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Tubularized Bladder Flap (Continent Catheterizable Vesicostomy)

The tubularized bladder flap (TBF), also called continent catheterizable vesicostomy, is a continent catheterizable channel built entirely from native bladder wall, without harvesting appendix or bowel. The bowel-reservoir Nissen valve and bladder-flap-plus-appendix or Monti hybrid described below are related constructions, not native-bladder-only TBFs.[9][14] A full-thickness flap is raised, tubularized over a catheter, given a continence mechanism (intussusception, submucosal tunnel, detrusor tunnel, or rectus-strand compression), and brought to the skin as a flush stoma.[1][2]

The main advantage is that it spares both the appendix and the intestine, potentially avoiding intraperitoneal dissection in selected variants and avoiding bowel-mucosa incorporation when no augment is added. The main limitation is that it requires sufficient bladder capacity to sacrifice the flap without compromising reservoir function.[2][3]

For the design rules common to every catheterizable conduit see Principles of Continent Catheterizable Channels. Compared techniques: Appendicovesicostomy and Yang-Monti Channel.

Historical Variants and Nomenclature​

Multiple TBF descriptions exist, and the terminology is not standardized:

VariantDistinguishing feature
Casale continent vesicostomyBladder flap with a submucosal-tunnel continence mechanism; reported by the Riley group as continent vesicostomy.[4]
Rink modificationRiley Children's modification of the Casale vesicostomy; 31 patients in the largest single-institution report cited here.[2]
Yachia techniqueBladder-wall flap tubularized into a neourethra; continence by crossed rectus-muscle strands instead of a tunnel.[5]
Klauber–CendronCatheterizable posterior bladder tube, described in a single patient with prune-belly syndrome.[6]
Stief–BeckerLapides-style 4 × 8 cm U-shaped flap embedded in a Lich-Gregoir detrusor tunnel after bladder neck closure (adults).[7]
Peard modificationExtraperitoneal Pfannenstiel approach with intussusception continence mechanism.[1]
De Jong / Dik (Utrecht) TBFTechnique used in the Utrecht comparative series against APV and Monti.[3][8]

Indications​

  • Adequate safe storage capacity after flap harvest. Often a bladder not requiring augmentation, though combined augmentation has been reported.[1][2] Preoperative assessment includes capacity, compliance, and high-pressure detrusor overactivity. The Utrecht adult series defined favorable storage as maximum cystometric capacity of at least 400 mL or a full bladder reaching the umbilicus, no high-pressure detrusor overactivity, and compliance >20 mL/cm H₂O.[17] Confirm that the patient or caregiver can perform regular catheterization, especially when bladder-neck closure will make the channel the only emptying route.[16]
  • Appendix unavailable or unsuitable (prior appendectomy, MACE), and a bowel-free option is preferred.
  • Neurogenic bladder with adequate capacity when an abdominal channel facilitates catheterization.[1][2] For selected adults with neurogenic lower urinary tract dysfunction, AUA/SUFU states that clinicians may offer a continent catheterizable channel with or without augmentation to facilitate catheterization .[16]
  • Prune-belly (Eagle-Barrett) syndrome. The large, flaccid bladder can supply a flap.[2]
  • Cloacal exstrophy / cloacal anomaly.[2]
  • Devastated bladder outlet with bladder neck closure. The channel becomes the only emptying route.[10]
  • Intractable voiding dysfunction with preserved capacity.[1]

In the Riley series, primary diagnoses were neuropathic bladder (48%), prune-belly syndrome (19%), and cloacal exstrophy/anomaly (16%).[2]

Surgical Technique​

Flap location, geometry, access, and continence construction differ across variants.

1. Exposure and bladder mobilization​

Pfannenstiel or lower-midline incision. The Peard modification uses a 4 cm Pfannenstiel and is performed entirely extraperitoneally, avoiding intraperitoneal dissection.[1] The bladder is mobilized to allow flap creation and tension-free routing of the channel to the skin.

2. Bladder-flap creation​

Flap location varies by variant: dome, posterior wall, or anterior wall. The Utrecht adult technique uses an anterior U-shaped full-thickness flap with an intravesical mucosal extension.[17] Flap dimensions vary by technique:

  • Peard modification. A 2 cm vertical flap at the dome.[1]
  • Stief–Becker. A 4 × 8 cm U-shaped Lapides-like flap, base oriented to the planned stoma.[7]
  • Klauber–Cendron. A strip of posterior bladder wall.[6]

Adequate base width is needed to preserve detrusor blood supply.

3. Tubularization​

In the Peard modification, the dome flap is tubularized over a 12 Fr catheter with running 4-0 polyglactin (Vicryl).[1] The Utrecht adult technique uses a 14 Fr splint and an intravesical mucosal tunnel.[17] The resulting bladder-wall tube is urothelium-lined inside, with detrusor muscle outside.[1][7]

4. Continence mechanism​

MechanismConstructionUsed by
IntussusceptionTubularized flap is intussuscepted into the bladder lumen with four 4-0 PDS sutures, creating a nipple-valve compressed by intravesical pressure.Peard.[1]
Submucosal tunnelStandard Mitrofanoff-style submucosal tunnel under bladder mucosa, forming a flap valve.Casale, Rink.[2]
Lich-Gregoir detrusor tunnelAfter bladder neck closure, the tube is reflected and embedded in an extravesical detrusor trough.Stief–Becker.[7]
Crossed rectus strandsTube passes through strands raised from right and left rectus muscles near the pubis; lateral compression adds to resting closure pressure.Yachia.[5]
Nissen valveWhen the channel is created from reservoir-wall (augmented bladder), a Nissen-style fundoplication is wrapped around the tube base.Richter / Hanna.[9]

5. Channel routing and stoma​

Stoma sites and trade-offs:

  • Umbilicus. Assess reach and usability as well as cosmesis; stenosis occurred in 6/7 umbilical stomas in one small Rink series.[2]
  • Lower abdomen. Stenosis rates were lower than at the umbilicus in the same series.[2]
  • Neoumbilicus. Surgical creation when the native umbilicus is unsuitable.[2]

The stoma is matured as a flush stoma.

6. Cystotomy closure​

In the Peard modification, the bladder defect is closed in two layers with absorbable suture.[1] After bladder-neck closure, Stief–Becker embed the bladder-wall tube in a detrusor tunnel.[7] During initial healing, the Utrecht adult technique uses a 16–20 Fr suprapubic or urethral bladder drain separate from a 14 Fr channel splint; the splint's balloon channel is cut to prevent inflation.[17]

Outcomes​

Continence​

Selected TBF series report high stomal continence:[2][3][11]

  • Stomal continence was 100% in the Rink-modification series (n = 31, mean 41-month follow-up).[2]
  • Continence was 98% in the mixed Riley channel cohort.[4]
  • No leakage between catheterizations was reported in the Peard intussusception series (n = 6).[1]

Revision-free survival​

In a single-institution pediatric comparison (Polm 2017, 117 channels in 112 children, median follow-up 85 months), Kaplan-Meier analysis showed no significant difference in revision-free survival between TBF, APV, and Monti; 52% of channels required surgical revision.[3] A later cohort of adults under surveillance at the same center (Polm 2024, 173 channels including 32 TBFs) included channels created in childhood: 25/32 TBFs were constructed before age 18.[8] Median follow-up was 12.4 years across all channel types but 9.6 years for TBF; the 162-month mean revision-free survival also applies to the full cohort, with no significant between-type difference. Even so, 92/173 (53%) required revision, and major revision occurred in 27/90 APV, 31/51 Monti, and 12/32 TBF channels.[8]

In the 2017 series, total revision rates were similar, but major revision (distinct from complete channel replacement) was required significantly more often in Monti channels. Complete channel revision was needed in approximately 7% overall. The authors preferred TBF over Monti when the appendix is unavailable and bladder volume is sufficient.[3]

Complications​

Stomal stenosis — the principal weakness​

Stomal stenosis is the dominant complication. In the Riley aggregate series, continent vesicostomy was the most prone of the techniques to stomal problems:

  • Stenosis requiring revision occurred in 45% (14/31) of the Rink-modification series, including 86% of umbilical stomas and 60% of patients with neuropathic bladder.[2]
  • Stomal problems occurred in 6/21 (29%) of continent vesicostomies in the Riley aggregate series, the most prone of three techniques.[4]
  • Stenosis requiring revision occurred in 33% across all channel types in the Utrecht comparative series.[3]

Tissue characteristics, perfusion, tension, stoma design, and scarring may contribute to stenosis.[2][7]

Management

  • L-stent. A short catheter bridging skin-level narrowing without entering the reservoir may be used under specialist guidance. Seven users in a small series reported improvement; six also used topical betamethasone or catheterization.[12]
  • Balloon dilation. Used successfully in the Peard series.[1]
  • Surgical revision. In a retrospective series combining antegrade-enema and urinary catheterizable channels, half of stomal stenoses underwent surgical revision; the remainder were successfully dilated.[11]
  • Umbilicoplasty suture. In a retrospective 260-patient classic-exstrophy cohort, monofilament umbilicoplasty suture was associated with less stomal stenosis than multifilament suture (p = 0.009).[13]

Conversion to alternative channel​

In the Rink series, 6 of 31 patients (19%) ultimately required conversion to an alternative catheterizable channel for refractory stomal problems. The Riley group concluded they would prefer the Monti-Yang procedure over continent vesicostomy when bowel was already being used for bladder reconstruction.[2]

Other complications​

  • False passage requiring surgical revision. 10/117 (9%) across all channel types.[3]
  • Channel incontinence. 14/117 (12%) across all channel types; 4/117 (3%) had channel incontinence with low detrusor leak-point pressure.[3]
  • Superficial wound infection. 1/6 in the Peard series.[1]
  • Catheterization difficulty. 1/6 in the Peard series, treated with balloon dilation at 3 months.[1]

Variant-Specific Notes​

Rink modification (Riley)​

The most extensively reported TBF technique.[2]

  • Full-thickness flap, tubularized, implanted via submucosal tunnel (Mitrofanoff principle).
  • Frequent concurrent procedures: ureteral reimplantation (26%), augmentation (16%), bladder-neck surgery (13%), reduction cystoplasty (6%).[2]
  • 100% continence; 45% stomal stenosis drove the Riley group toward Monti-Yang when bowel was already being used.[2]

Peard modification (intussusception)​

Extraperitoneal Pfannenstiel; intussusception nipple-valve secured with four 4-0 PDS sutures; umbilical stoma; median 8-day length of stay. Early results encouraging (5/6 self-catheterizing, no leakage) but follow-up was short (median 6 months).[1]

Stief–Becker (adults)​

4 × 8 cm Lapides-like flap; bladder neck closure combined with Lich-Gregoir detrusor-tunnel embedding; bladder capacity 250–560 mL; all 5 patients continent; 2/5 epifascial stomal revisions; minimum follow-up 11 months.[7]

Yachia​

Bladder-wall flap based near the bladder neck, tubularized, then routed through crossed strands raised from right and left rectus muscles. Lateral compression supplements resting closure pressure. All 7 patients dry day and night at mean 28 months.[5]

Nissen valve (Richter / Hanna)​

When the reservoir is augmented with bowel, a flap of the bowel reservoir is raised, tubularized, and a Nissen-style fundoplication is wrapped around the tube base. Five of 6 children were doing well at 1 to 8 years; one was lost to follow-up.[9]

Casella–Ost hybrid​

Hybrid bladder-flap-plus-appendix (or Monti) technique. The flap partially spans the distance between bladder and abdominal wall; the appendix or tubularized ileum completes the run to the skin. Useful in obesity (thick abdominal wall outstrips appendix length) and short appendix. The flap also provides a clean surface for a tunneled, nonrefluxing anastomosis to the bladder. All 3 patients catheterized without difficulty at 23 to 32 months; two had mild stomal stress incontinence.[14]

TBF vs APV vs Monti — Practical Differences​

FeatureTBFAppendicovesicostomyYang-Monti
Tissue sourceNative bladder wallVermiform appendixRetubularized ileum
Bowel harvestNoneNoneRequired
Intraperitoneal dissectionAvoidable (Peard)Usually requiredRequired
PrerequisiteLarge bladder capacityAvailable appendixAvailable ileum
ContinenceHigh in selected series; no valid cross-study rankingDepends on tunnel, reservoir, and follow-upDepends on tunnel, reservoir, and follow-up
Stomal stenosisImportant risk; 45% revision in one 31-patient series[2]Important long-term riskImportant long-term risk
Major-revision burden12/32 in the 2024 cohort27/90 in the 2024 cohort31/51 in the 2024 cohort; observational comparison[8]
Revision-free survivalNo significant difference vs APV / Monti——
Conversion to new channel6/31 in the Rink series[2]—Requires population-specific evidence
Structural problemsNarrowing, angulation, or redundancy may impair catheterizationSimilar general channel concernsRetubularized bowel may develop pouch-like dilation
Best slot in algorithmAppendix unavailable + adequate capacityFirst choice when appendix is suitableAppendix unavailable + capacity insufficient or augmentation planned

References:[1][2][3][4][8]

Special Considerations​

  • Bladder-capacity prerequisite. Flap harvest must leave adequate safe capacity. A marginal reservoir is a concern, but planned augmentation is not an absolute contraindication: five of 31 Rink patients underwent simultaneous augmentation. Those authors favored Monti when bowel was already being used. When augmentation is being done, the Yang-Monti channel can be cut from the same mesenteric pedicle as the augmentation patch.[2]
  • Urothelial versus intestinal lining. A native-bladder channel avoids intestinal mucus production; its clinical stenosis risk is multifactorial.[2]
  • Adult applications. Adult descriptions include use with bladder-neck closure for the devastated outlet (post-prostatectomy stricture, neurogenic bladder). The Stief–Becker 4 × 8 cm flap suits adult anatomy. Spahn’s 17-patient mixed-age closure series used appendiceal or ileal-intussusception outlets, with or without ileocecal augmentation; its 82% primary continence and 23% stenosis are not TBF outcomes.[10]
  • Adult outcomes. In a retrospective series of 11 adult TBFs (median follow-up 25 months), 6/11 had a grade 1 complication within 30 days and four unique patients underwent surgical revision: two for stenosis and three for stomal leakage, with one patient counted in both indication groups.[17] A 2025 single-center mixed-channel study identified 44 adults, with long-term outcomes reported for 37: 28/37 (75.7%) still used the channel at median follow-up of 61 months, six had recurrent UTI and six had incontinence per urethra.[15]

Decision Algorithm​

  1. Appendix available and suitable. Appendicovesicostomy is an option; the Riley group used it as their first choice.[4] An observational Utrecht comparison found no significant difference in revision-free survival among channel types.[8]
  2. Appendix unavailable and adequate bladder capacity (no augmentation): TBF is an option (bowel-sparing, with a lower major-revision burden than Monti in one observational program); consider local experience and the individual reservoir.[3]
  3. Appendix unavailable and capacity marginal or augmentation planned: Yang-Monti (channel and augmentation patch from a single pedicle).[2]
  4. Insufficient channel length: consider a spiral or double Monti when appropriate. Lengthening a channel does not itself correct inadequate bladder capacity or unsafe storage pressure.

See Also​

References​

1. Peard L, Fox PJ, Andrews WM, et al. Continent catheterizable vesicostomy: an alternative surgical modality for pediatric patients with large bladder capacity. Urology. 2016;93:217–222. doi:10.1016/j.urology.2016.03.018

2. Cain MP, Rink RC, Yerkes EB, Kaefer M, Casale AJ. Long-term followup and outcome of continent catheterizable vesicostomy using the Rink modification. J Urol. 2002;168(6):2583–2585. doi:10.1016/S0022-5347(05)64221-8

3. Polm PD, de Kort LMO, de Jong TPVM, Dik P. Techniques used to create continent catheterizable channels: a comparison of long-term results in children. Urology. 2017;110:192–195. doi:10.1016/j.urology.2017.08.030

4. Cain MP, Casale AJ, King SJ, Rink RC. Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital. J Urol. 1999;162(5):1749–1752. doi:10.1016/s0022-5347(05)68230-4

5. Yachia D. A new continent vesicostomy technique: preliminary report. J Urol. 1997;157(5):1633–1637. doi:10.1016/s0022-5347(01)64816-x. PMID 9112493

6. Klauber GT, Cendron M. Continent vesicostomy using a catheterizable posterior bladder tube: modification of the Mitrofanoff principle. J Pediatr Surg. 1994;29(1):71–73. doi:10.1016/0022-3468(94)90527-4

7. Stief CG, Becker AJ. A simple and reliable continent bladder stoma constructed from bladder wall. World J Urol. 2003;21(3):144–146. doi:10.1007/s00345-003-0350-3

8. Polm PD, Christiaans CHH, Dik P, Wyndaele MIA, de Kort LMO. Continent catheterizable urinary channels: lessons for lifelong urological care from a comparative analysis of very long-term complications and revision-free survival of three different types. Neurourol Urodyn. 2024;43(5):1083–1089. doi:10.1002/nau.25350

9. Richter F, Stock JA, Hanna MK. Continent vesicostomy in the absence of the appendix: three methods in 16 children. Urology. 2002;60(2):329–334. doi:10.1016/s0090-4295(02)01735-1

10. Spahn M, Kocot A, Loeser A, Kneitz B, Riedmiller H. Last resort in devastated bladder outlet: bladder neck closure and continent vesicostomy — long-term results and comparison of different techniques. Urology. 2010;75(5):1185–1192. doi:10.1016/j.urology.2009.11.070

11. Thomas JC, Dietrich MS, Trusler L, et al. Continent catheterizable channels and the timing of their complications. J Urol. 2006;176(4 Pt 2):1816–1820; discussion 1820. doi:10.1016/S0022-5347(06)00610-0

12. Mickelson JJ, Yerkes EB, Meyer T, Kropp BP, Cheng EY. L stent for stomal stenosis in catheterizable channels. J Urol. 2009;182(4 Suppl):1786–1791. doi:10.1016/j.juro.2009.02.068

13. Harris TGW, Haffar A, Crigger CB, et al. Stomal stenosis after continent urinary diversion in bladder exstrophy: risk factors and management. Urology. 2024;191:110–118. doi:10.1016/j.urology.2024.07.003

14. Casella DP, Dudley AG, Ost MC. Overcoming obesity and a short appendix in the creation of continent catheterizable stomas. Preliminary outcomes of the "Casella-Ost procedure". Urology. 2015;86(3):625–627. doi:10.1016/j.urology.2015.05.019

15. Morris KE, Burns R, Snook V, et al. Outcomes of continent catheterizable channels created in adults. Urology. 2025;206:157–161. doi:10.1016/j.urology.2025.07.023

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

17. Polm PD, Wyndaele MIA, Dik P, de Kort LMO. "Tubularized Bladder Flap as a Continent Catheterizable Channel in Adults." Urology. 2024;187:140-146. doi:10.1016/j.urology.2024.03.017