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Salvage intravesical lengthening of the incontinent Monti-Yang channel
Keara DeCotiis, MD1, Peter Cai, MD2, Courtney Stewart, MD3, T. Ernesto Figeueroa, MD1.
1Nemours Children's Health, Wilmington, DE, USA, 2Nemours Children's Health, Orlando, FL, USA, 3Thomas Jefferson University, Philadelphia, PA, USA.
Title: Salvage intravesical lengthening of the incontinent Monti-Yang channel
Background: Incontinence after creation of a catheterizable continent channel using a reconfigured ileal segment (Monti-Yang channel) is a recognized complication of this reliable operation, primarily related to poor mucosal coaptation from a deficient submucosal tunnel. The rate of incontinence after this procedure has been reported in 3 to 16% of patients, with a higher incidence in patients who have undergone a bladder neck closure. Managing the incontinent catheterizable channel remains a very challenging problem. Options include endoscopic injection of bulking agents, re-tunneling the channel into a new submucosal tunnel, extravesical bolstering of detrusor or portion of the ileal augment around the channel, and lastly, replacement of the channel with a new ileal segment. We describe a relatively simple technique of intravesical lengthening of the channel which is then covered by adjacent bladder mucosa to create a longer submucosal channel and continence mechanism, similar to the Bischoff ureterovesicoplasty. This procedure was used in three patients with complex urinary reconstruction who experienced persistent incontinence from the channel after the initial implantation.
Methods: The patients were 24 (M), 23(F), and 17 (F) years of age at the time of the revision. All had undergone previous bladder augmentation and implantation of a catheterizable channel into the bladder. Two had prior bladder neck closures. The older patients had been lifelong patients at our institution. All patients underwent preoperative video urodynamic testing demonstrating satisfactory bladder capacity, bladder compliance, and incontinence into the channel. The surgical technique consists of reopening the augmented bladder and exposing the intravesical entry of the channel. There is no intra- or extra-vesical mobilization of the channel. A straight catheter is placed through the catheterizable channel and remains throughout the case. Once the intravesical entry of the channel is exposed, a "U " shaped bladder mucosal strip is fashioned measuring approximately 4 cm in length, incorporating the entry of the channel into the strip. The width of the strip is 2-1/2 cm. Exposure is enhanced by placement of several stay sutures. The strip is injected with lidocaine with epinephrine solution, and the incision is made using electrocautery. The strip is then tubularized with 4-0 Monocryl suture over the catheter. The adjacent bladder mucosal layers parallel to the mucosal strip are brought over the new tubularized strip and closed with 3 or 4-0 Monocryl sutures. Catheterization is then tested. The catheter is left in place for 4 weeks as well as a suprapubic tube.
Results: All 3 patients experienced cessation of incontinence, and no difficulty with catheterization. One patient is 3 years out, the second patient is 2 years out, and the third patient is 6 months out.
Conclusions: Incontinence of the reconfigured ileal (Monti-Yang) channel remains a particularly challenging problem for the pediatric urologist. We describe a relatively simple approach of lengthening the mucosal continent mechanism, avoiding the need for mobilization of the channel, for the successful correction of channel incontinence.
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