Q.  I’ve been using a suprapubic catheter in my 18 years as a C4 quad, and it has worked fine — until recently. For the past year, I’ve been having a lot of pain from the Foley balloon rubbing against my bladder wall. I’ve tried having my attendant tape the SP tubing in different locations to stop the balloon from rubbing, but it hasn’t helped. I’ve also started having problems with the catheter getting plugged up with mucus — it seems like my attendant is having to constantly flush it out with saline to keep it draining.

I had a urological check-up, including ultrasound, X-rays and a cystoscopy to look inside my bladder. There are no stones or obstructions, but my bladder has shrunk quite a bit. My urologist suggested an ileovesicostomy as an option, and I have an appointment with a surgeon to discuss it further.

I’ve looked up the procedure on the web and am confused. There are explanations on the surgical part but no explanations on how it works. On forums, I see “ileovesicostomy” and “Mitrofanoff,” and they seem to be used interchangeably. Is there a difference?

What exactly is an ileovesicostomy and how does it work?

– Steve

A. Steve, I found the same thing: lots of information, but nothing that explains the basics of how an ileovesicostomy works, or the difference between a Mitrofanoff and ileovesicostomy. To clarify things, I turned to Paula Wagner, a urology nurse practitioner at U.C. Davis Medical Center in Sacramento, Calif. Wagner explains that some of the confusion is because both surgical procedures are considered “urinary diversions,” meaning they reroute urine flow from it’s normal pathway. A Mitrofanoff requires intermittent catheterization and an ileovesicostomy is free-flowing and requires a collection pouch.

To further clarify things, a Mitrofanoff is considered a “continent diversion.” A piece of tubular tissue — usually the appendix — creates a conduit from the bladder to a stoma (small hole), usually near the belly button. A person with a Mitrofanoff empties the bladder by passing an intermittent catheter through the stoma into the bladder and must catheterize with the same frequency as urethral intermittent catheterization. For further information the Mitrofanoff procedure, see the August 2010 Bladder Matters.

Wagner explains that an ileovesicostomy — pronounced il-eo-ves-i-kos’tah-me — takes part of the ileum (small intestine) and attaches one end to the bladder wall and routes the other end to create a stoma on the lower right side of the abdomen to create a “free-flowing diversion.” She says that a surgeon will usually start people that are unable to perform intermittent catheterization on their own with a suprapubic catheter first, because it is a simple procedure, and easy to reverse if another option is needed (see the June 2010 Bladder Matters). An ileovisicostomy becomes an option if a suprapubic isn’t working.

According to journal articles, advantages of an ileovisicostomy over more invasive procedures like an ileal conduit include preservation of the urological system — the bladder and urological system remain intact. It is reversible if a newer or better methods of bladder management become available, keeps bladder pressure low and works for men or women.

With an ileovisicostomy, urine goes from the stoma to a collection bag that either adheres directly to the skin around the stoma or attaches to a replaceable gasket known as a “wafer” or “port” which adheres to the skin around the stoma. To attach the wafer, the skin around the stoma is cleaned, a barrier skin prep is applied, and the wafer is pressed onto the skin. One side of the wafer has a hydrocolloid (waterproof, nonbreathable, skin-friendly) adhesive that seals it around the stoma. Wafers are changed every three to seven days, depending on the type used. With a wafer, urine is collected in a pouch that snaps onto the wafer, or tubing can be adapted to use with a leg bag or larger night bag, explains Wagner.

You can still shower, bathe, swim and enjoy recreational activities with an ileovisicostomy, and still wear any type of clothing as long as it is loose around the stoma area.

The ileovisicostomy procedure itself is considered major surgery. Because part of the intestine is used to create the urinary diversion, a patient usually spends two days in the hospital prior to the surgery in order to do bowel prep. The surgery is done through the abdomen, and some centers are performing the procedure laparoscopically. Journal articles say laparoscopic ileovisicostomy surgery takes about four hours.

During the operation, the surgeon removes and cleans a 10-cm to 15-cm section of ileum and attaches one end to the bladder and the other is brought through the skin on the lower right side of the abdomen to create a stoma. A 20 French Foley catheter is placed through the stoma into the bladder to allow drainage during the healing process. Average length of hospital stay following the surgery is around seven days.

After two to four weeks, docs will order a cystogram, an X-ray in which a contrast agent injected into the bladder shows its shape and checks for reflux (urine backing up into the kidneys). If everything checks out OK, the Foley is removed and the patient is cleared to go about his or her life, with yearly urological follow-ups.

Journal articles on urethral continence following ileovisicostomy say that the bladder neck is not routinely surgically closed following the procedure. As with a suprapubic catheter, continence at the urethra varies from person to person. Also, like a suprapubic catheter, urethral leakage with an ileovisicostomy can be caused by bladder spasms, including increased bladder spasms associated with bladder infections. Urethral leakage caused by non-UTI-related bladder spasms can be controlled by anticholinergic drugs such as Ditropan. The articles go on to say that if urethral leakage continues to persist following the procedure, the bladder neck can be surgically closed.

Best of luck, Steve. If any readers have had an ileovisicostomy, we would like to hear your feedback.

Resources

• Ileal Conduit information

• Ileovesicostomy literature review (2009)

• Ileovicostomy patient information from University of Michigan Health System