Outpatient Surgery Restores Urinary Continence


CLEVELAND — Surgeons at the Cleveland Clinic have developed an outpatient procedure for creating a continent catheterizable channel to the bladder or neobladder in patients with lower urinary tract dysfunction, Dr. Raymond R. Rackley said at the annual international meeting of the Endourological Society.

“While we've made great advances in helping people with failure-to-store conditions, this is probably one of the first minimally invasive procedures that helps those with failure-to-empty conditions,” Dr. Rackley said in an interview.

“That's the real frontier left in lower urinary pelvic reconstruction,” he added.

Surgeons formed this “continent neo-urachus” by making a tube of skin from an in situ abdominal skin flap over an 18F catheter that extends from the umbilicus to the dome of the bladder. The skin tube is placed through an opening between the braiding or crossing of the overlying rectus muscle fibers to form an external compressive continence mechanism, said Dr. Rackley, a professor of surgery at Case Western Reserve University, Cleveland.

“We form a subcutaneous tunnel to the dome of the bladder and make that bladder access dry by surrounding it and compressing it with the muscles of the patient's abdomen,” he said.

The abdominal skin is reapproximated, and the 18F catheter through the neostomal channel is left to heal for about 6 weeks while providing bladder drainage to a leg bag. Once the channel heals, the catheter is removed and the patient begins intermittent catheterization on a regular basis.

The surgery is all subcutaneous, unlike the traditional 8-hour procedure, in which intestines are harvested and reconstruction performed to create a continent mechanism, Dr. Rackley said. The new procedure “takes less than 1 hour under minimal sedation,” he noted.

In addition to being less invasive, the procedure eliminates the need for a foreign body or chronic catheter in the bladder, thereby reducing the risk of infection.

The procedure is a good alternative for those who wish to avoid a catheter in their native urethra or who can't catheterize in the sitting position because of a spinal cord injury or neurologic condition.

“It's also a good choice for patients who have had pelvic reconstruction and are not dry because of leaking channels,” Dr. Rackley said.

The continent neo-urachus, now with 18 months of follow-up, has been successful in more than 20 patients at the Cleveland Clinic and has been performed by urologists worldwide since its recent inception, he said.

The concept of braiding or crossing the rectus muscle for a continence mechanism may be extended to revisions of nondiversion channels that have developed incontinent catheterizable stomas due to outlet resistance pressure that is less than the bladder or neobladder filling pressure, Dr. Rackley said.

'This is probably one of the first minimally invasive procedures that helps those with failure-to-empty conditions.' DR. RACKLEY


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