Liard A, Séguier-Lipszyc E, Mathiot A, Mitrofanoff P
Department of Pediatric Surgery, University Hospital Charles Nicolle, Rouen, France.
J Urol. 2001 Jun;165(6 Pt 2):2394-8. doi: 10.1016/S0022-5347(05)66213-1.
We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup.
Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux.
One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion.
The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency.
我们回顾了我们最初的可控膀胱造瘘术病例，以评估至少15年随访后的长期功能结果和并发症。
1976年至1984年间，对15名男孩和8名患有神经源性膀胱的女孩进行了23例可控膀胱造瘘术。手术时患者的平均年龄为8岁4个月（范围3至16岁），平均随访时间为20年（范围15至23年）。神经病变的原因是21例脊髓脊膜膨出（21例中有2例合并肛门闭锁）、1例脊髓神经母细胞瘤和1例合并肛门闭锁的复杂泌尿生殖系统畸形。21例患者进行了膀胱颈闭合术（16例在同一手术中进行，5例为二期手术），2例未进行此手术。20例患者使用阑尾作为可插管通道，2例使用1条输尿管，1例使用膀胱管。2例患者在同一手术中进行了膀胱扩大术，8例在后期进行。5例患者出现单侧或双侧继发性膀胱输尿管反流。
1例患者因术后感染导致脑室腹腔分流阀感染，转为皮肤造口术后死亡。其余22例患者每6至12个月随访一次。未发现代谢紊乱、继发性恶性肿瘤或自发性膀胱穿孔。10例患者出现双侧上尿路恶化，6例通过肠膀胱扩大术进行二期膀胱扩大，4例进行不可控分流。5例患者膀胱颈闭合后出现渗漏。5例患者发现膀胱结石（2例曾行膀胱扩大术）。与通道相关的并发症包括11例造口狭窄或持续渗漏，需要手术修复和/或反复扩张，修复失败后1例进行不可控分流。5例患者出现肠梗阻，其中3例因肠扭转，2例因粘连。我们注意到，随访10年后并发症很少见，主要与可插管通道有关。因此，16例患者结果良好且稳定，6例进行了不可控分流。
并发症发生率有随时间下降的趋势。本系列取得的结果可能不如近期系列令人满意，这可能是因为这些最早的可控膀胱造瘘术对应于这种新方法经验的积累期，以及当时低压储尿囊的概念尚未确立且膀胱扩大术未常规进行的时期。自1984年以来，我们机构进行的可控膀胱造瘘术没有一例转为不可控分流。这个长期随访的系列表明可控膀胱造瘘术是一种具有持久疗效的手术。
