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

Summary Introduction Stomal stenosis is the most common complication after the creation of a continent catheterizable channel (CCC), but is challenging to treat. Objective To describe early experience with triamcinolone injection for the treatment of stomal stenosis. Materials and methods A 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. Results A 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. Discussion The 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. Conclusions Triamcinolone 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 (%) Male 7 (41) Female 10 (59) Primary diagnosis (%) Myelomeningocele 9 (53) Cloaca, cloacal exstrophy, and variants 4 (23) Sacral agenesis 2 (12) Tethered cord 1 (6) Prune belly syndrome, anorectal malformation 1 (6) Type of CCC (%) Appendicovesicostomy 8 (44) Monti ileovesicostomy 4 (22) Spiral Monti ileovesicostomy 1 (6) Malone appendicocecostomy 2 (10) Malone appendicocecostomy with cecal extension 1 (6) Monti ileocecostomy 1 (6) Neo-Malone with cecal flap 1 (6) Split-appendix technique (%) 10 (56) Location of stoma (%) Right lower quadrant 14 (78) Left lower quadrant 2 (11) Umbilicus 2 (11) Prior intervention (%) Temporary placement of indwelling catheter 6 (33) Topical corticosteroids 13 (72) Stomal stopper or L stent 5 (28) Stomal dilation 1 (6) Stomal revision 4 (22) Subfascial revision 1 (6) Anesthesia for injection (%) General anesthesia 20 (91) No anesthesia 2 (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.