Do anterior catheterizable urinary channel have fewer complications than posterior channels? An international cohort study
Konrad M. Szymanski, MD MPH1, Pedro-Jose Lopez, MD2, Juan P. Corbetta, MD3, Francisco Reed, MD2, Javier Ruiz, MD3, Yolanda Pullin, MD2, Santiago Weller, MD3, Ricardo Zubieta, MD2, Mark P. Cain, MD MPH1, Richard C. Rink, MD1.
1Riley Hospital for Children, Indianapolis, IN, USA, 2Service of Pediatric Urology, Hospital Exequiel Gonzalez Cortes, Santiago, Chile, 3Department of Pediatric Urology, Hospital Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.
BACKGROUND: Appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) are durable catheterizable channels. While subfascial revision rates vary by channel type and stomal location, a channel implanted in the anterior (vs. posterior) aspect of the bladder may have a lower subfascial revision risk due to decreased channel mobility and better fascial fixation. We aimed to compare long-term durability of anteriorly (vs. posteriorly) implanted APV and Monti channels in a large international cohort.
METHODS: We conducted a retrospective cohort study of patients <=21 years old undergoing APV or Monti surgery with an open technique at 3 high volume centers (1990-2015). We noted patient demographics, stomal and subfascial revisions, stomal location, channel configuration (anterior/posterior), and channel type: APV, spiral Monti to umbilicus (SMU), other Monti channels. Survival analysis and Cox proportional hazards regression were used to examine the 3 channel groups separately.
RESULTS: Of 675 patients meeting inclusion criteria, 387 had an APV (71.3% anterior), 53 had an SMU (13.2% anterior) and 235 other Monti channels (42.1% anterior). Median age at surgery was 8.8 years for APV (median follow-up: 5.5 years), 9.2 years for other Monti (follow-up: 6.6 years) and 7.9 years for SMU (follow-up: 9.0 years). Patients originated from the United States (67.9%), Argentina (26.4%) and Chile (5.8%).Overall, 76 stomal and 77 subfascial revisions occurred. At 5 years of follow-up, 9.3-12.0% of channels underwent stomal revision, with no difference between channel types (p=0.57). Risk of subfascial revision at 5 years was 7.4% for APV, 12.7% for all other Monti channels and 25.9% for SMU (p=0.001). On survival analysis, stomal and subfascial revision rates were similar between anterior and posterior channels for APV (p>=0.16), other Monti channels (p>=0.62) and SMU (p>=0.43). On multivariate regression, channel configuration was not associated with stomal or subfascial revision for APV (p>=0.18) or other Monti channels (p>=0.64). Gender, age, diagnosis, country and stomal location were not associated with revision risk (p>=0.06). CONCLUSIONS: We demonstrate durable long-term results with the APV and Monti techniques in an international cohort. Risks of stomal and subfascial complications are not significantly different between anteriorly and posteriorly implanted channels. As previously reported, Monti channels, particularly SMU, are more prone to undergoing subfascial revisions.
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