Complications of Benchekroun vesicostomy in a spina bifida patient: severe stenosis requiring permanent suprapubic cystostomy, recurrent vesical calculi and abdominal hernia containing ileocystoplasty - a case report
© Vaidyanathan et al; licensee BioMed Central Ltd. 2009
Received: 14 October 2009
Accepted: 22 December 2009
Published: 22 December 2009
In female patients with neuropathic bladder, the urethra is closed permanently in order to avoid urine leak. Then Benchekroun hydraulic ileal valve is attached to urinary bladder, thus providing a continent stoma for performing intermittent catheterisations.
We present a female patient with spina bifida who underwent Benchekroun continent vesicostomy in 1993. This patient developed severe stenosis of Benchekroun stoma and stones in urinary bladder. Dilatation of stoma and vesicolithotomy were carried out in 1995. Vesical calculi recurred; suprapubic cystolithotomy was performed in 1999. In March 2000, catheterisation of stoma was not possible and emergency suprapubic cystostomy was done. In April 2000, endoscopy was attempted through Benchekroun stoma. It was not possible to insert ureterorenoscope beyond two inches. The track was completely blocked. In November 2001, X-ray of abdomen showed several vesical calculi; suprapubic cystolithotomy was performed.
In March 2005, this patient developed pain in abdomen. X-ray of abdomen showed a large vesical calculus. In June 2005, suprapubic catheter was removed and a cystoscope was introduced in to the bladder. Then electrohydraulic lithotripsy was performed. In 2007, this patient was concerned about the increasing swelling in lower abdomen. Computed tomography of abdomen revealed midline, lower abdominal wall hernia, which contained several loops of small bowel and ileal cystoplasty. The large hernia was uncomfortable and tender on coughing, but did not cause obstructive bowel symptoms. Surgical repair of hernia was considered. But this patient would require alternative way of urinary diversion because the current location of suprapubic catheter would almost lead to infection of prosthetic material used in reconstruction of the anterior abdominal wall. After discussing risks of operative procedures with patient and her husband, it was decided not to proceed with surgery.
This case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously, and patients should be informed of potential complications of surgical procedures some of which could be irreversible.
Benchekroun hydraulic ileal valve is constructed by isolating a 14 cm long intestinal loop with its mesentery . The isolated ileal segment is then folded inward on itself throughout its length. While performing Benchekroun continent vesicostomy in female patients with neuropathic bladder, the urethra is closed permanently in order to avoid urine leak. Then Benchekroun hydraulic ileal valve is attached to urinary bladder, thus providing a continent vesicostomy. The stoma of Benchekroun hydraulic ileal valve is sited in lower abdomen where it is readily accessible for self-catheterisation.
In female patients, urethral meatus may not be easily accessible for catheterisation. Some patients may develop patulous bladder neck and urethra; in these patients, urine leak between catheterisations may be a significant problem affecting quality of life. Therefore, Benchekroun hydraulic ileal valve appears to provide a viable solution for patients, who find difficulty in performing self-catheterisation through urethral meatus, or who leak urine between catheterisations despite taking anticholinergic drugs.
We present a female patient with spina bifida who underwent Benchekroun continent vesicostomy. This patient developed severe stenosis of stoma, marked dilatation of Benchekroun hydraulic valve, large abdominal ventral hernia containing ileocystoplasty, and recurrent vesical calculi. These complications severely compromised the quality of life for this patient. This case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously, and patients should be informed of potential and sometimes, irreversible complications of surgical procedures.
Dilatation of Benchekroun stoma was performed on 21 July 1995. Open vesicolithotomy was carried out. The stoma had retracted to the back of abdominal wall. From there to the skin was a fibrous track, which had been kept open by catheterisations. Attempted dilatation with guide wire, Lister and open ended Clutton bougies allowed dilation of track but the cystoscope could not be passed along the track even over a guide wire. The track was dilated with Jacques catheters until a 14 Charriere catheter was passed in to urinary bladder. Suprapubic vesicostomy was made. Stones were delivered. A 20 Fr. 3-way catheter was left in bladder. Post-operative period was uneventful. Wound healed well. The Foley catheter was taken out and this patient started doing intermittent catheterisations.
Video urodynamics was attempted on 16 November 2004. Pressure-recording catheter was inserted alongside suprapubic catheter. Attempts at monitoring pressures were unsuccessful. The procedure was abandoned, as there was extravasation of contrast.
Information regarding delayed complications of a surgical procedure is very important especially from patient's viewpoint. In spinal cord injury patients, urethral sphincterotomy is often portrayed as a successful procedure for treatment of detrusor-sphincter dyssynergia. But review of 84 patients undergoing external sphincterotomy at a large tertiary referral spinal injuries centre revealed that duration of successful outcome was only 81 months for primary sphincterotomies . A second procedure was required in 30 patients and mean duration of success thereafter was 80 months. However, recurrent symptomatic episodes of urinary tract infection, recurrent detrusor-sphincter dyssynergia or upper tract dilatation eventually ensued in 57 of 84 patients (68%).
While recommending a surgical procedure to a spinal cord injury patient, physicians should provide results of long-term follow-up in order to assess benefits of proposed surgical procedure. Ileal conduit urinary diversion is recommended to spinal cord injury patients, who develop severe vesicourethral dysfunction. But follow-up of sixteen tetraplegic subjects, who underwent ileal conduit urinary diversion, revealed that five patients suffered from repeated renal or ureteral stone, and eight patients suffered from empyema of the bladder. Kato and associates from Department of Urology, Shinshu University School of Medicine in Matsumoto, Japan  concluded that ileal-conduit formation should be cautiously considered as an option in the urinary management of tetraplegic patients.
Complications of Benchekroun continent vesicostomy are not uncommon. Mouriquand and Boddy from Great Ormond Street Hospital, London  described four patients, who developed complications related to devagination, over-distension of the hydraulic valve, and stoma of Benchekroun valve. These authors concluded that complications or failure of the Benchekroun valve and its variants (e.g. Guzman's technique) were common, and salvage procedures were often necessary to recreate an efficient continent conduit.
This case reiterates the importance of discussing possible delayed complications of any surgical intervention with patients. Knowledge regarding risks of a procedure will help patients to make an informed decision as to whether they should agree to undergo a surgical procedure. Our patient developed series of adverse events following Benchekroun continent vesicostomy, which affected seriously the quality of her life.
This case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously. Physicians should inform patients of potential complications of surgical procedures, as some complications might be irreversible and adversely affect quality of life.
➢ After having my Mitrofanoff performed around 20 years ago, I was dry for a while. One day, it stopped working. In the middle of the night, I was rushed to spinal unit, Southport where the doctors had to do an urgent suprapubic cystostomy.
➢ The thing about Mitrofanoff I did not like was that I got bladder stones a lot. I had to get stones removed surgically several times.
➢ Suprapubic cystostomy works well most of the time. But I do get some leakage of urine around suprapubic site.
➢ I have an abdominal hernia. When I cough or sneeze, it hurts.
➢ The abdominal hernia and leak of urine cause problems in my marriage.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Benchekroun A: Hydraulic valve for continence and antireflux. A 17-year experience of 210 cases. Scand J Urol Nephrol Suppl. 1992, 142: 66-70.PubMedGoogle Scholar
- Pan D, Troy A, Rogerson J, Bolton D, Brown D, Lawrentschuk N: Long-term outcomes of external sphincterotomy in a spinal injured population. J Urol. 2009, 181 (2): 705-709. 10.1016/j.juro.2008.10.004. Epub 2008 Dec 16View ArticlePubMedGoogle Scholar
- Kato H, Hosaka K, Kobayashi S, Igawa Y, Nishizawa O: Fate of tetraplegic patients managed by ileal conduit for urinary control: long-term follow-up. Int J Urol. 2002, 9 (5): 253-256. 10.1046/j.1442-2042.2002.00463.x.View ArticlePubMedGoogle Scholar
- Mouriquand PD, Boddy S: Salvage procedures for failed Benchekroun hydraulic valves: experience in four patients. Br J Urol. 1996, 77 (5): 740-744.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.