Casale (1999) has used an initial segment that was twice as long

that was partially split in the middle and then opened in a spiral
fashion on opposite sides to make a longer strip that could be
tubularized in continuity. Narayanaswamy and colleagues

Casale (1991) has described a form of continent vesicostomy in

which the continence mechanism is based on a flap valve made
from a tubularized strip of bladder mucosa. It is particularly suitable
when the bladder is compliant and of large capacity. An
anterior detrusor strip is also used to construct a catheterizable
limb.
Technique. Parallel incisions 3 cm apart are made into the anterior
bladder and used to form a long rectangular flap. The abdominal
wall should be measured to ensure that the strip

enough to reach the skin without tension. The full-thickness strip

is tubularized down to the bladder, typically in two layers. The
muscle portion is left broad to come around without tension and
provide good blood supply. The mucosa may be trimmed in width
before tubularization to avoid redundancy. A strip of mucosa
within the bladder, 2 to 3 cm in length and 1.5 cm in width, is
incised in a direct line and in continuity with the mobilized
bladder tube. The edges of this strip are mobilized until it can be
tubularized along its entire length. It may be beneficial to mobilize
only one edge over to the other side, which allows one to avoid
overlapping suture lines. Casale (1991) originally incised the
mucosa transversely at the end of the intravesical strip to be tubularized;
Rink and associates (1995b) then suggested that it could
be left intact (Fig. 129–21). The bladder mucosa from either side
of the tube is then mobilized and closed over the mucosal tube to
create a flap valve. More extensive mobilization of the side opposite
that mobilized for the inner tube allows closure without overlapping
suture lines, which may help avoid fistula formation and
incontinence. A soft stent is usually left through the tube for 3
weeks during healing to prevent stenosis. It does tend to close if
it is not catheterized regularly and may be even more susceptible
than other catheterizable channels to stomal stenosis (Cain et al,
2002; Thomas et al, 2005).
Results. Continence rates have been good, as with most flap
valve mechanisms (Cain et al, 1999, 2002). Stomal stenosis
remains a significant problem—45% in the experience at Indiana
University (Cain et al, 2002). Skin flaps and avoidance of tension
to reach the skin may minimize this risk but not remove it. Advantages
include avoidance of an intraperitoneal procedure and bowel
anastomosis; the appendix can be reserved for use with enemas.
It does use some bladder and decreases capacity, which may not
be appropriate for some patients.

enough to reach the skin without tension. The full-thickness strip

is tubularized down to the bladder, typically in two layers. The
muscle portion is left broad to come around without tension and
provide good blood supply. The mucosa may be trimmed in width
before tubularization to avoid redundancy. A strip of mucosa
within the bladder, 2 to 3 cm in length and 1.5 cm in width, is
incised in a direct line and in continuity with the mobilized
bladder tube. The edges of this strip are mobilized until it can be
tubularized along its entire length. It may be beneficial to mobilize
only one edge over to the other side, which allows one to avoid
overlapping suture lines. Casale (1991) originally incised the
mucosa transversely at the end of the intravesical strip to be tubularized;
Rink and associates (1995b) then suggested that it could
be left intact (Fig. 129–21). The bladder mucosa from either side
of the tube is then mobilized and closed over the mucosal tube to
create a flap valve. More extensive mobilization of the side opposite
that mobilized for the inner tube allows closure without overlapping
suture lines, which may help avoid fistula formation and
incontinence. A soft stent is usually left through the tube for 3
weeks during healing to prevent stenosis. It does tend to close if
it is not catheterized regularly and may be even more susceptible
than other catheterizable channels to stomal stenosis (Cain et al,
2002; Thomas et al, 2005).
Results. Continence rates have been good, as with most flap
valve mechanisms (Cain et al, 1999, 2002). Stomal stenosis
remains a significant problem—45% in the experience at Indiana
University (Cain et al, 2002). Skin flaps and avoidance of tension
to reach the skin may minimize this risk but not remove it. Advantages
include avoidance of an intraperitoneal procedure and bowel
anastomosis; the appendix can be reserved for use with enemas.
It does use some bladder and decreases capacity, which may not
be appropriate for some patients.

Casale described a long ileovesicostomy technique using a single piece of bowel to create a
channel 10 to 14 cm in length (4). This technique involves a 3.5- to 4-cm segment of bowel that is
isolated on its mesentery and divided into two equal segments for approximately 80% of the
bowel circumference, leaving the two segments attached on the antimesenteric side. The two
loops of intestine are opened close to the mesentery on opposite sides, allowing the bowel to
unfold in opposite directions, creating a long flat plate of intestine that can be retubularized after
trimming the redundant lateral edges.