channel. This study describes the steps for providing a reliable flap-valve mechanism for the continent catheterizable channel using the serosal trough technique.
  
  
  OBJECTIVE
  To evaluate the efficacy and potential complications of the serosal-trough (ST) technique for the implantation of a continent catheterizable stoma (CCS) during enterocystoplasty. To describe the surgical technique and provide detailed illustrations.
  
  
  METHODS
  Using an institutional review board-approved departmental database, children with bladder exstrophy, born after 1990, were selected, and patients who had undergone urinary diversion with a CCS created using the ST technique were identified. Demographic and technical characteristics, as well as the eventual clinical outcomes, were retrospectively reviewed.
  
  
  RESULTS
  A total of 135 patients with urinary diversion were identified, of whom 26 (13 males) had undergone CCS implantation using the ST technique. Patients included 14 classic exstrophies, 10 cloacal exstrophies, and two epispadias. The appendix and tapered ileum were used for the creation of a CCS in 11 and 15 patients, respectively. The median (range) age at creation of a CCS was 10.7 (4.4-17.4) years. At the time of CCS creation, 21 patients underwent initial enterocystoplasty, four had repeat augmentations, and one had a CCS on a previously augmented bladder. Ileum (mean length 18 cm) was used in 24/25 augmentations and was selected owing to lack of redundant sigmoid in 52% of patients and intraoperative surgeon preference in the remaining cases. In one case of cloacal exstrophy, a hindgut remnant was used. In 24 (92%) cases, initial CCS resulted in complete continence of the catheterizable channel. After a median (range) of 2.5 (0.2-7.5) years' follow-up all patients were dry via intermittent catheterization. The CCS failed at postoperative months 6 and 21 and required complete revision in two cases.
  
  
  CONCLUSIONS
  Using a ST to provide a strong backing for a catheterizable channel is an excellent option when a channel must be placed in the ileum, hindgut, or in an area of augmentation where muscular backing is not available. The ST technique provides a reliably catheterizable tunnel, durable continence mechanism and a good success rate when creating a CCS in combination with a urinary diversion.
authors.affiliation: Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
authors.forename: Nima
authors.initials: N
authors.lastname: Baradaran
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Stec
authors.forename: Angela
authors.initials: A
authors.lastname: Gupta
authors.forename: Michael A
authors.initials: MA
authors.lastname: Keating
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D000293:Adolescent; D001746:Bladder Exstrophy / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003559:Cystostomy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007082:Ileum / Q000601:surgery*; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D012704:Serous Membrane / Q000637:transplantation*; D001743:Urinary Bladder / Q000601:surgery*; D014546:Urinary Catheterization; D014547:Urinary Diversion / Q000379:methods*; D016476:Urinary Reservoirs, Continent