Vesicocutaneous fistula: continent vesicostomy, an easier route for comfortable clean intermittent catheterization.

INTRODUCTION: Clean intermittent catheterization (CIC) through the urethra is the treatment of choice for patients with neurogenic bladder (NGB) or other etiologies that lead to incomplete bladder emptying. However, urethral catheterization can be problematic. Vesicocutaneous fistula (VCF) is a continent catheterizable channel with a low rate of complications. The aim of the study was to evaluate the safety and effectiveness of VCF as a route for CIC.

MATERIAL AND METHODS: The authors retrospectively reviewed patients who underwent creation of the VCF for bladder drainage from November 2001 to December 2017. Demographics, indication for VCF, pre-operative and postoperative laboratory/radiologic studies, incidence of febrile urinary tract infection (UTI), and adherence to CIC through VCF were examined.

RESULTS: Vesicocutaneous fistula was created in a total of 20 patients (nine males and 11 females; median age, 13.2 years [range: 3.8 months-22.8 years]). The median follow-up time was 30.5 months (range: 5.9 months-16.9 years). The underlying etiologies that resulted in NGB included spina bifida (n = 10), cerebral palsy (n = 2), caudal regression syndrome (n = 2), and others (n = 6). Before creation of the VCF, 13 patients (65%) had either grade ≥3 unilateral or bilateral hydronephrosis as per the Society for Fetal Urology grading system. Thirteen patients (65%) had experienced at least one febrile UTI the year before the creation of the VCF. At the last follow-up, renal function was improved or stabilized in 14 patients (70%). Fifteen patients (75%) had experienced no febrile UTI in the last 1 year. Upper urinary tract dilatation resolved or improved in 10 patients (77%). The VCF continence rate was 88%. In this study, bladder augmentation or the Mitrofanoff procedure was not performed. During maturation, nine patients (45%) had granuloma; five of those cases subsided within 2 years without any intervention. Five patients had VCF stricture, and only one required revision surgery (5%).

DISCUSSION: The VCF continence rate was comparable with that of the Mitrofanoff procedure. Adherence to CIC through VCF lowered the rate of UTI and preserved the upper urinary tract. Bladder emptying by CIC through VCF provided the same benefits as those of the Mitrofanoff procedure: extra privacy, social independence, and reduction of parental burden. Although a long maturation stage of 6 months was required, the rate of major complications was low. Most complications were conservatively manageable and seldom required revision surgery.

CONCLUSIONS: Vesicocutaneous fistula is a continent catheterizable conduit, an alternative option for bladder management in patients with NGB who cannot undergo urethral CIC smoothly.