Continent Catheterizable Ileal Cecocystoplasty (CCIC): Overview and Hospital Course
Catheterizable Ileal channel
What is a CCIC?
It's a mouthful! It is a bladder augmentation made out of the cecum (cecocystoplasty) and an extension out of the top of it that connects to the navel (“belly button”). This extension is otherwise known as a continent catheterizable stoma. So, that is how we get to a complicated name like continent catheterizable ileal cecocystoplasty. Like it sounds, a catheterizable channel is a tube through which you can pass a bladder catheter. The tube is constructed from intestine and is the same diameter as your catheter, so that the catheter glides through in a straight line to the b¬¬ladder. The last part of the small intestine (ileum) connects to the first part of the large intestine (cecum). So, when we do a CCIC we take both of these as a unit and place them on the bladder while still connected to each other. This allows for an augmentation of the bladder and a catheterizable channel at the same time.
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Why do some people need a CCIC?
Some people who perform intermittent catheterization to drain the bladder are unable to do so through their urethra and so we create an alternative route for catheterization on the abdominal wall. Reasons for this include: (1) the urethra is blocked by scar tissue; (2) the urethra (or bladder neck) has been surgically closed to prevent urinary leakage; (3) pain with urethral catheterization; (4) the urethra is difficult to access. The last reason (problems accessing the urethra) is the most common reason we create a catheterizable channel. The most common reason people have difficulty accessing their urethra is that spinal cord injury, spina bifida, cerebral palsy or some other neurologic condition causes them to use a wheelchair for mobility and it is difficult to access the urethra in the wheelchair. Being able to catheterize while in your wheelchair give people a lot of independence – they don’t have to depend on others to transfer them out of their chair or catheterize them. Even people with partial quadriplegia and limited hand dexterity can often catheterize through a channel.
Is this the same thing as a stoma?
A stoma is really any opening on your body that was created surgically. So, yes, a CCIC stoma does have an opening on the abdominal wall and that opening is called a stoma. Other types of stomas include a colostomy or urostomy.
Is it the same thing as a Mitrofanoff?
They are both catheterizable channels but are slightly different. Our first choice piece of intestine for a catheterizable channel is the appendix because it is easy to use and it is the same size as a catheter. When we use the appendix we call this channel a Mitrofanoff. However, sometimes the appendix is missing or it is too short to reach from the bladder to the umbilicus (belly button or navel). When this happens, and especially if we need to do a bladder augmentation at the same time then a CCIC is a good alternative.
Does it hurt to catheterize a stoma?
No, intestines don't feel pain in that way.
Will people see my stoma?
The stoma is usually in the belly button and not visible to most people. It is about the size of a pencil eraser
Will I leak urine out the stoma?
No, you should not leak urine. You might have a few drops of mucous come out the stomal opening each day but you should not leak urine. There is a natural one-way valve between the cecum and the ileum that we repurpose to serve as an anti-leak valve. When the catheter passes through, it opens this valve and drains the bladder. When the catheter is removed, the valve closes.
After surgery people usually remain in the hospital for 5-9 days. We know you are ready to go home when you have good pain control with pills, are able to eat and are back to your baseline level of mobility.
There will be several people seeing you every day in the hospital. These may include: nurses, nursing assistants, dieticians, physical therapists, occupational therapists, social workers, surgeons, medical doctors, nurse practitioners, physician assistants, residents and medical students. At a teaching hospital like this one, the residents and medical students are central members of the care team. Your surgeon may not be able to see you every day in the hospital because they work in several different hospitals and clinics each day; so they have to rely on their team of doctors to help manage you after surgery. Rest assured that this team is communicating with your surgeon multiple times a day and that as the captain of the team your surgeon is making the decisions about your care.
When we operate on the intestines they tend to go to sleep for a few days. If you try to eat right away you are likely to vomit. So, we typically allow you to have just sips of water and ice chips for the first two days. Once you feel hungry and not bloated with gas we know that your intestines are waking up. Then we try a diet of clear liquids (juice, soda, Jello and soup broth). If this goes well, then we try a regular diet.
When we operate on the intestines they tend to go to sleep for a few days. This, plus the fact that you may not have eaten normally right before and after surgery means that you might not have a bowel movement for a few days. If you normally need help from things like enemas in order to have a bowel movement, then please explain this to the doctors or nurses in the hospital. We can make sure you are on the medicines you need in order to have a bowel movement. When you do have a bowel movement the first few may be loose because of the recent intestinal surgery plus the alterations in your diet.
Some people opt for an epidural or a nerve block before surgery. This can help with pain control in your abdominal incision for the first few days. You may have a pain pump or pain button, also called Patient Controlled Analgesia (PCA). This is a button that you push that automatically delivers a narcotic pain medicine through your IV. If you cannot push the pain button or prefer not to have one, then an alternative is that a nurse can deliver pain medicines through the IV as needed. You may also get an IV form of non-narcotic pain medicines to allow you to take fewer narcotics. Once your intestines start working we will have you try taking pain pills by mouth (a.k.a., orally). Oral pain medicines work longer than IV forms and are, of course, the type that need to be working for you in order to go home
At the end of the surgery 2 catheters are inserted to help keep the bladder empty during the healing process so that urine does not leak between the stitches. Typically, one catheter comes out the stoma and one is either a urethral catheter or a suprapubic catheter that comes out the abdominal wall. Both are removed one month after surgery and the person is taught to catheterize their bladder to empty it. Both catheters will be attached to their own bag after surgery. By the time you go home we may cap or plug one of the catheters and keep the other attached to one bag. Whether the catheter is plugged or attached to a bag, it is important to flush (a.k.a., irrigate) both catheters twice a day to remove mucous and prevent clogging of the catheter. The flushing can be done with sterile saline. You will be taught by the nurses and/or doctors how to flush the catheters.
There will be a dressing over your incision after surgery. This will be removed 2 days after surgery and the incision can be left open to air. If there are staples then these will be removed about 2 weeks after surgery. If you go home with them then you can arrange to have us or your local doctor remove them.
At the end of surgery, a tube is placed that is on the outside of the bladder and comes through the abdominal wall through a small puncture hole. This tube is called a JP drain and it attaches to a suction cannister that looks like a grenade. The JP drain suctions out any urine or blood that may accumulate outside the bladder; it is removed before the patient leaves the hospital. After removing the drain, a bandage will be placed over the hole and it can be removed in 2 days. The hole in the skin closes on its own in 1-2 days.
At first, it can be hard to move around or transfer out of bed after surgery due to the pain of the incision. But, it is important to try to get back to your baseline level of activity after surgery. By moving around, you help prevent bed sores and pneumonia, and you help wake up the intestines. Physical therapists may see you in the hospital to help you regain mobility. Some people will need to go to a rehabilitation center after the hospital in order to get further help with mobility; the physical therapists will help determine your level of need and their documentation will help ensure that your insurance company will pay for any rehabilitation care you need.