Patient Presentation
A 15-month-old male came to clinic for his health maintenance visit. He had a past medical history of posterior urethral valves that were treated by ablation after a vesicostomy. The vesicostomy was still in place and his renal function were at the upper end of normal but stable. He had few problems with the vesicostomy including skin breakdown and some bleeding. Otherwise his parents had no concerns.

The pertinent physical exam showed a curious toddler exploring the examination room. His vital signs were normal including his blood pressure and his height and weight were at the 25% with mid-parental height at the 25-50%. His head circumference was 50%. His physical examination was normal except for the vesicostomy opening mid-way between the umbilicus and pubis. There was some mild irritation that was treated with a barrier emollient.

The diagnosis of a happy toddler with a vesicostomy was made. “At this point we’re happy with how things are going and there’s no problem with daycare. They just change his diaper like the rest of the kids but are really good about watching his skin. We’ll have to see how his kidneys do with more time and mad\ke some decisions about the vesicostomy. We’re not in a hurry to get rid of it as he’s doing so well with it and diapers are just normal at his age,” the parents remarked.

Discussion
A cutaneous vesicostomy is an incontinent diversion of the bladder to the external abdominal wall usually below the umbilicus that maintains a low-pressure urinary system. The urine drains into a collecting bag or hygiene product such as a diaper. It is usually used as a temporary diversion until bladder function resolves or another treatment can be carried out. However, it can also be used as a permanent diversion in some cases. A vesico-cutaneous fistula is similar but performed slightly differently. It is often intended to be a longer-term diversion procedure and is a continent diversion of the bladder.

Some of the conditions treated with a vesicostomy include:

• Neuropathic bladder due to a brain, spinal cord or muscle problem such as spina bifida
• Lower urinary tract obstruction e.g. posterior urethral valves
• Dysfunctional voiding
• Vesicoureteral reflux
• Hydronephrosis
• Congenital megaureter

Learning Point
Before a vesicostomy is performed other treatments are usually tried such as clean intermittent catheterization (CIC), anticholinergic medications and botulinum toxin injection. If these do not achieve satisfactory results then vesicostomy is considered. CIC is widely used with a low complication rate but it can have bleeding, stricture formation and creation of a false tract. Cholinergic medications may have unwanted side effects (e.g. blurred vision, abdominal pain, constipation, diarrhea, etc.) that cause discontinuation. Botulinum toxin is temporary, usually for a few months, and may only work 50% of the time.

The hoped for outcomes of a vesicostomy are protection of the upper urinary tract, decreased rates of febrile urinary tract infection, delaying the need for other procedures such as bladder augmentation and importantly to preserve renal function. Therefore the indications for a vesicostomy include:

• Treatment failure
• Treatment refusal, e.g. refusing CIC due to age, anatomy, sensation issues
• Upper urinary tract deterioration
  • Recurrent febrile urinary tract infection
  • High pressure bladder
  • Worsening renal failure
• Temporary diversion until other treatment can be instituted

Vesicostomy is a good procedure for many patients but complications occur in about 30-40% of patients including dermatitis, febrile UTI, mucosal prolapse or stenosis of the stoma.
Incontinence is not a complication as it is expected post-procedure but this may not be acceptable to patients long term.

Questions for Further Discussion
1. What can be the roles of a primary care physician on a multi-specialty team providing specialty care?
2. What are causes of antenatal hydronephrosis? A review can be found here
3. How is bladder dysfunction categorized? A review can be found here

Related Cases

Disease: Vesicostomy | Ostomy | Urinary Incontinence

Symptom/Presentation: Enuresis and Urinary Incontinence | Urine

Specialty: Nephrology / Urology

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Ostomy, Urinary Incontinence, and Urine and Urination.

To view current news articles on this topic check Google News.

Yang. W, Chang P.-Y, Lai J.-Y, Change C.-H, Tseng M.-H. Vesico-cutaneous fistula: A simple method for continent urinary diversion J Pediatr Urol. 2014;10:1227-1231.

Donmez MI, Carrasco A, Saltzman AF, Vemulakonda V, Wilcox DT. Long-term outcomes of cutaneous vesicostomy in patients with neuropathic bladder caused by spina bifida. J Pediatr Urol. 2017;13(6):622.e1-622.e4. doi:10.1016/j.jpurol.2017.05.015

Sharifiaghdas F, Mirzaei M, Nikravesh N. Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients? J Pediatr Urol. 2019;15(4):379.e1-379.e8. doi:10.1016/j.jpurol.2019.03.026

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa