Vesicostomy is a temporary surgical procedure in which a small opening is created between the bladder and the surface of the skin of the lower abdomen, allowing urine to drain freely from the bladder without having to pass through the urethra at all. In a baby with posterior urethral valves whose urethra is too narrow to allow the cystoscope to pass safely, the vesicostomy is the alternative that provides the same essential benefit as immediate endoscopic ablation: it removes the back-pressure on the kidneys by giving the urine a route out of the bladder that bypasses the obstruction entirely. The urethra of a very small or premature newborn male is an extremely narrow structure. The smallest paediatric cystoscopes are designed to pass safely in newborns of sufficient size, but attempting to pass even the smallest instrument through a urethra that is not ready for it risks urethral injury, scarring, and stricture formation, which would create a new and permanent obstruction on top of the one being treated. The safer clinical decision in these situations is the vesicostomy, which protects the kidneys immediately without the risk of urethral injury. The vesicostomy is a small surgical operation under general anaesthesia that takes approximately 30 to 45 minutes. The opening created is deliberate and controlled: it is not a wound or a complication, but a planned diversion. Urine drains through this opening into a nappy in the usual way, and the baby is otherwise managed normally. As the baby grows and the urethra reaches the diameter that allows the cystoscope to pass safely, endoscopic valve ablation is performed, and after the ablation has healed and the urinary flow through the urethra is confirmed to be normal, the vesicostomy is surgically closed. The entire sequence is planned from the beginning: the vesicostomy is not a failure to do the right operation, it is the right operation for this specific baby at this specific size. At Vatsalya Children Hospital, Varanasi, the decision between immediate endoscopic ablation and temporary vesicostomy is made on the individual baby's size, urethra calibre, and overall clinical stability, with the single goal of protecting the kidneys from further damage in the safest way available for that particular baby.
Written by Dr. Greeshma Suresh, MBBS, MS General Surgery, MCh Paediatric Surgery (Institute of Medical Sciences, Banaras Hindu University), Paediatric Surgeon, Vatsalya Children Hospital, Varanasi 221002. Phone: +91 9838585111.
