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Ileovesicostomy

Ileovesicostomy is an incontinent cutaneous urinary diversion that connects the bladder dome to an abdominal stoma through an ileal conduit ("bladder chimney") without ureteroenteric anastomosis. It aims to provide continuous low-pressure drainage.[1][2] It was popularized by Schwartz, Kennelly, McGuire, and Faerber in 1994 for patients with severe neurogenic LUTD who cannot perform CIC and have suffered chronic-catheter morbidity.[1] Its advantage over an ileal conduit is that it preserves the native bladder and ureterovesical junctions, avoiding a new ureteroenteric anastomosis and sometimes permitting later undiversion.[2][3]

Concept and Rationale​

It may be offered to selected patients with neurogenic bladder who cannot perform CIC because of poor hand function, immobility, body habitus, or social or cognitive limitations.[5][19] Retrospective series included patients with prior catheter-associated urosepsis, calculi, urethrocutaneous fistulae, autonomic dysreflexia, or progressive hydronephrosis.[1][4]

The procedure creates a tubularized ileal segment connecting the bladder dome to the skin for continuous low-pressure drainage into a urostomy bag. Unlike an ileal conduit, the ureters are not transected or reimplanted; they remain in their native position within the bladder wall.[2][3]

Indications​

AUA/SUFU states that clinicians may offer ileovesicostomy to select NLUTD patients and must counsel them on risks, benefits, alternatives and the high risk of needing additional treatment or surgery .[5] Obesity and a long poorly draining channel can make it unsuitable.[5] Specific indications:

  • High cervical SCI or tetraplegia. Most common indication.[1][3]
  • MS with progressive disability precluding CIC.[2]
  • Myelomeningocele with failed prior management.[2][6]
  • Complications of chronic indwelling catheter drainage.[4]
  • Failed prior bladder management (sphincterotomy, augmentation, AUS).[2][7]
  • Pediatric patients unable to perform reliable CIC.[6]
  • Patients who are poor candidates for or refuse continent diversion or augmentation.[2]

Surgical Technique (Open, McGuire/Schwartz)[1][8][9]​

Before surgery, review upper-tract imaging and urodynamics to assess storage pressure, reflux, expected emptying, and outlet competence; use the findings to plan drainage and any outlet procedure.[8][19]

  1. Ileal segment harvest: Select a well-perfused 15–20 cm distal-ileal segment on its mesentery while preserving the ileocecal valve and distal-most ileum when feasible; restore bowel continuity.[8][20]
  2. Proximal detubularization. The proximal 6–8 cm is opened along the antimesenteric border to create a wide funnel for the bladder anastomosis.
  3. Cystotomy: dome opened widely.
  4. Ileovesical anastomosis. Detubularized proximal ileum sutured to the bladder dome in a wide funnel to prevent obstruction at the ileovesical junction.
  5. Stoma: Mark a pouch-compatible site with the patient in usual positions, including wheelchair seating when relevant.[21] The right lower quadrant is a described location when pouch fit and mesenteric reach permit.[3] Bring the tubular distal ileum through the wall and mature an everted, protruding stoma when feasible; an ileal-conduit technique report suggests that a flush stoma can impair pouch fit.[22][23]

Principles: the ileal segment functions as a conduit and not a reservoir; ureters are not touched; a wide funnel reduces junctional narrowing, but stomal stenosis, angulation, redundancy, and retained debris can still impair drainage.

Concomitant procedures​

  • Pubovaginal sling (PVS) in women with intrinsic sphincter deficiency from prolonged catheterization to achieve functional urethral closure.[8][10]
  • Bladder-neck closure may be considered for a nonreconstructible leaking outlet; it is not obligatorily preceded by a sling. Closure sacrifices native urethral access and makes dependable alternate drainage necessary.[11][12]
  • Bladder calculus removal when stones are present.[8]
  • Postoperative anticholinergic treatment. Four women with mild urethral urge leakage after ileovesicostomy were treated with oxybutynin or tolterodine in Atan's 15-patient series.[2]

Minimally invasive approaches​

  • Laparoscopic (Hsu 2002): a single-patient report of a 5-port transperitoneal approach with a 17 cm ileal segment and an operative time of about 4 hours.[13]
  • Robotic-assisted (Vanni/Stoffel 2009, n=8): 5-port; intracorporeal enterovesical anastomosis; extracorporeal bowel reanastomosis through stoma site. Median EBL 100 mL, OR 330 min, LOS 7.7 d; four patients had postoperative complications (urethral incontinence in 2, ileus in 2). All were functioning at median 14 months, with median residual bladder volume 10 mL.[9]
  • Open versus robotic (7 versus 8 patients): this retrospective comparison found no statistically significant difference in operative time (293 versus 330 minutes; p = 0.24), blood loss (257 versus 100 mL; p = 0.09), or hospital stay (11 versus 8 days; p = 0.14). Robotic inpatient cost was $17,344 versus $14,356 (p = 0.05), largely from operating-room supplies. The robotic cohort may overlap with the 2009 series.[14]

Outcomes​

SeriesnEtiologyFollow-upDrainage, storage and upper-tract findingsUrethral continenceConversion to ileal conduit
Schwartz/McGuire 1994[1]23Lower urinary tract dysfunctionMean 45 mo (range 3–240)22/23 (96%) had low-pressure drainage; upper tracts stable/improved in all 23NR1/23 (4%)
Mutchnik/Boone 1997[3]6Tetraplegia12–15 moStomal leak point pressure 7.7 cm H₂O; no refluxNRNone reported
Atan/Chancellor 1999[2]15MS, SCI, other23 mo14/15 low-pressure drainageFour mild and one severe urge-leakage cases2/15
Leng/McGuire 1999[4]38SCI, MS, otherMean 52 mo83–91% maintained normal upper tracts and storage compliance——
Gauthier/Winters 2003[8]7TetraplegiaMean 37.4 moMean detrusor leak point pressure: 42.7 preoperatively to 16.7 cm H₂O postoperativelyNRNone reported
Tan/Latini 2008[11]50MixedMean 26 mo—36/50 (72%) at last follow-up; cohort included outlet procedures—
Hellenthal 2009[7]12NeurogenicMean 5.5 yr——17%
Vanni/Stoffel 2011[14]15 (7 open, 8 robotic)NeurogenicNRNo hydronephrosisImproved (p=0.02)None reported
Ching 2014 (pediatric)[6]9Neurogenic / non-neurogenicMean 48 mo (median 11.5)Not reported; creatinine stable or improved in allTemporary urethral leakage in 1None reported

A later single-center pediatric cohort (n=17), likely overlapping Ching's series, reported median 6.4-year follow-up and surgical complications in 7/17 (41%). Its retrospective design and lack of a comparator limit treatment comparisons.[26]

Leng/McGuire 1999 compared 38 patients with their preoperative catheter-management state; this cohort includes the earlier 23-patient series.[4]

Before surgery, Leng reported poor compliance in 50%, urosepsis in 45%, hydronephrosis in 21%, renal struvite stones in 18%, urethrocutaneous fistula in 18%, and autonomic dysreflexia in 13%. After surgery, 83–91% maintained normal upper tracts and storage compliance.[4]

Comparative caution: in Husmann’s 48-patient retrospective cohort with complete urethral destruction, urosepsis hospitalization occurred in 14/17 after closure+ileovesicostomy, 6/10 after cystectomy+conduit, and 6/21 after closure+suprapubic drainage. Additional surgery occurred in 15/17, 5/10, and 11/21 respectively over median 8-year follow-up. Selection differed between groups. The authors abandoned ileovesicostomy after this experience.[19]

Urodynamic outcomes​

  • Stomal leak point pressure: mean 7.7 cm H₂O (Mutchnik).[3]
  • Mean detrusor leak point pressure fell from 42.7 cm H₂O preoperatively to 16.7 cm H₂O postoperatively (p=0.0061, Gauthier).[8]
  • Normal upper tracts and bladder storage compliance were maintained in 83–91% (Leng).[4]
  • Median residual bladder volume 10 mL postoperatively (robotic series).[9]

Advantages Over Ileal Conduit​

FeatureIleovesicostomyIleal Conduit
Ureteroenteric anastomosisNot requiredRequired; ureteroenteric stricture is a recognized risk
Native UVJsPreserved anatomically; reflux may still occurReplaced by ureteroenteric anastomoses
Future reconstructionSelected undiversion may be possible if native anatomy/function permitsDepends on prior cystectomy, remaining anatomy, and clinical goals
CystectomyNot required; bladder preservedConsider with supravesical diversion according to bladder condition and indication[5]
Surgical complexitySimpler (no ureteral dissection)More complex
Upper-tract obstructionNo new ureteroenteric junction, but other obstruction remains possibleUreteroenteric stricture is one recognized risk

The AUA/SUFU guideline notes that with longer follow-up, ileovesicostomy patients have an increased risk of requiring revision or alternate surgery. A 2026 perspective by Ginsberg favors conduit diversion for selected poorly compliant refractory bladders. Conduit patients still require stoma, renal, and metabolic follow-up.[5][15]

Complications​

  • Stomal complications. Occurred in 19/50 (38%) in Tan 2008, with a mean of 1.47 stomal complications per affected patient; stomal stenosis occurred in 3/23 (Schwartz) and 2/15 (Atan).[1][2][3][11]
  • Urethral incontinence. Atan reported four women with mild urge leakage managed medically and a separate woman converted to an ileal conduit with concurrent cystectomy for severe leakage.[2] Tan reported 36/50 (72%) continent per urethra at last follow-up.[11] Atan's 15-patient series suggested that severe preoperative detrusor hyperreflexia with urge incontinence may predict persistent postoperative urge leakage in women; selected patients with outlet incompetence received concurrent outlet procedures in other series.[2][10][11]
  • Mechanical obstruction after ileovesicostomy. Tan reported this composite complication in 11/50 patients (22%); it includes sites beyond the ileovesical junction. A wide funnel is intended to reduce junctional narrowing, but stomal stenosis, limb angulation, and debris can also impair drainage.[1][11]
  • Calculus formation. 33% in Atan (urinary stasis, chronic bacteriuria, mucus).[2]
  • UTIs. Symptomatic 20% (Atan); 58% reduced antibiotic use or hospitalization (Hellenthal).[2][7]
  • Inflammatory or infectious complications. 54% (Tan).[11]
  • Early ileus and wound infection. Gauthier's seven-patient adult series and Ching's nine-patient pediatric series both reported these events; Ching described an ileus requiring parenteral nutrition.[8][6]
  • Additional procedures. In Tan's 50-patient retrospective cohort, 27/50 (54%) required reoperation or another procedure, averaging 2.85 such interventions per affected patient. The mean count of measured urinary-tract comorbid conditions fell from 3.38 before surgery to 1.16 afterward; postoperative UTIs were excluded from this comparison.[11]
  • Conversion to ileal conduit. Reported for intractable urethral incontinence or persistent fistula.[2][7]

Risk factors for adverse outcomes​

Tan 2008: BMI trended toward significance (p=0.0569). Age, tobacco, diabetes, etiology, preoperative indwelling catheterization, and urethral closure were not significant predictors.[11]

Managing the Urethral Leakage Problem​

Persistent urethral leakage is a recognized problem after ileovesicostomy. Options:[2][10][11][12]

  1. Assess emptying, obstruction, reservoir pressure and outlet competence; treat demonstrated detrusor overactivity as appropriate.
  2. Occlusive pubovaginal sling is a selected salvage option with a preplanned alternate emptying strategy. Chancellor’s 14-woman series included only five ileovesicostomies; all were dry across mixed drainage strategies.[10]
  3. Bladder-neck closure may suit a devastated outlet.[17] Willis reported urethral continence after the first bladder-neck closure in 85.7% of transvaginal and 81.5% of retropubic patients, all women with suprapubic catheters.[17]
  4. Conduit diversion with appropriately considered cystectomy may be needed for refractory leakage, poor drainage, or an unsalvageable reservoir.[2]

Continent Ileovesicostomy (Casale Modification)​

A separate continent modification using the Yang-Monti principle: a long, narrow catheterizable tube from a short ileal segment.[18] Distinct from the standard incontinent procedure; essentially a Monti channel.

Reversibility — A Unique Advantage​

Because the native bladder and UVJs are preserved:[2][16]

  • After neurologic recovery, reassess catheterization ability and bladder storage and outlet function before undiversion. Simple chimney excision and bladder closure may be feasible in selected patients; a three-patient SCI series instead converted the limb to augmentation ileocystoplasty with intermittent catheterization.[1][24]
  • The procedure can be converted to an ileal conduit if it fails.
  • Particularly attractive for younger patients and those with potentially reversible neurologic conditions.

Long-Term Surveillance​

AUA/SUFU advises annual assessment after lower urinary tract reconstruction incorporating bowel , and states that clinicians should perform cystoscopy for gross hematuria or symptomatic recurrent UTI :[5]

  • Focused history, exam, symptom assessment (stoma, leakage, UTI, autonomic dysreflexia).
  • Basic metabolic panel for electrolyte and acid-base abnormalities, including hyperchloremic acidosis; monitor vitamin B12 over time if terminal ileum was used.[5]
  • Urinary tract imaging, usually renal ultrasound for hydronephrosis and calculi.

Stoma assessment for stenosis, retraction and parastomal hernia is added in practice. AUA/SUFU also advises repeating urodynamics at an appropriate interval after treatment when impaired storage or voiding places the upper tracts at risk .[5]

Hellenthal: all 12 patients in the long-term cohort experienced some form of urinary tract problem during 5.5 yr of follow-up; continued surveillance is needed.[7]

Current Status​

A valuable but niche procedure:[2][5][16]

  • Before choosing ileovesicostomy, assess whether an accessible continent catheterizable stoma would permit self- or caregiver catheterization; also discuss suprapubic drainage and ileal conduit diversion. Reversibility is one factor when choosing among drainage options.[5]
  • A severely fibrotic, very small, high-pressure bladder is not an automatically favorable candidate. Some experts also caution that a completely acontractile bladder may empty poorly through the chimney. Assess expected drainage before retaining the bladder; another diversion may be more appropriate.[25]
  • Atan's 15-patient series suggested that severe preoperative detrusor hyperreflexia with urge incontinence may predict persistent postoperative urge leakage in women; concomitant outlet procedures (PVS or BNC) can be considered after assessment of outlet competence and the drainage plan.[2][10][11]
  • In Tan's 50-patient series, 27/50 (54%) needed reoperation or another procedure; lifelong surveillance remains necessary.[11][5]

References​

1. Schwartz SL, Kennelly MJ, McGuire EJ, Faerber GJ. "Incontinent Ileo-Vesicostomy Urinary Diversion in the Treatment of Lower Urinary Tract Dysfunction." The Journal of Urology. 1994;152(1):99-102. doi:10.1016/s0022-5347(17)32826-4

2. Atan A, Konety BR, Nangia A, Chancellor MB. "Advantages and Risks of Ileovesicostomy for the Management of Neuropathic Bladder." Urology. 1999;54(4):636-40. doi:10.1016/s0090-4295(99)00192-2

3. Mutchnik SE, Hinson JL, Nickell KG, Boone TB. "Ileovesicostomy as an Alternative Form of Bladder Management in Tetraplegic Patients." Urology. 1997;49(3):353-7. doi:10.1016/S0090-4295(96)00510-9

4. Leng WW, Faerber G, Del Terzo M, McGuire EJ. "Long-Term Outcome of Incontinent Ileovesicostomy Management of Severe Lower Urinary Tract Dysfunction." The Journal of Urology. 1999;161(6):1803-6. doi:10.1016/s0022-5347(05)68808-8

5. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up." The Journal of Urology. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239

6. Ching CB, Stephany HA, Juliano TM, et al. "Outcomes of Incontinent Ileovesicostomy in the Pediatric Patient." The Journal of Urology. 2014;191(2):445-50. doi:10.1016/j.juro.2013.08.008

7. Hellenthal NJ, Short SS, O'Connor RC, et al. "Incontinent Ileovesicostomy: Long-Term Outcomes and Complications." Neurourology and Urodynamics. 2009;28(6):483-6. doi:10.1002/nau.20695

8. Gauthier AR, Winters JC. "Incontinent Ileovesicostomy in the Management of Neurogenic Bladder Dysfunction." Neurourology and Urodynamics. 2003;22(2):142-6. doi:10.1002/nau.10093

9. Vanni AJ, Cohen MS, Stoffel JT. "Robotic-Assisted Ileovesicostomy: Initial Results." Urology. 2009;74(4):814-8. doi:10.1016/j.urology.2009.03.038

10. Chancellor MB, Erhard MJ, Kiilholma PJ, Karasick S, Rivas DA. "Functional Urethral Closure With Pubovaginal Sling for Destroyed Female Urethra After Long-Term Urethral Catheterization." Urology. 1994;43(4):499-505. doi:10.1016/0090-4295(94)90241-0

11. Tan HJ, Stoffel J, Daignault S, McGuire EJ, Latini JM. "Ileovesicostomy for Adults With Neurogenic Bladders: Complications and Potential Risk Factors for Adverse Outcomes." Neurourology and Urodynamics. 2008;27(3):238-43. doi:10.1002/nau.20467

12. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline (2023)." The Journal of Urology. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435

13. Hsu TH, Rackley RR, Abdelmalak JB, et al. "Laparoscopic Ileovesicostomy." The Journal of Urology. 2002;168(1):180-1. doi:10.1016/s0022-5347(05)64856-2

14. Vanni AJ, Stoffel JT. "Ileovesicostomy for the Neurogenic Bladder Patient: Outcome and Cost Comparison of Open and Robotic Assisted Techniques." Urology. 2011;77(6):1375-80. doi:10.1016/j.urology.2010.09.021

15. Ginsberg DA. "The Argument for Ileal Conduit for the Poorly Compliant Bladder in the Neurogenic Lower Urinary Tract Dysfunction Patient Refractory to Minimally Invasive Treatment." Neurourology and Urodynamics. 2026. doi:10.1002/nau.70220

16. Sorokin I, De E. "Options for Independent Bladder Management in Patients With Spinal Cord Injury and Hand Function Prohibiting Intermittent Catheterization." Neurourology and Urodynamics. 2015;34(2):167-76. doi:10.1002/nau.22516

17. Willis H, Safiano NA, Lloyd LK. "Comparison of Transvaginal and Retropubic Bladder Neck Closure With Suprapubic Catheter in Women." The Journal of Urology. 2015;193(1):196-202. doi:10.1016/j.juro.2014.07.091

18. Casale AJ. "A Long Continent Ileovesicostomy Using a Single Piece of Bowel." The Journal of Urology. 1999;162(5):1743-5. doi:10.1016/s0022-5347(05)68228-6

19. Husmann DA, Viers BR. Neurogenic bladder: management of the severely impaired patient with complete urethral destruction: ileovesicostomy, suprapubic tube drainage or urinary diversion—is one treatment modality better than another? Transl Androl Urol. 2020;9:132–141. doi:10.21037/tau.2019.09.06.

20. Dolat MT, Moore BW, Grob BM, Klausner AP, Hampton LJ. "Completely intracorporeal robotic-assisted laparoscopic ileovesicostomy: initial results." J Robot Surg. 2014;8(2):137-140. doi:10.1007/s11701-013-0443-y

21. WOCN Society, AUA, ASCRS. "WOCN Society, AUA, and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Ostomy Surgery." J Wound Ostomy Continence Nurs. 2021;48(6):533-536. doi:10.1097/WON.0000000000000820

22. Dolat MT, Wade G, Grob BM, Hampton LJ, Klausner AP. "Completely intracorporeal robotic-assisted laparoscopic ileovesicostomy." Case Rep Urol. 2014;2014:823813. doi:10.1155/2014/823813

23. Taneja SS, Godoy G. "Creation of urinary stoma before abdominal wall transposition of ileal conduit improves stomal protrusion, eversion, and symmetry." Urology. 2009;73(4):893-895. doi:10.1016/j.urology.2008.10.051

24. Shenot PJ, Teplitsky S, Margules A, Miller A, Das AK. "Urinary undiversion by conversion of the incontinent ileovesicostomy to augmentation ileocystoplasty in spinal cord injured patients." J Spinal Cord Med. 2022;45(4):614-621. doi:10.1080/10790268.2020.1829420

25. Zimmerman WB, Santucci RA. "Ileovesicostomy Update: Changes for the 21st Century." Adv Urol. 2009;2009:801038. doi:10.1155/2009/801038

26. Flores VX, Frainey B, Mikhael M, et al. "Long-term surgical outcomes of ileovesicostomy at a single children's hospital." J Pediatr Urol. 2025;21(2):405-410. doi:10.1016/j.jpurol.2024.10.028