Case report: Nearly total bladder prolapse
after cutaneous vesicostomy
Chia-Hung Tsai1, Yi-Yang Liu1
Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan1
Cutaneous vesicostomy is an operation choice for child with high intravesical pressure by decompression. This operation can prevent upper urinary tract damage and further dysfunction. According to previous study, some complication was found after cutaneous vesicostomy including cellulitis, perivesicostomy abscess, stoma stenosis. Previous report showed the incidence of bladder prolapse was around 4.3% to 7.5%. The extent of bladder prolapse was usually mild and only a few patients required operation. This time, we present a case of nearly total bladder prolapse after cutaneous vesicostomy, who underwent surgical intervention to resolve the problem finally.
A 4-year-old boy was a patient of neurogenic bladder and right side Grade 5 vesicoureteral reflux status post cutaneous vesicostomy when he was 9-month-old. The cutaneous vesicostomy condition was stable after operation. This time, he suffered from difficult defecation for 3 times and he strained to make stool passage three times within a day. Then a huge protruding mass was noted from cutaneous vesicostomy. He was sent to our emergency department for help, where physical examination and CT scan confirmed distended colon and rectum with bladder compression and nearly total bladder prolapse via cutaneous vesicostomy opening. Initially, an 8Fr. Foley tube was inserted from urethra but the bladder was still hard to be reduced at bedside. Emergent operation under general anesthesia was arranged. We applied fleet enema first then tried manual reduction but failure. We then incised around the cutaneous vesicostomy wound till fascia layer and pushed the bladder into abdominal cavity successfully. Redo cutaneous vesicostomy was created with a 16Fr. Foley via cutaneous vesicostomy opening and a 12Fr. Foley via urethral meatus. We removed the urethral Foley tube four days after operation and he was discharged 6 days postoperatively under stable condition.
Cutaneous vesicostomy is a procedure of tubeless urinary diversion for patient with severe vesicoureteral reflux. Bladder prolapse complication was reported and reoperation was indicated when persistent prolapse was noted. The study suggested that suturing the anterior bladder wall to the undersurface of the anterior rectus sheath, cephalad to the skin incision may reduce the complication. As for our patient, the cutaneous vesicostomy has been stable for 3 years after the operation. But the patient suffered from difficult defecation just before bladder prolapse. Redo cutaneous cystostomy was done with satisfactory result. We supposed that constipation may be an important risk factor for bladder prolapse after cutaneous cystostomy. Adequate treatment for difficult defecation may reduce the risk of prolapse.