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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. 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 defining 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 defining 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 vesicostomyOriginal description — bladder flap with submucosal-tunnel continence mechanism.[4]
Rink modificationRiley Children's modification of the Casale; the most extensively reported series.[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.[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 largest 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]
  • Appendix unavailable or unsuitable (prior appendectomy, MACE), and a bowel-free option is preferred.
  • Neurogenic bladder with adequate capacity.[1][2]
  • Prune-belly (Eagle-Barrett) syndrome — the large floppy bladder is well-suited.[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. The descriptions below should not be combined into a single operative recipe.

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​

A full-thickness bladder-wall flap is raised from the dome or posterior wall. Flap dimensions vary by technique:

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

Adequate base width is essential to preserve detrusor blood supply.

3. Tubularization​

The flap is tubularized over a 12 Fr catheter with running absorbable suture (4-0 polyglycolic acid or Vicryl). The resulting tube is urothelium-lined inside, with detrusor muscle on the 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 — 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. This is not a general umbilical-stoma risk estimate.[2]
  • Lower abdomen — lower stenosis rates.[2]
  • Neoumbilicus — surgical creation when the native umbilicus is unsuitable.[2]

The stoma is matured as a flush stoma.

6. Cystotomy closure​

The bladder defect from flap harvest is closed in two layers with absorbable suture. A suprapubic and/or urethral catheter drains the bladder during initial healing.[1][7]

Outcomes​

Continence​

Selected TBF series report high stomal continence, but these data do not establish superiority or equivalence to APV or Monti:[2][3][11]

  • 100% stomal continence in the Rink-modification series (n = 31, mean 41-month follow-up).[2]
  • 98% continence in the mixed Riley channel cohort; not a TBF-specific rate.[4]
  • No leakage between catheterizations in the Peard intussusception series (n = 6).[1]

Revision-free survival​

In the largest comparative series (Polm, n = 117 channels, median 85 months), Kaplan-Meier analysis showed no significant difference in revision-free survival between TBF, APV, and Monti.[3] A later 173-channel cohort at median 12.4-year follow-up reported overall mean revision-free survival 162 months, with no significant difference between types. However, 92/173 (53%) required revision and major revision occurred in 27/90 APV, 31/51 Monti, and 12/32 TBF channels.[8]

Although total revision rates were similar, major revision (distinct from complete channel replacement) was required significantly more often in Monti channels than in TBF or APV. Complete channel revision was needed in only ~7% overall — leading the authors to recommend TBF over Monti when appendix is unavailable and bladder capacity is sufficient.[3]

Complications​

Stomal stenosis — the principal weakness​

Stomal stenosis is the dominant complication and is higher than with APV or Monti in several series:

  • 45% stenosis requiring revision in the Rink-modification series (14/31).[2]
  • 86% at the umbilicus, 60% in neuropathic-bladder patients.[2]
  • 29% stomal problems (6/21) in the Riley aggregate series — most prone among the three techniques.[4]
  • 33% stenosis across all channel types in the Utrecht comparative series.[3]

Tissue characteristics, perfusion, tension, stoma design, and scarring may contribute to stenosis. These cohorts do not establish intolerance of air or skin flora as its single mechanism.[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. This does not establish a universal cure or an independent stent effect.[12]
  • Balloon dilation — used successfully in the Peard series.[1]
  • Surgical revision — required in roughly half of stenosis cases.[11]
  • Monofilament suture was associated with less stenosis than multifilament in a retrospective 260-patient classic-exstrophy cohort (p=0.009); this was not a randomized TBF comparison.[13]

Conversion to alternative channel​

In the Rink series, 6 of 31 patients (19%) ultimately required conversion to APV or Monti 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 ~9% across all channel types.[3]
  • Channel incontinence with low leak-point pressure ~12%.[3]
  • Superficial wound infection 1/6 in the Peard series.[1]
  • Catheterization difficulty 1/6 (balloon dilation at 3 months) in the Peard series.[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%).
  • 100% continence; 45% stomal stenosis drove the Riley group toward Monti-Yang when bowel was already being used.

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 reservoir wall is raised, tubularized, and a Nissen-style fundoplication wrapped around the tube base. 5/6 children doing well at 1–8 years.[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 catheterizing without difficulty at 23–32 months.[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 seriesImportant 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
Revision-free survivalNo significant difference vs APV / Monti——
Conversion to new channel6/31 in the Rink seriesDo not extrapolate whole-cohort replacement rates to individual techniquesRequires 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 vs 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-adult 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]
  • Long-term durability in adults. A 2025 study identified 44 adults, with long-term outcomes reported for 37: 28/37 (75.7%) still used the channel at median 61 months. Six of 37 had recurrent UTI and six had urethral incontinence; the abstract’s 18.2% is inconsistent with that denominator. These mixed-channel findings are not TBF-specific.[15]

Decision Algorithm​

  1. First choice: Appendicovesicostomy when the appendix is available and suitable.
  2. Appendix unavailable + 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 + 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.

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;S0090-4295(25)00697-1. doi:10.1016/j.urology.2025.07.023