A COMPARISON BETWEEN ILEAL AND COLONIC CHIMNEYS IN THE TREATMENT OF BLADDER DYSFUNCTION IN CHILDREN
Martin Kaefer, MD1, Randall Lou, MD2, Richard Rink, MD1, Rosalia Misseri, MD1, Benjamin Whitham, MD1, Konrad Szymanski, MD1, Josh Roth, MD1, Javier Bolanos, MD2.
1Indiana University, Indianapolis, IN, USA, 2Roosevelt Hospital, Guatemala City, Guatemala.
BACKGROUND: Bladder dysfunction resulting in decreased compliance and elevated storage pressures can result in irreversible renal injury. Bladder augmentation can serve to increase reservoir capacity but confers certain long-term risks. For patients who are poorly compliant with catheterization schedules, these risks may significantly outweigh the benefits. It is for this reason that incontinent diversion may be preferred in a certain cohort of patients with anatomic and neurologic bladder dysfunction. We hypothesize that the enteric chimney provides reliable decompression of the upper urinary tracts and carries a low risk of complications in children. We furthermore hypothesize that the larger caliber sigmoid colon may serve as a more reliable conduit than ileum. METHODS: This is a retrospective review of all enteric chimneys performed over a 15-year period. The proximal end of the enteric segment is anastomosed widely to the dome of the bladder and the distal end brought out as a budded stoma. In patients with prior bladder augmentation, the augmented segment is excised at the time of operation. Daily postoperative bladder irrigation is maintained in order to minimize infection and stone formation. RESULTS: Between 2003-2018, 39 children underwent creation of a chimney (27 Ileum, 12 Sigmoid Colon). Diagnosis included Neurogenic Bladder(24),Posterior Urethral Valves(6),Exstrophy(4), Cerebral Palsy (4) and Prune Belly Syndrome(1). Average age at operation was 8.9 (range 1-16) years. Average follow up was 4.8 (range 1-15) years. Renal function stabilized and hydronephrosis (if present) improved in all patients. Complications occurred in 12 patients (30%): urethral leakage (6), poor drainage (3), lithiasis (2), SBO (1). Although colonic chimneys experienced fewer complications [(Colon 2/12 (16%) vs. Ileum 10/27(37%)] this did not reach statistical significance (p=0.27, Fisher exact test). CONCLUSIONS: The Chimney provides safe evacuation of urine from the bladder. Sigmoid may provide superior drainage due to its wider diameter. In contrast to an enteric loop diversion, this technique does not require construction of uretero-enteric anastomosis, preserves the ureterís natural anti-refluxing mechanism and can easily be converted into a bladder augmentation at a future date.
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