ILEOCECAL VALVE RESISTANCE AUGMENTATION USING FOR ENDOSCOPIC SALVAGE OF THE LEAKING INDIANA RESERVOIR GLUTARALDEHYDE CROSS-LINKED COLLAGEN: A CANINE MODEL

Purpose: Periurethral iqjection of glutaraldehyde cross-linked collagen is a well-established modality for the treatment of patients with incontinence caused by structural defects at the bladder outlet. Little is known about the potential usefulness of this approach to the nonfunctioning continence mechanism of a leaking continent urinary reservoir. An animal model of an incontinent Indiana reservoir was created using the naturally incompetent canine ild valve. The effectiveness and feasibility of endoscopic submucosal injection of glutaraldehyde cross-linked collagen into the ileocecal valve to increase resistance were examined. Materials and Methods: Seven beagle dogs underwent isolation of the ild segment. The right colon and ileum were brought to the skin as 2 stomas. Baseline leak point pressures of the ileocecal valve were determined while infusing contrast material into the right colon. The leak point was observed fluoroscopically, and the pressure at which contrast material crossed the valve was measured. Glutaraldehyde cross-linked collagen, 4 to 10 ml., was iqjected endoecopically into the valve in a circumferential pattern. Leak point pressures were measured immediately, 1 month aRer iqjection and 3 months aRer injection. Resulk. An average of 7.1 gm. (range, 4.1 to 10.1 gm.) was required to create an endoeeopidy “closed” ileocecal valve. Leak point pressure increased hm a mean 3.8 mm. water (range, 2.5 to 6.0 mm. water) at baseline to mean 35.7 mm. water aRer injection (range, 22.0 to 67.0 mm. water). At 1 month, mean leak point pressure decreased slightly to 26.7 mm. water. This pressure stabilized at 3 months at 29.5 mm. water. Conclusions: Endoscopic delivery of glutaraldehyde cross-linked collagen into the ileocecal valve consistently enhanced resistance as measured by leak point pressure. This effect was durable over a 3-month period of observation. Admittedly, this period of observation is relatively short. Longer followup may have demonstrated significant diminution of collagen migration or resorption. However, this feasibility study demonstrates that collagen injections may provide a minimally invasive means of treating the incontinent continent urinary reservoir. KFX WORDS: ild valve, collagen, urinary incontinence, urinary diversion The wide variety of strategies currently employed to construct leakproof outlet mechanisms for continent urinary reservoirs refl& the absence of 1 clearly superior, reliable, dry stoma design. The incontinent continent reservoir, the pouch that leaks, presents a formidable problem to patient and surgeon. The Indiana pouch is a well-known continent catheterizable reservoir based on the ileocecal segment. Since the 1950s, this bowel segment has been employed successfully, exploiting the native ileacecal valve mechanism. In the Indiana design, a detubdarized right colon pouch is drained by a catheterizable stoma conetruded of tapered terminal ileum. neocecal valve continence is critical for a dry stoma. The procedure is reliable, with a continence rate of 93%.1 Of reoperations, 36% are performed for recurrent inmntinence.2 The development of an alternative, less invasive procedure to improve postoperative continence is clearly desirable. Submucosal injection of biocompatible bulking agenta was first described in 1938 as a treatment for stress incontinence. By increasing urethral bulk, a more narrow urethral channel Providing more resistance to urinary flow was created. In the 1970s. Berg9 and Politano et a14 described the iqjection of