The use of vesicostomy as permanent urinary diversion in the child with myelomeningocele

Purpose: Treatment of the child with myelomeningocele presents the urologis t with many challenges. While vesicostomies are usually used for temporary bladder drainage until continent reconstruction is performed, we have a pop ulation of postpubertal patients with myelomeningocele in whom vesicostomie s have been preserved. We review our experience with these older children. Materials and Methods: A search of our database of 350 patients with myelod ysplasia identified 23 with urinary diversion accomplished by permanent ves icostomy. Those who had undergone vesicostomy after age 11 years were desig nated as group 1. Those who received a vesicostomy early in life that was m aintained post puberty were designated as group 2. Indications for vesicost omy, upper tract status before and after vesicostomy, recurrent infections and complications were noted. Upper tract status was determined by serial u ltrasounds during routine followup. Results: Group 1 was comprised of 5 patients with mean age at vesicostomy o f 17 years and a mean followup interval of 5.2 years. Group 2 was comprised of 18 patients with mean age of vesicostomy at 2.6 years and mean followup interval of 13 years. Hydronephrosis resolved in all children from both gr oups. Vesicostomy revision was required in 1 patient secondary to prolapse. Other complications included mild prolapse that did not require revision, stenosis requiring revision 5 months after the initial procedure and an ear ly bilateral ureterovesical obstruction that resolved. Of the patients 33% had recurrent upper tract calculi. Conclusions: While the goal of achieving urinary continence is well worth s triving for in the child with myelomeningocele, it is not realistic for all patients. We believe that permanent cutaneous vesicostomy is an acceptable alternative that the reconstructive surgeon should consider. This reliable and simple technique ensures safe decompression of the upper urinary tract s, while avoiding the complications of urinary diversion using segments of bowel.