PEDIATRIC UROLOGY
CECAL TUBULARIZATION: L E N G T H E N I N G TECIINIQUE FOR CREATION OF CATHETERIZABLE CONDUIT WILLIAM J. CROMIE, M.D. JAMES H. BARADA, M.D. JEFFREY L. WEINGARTEN, M.D. From the Division of Urologic Surgery', Albany Medical Center, Albany, New York
A B S T R A C T - - T h e creation of a continent, catheterizable stoma is an integral component o~ ':success.ful continent urinary diversion. A technique is described which allows lengthening of a : continent appendicovesicostomy. This technique extends the applications,for the Mitro~anofj principle oJ urinary tract reconstruction.
The concept of successful continent urinary diversion only recently has been realized by !urologic surgeons and their patients. While the principles of continent urinary diversion are :soundly established, many operative procedures exist which achieve a similar endpoint. The MitrofanofP principle of continent urinary diversion involves utilizing the appendix as a catheterizable conduit linking a low-pressure urinary ~reservoir to the skin in an antirefluxing manner. I n certain patients, the isolated appendix is of insufficient length to provide a tension-free anastomosis. The following technique utilizes itubularized contiguous cecum, with the appendix, to significantly increase the length of the eatheterizable conduit. :
qbchnique
Knowledge of the anatomy and blood supply o f the ileoeecal region is prerequisite to the ':success of this technique. The ileocolic artery is t h e lowermost branch of the superior mesenteric artery. It represents the main blood supply to the appendix and ileocecal region. The ileoeolic artery has five branches: (1) colic branch to the right colonic region, (2) anterior cecal arter3; (3) posterior cecal artery, (4) ileal branch, and (5)appendieeal branch. 2 These arteries are not end arteries but form an arcade with submucosal collateralization.
UROLOC'i
/
JANUARY 1991
/
The creation of a ceeoappendiceal segment for use as a eatheterizable conduit involves the isolation of the appendieeal artery within the mesoappendix. Following this, a small window is made in the appendiceal mesentery near the base of the appendix at its junction with the cecum (Fig. 1). Next, the base of the cecum is divided utilizing either an Allen intestinal clamp or a gastrointestinal stapler (Fig. 2). If gastrointestinal stapling techniques have not been employed, the base of the ceenm is closed in two layers. After the tip of the appendix has been excised to allow passage of a 12F red rubber catheter, the excised contiguous cecal segment is tubularized over the same catheter (Fig. 3). A running absorbable suture forms the inner layer which incorporates all layers of the bowel wall. An outer seromuseular layer of interruptcd nonabsorbable sutures is used to further imbricate the cecal segment over the catheter (Fig. 4). The catheter should comfortably pass through the imbricated region. Following this, the tubularized segment is anastomosed to the bladder or urinary reservoir in an extravesieal fashion. Orientation of either the appendiceal or cecal end of the conduit toward the reservoir is acceptable depending on the intraoperative anatomy encountered. A direct mucosal-to-mucosal anastomosis is performed. This procedure is performed in conjunction with a unilateral psoas hitch to eliminate tension and stabilize
VOI,UME XXXVII, NUMBER 1
41
~ !~ ~/ ~ ppendi c eal ""---.\ "°I ._.d
FIcuI~F, 1. Window made i7~ mesoappendix at base o~cec~177~.
FIGUI/E 3. Appendieeal lip excised and 12F catheter used to calibrate tubularization.
/
/
"I"A-55stapler positioned across base qf
FIGt:R~: 4. Cecal tubularization t)e(formcd i7~ two layers over catheter.
the conduit. Finally; creation of the catheterizable stoma is performed at a skin site selected preoperatively.
One year postoperatively she is doing well and catileterizes her abdominal wall stoma 4-5 times daily for volumes of .300 ,500 ec. There is no associated incontinence, and her deeubitus have healed.
Flctm~
£ 2.
CeClllll.
Case Abstract A fifteen-year-old white female had a lumbar myelomeningoeele and secondary neuropathic bladder. An artificial urinary sphincter was placed at another institution in 1982; however, malfunction of the cuff occurred. Revision was attempted in 1983 and was unsuccessful. Since that time, she had been managed with longterm indwelling Foley catheter. Due to recurrent febrile urinary tract infections and leakage around her catheter with secondary decubitus formation, continent urinary diversion was indicated. Preoperatively, an intravenous pyelogram demonstrated normal upper urinary tracts. Voiding c y s t o u r c t h r o g r a p h y d e m o n s t r a t e d grade I/V left vesicoureteral reflux. Cystometry revealed a bladder capacity of 160 cc with a hypertonic curve. The patient underwent a left IAch-Gregoir vesicoureteroplast> sigmoid augmentation cystoplast> a rectus fascia pubovaginal sling, and a continent cecoappendicovesicostomy.
42
Conclusion Cecal tubularization allows lengthening of the available appendix, if necessary, to create a c u t a n e o u s , c a t h e t e r i z a b l e c o n d u i t . The lengthening procedure does not alter tile continence mechanism which is dependent on the7 submucosally lunnelled vesicoappendiceal anastomosis.3 This technique markedly extends'. the applications of the Mitrofanoff principle for: continent urinary diversion in those patient s who have a very short appendiceal length or a: thick anterior abdominal wall. .,\]ban3; New York 12208 (DB. ClqOMIE): References '~. Mitmfanoff P: Cvstotomic con~i1:emc trans appendiculairC dans le traitemept des (,essies rwurolo
CECAL TUBULARIZATION: L E N G T H E N I N G TECIINIQUE FOR CREATION OF CATHETERIZABLE CONDUIT WILLIAM J. CROMIE, M.D. JAMES H. BARADA, M.D. JEFFREY L. WEINGARTEN, M.D. From the Division of Urologic Surgery', Albany Medical Center, Albany, New York
A B S T R A C T - - T h e creation of a continent, catheterizable stoma is an integral component o~ ':success.ful continent urinary diversion. A technique is described which allows lengthening of a : continent appendicovesicostomy. This technique extends the applications,for the Mitro~anofj principle oJ urinary tract reconstruction.
The concept of successful continent urinary diversion only recently has been realized by !urologic surgeons and their patients. While the principles of continent urinary diversion are :soundly established, many operative procedures exist which achieve a similar endpoint. The MitrofanofP principle of continent urinary diversion involves utilizing the appendix as a catheterizable conduit linking a low-pressure urinary ~reservoir to the skin in an antirefluxing manner. I n certain patients, the isolated appendix is of insufficient length to provide a tension-free anastomosis. The following technique utilizes itubularized contiguous cecum, with the appendix, to significantly increase the length of the eatheterizable conduit. :
qbchnique
Knowledge of the anatomy and blood supply o f the ileoeecal region is prerequisite to the ':success of this technique. The ileocolic artery is t h e lowermost branch of the superior mesenteric artery. It represents the main blood supply to the appendix and ileocecal region. The ileoeolic artery has five branches: (1) colic branch to the right colonic region, (2) anterior cecal arter3; (3) posterior cecal artery, (4) ileal branch, and (5)appendieeal branch. 2 These arteries are not end arteries but form an arcade with submucosal collateralization.
UROLOC'i
/
JANUARY 1991
/
The creation of a ceeoappendiceal segment for use as a eatheterizable conduit involves the isolation of the appendieeal artery within the mesoappendix. Following this, a small window is made in the appendiceal mesentery near the base of the appendix at its junction with the cecum (Fig. 1). Next, the base of the cecum is divided utilizing either an Allen intestinal clamp or a gastrointestinal stapler (Fig. 2). If gastrointestinal stapling techniques have not been employed, the base of the ceenm is closed in two layers. After the tip of the appendix has been excised to allow passage of a 12F red rubber catheter, the excised contiguous cecal segment is tubularized over the same catheter (Fig. 3). A running absorbable suture forms the inner layer which incorporates all layers of the bowel wall. An outer seromuseular layer of interruptcd nonabsorbable sutures is used to further imbricate the cecal segment over the catheter (Fig. 4). The catheter should comfortably pass through the imbricated region. Following this, the tubularized segment is anastomosed to the bladder or urinary reservoir in an extravesieal fashion. Orientation of either the appendiceal or cecal end of the conduit toward the reservoir is acceptable depending on the intraoperative anatomy encountered. A direct mucosal-to-mucosal anastomosis is performed. This procedure is performed in conjunction with a unilateral psoas hitch to eliminate tension and stabilize
VOI,UME XXXVII, NUMBER 1
41
~ !~ ~/ ~ ppendi c eal ""---.\ "°I ._.d
FIcuI~F, 1. Window made i7~ mesoappendix at base o~cec~177~.
FIGUI/E 3. Appendieeal lip excised and 12F catheter used to calibrate tubularization.
/
/
"I"A-55stapler positioned across base qf
FIGt:R~: 4. Cecal tubularization t)e(formcd i7~ two layers over catheter.
the conduit. Finally; creation of the catheterizable stoma is performed at a skin site selected preoperatively.
One year postoperatively she is doing well and catileterizes her abdominal wall stoma 4-5 times daily for volumes of .300 ,500 ec. There is no associated incontinence, and her deeubitus have healed.
Flctm~
£ 2.
CeClllll.
Case Abstract A fifteen-year-old white female had a lumbar myelomeningoeele and secondary neuropathic bladder. An artificial urinary sphincter was placed at another institution in 1982; however, malfunction of the cuff occurred. Revision was attempted in 1983 and was unsuccessful. Since that time, she had been managed with longterm indwelling Foley catheter. Due to recurrent febrile urinary tract infections and leakage around her catheter with secondary decubitus formation, continent urinary diversion was indicated. Preoperatively, an intravenous pyelogram demonstrated normal upper urinary tracts. Voiding c y s t o u r c t h r o g r a p h y d e m o n s t r a t e d grade I/V left vesicoureteral reflux. Cystometry revealed a bladder capacity of 160 cc with a hypertonic curve. The patient underwent a left IAch-Gregoir vesicoureteroplast> sigmoid augmentation cystoplast> a rectus fascia pubovaginal sling, and a continent cecoappendicovesicostomy.
42
Conclusion Cecal tubularization allows lengthening of the available appendix, if necessary, to create a c u t a n e o u s , c a t h e t e r i z a b l e c o n d u i t . The lengthening procedure does not alter tile continence mechanism which is dependent on the7 submucosally lunnelled vesicoappendiceal anastomosis.3 This technique markedly extends'. the applications of the Mitrofanoff principle for: continent urinary diversion in those patient s who have a very short appendiceal length or a: thick anterior abdominal wall. .,\]ban3; New York 12208 (DB. ClqOMIE): References '~. Mitmfanoff P: Cvstotomic con~i1:emc trans appendiculairC dans le traitemept des (,essies rwurolo
