Laparoscopy-Assisted Cutaneous Vesicostomy in Combination with Radical Nephrectomy in an Adult Patient with Neurogenic Bladder and Difficulty with Permanent Urinary Catheterization

Abstract

Background: Cutaneous vesicostomy is a urinary diversion for chronic urinary retention caused by neurogenic bladder. In this procedure, urine is drained directly from the bladder into a pouch attached to the lower abdomen, where the use of a catheter is unnecessary. Although complications of this procedure have been described, such as stoma stenosis, bladder prolapse, bladder calculi, and peristomal dermatitis, it is useful for patients who have difficulty with permanent bladder catheterization. The laparoscopy-assisted technique for cutaneous vesicostomy has not been described in the existing literature. In this report, we describe the case of an adult patient with chronic urinary retention caused by a neurogenic bladder who underwent laparoscopy-assisted cutaneous vesicostomy.

Case Presentation: A 61-year-old man with intellectual disability was referred to our department because of macroscopic hematuria and urinary retention. Abdominal ultrasonography and computed tomography images showed excessive bladder dilation and bilateral hydronephrosis. A left kidney tumor was found incidentally. We diagnosed left renal carcinoma and chronic urinary retention caused by a neurogenic bladder. We suspected that the hematuria resulted from the renal cancer or from mucosal or submucosal vessel injury caused by excessive dilation of the bladder. Because of the patient's intellectual disability, self-intermittent catheterization or management of a urethral catheter was not possible. Therefore, we performed left radical nephrectomy laparoscopically followed by laparoscopy-assisted cutaneous vesicostomy under general anesthesia. By using laparoscopy, we could construct the vesicostomy in the bladder dome with less tension, and no stomal complications had occurred at 7 months postoperatively.

Conclusion: Laparoscopy-assisted cutaneous vesicostomy was a safe and feasible surgical technique in our adult patient with chronic urinary retention. This procedure may be considered effective for patients having difficulty with permanent urinary catheterization.

Introduction and Background

Permanent urinary catheterization or urinary diversion is required when urinary retention caused by a neurogenic bladder does not improve with medication. Although clean intermittent catheterization is considered the initial option, some patients or their family cannot perform the procedure. In such situations, placement of permanent urethral or suprapubic cystostomy catheters is performed. However, this can be challenging in patients with cognitive or intellectual impairment, as they cannot tolerate it and may remove the catheter themselves.

Cutaneous vesicostomy is a catheter-free permanent incontinent urinary diversion, where the bladder wall is pulled up to the skin, opened, and fixed to the lower abdominal wall. Urine is drained directly from the bladder into a pouch attached to the lower abdomen. Two major open surgical techniques have been described by Lapides et al.¹ and Blocksom.² Although the Blocksom vesicostomy is typically performed in children for temporary urinary diversion, it is reportedly useful in older adults with dementia.³

Stomal obstruction caused by improper placement of the stoma, stomal stenosis, or posterior bladder wall prolapse has been described as a complication of Blocksom vesicostomy.⁴ We hypothesized that a laparoscopy-assisted technique can contribute to reduce stomal complications, despite the fact that laparoscopy-assisted cutaneous vesicostomy has not yet been reported.

We report the first experience of laparoscopy-assisted cutaneous vesicostomy in a 61-year-old man with chronic urinary retention caused by a neurogenic bladder who would have difficulty managing a permanent urinary catheter caused by intellectual disability.

Presentation of Case

A 61-year-old man with intellectual disability was referred to our department for macroscopic hematuria and urinary retention. He had no medical history of urologic disease, but had undergone left femoral head fracture repair 20 years ago. He was lean with a body mass index of 18.7 kg/m². His lower abdomen was distended and overflow incontinence was observed. He had difficulty voiding spontaneously and had a residual urine volume of >600 mL. Underactive bladder was considered and treated with medication; however, there was no improvement. Abdominal ultrasonography and computed tomographic images showed excessive bladder dilation and bilateral hydronephrosis (Fig. 1) without prostatic enlargement. Although no tumor was detected in the bladder, the ureter, or the renal pelvis, a left kidney tumor was found incidentally. Cystoscopy was not performed, because the patient could not tolerate the procedure; however, urine cytology was performed and was negative. His serum creatinine level was 1.02 mg/dL. We diagnosed him with left renal cancer with no metastatic lesions and chronic urinary retention caused by a neurogenic bladder. We suspected that the hematuria resulted from the renal cancer or from mucosal and submucosal vessel injury caused by excessive dilation of the bladder. The patient could not perform clean intermittent catheterization or tolerate an indwelling urethral catheter. Therefore, we decided to perform a laparoscopic left radical nephrectomy followed by laparoscopy-assisted cutaneous vesicostomy. Informed consent for the surgery and publication of this article was obtained from the patient's family members.

FIG. 1.

Axial plane of preoperative computed tomography images (A). The red arrowhead indicates a left renal tumor sized 36 mm. The tumor protrudes into the renal hilar fat. The blue arrowheads show the bilateral hydronephrosis of the kidneys. (B). The blue arrow shows the excessive dilation of the bladder caused by urinary retention.

Under general anesthesia, laparoscopic radical left nephrectomy was finished. Next, we performed a laparoscopy-assisted cutaneous vesicostomy in the open-leg supine position with head-down tilt. The schema of the surgical procedure and intraoperative laparoscopic view are shown in Figures 2 and 3. After the incision of the urachus, the peritoneum was incised along the internal side of the medial umbilical fold bilaterally. The retropubic space (space of Retzius) was widely dissected toward the pubic bone. A 5-mm trocar was inserted where the stoma construction was planned. From the stoma site trocar, the bladder dome was grasped and elevated to check whether the top of the bladder adequately reached the abdominal wall. The bladder dome could be stretched with less tension by additionally incising the peritoneum on both sides of the bladder. To construct the stoma, we first stopped the pneumoperitoneum, resected the skin 2 cm in diameter around the stoma site trocar and incised the anterior rectus fascia. The midline of the two rectus abdominis muscles was separated, and the bladder dome could then be pulled up outside the skin. The bladder dome was resected to the size of an index finger. The opened bladder dome was everted and fixed to the anterior rectus fascia and the skin. After re-establishing the pneumoperitoneum, we laparoscopically sutured the opening of the peritoneum bilaterally intraperitoneally and completely closed the retropubic space.

FIG. 2.

The laparoscopy-assisted cutaneous vesicostomy procedure (A). The sites of trocar placement (B–F). Schema of the intraoperative laparoscopic views (B). The urachus was cut (two-way red arrow), and the peritoneum was incised along the internal side of the bilateral medial umbilical fold (red arrows). (C) The retropubic space was opened (space of Retzius, shown in yellow). The blue area shows the bladder. (D) A 5-mm trocar was inserted at the stoma site (star, also indicated by a red circle in (A). (E) The bladder dome was pulled out at the stoma site and sutured to the abdominal wall. The retropubic space remained open (asterisks). (F) The peritoneum on both sides of the bladder was sutured and the retropubic space was closed completely (G–I). Schema of the sagittal plane (G). The peritoneum and urachus were incised and the retropubic space (space of Retzius) was dissected toward the pubic bone (red arrows). (H) The bladder dome was pulled out at the stoma site. (I) The bladder dome was resected and everted, and stoma was constructed.

FIG. 3.

Intraoperative laparoscopic view of the pelvic cavity through the supraumbilical camera port (A). A median umbilical fold, including the urachus (indicated by black arrowhead), and medial umbilical folds, including the umbilical arteries (indicated by white arrowheads), are visible. (B) The urachus was cut and the peritoneum was incised to the internal side of the bilateral medial umbilical fold. (C) The retropubic space (space of Retzius) was dissected, and the pubic bone is shown (asterisks). (D) The bladder dome (black arrow) was easily identified. (E) The 5-mm trocar (star) was inserted where the stoma construction was planned. (F) The bladder dome was grasped and elevated from the stoma site trocar to check that it can reach the abdominal wall with less tension. (G) Laparoscopic view after stoma construction. (H) The peritoneum on both sides of the bladder was sutured to close the retropubic space.

The total surgical time was 4 hours and 21 minutes, and the laparoscopy-assisted cutaneous vesicostomy procedure was performed in 2 hours and 6 minutes. The total estimated blood loss, including the nephrectomy procedure, was 20 mL. No perioperative complications occurred, and the patient was discharged 7 days after surgery. Pathologic analysis revealed a pT1a clear cell renal carcinoma without invasion of the renal pelvis. On follow-up, no postoperative complications were observed, and the gross hematuria had resolved. At 7 months postoperatively, no stomal complications had occurred and computed tomography showed resolution of the right hydronephrosis and dilation of the bladder (Fig. 4). Although the left kidney was resected, the serum creatinine level was stable at 1.17 mg/dL.

FIG. 4.

Findings at 7 months postoperatively (A–C). Axial plane of computed tomography images. (A) Hydronephrosis of the right kidney was not observed (blue arrowhead). (B) The stoma is indicated by the white arrowhead. (C) The excessive dilation of the bladder had disappeared (blue arrow). (D) The stoma is indicated by the white arrowhead. No stomal stenosis was observed.

Discussion and Literature Review

This report described our first experience of laparoscopy-assisted cutaneous vesicostomy. The patient was an adult with chronic urinary retention caused by neurogenic bladder facing difficulty in managing either an indwelling Foley catheter or intermittent catheterization because of intellectual disability. Surgery was performed safely with no perioperative or postoperative complications.

Two major open surgical cutaneous vesicostomy techniques have been described. Lapides et al. described a procedure involving pulling of the flap of the anterior bladder wall to insert the abdominal skin flap.¹ However, bladder calculi, peristomal dermatitis, and maladjustment of the pouch caused by skin hair contamination are known as complications of this technique. Blocksom reported another procedure modified by Duckett, which requires pulling up the bladder dome from the lower abdominal skin followed by opening, everting, and fixing it to the anterior rectus fascia and the skin.^2,4 Complications of this technique reportedly include stomal stenosis, posterior bladder wall prolapse, and stomal obstruction caused by improper placement of the stoma. In this case, we performed a Blocksom vesicostomy through a laparoscopy-assisted approach. Stomal obstruction was not observed at 7 months postoperatively.

It is important to consider the correct location of the stoma on the abdominal wall.⁴ If the stoma is too close to the pubic symphysis, it can be crushed and cause obstruction when the patients are seated. However, if the stoma is constructed too distant from the pubic symphysis, excessive tension in the bladder dome may occur, which is a risk factor for stomal stenosis. Thus, Blocksom vesicostomy is typically performed as a temporary urinary diversion in children whose distended bladder is sufficiently outside the pelvis. The bladder dome can be pulled up with less tension by additionally incising the peritoneum on both sides of the bladder during laparoscopy-assisted surgery. Another important factor is selecting the proper bladder region for the stoma.⁴ If the stoma is constructed in the anterior aspect of the bladder rather than the dome, the posterior wall of the bladder may prolapse through the anterior wall defect and create an obstruction. Identifying and approaching the correct region of the bladder dome is easier during laparoscopic surgery than in open surgery. Therefore, laparoscopy-assisted surgery has the advantages of facilitating construction of the stoma in the appropriate region of the bladder with less tension.

Although spinal anesthesia can be used for conventional cutaneous vesicostomy procedures, general anesthesia is required for laparoscopy-assisted surgery. Patients with dementia or intellectual disability, however, may be unable to tolerate the procedure using spinal anesthesia. In addition, pneumoperitoneum is necessary in laparoscopy-assisted surgery; however, we do not believe that this greatly increases the invasiveness of the operation. This procedure would be best performed by an experienced surgeon who has performed pelvic surgery, such as radical prostatectomy or cystectomy, laparoscopically. Although our approach has limited applicability in obese adults or patients with severely contracted bladders, and further large-scale studies with a longer follow-up periods are required to investigate in detail its feasibility, laparoscopic surgery may decrease stomal complications in cutaneous vesicostomy.

Conclusion

Laparoscopy-assisted cutaneous vesicostomy is a catheter-free urinary diversion technique, which was feasible and effective in our adult patient with chronic urinary retention caused by neurogenic bladder who could not undergo permanent urinary catheterization. This procedure is expected to reduce stomal obstructive complications because the stoma can be constructed at an appropriate position in the lower abdominal wall and bladder dome with less tension.

Ethical Considerations Statement

This case report was approved by the Board of Ethics of Kameda Medical Center (19-012).

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Ochi A, Aikawa K, Kimura N, Abe H (2020) Laparoscopy-assisted cutaneous vesicostomy in combination with radical nephrectomy in an adult patient with neurogenic bladder and difficulty with permanent urinary catheterization, Journal of Endourology Case Reports 6:4, 291–296, DOI: 10.1089/cren.2020.0030.