LEAK POINT PRESSURE USE FOR INTRAOPERATIVE ADJUSTMENT OF THE CONTINENCE MECHANISM IN PATIENTS UNDERGOING CONTINENT CUTANEOUS URINARY-DIVERSION

Objectives. Failure of the continence mechanism is the most common cau se of unsatisfactory results and the need for revision in patients wit h continent cutaneous urinary diversion. We believed that incontinence in these patients could be eliminated or minimized by using the conce pt of leak point pressure intraoperatively to make appropriate adjustm ents and thus ensure adequate continence postoperatively. Methods. The appropriate ileocolonic bowel segment for continent urinary diversion was isolated. Whenever the appendix was available, the unaltered or m inimally altered appendicocolic junction was used for continence. In t he absence of an appendix, the tapered distal ileum and reinforced ile ocecal valve were used. Intraoperative leak point pressure (pressure a t which leakage occurs) was measured before detubularization using a s imple standing column manometer and arterial line tubing. Whenever lea kage occurred at pressure less than 75 to 80 cm H2O, adjustment of the continence mechanism was performed and leak point pressure measuremen t was repeated to ensure adequate continence. Results. Seventy-seven p atients had long-term follow-up (30 to 100 months). These included 41 in whom the native appendix was used and 36 in whom the terminal ileum and ileocecal values were used. Adjustment of the continence mechanis m was required in 32 of the 41 patients in whom the native appendicoco lic junction was used and in all 36 patients in whom the tapered ileum and ileocecal valve were used. After adjustment, all patients attaine d leak pressures over 80 cm H2O. At the last follow-up visit, all 77 p atients were continent on intermittent catheterization every 3.5 to 6 hours. None has required revision of the continence mechanism. Conclus ions. Intraoperative measurement of leak point pressure is valuable in predicting the need for adjusting the continence mechanism and elimin ating or substantially minimizing the need for subsequent revision. (C ) 1998, Elsevier Science Inc. All rights reserved.