More than 52,000 soldiers have been injured and 6,800 have been killed during the wars in Iraq and Afghanistan.1 Blast injuries from improvised explosive devices (IEDs) account for 70% to 79% of combat-related injuries and deaths in these wars.2 Advances in personal body armor, rapid and advanced surgical treatment, and the changing nature of combat in Iraq and Afghanistan have changed injury patterns and survival compared with prior military conflicts such as those in Vietnam and Korea.3
The most common combat-related injuries in the recent wars are extremity, facial, brain, and gastrointestinal injuries. Pelvic and genitourinary injuries are also common, accounting for about 8% of total injuries.2 Pelvic and genitourinary injury can cause long-term disability from nerve injury (neurogenic bladder, neurogenic bowel, sexual dysfunction, urethral injury), as well as general loss of genital structures from blast injuries.
The usual care for bladder dysfunction from pelvic or genitourinary injury ranges from the use of chronic indwelling catheters to reconstructive surgery. However, there is no standard of care for long-term treatment of patients with pelvic or genitourinary injury who experience bladder dysfunction. Reconstructive surgery has the potential to improve quality of life (QOL) and eliminate chronic indwelling catheters, which are prone to cause infection and long-term kidney problems in patients with bladder dysfunction from traumatic injury.
This case report evaluates the efficacy of reconstructive surgery for bladder dysfunction to improve independence and QOL and decrease complications associated with chronic indwelling urinary catheters. The authors hope to raise awareness regarding this option for patients with pelvic, spinal cord, or genitourinary injury who are young and face long-term disability from their injuries.
A 22-year-old man presented to the George E. Wahlen VAMC Urology Clinic in Salt Lake City, Utah with a complicated history related to combat injuries. During combat operations 3 years earlier, he was injured by an IED blast while on foot patrol. His injuries included bilateral severe extremity injury, perineal and genital blast wounds, a bladder injury, pelvic fracture, colorectal injury, and extensive soft tissue loss. He underwent multiple abdominal explorations, left leg amputation below the knee, multiple skin grafts, soft tissue debridements, left-side orchiectomy, bladder repair, and diverting colostomy. He survived the injuries and was eventually discharged from active military service and returned home.
Upon presentation to the VAMC, the patient had a diverting colostomy, suprapubic bladder catheter, and bladder and bowel function consistent with cauda equina syndrome (pelvic nerve injury). Given the lack of rectal tone, fecal incontinence was likely with colostomy reversal. His bladder had low volume and poor compliance (elasticity). In addition, the patient had no volitional control of urination or defecation.
The patient previously performed intermittent self-catheterization but experienced total urinary incontinence (UI) between catheterizations, due to his bladder dynamics and a lack of urinary sphincter tone. A suprapubic bladder catheter was previously placed to control UI. However, the patient remained incontinent, and urinary leakage, need for diapers, and urinary tract infections (UTIs) negatively impacted QOL. The patient ambulated well and was physically active. His priority was to reduce incontinence and improve QOL.
Catheterizable Ileal Cecocystoplasty
The patient underwent cutaneous catheterizable ileal cecocystoplasty (CCIC) (Figure 1). In this surgery, a segment of the cecum and ascending colon with attached terminal ileum is used to increase the size of the bladder (augmentation cystoplasty) and create a channel for catheterization from the umbilicus. The cecum and colon are detubularized, and a large rectangular plate of large bowel is formed, which is then sewn to the bladder, expanding its volume. About 10 to 15 cm of the terminal ileum is tapered to the diameter of a pencil and brought through the base of the umbilicus, creating a small stoma for intermittent bladder catheterization. The ileocecal valve is tightened and serves as a continence mechanism to prevent urinary leakage through the small stoma in the umbilicus.4
A perineal urethral mesh sling was placed at the time of the patient’s surgery to bolster the deinnervated urinary sphincter and prevent urethral leakage. The goal of reconstructive surgery for this patient was to create a small bowel channel connecting the umbilicus and bladder that could be catheterized every 4 to 6 hours, increase bladder capacity, and increase sphincteric resistance to reduce urethral leakage through the penis. Because there can be damage from passing a catheter through mesh slings and the urethra over time, including stenosis or erosion of the sling, an alternative catheterizable channel was needed in this patient.
The patient recovered after the surgery and was able to self-catheterize without difficulty. However, the urethral mesh sling did not place enough pressure on the urethra to prevent leakage, and he had persistent incontinence from the penis. Three months after the original surgery the patient had exploration of the perineum, which revealed that the mesh sling was loose and exerting inadequate pressure on the urethra. It was likely the sling slipped postoperatively—a known complication of urethral slings. An artificial urinary sphincter (AUS) was placed around the urethra during the second surgery to address the patient’s UI.