Urologists At Work FASCIAL SLING CORRECTION OF KINKED EFFERENT LIMB IN PATIENTS WITH CONTINENT DIVERSION AND CATHETERIZATION DIFFICULTY

Purpose: We determined the efficacy of using a rectus fascial sling to revise an angulated efferent limb in patients with continent urinary diversion and difficulty with intermittent catheterization. Materials and Methods: Two spinal cord injured women who underwent modified Indiana pouch urinary diversion required revision of each efferent limb because of difficulty with catheterization. A strip section of anterior rectus sheath was harvested and used to fix the efferent limb in position, assuring freedom from angulation and facilitating catheterization. Results: Both patients remained continent for more than 2 years postoperatively and neither had further difficulties with catheterization or required additional surgery. Conclusions: Use of the rectus fascial sling in continent urinary diversion enables fixation of the efferent limb to facilitate catheterization and enhance continence. KFI WORDS: urinary diversion; urinary reservoirs, continent; spinal cord injuries; urinary incontinence The efferent limb of a continent urinary diversion or continent bladder augmentation may become difficult to catheterize because of the development of angulation due to tortuousity of the portion of the conduit between the posterior rectus fascia and urinary reservoir. Despite the use of various catheters of different materials and styles a patient may ultimately require surgical revision of the efferent limb via partial excision, reduction or tapering. Dissection in a surgical field with extensive adhesions and scarring may threaten the viability of the efferent limb. Furthermore, despite the risks of vascular compromise, tissue ischemia and conduit necrosis, plication and reduction of the efferent limb may be unsuccessful in correcting angulation of the conduit, resulting in continued difficulty with catheterization postoperatively.1-7 The suspensory sling has been used to enhance continence and reinforce the proper vesico-urethral angle in women with stress urinary incontinence. The autologous pubovaginal sling, used to suspend the urethra from the overlying abdominal wall, has proved to be a safe, efficacious and durable treatment of stress urinary continence without risk of urethral erosion or infection.8 We used an autologous supportive sling to relieve efferent limb tortuousity, enhance continence through light compression and facilitate catheterization of the continent stoma in 2 patients experiencing difficulty with catheterization shortly after creation of a continent urinary reservoir.