Triamcinolone injection for treatment of Mitrofanoff stomal stenosis: Optimizing results and reducing cost of care

SummaryIntroductionStomal stenosis is the most common complication after the creation of a continent catheterizable channel (CCC), but is challenging to treat.ObjectiveTo describe early experience with triamcinolone injection for the treatment of stomal stenosis.Materials and methodsA retrospective review was performed of patients who had undergone a triamcinolone injection (40 mg/ml) for the treatment of stomal stenosis at the present institution. The primary outcome of success was defined as a patient-reported or caregiver-reported return to ease with catheterization, and avoidance of stomal revision or indwelling catheter. The cost of care with various techniques for the treatment of stomal stenosis was also assessed by representing the cost as a percentage of charges for a re-operative Monti ileovesicostomy.ResultsA total of 22 injections were performed in 18 CCCs of 17 patients. Demographic and clinical data are provided in the Summary Table. Thirteen CCCs (72%) were successfully treated with a single injection. Three patients (10%) required a total of five repeat injections at a median of 5.1 months between injections (IQR, 4.6-12.4). One patient required a stomal revision at 34.9 months after the initial injection, while one patient also required a Chait cecostomy catheter. The median length of time for ease with catheterization was 11.6 months (IQR, 3.5-18.0) after the initial injection, and 10.4 months (IQR, 4.5-16.0) after any injection. No adverse effects or complications occurred from the injection. There were no variables associated with failure after the initial or any injection on univariate analysis. Represented as a percentage of charges for a reoperative Monti ileovesicostomy, the cost of care was 11.3% for a stomal revision, 5.8% for triamcinolone injection in the operating room, and 0.3% as an office-based procedure.DiscussionThe success rate for triamcinolone injection favorably compared with other options for the treatment of stomal stenosis. It surpassed the reported success rate of stomal dilation and approached that of stomal revision. Other studies have similarly observed a minimal risk of adverse effects and complications from both topical and intralesional corticosteroids. The limitations of the present study included its retrospective design at a single institution. A larger cohort of patients with a longer follow-up is necessary to determine its long-term durability.ConclusionsTriamcinolone injection was an effective and well-tolerated option for the treatment of stomal stenosis in any cutaneous stoma, thereby avoiding the need for a more invasive and costly stomal revision.Summary Table. Demographic and clinical data.Median age at surgery in years (IQR)10.5 (7.9-12.2)Gender (%) Male7 (41) Female10 (59)Primary diagnosis (%) Myelomeningocele9 (53) Cloaca, cloacal exstrophy, and variants4 (23) Sacral agenesis2 (12) Tethered cord1 (6) Prune belly syndrome, anorectal malformation1 (6)Type of CCC (%) Appendicovesicostomy8 (44) Monti ileovesicostomy4 (22) Spiral Monti ileovesicostomy1 (6) Malone appendicocecostomy2 (10) Malone appendicocecostomy with cecal extension1 (6) Monti ileocecostomy1 (6) Neo-Malone with cecal flap1 (6)Split-appendix technique (%)10 (56)Location of stoma (%) Right lower quadrant14 (78) Left lower quadrant2 (11) Umbilicus2 (11)Prior intervention (%) Temporary placement of indwelling catheter6 (33) Topical corticosteroids13 (72) Stomal stopper or L stent5 (28) Stomal dilation1 (6) Stomal revision4 (22) Subfascial revision1 (6)Anesthesia for injection (%) General anesthesia20 (91) No anesthesia2 (9)Median time from creation of CCC to injection in months (IQR)26.1 (13.1-48.8)Median follow-up in months (IQR)10.9 (7.0-21.5)CCC, continent catheterizable channel.