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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, avoiding intraperitoneal dissection and the metabolic burden of a bowel segment. 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​

  • Large-capacity bladder that does not require augmentation — the critical prerequisite.[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​

The core operation is shared across variants; the continence mechanism is the principal point of divergence.

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 — preferred for cosmesis; 86% stomal stenosis in one series at this site.[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​

TBF achieves 98–100% continence, comparable to or marginally better than APV and Monti:[2][3][11]

  • 100% stomal continence in the Rink-modification series (n = 31, mean 41-month follow-up).[2]
  • 98% continence across the Riley aggregate series including continent vesicostomy.[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] The very-long-term update (median >12 years) confirmed similar trajectories with mean revision-free survival exceeding 13 years for all three techniques.[8]

Although total revision rates were similar, major revision (full channel takedown and creation of a new channel) 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]

The mechanism is the urothelial-to-cutaneous junction: urothelium tolerates chronic air exposure and skin flora less well than intestinal mucosa, predisposing to contracture at skin level.[2][7]

Management

  • L-stent — short knotted catheter placed flush with the skin overnight for several days; 100% reported improvement in one series, with patients using it intermittently as prophylaxis.[12]
  • Balloon dilation — used successfully in the Peard series.[1]
  • Surgical revision — required in roughly half of stenosis cases.[11]
  • Monofilament suture for umbilicoplasty reduced stenosis vs multifilament (p = 0.009).[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.[19]

TBF vs APV vs Monti — Head-to-Head​

FeatureTBFAppendicovesicostomyYang-Monti
Tissue sourceNative bladder wallVermiform appendixRetubularized ileum
Bowel harvestNoneNoneRequired
Intraperitoneal dissectionAvoidable (Peard)Usually requiredRequired
PrerequisiteLarge bladder capacityAvailable appendixAvailable ileum
Continence98–100%91–98%91–98%
Stomal stenosis29–45%13–33%8–33%
Major-revision burdenComparable to APVLowestHighest
Revision-free survivalNo significant difference vs APV / Monti——
Conversion to new channel19% (Rink)Rare~7%
Pouch-like dilationNoNoYes (Monti-specific)
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. TBF is contraindicated when capacity is marginal or augmentation is planned — flap harvest reduces volume. 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. Urothelium tolerates chronic skin-level exposure poorly (drives stenosis) but does not produce mucus (less plugging at catheterization).[2]
  • Adult applications. Most often used with bladder-neck closure for the devastated outlet (post-prostatectomy stricture, neurogenic bladder). The Stief–Becker 4 × 8 cm flap suits adult anatomy. In a 17-adult bladder-neck-closure-plus-continent-vesicostomy series, primary continence was 82% and stomal stenosis 23%.[10]
  • Long-term durability in adults. A 2025 study of 44 adults with continent catheterizable channels (mixed techniques) reported continued channel use in 75.7% at median 61 months, with recurrent UTI (18.2%) and per-urethral incontinence (18.2%) as the most common long-term complications.[20]

Decision Algorithm​

  1. First choice: Appendicovesicostomy when the appendix is available and suitable.
  2. Appendix unavailable + adequate bladder capacity (no augmentation): TBF preferred over Monti — bowel-free, comparable outcomes, lower major-revision burden.[3]
  3. Appendix unavailable + capacity marginal or augmentation planned: Yang-Monti (channel and augmentation patch from a single pedicle).[2]
  4. Appendix unavailable + adequate capacity unattainable: Casale (spiral) or double Monti.

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

19. 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

20. 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