Date Published: October 27, 2009
Publisher: Hindawi Publishing Corporation
Author(s): W. Britt Zimmerman, Richard A. Santucci.
Objectives. To review the literature regarding ileovesicostomy and evaluate our patient population for clinical characteristics. Methods. Various surgical reconstructive techniques allow management of difficult clinical scenarios involving patients with neurogenic bladder, irretraceable lower urinary tract symptoms, lower urinary tract disaster, and urethrocutaneous fistulae. One such reconstructive technique employed is the ileovesicostomy. This procedure provides patients with a low-pressure urinary conduit utilizing the ileum and native bladder that empties without catheterization. We describe our patient population who underwent ileovesicostomy for 5 consecutive years ending 2007 at Detroit Receiving Hospital. Results. Most common diagnosis was neurogenic bladder secondary to spinal cord injury. Our population and clinical outcomes are similar to those previously reported in the literature. Conclusions. Based on our experience, we suggest that patients with severe lower urinary tract symptoms and who are unable to perform clean intermittent catheterization and/or refractory to medical therapy ileovesicostomy should be the procedure of choice.
In the 21st century, various surgical reconstructive techniques allow management of difficult clinical scenarios involving neurogenic bladder, intractable lower urinary tract obstruction, and lower urinary tract disasters such as sometimes occur after prostate cancer treatments. As a method in dealing with the worst of these problems, suprapubic diversion has progressed significantly over the past 50 years. In the 1950s, cutaneous vesicostomy evolved into ileocystostomy (which is now called ileovesicostomy), which improved the location and quality of the stoma, allowing improved patients dryness [1, 2]. During the late 1900s, cystectomy and ileal loop also became common, but likely is an unnecessarily invasive treatment for many patients nowadays. From the 1960s to 1980s, ileal loop diversion and chronic indwelling urethral catheterization were the mainstays of therapy. In the 1970s, clean intermittent self-catheterization (CIC)  took the forefront, but more complex techniques such as ileovesicostomy are still commonly necessary in special or refractory cases.
Smith and Hinman first described ileovesicostomy in 1955, using dogs and anastomosing ileum to the native bladder in situ. This allowed the bladder to act as a “continent reservoir,” which was drained volitionally through the ileal conduit instead of the urethra. They postulated that the bladder neck continence mechanism would remain, and that voiding would occur through the subject’s own detrusor contraction . Of course, in humans, ileovesicostomy is designed as a completely incontinent suprapubic diversion.
There are four major reasons to consider an ileovesicostomy in the modern day.
McGuire and associates  reported that ileovesicostomy maintains a detrusor leak point pressure less than 40 cm of water and preserves upper tract function as well or better than the traditional treatments of anticholinergic medications and CIC. However, this patient population was “self-selected” as they generally chose to abandon CIC either by choice or through lack of home care support. In a long-term study, Leng reported that yearly measures of detrusor leak point pressure less than 40 cm of water were achieved in the 38 of 41 of these patients (93%) .
In the neurogenic bladder patient who is unable to store urine, Elliot and associates indicated that medical therapy was considered first treatment. Among surgical treatments, the “gold standard” operations included supravesical diversion or augmentation cystoplasty . Ileovesicostomy may be particularly useful in those with poor bladder compliance. It is known that a poorly compliant bladder can develop in about 10% percent of patient with suprasacral spinal cord injuries and 50% with sacral level injuries . With spinal cord injury, a correlation exists with upper tract complications and poor bladder compliance. This has been associated with radiographic upper tract abnormality, vesicoureteral reflux, pyelonephritis, and upper tract stones [4, 15]. Reliable low-pressure egress of urine without the need for catheters provided by the ileovesicostomy is an ideal answer to this problem.
In 1994, Schwartz and associates reported 23 patients who underwent ileovesicostomy. Of these cases, 17 patients were quadriplegic, five had lower spinal cord abnormalities, and one patient had a “watering pot perineum.” They reported a mean followup of 45 months. Twenty-one of 23 (91%) patients had egress of urine at bladder pressure less than 20 cm of water. Early complications included pneumonia, bladder outlet obstruction, poor drainage, and increased leak point pressure. Late complications included stomal stenosis, parastomal hernia, and detrusor hyperreflexia .
As the world of minimally invasive surgery has grown, the attempt to perform ileovesicostomy via the laparoscopic approach is evolving. The proposed benefits for laparoscopic approach include comparable operative time, decrease in blood loss, and decreased postoperative convalescence. Currently, there are two case reports in humans describing laparoscopic ileovesicostomy. The first case was performed in 240 minutes and blood loss of 100 mL. The patient had an uneventful postoperative course and was discharged on hospital day four . The second case study described the first successful pure laparoscopic approach performed in 270 minutes and an estimated blood loss of 50 mL .
In performing an ileovesicostomy, the question will arise as whether to routinely close the bladder neck in order to fix continued urinary incontinence from the patient’s urethra. The literature does not readily identify patients that would benefit from this procedure. Usually we do not perform urethral/bladder neck closure at the time of ileovesicostomy unless we have objective evidence that it is required (such as a patient with a pre-existing suprapubic tube who has persistent total incontinence through the urethra). Only one study addressed this issue in patients with ileovesicostomy for neurogenic bladder; Mutchnik had one patient (17%) who subsequently required bladder neck closure secondary to persistent urethral leakage. Another author reported no patients in their series of 13 patients, who required bladder neck closure . However, patients who are treated for urethral destruction have a high rate of requiring subsequent urethral closure (perhaps because the urethral destruction is associated with concomitant bladder neck destruction). In addition, Schwartz et al. provide some helpful guidance, as they performed bladder neck closure at the time of ileovesicostomy in women patients when fluorourodynamic studies demonstrated poor proximal urethral function.
After approval by the Human Investigations Committee at Wayne State University, we evaluated our patients who had undergone ileovesicostomy to characterize the common complications following the procedure and determine success rates. Patients were included if 18 years of age or older and had undergone an ileovesicostomy for a five-year period ending September 2007 at Detroit Receiving Hospital. Patients were treated according to our algorithm (Figure 1).
Ileovesicostomy serves as an alternative in those patients with chronic outlet obstruction who have failed conservative management. The expected complication rate from ileovesicostomy is enumerated previously in this paper. The complications of chronic urethral or suprapubic catheterization are well known, but harder to quantify in the literature. Schwartz et al. reported 30% patients with progressive incontinence or urethrocutaneous fistulas, 39% with urosepsis, 39% with recurrent upper and/or lower tract urolithaisis, 13% had autonomic dysreflexia, and 17% had worsening hydronephrosis and/or ureteral reflux . In a related article, Larsen et al. reported 49 of 56 (88%) of urethrally catheterized patients experienced a total of 202 complications including renal damage, UTIs, stones, urethral erosions, strictures, abscesses, and 2 deaths associated to urosepsis .
Currently, debate exists amongst practitioners regarding neurogenic bladder patients where ileovesicostomy should be placed in the algorithm for treatment. The current practice standard is trial of management with CIC, followed by indwelling urinary catheter (urethral versus suprapubic cystotomy), and later, operative maneuvers to eliminate the chronic catheter altogether. Operative intervention consists of cystectomy with ileal diversion, augmentation cystoplasty with or without appendicovesicostomy, or ileovesicostomy. Multiple authors have suggested that in patients with severe lower urinary tract symptoms and who are unable to perform CIC and/or refractory to medical therapy, ileovesicostomy should be the procedure of choice. In light of the known complications associated with chronic indwelling urinary catheters, we have found this procedure beneficial, as well as easy to perform, generally successful, and durable. Postoperative or intraoperative closure of the incompetent bladder neck might sometimes also be required in the ileovesicostomy patient.