The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results

Outcomes according to channel type for continent catheterizable channels in patients undergoing simultaneous urinary and fecal reconstruction

INTRODUCTION

When creating a continent catheterizable channel (CCC) the choice of bowel segment used as the conduit should be tempered with the morbidity associated with it. The split-appendix technique allows the creation of both a urinary and fecal CCC without the need for a bowel anastomosis. However, there is concern that by splitting the appendix there is compromise to its blood supply and may affect outcomes. We aim to compare what affect the bowel segment used for urinary and fecal CCCs has on perioperative and long-term outcomes in patients undergoing simultaneous urinary and fecal reconstruction.

METHODS

A retrospective review was performed analyzing all patients that underwent simultaneous continent catheterizable urinary and fecal CCC between the years 2010-2016. Patient demographics, channel characteristics, perioperative complications and clinical success rate were analyzed.

RESULTS

A total of 106 patients were identified that had simultaneous fecal and urinary CCC created at time of reconstruction. For urinary CCC, there were 64 patients (60.4%) that underwent a split-appendix technique, 27 patients (25.4%) underwent a Monti, and 15 patients (14.2%) had the appendix used only for the urinary channel. Those patients undergoing a split-appendix technique had median operative time of 447 min compared to 619 min when a Monti channel was created. The median length of hospital stay was 9 days for the split-appendix technique compared to 12 and 13 day median hospital stay when the appendix was used only for the urinary channel or a Monti was created, respectively. There was no difference seen in revision free survival of the channel following surgery of any of the channels with median follow-up of 44.5 months. However, there were more subfascial revisions of urinary CCC in those that underwent a Monti (5 patients, 18.5%) compared to other bowel segments (0 patients).

CONCLUSIONS

Utilizing a split-appendix approach for creation of urinary and fecal CCCs does not affect 30-day complications or long-term revision rates compared to other established techniques. This technique minimizes the potential surgical morbidity of a bowel anastomosis and provide shorter operative times, when feasible, at time of simultaneous creation of fecal and urinary CCC.

The Double Dutch technique: A new way of creating an ileocystoplasty with a lengthy catheterizable ileal tube

INTRODUCTION

A tubularized conduit from an open 2-cm vascularized ileal segment is a frequently used technique to create a continent catheterizable channel in cases of an inappropriate or absent appendix. In the long term, many patients experience catheterization problems with the classic ileal segment tube, and even more with spiral or double-segment tubes.

OBJECTIVE

The objective of this paper was to introduce an ileocystoplasty modification combined with a long ileal segment tube that has better support by surrounding tissue than other lengthy ileal segment tubes. Briefly summarized, this newly introduced method begins with isolating approximately 30 cm of ileum and dividing it into two parts. Two strips are then created and closed as a double-length tube. The ileal segments are opened antimesenterically and closed over the tube in the middle. The lower part of the tube is implanted with a submucosal tunnel in the bladder wall, and the ileal patch is then anastomosed with the bladder. The tube is anastomosed to the umbilicus in an ordinary way without any traction (see Summary Fig.).

STUDY DESIGN

Between May 2005 and November 2012 the new technique was used at the current institution in nine children who needed an ileocystoplasty (mean age: 9 years and 3 months). Underlying etiology was neurogenic bladder in seven cases and epispadias in two.

RESULTS

All patients ultimately had stomas without leakage or strictures. During follow-up, three of nine tubes developed stenoses that were corrected; four stomas in total had some sort of surgical revision. Median follow-up was 93 months. Intermittent catheterization was uncomplicated in all at this time.

DISCUSSION

With this modification of the standard technique it seemed to be possible to create a more stable channel. The blood supply of the tube was secured by completely embedding the mesentery of the tube. Limitations included the small number of patients treated so far.

CONCLUSION

The lengthy tubes appeared to be straight and well supported by the surrounding tissues, which prevented kinking and sacculation. It is hoped that this technique will have better results and fewer complications at long-term follow-up.

Does endoscopy of difficult to catheterize channels spare some patients from formal open revision?

INTRODUCTION

Patients with continent catheterizable channels (CCC) may develop difficulty catheterizing postoperatively. In complex cases, endoscopic evaluation with indwelling catheter placement may be indicated, but the risk factors for subsequent formal channel revision are not well defined. The purpose of this study was to determine the risk factors for formal channel revision after attempted endoscopic management of difficulty catheterizing.

MATERIALS AND METHODS

We performed an IRB-approved retrospective review of pediatric (<21 years old) patients undergoing CCC construction at our institution from 1999 to 2014 to identify patients who underwent endoscopy for difficulty catheterizing. Fisher's Exact test was used for categorical data and Mann-Whitney U test for continuous variables to examine the association between endoscopic intervention and subsequent formal revision.

RESULTS

Sixty-three of 434 patients (14.5%) underwent at least one endoscopy for reported difficulty catheterizing their CCC, with 77.8% of these requiring additional intervention during endoscopy (catheter placement, dilation, etc.). Of these, almost half with functioning channels (43.5%, 27/62) were managed successfully with endoscopy without formal revision; six (22.2%) of whom underwent more than one endoscopy. These 27 patients continued to catheterize well at a median follow-up of 3.2 years (interquartile range 2.0-6.0). Patients requiring revision had a median of 1.7 years between CCC creation and first endoscopy, versus 1.6 years in those who were not revised (p = 0.60). There was no statistically significant difference between revised and non-revised channels in terms of patient age at CCC creation, underlying patient diagnosis, status of bladder neck, stomal location, or channel type (p ≥ 0.05) (see Table).

CONCLUSION

Approximately half of our patients did not require a formal channel revision after endoscopic management. We did not identify any specific risk factors for subsequent formal revision of a CCC. We recommend performing at least one endoscopic evaluation for those with difficulty catheterizing prior to proceeding with formal open revision.

Evoluting the invaginated--one step closer to the perfect valve? Modified serosal lined tapered ileum (Kälble's procedure) as a continence mechanism for catheterizable pouches

INTRODUCTION

A sufficient and easily catheterizable continence mechanism is essential in continent cutaneous pouches. Kälble embedded a tapered ileum as efferent segment into a serosal lined tunnel formed by an ileal 'U' according to the principle of Abol-Enein and Ghoneim. We report a modified technique applied in a series of 12 patients who had undergone different urinary diversions.

METHODS

All patients received a modified Kälble procedure (first-line urinary diversion, n = 8; revision/undiversion, n = 4) for different forms of continent pouches. To alleviate embedding of the efferent segment, ileal detubularization was performed asymmetrically. Mean follow-up was 9.5 months.

RESULTS

All patients were continent and performed self-catheterization easily. Of 12 patients, 2 underwent endoscopic incision for stomal stenosis 8 and 12 months postoperatively.

CONCLUSIONS

Subject to our short follow-up, Kälble's technique is a promising alternative in patients undergoing a continent cutaneous urinary diversion but offers an inapplicable or missing appendix.

Use of cutaneous flap for continent cystostomy (daoud technique)

PURPOSE

We present the results of a new technique using a pedicled cutaneous flap for continent cystostomy.

MATERIALS AND METHODS

A total of 15 boys and 8 girls (mean +/- SD age 13.4 +/- 6.4 years) underwent continent cystostomy for neurogenic bladder (20), bladder exstrophy (2) and sequelae of hypospadias (1) between 1999 and 2008. In this procedure a rectangular pedicled flap is surgically elevated from a hairless area on the abdomen. The flap is tubularized and passed through the anterior abdominal wall directly into the bladder. A submucosal detrusor incision is made to expose the bladder mucosa, and the distal part of the flap is anastomosed to the bladder mucosa in a circular manner. The tube is positioned along the incised detrusor, which is closed over. Viability of the flap, self-catheterization management and continence status are then evaluated.

RESULTS

Mean +/- SD followup was 4.5 +/- 3.1 years. There was 1 case of distal necrosis of the flap, which required a secondary surgery using the Mitrofanoff technique. The 22 remaining flaps were initially viable, although 2 patients were eventually lost to followup and 3 subsequently presented with false-passage incidents requiring a few days of calibration using a balloon catheter. Dryness was achieved immediately in 73% of the cases. After adding a complementary bulking agent the dryness rate reached 77%.

CONCLUSIONS

We present a novel approach to continent cystostomy that is safe and easy to perform. This technique is a less invasive and more efficient alternative to other commonly used approaches.

[Outcomes the Mitrofanoff technique in the management of patients with neurogenic bladder: the experience in the San Vicente de Paul Universitary Hospital]

INTRODUCTION

The care for children with neurogenic bladder, should be integral, multidisciplinary look to preserve renal function and to accomplish urinary and fecal continence, achieving that the patient becomes self-sufficient and useful to society.

METHODS

The result of the use of the Mitrofanoff technique for the treatment of patients with neurogenic dysfunction bladder used in the HUSVP 1998-2003, and the current condition of the patients with respect to their illness and treatment are described in this article. A descriptive retrospective study 1998-2002 and a prospective study during 2003 were done, in which a series of cases were analyzed.

RESULTS

41 patients had surgery. Average age 10.2 years; average follow-up time 27.2 months; the most frequent illness was myelomeningocele (46.3%) and 46.3% had dysinergic bladder. Bladder augmentation was performed on 63.3%, of which 71.4% were constructed with ileum. A surgical intervention of the bladder neck was done on 51.2%. A continent conduct (Mitrofanoff) was performed on 95.1% of the patients with complete continence 70.4%, complete incontinence 14.6% and occasional incontinence 14.6%. 31.7% had Malone surgery with adequate fecal management on 90.2%. 19% of the stomas presented stenosis and 21.9% presented urine leakage. 80% reached appropriate social adaptation.

CONCLUSIONS

The continent catheterizable stomas are useful for the treatment of urinary and fecal incontinence. The conducts constructed with ileum had more complications than the conducts done with cecal appendix, which is why the appendix is the choice tissue to perform the continent catheterizable stomas, as long as it is available.

Experimental use of labial mucosa free graft urinary conduit in the Mitrofanoff principle

PURPOSE

One method of treating urinary incontinence is to create a catheterizable and continent vesicostomy by the Mitrofanoff principle, based on the use of a conduit, which in the original method is the appendix. The authors present an experimental technique in which a continent vesicostomy is created by the Mitrofanoff principle, using a conduit made of a labial mucosa free graft.

METHODS

Six 30-day-old pigs underwent surgery to create a continent vesicostomy by the Mitrofanoff principle. A tube, made of labial mucosa free graft from the lower lip, was used. The labial mucosal conduit was anastomosed to the bladder mucosa. The tunnel was then prepared, part of which passed through the fibers of the right rectus muscle. The conduit was taken through the tunnel and anastomosed to the skin in the right iliac fossa.

RESULTS

Fifty days after the operation, the vesicostomy was continent, pervious, and easily catheterizable in 5 animals. In the sixth pig, the cystostomic tube did not graft successfully because it was infected.

CONCLUSIONS

A number of investigators have extrapolated Mitrofanoff method using the ileum, the ureter, or others. The use of a tube made by labial mucosa free graft is an easily performed technique, and as with the Mitrofanoff method, continence and easy catheterization are successfully achieved.

Bladder-sparing surgery and continent urinary diversion using the appendix (Mitrofanoff procedure) for urethral cancer

We performed bladder-sparing surgery and continent urinary diversion in two patients with urethral cancer. The first patient was a 58-year-old man with bulbomembranous urethral cancer (squamous cell carcinoma, cT2N0M0). The second patient was a 77-year-old woman with urethral cancer invading the vaginal wall (transitional cell carcinoma with squamous cell carcinoma, cT3N0M0). After bladder-sparing urethrectomy, continent urinary diversion with appendicovesicostomy (Mitrofanoff procedure) was performed in the both patients. More than 4 years after the surgery, both patients were continent, had no trouble with catheterization, and experienced no recurrence of cancer. Bladder-sparing surgery and urinary diversion based on the Mitrofanoff procedure can be considered for appropriately selected patients with urethral cancer.

Hemi-T pouch modification for pediatric urinary diversion

PURPOSE

When the appendix is unavailable, there are limited reliable methods for continent urinary diversion. After successful application of double-T pouch urinary diversion in adults we modified the technique for bladder augmentation and continent diversion.

MATERIALS AND METHODS

A 10-year-old male underwent bladder augmentation and continent urinary diversion with a hemi-T augment. Modifications of the T pouch technique are described in detail. We also reviewed the literature on tapered ileal diversions, such as the Yang-Monti procedure.

RESULTS

One year after surgery the patient was continent. He was free of infection and bilateral hydronephrosis resolved. Urodynamics demonstrated a continent 350 ml reservoir without reflux.

CONCLUSIONS

For patients who require concomitant bladder augmentation and continent diversion a hemi-T augment is a suitable option when the appendix is unavailable. It is especially true when there is minimal bladder available for implantation of a Yang-Monti conduit.

Concealed umbilical stoma: long-term evaluation of stomal stenosis

PURPOSE

The technique of forming a concealed umbilical stoma has been described previously and includes a posterior umbilical flap for improved cosmesis and stenosis prevention. We assessed long-term stomal stenosis.

MATERIALS AND METHODS

We reviewed retrospectively the charts of 46 patients (mean age at surgery 14 years) of whom 35 had undergone concealed umbilical stoma creation and 11 the Malone antegrade continence enema procedure for continent urinary diversion. Urinary stomas were created from appendix in 20 cases, ileum in 8, sigmoid colon in 5, bladder in 1 and stomach in 1. Malone antegrade continence enema stomas were constructed from appendix in 10 cases and sigmoid colon in 1. A total of 21 patients underwent urinary diversion and augmentation cystoplasty.

RESULTS

At followup of 12 to 84 months (median 3.4 years) 93.5% of patients had an intact stoma with no need for surgical revision. Of the remaining patients 3 (6.5%) required revision of the stoma at skin level for stomal stenosis at 1, 4 and 38 months after initial surgery and 2 had a brief period of indwelling catheterization for correction of stenosis.

CONCLUSIONS

The concealed umbilical stoma technique provides an excellent cosmetic result with a low rate of stomal stenosis in patients requiring intermittent bladder or bowel catheterization.

The Yang-Monti ileovesicostomy: a problematic channel?

OBJECTIVE

To compare the differences in the quality of Mitrofanoff channels created using appendix and re-tubularized small bowel (the Yang-Monti ileovesicostomy). Patients and methods The case-notes were reviewed retrospectively for all patients who underwent a Mitrofanoff procedure using either appendix or small bowel, over a 5-year period from June 1994 to July 1999.

RESULTS

In all, 92 patients underwent 94 Mitrofanoff procedures; the appendix was used in 69 and small bowel in 25. The underlying diagnoses were exstrophy-epispadias complex (38), neuropathic bladder (21), anorectal malformations and cloacal anomalies (15), posterior urethral valves (nine) and miscellaneous (nine). The mean (range) age at operation was 9.2 (1.1-18.3) years. The mean (range) follow-up for the appendix group was 37 (6.7-65) months and for the Monti group 25 (6-66) months. Catheterization problems occurred in 18 (27%) patients from the appendix group; two needed an adjustment of technique, six dilatation and 10 revision. Stomal stenosis occurred in 10 (15%) patients, bladder level stenosis in four (6%) and conduit necrosis in two. Catheterization problems were reported in 15 (60%) patients from the Monti group; five needed revision, three dilatation and seven are being managed conservatively. The incidences of stomal stenosis (four, 16%) and bladder level stenosis (two, 8%) were comparable with the appendix group. In addition, two patients had distal channel (sub-stomal) stenosis and two had mid-channel stenosis. The problem unique to the Yang-Monti channel was a pouch-like dilatation in seven patients (28%), all of whom presented with catheterization problems; five are being managed conservatively and two have needed pouch resection. Stomal prolapse occurred in five (7%) patients in the appendix group, but in none of the Monti group.

CONCLUSIONS

The appendix is the conduit of choice for a Mitrofanoff procedure. Re-tubularized small bowel conduits have a considerably higher incidence of catheterization problems. Anatomical factors may contribute to the unique incidence of pouch formation.

Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital

PURPOSE

We present our experience using the various Mitrofanoff techniques to create a continent catheterizable stoma as an adjunct to continent urinary tract reconstruction in children and young adults.

MATERIALS AND METHODS

Between 1990 and 1998 a Mitrofanoff procedure was performed at our institution in 55 male and 45 female patients with a mean age of 10.5 years. The etiology of incontinence was diverse but more than 90% of the patients had neurogenic bladder, the epispadias-exstrophy complex or a cloacal anomaly. Surgery included appendicovesicostomy in 57 cases, a Yang-Monti ileovesicostomy in 21, continent vesicostomy in 21 and formation of a tapered ileal segment as a catheterizable channel in 1. Simultaneously bladder augmentation was performed in 52 patients, bladder neck reconstruction was done in 48 and a Malone antegrade colonic enema stoma was constructed for fecal incontinence in 17.

RESULTS

The abdominal stoma is continent in 98 of our 100 patients. Mean followup is 2 years (range 2 months to 8 years) with the longer followup in the appendicovesicostomy group. One patient with stomal incontinence who underwent revision is now dry. Postoperative complications requiring an additional procedure developed in 20 patients, including stomal stenosis in 12. Continent vesicostomy was most prone to stomal problems (6 of 21 patients, 29%).

CONCLUSIONS

The Mitrofanoff procedure is a reliable technique for creating a continent catheterizable urinary stoma. Appendicovesicostomy continues to be our first option for this procedure, although we have also had good results with the Yang-Monti ileovesicostomy and continent vesicostomy. These newer options have allowed preservation of the appendix for the Malone antegrade colonic enema stoma procedure in patients with urinary and fecal incontinence.

Clinical applications of the Monti procedure as a continent catheterizable stoma

OBJECTIVES

Monti et al. recently described a technique for the construction of a continent catheterizable conduit using short segments of small bowel in a canine model. We review our experience with 25 adult and pediatric patients in whom the Monti procedure was used in their reconstructive efforts.

METHODS

Since October 1995, 25 patients (13 males and 12 females), aged 4 to 67 years (median 29), underwent the construction of 29 catheterizable stomas with a short (2.5 cm) segment of bowel following the Monti technique. Twenty-seven tubes were created as urinary stomas and two as part of the Malone antegrade continent enema procedure (MACE). Continence is based on the Mitrofanoff flap valve mechanism. Tubes were created when the appendix was unavailable as part of urinary reconstructive efforts or after exenterative oncologic surgery of the lower urinary tract. Tubes were created using ileum (24) and sigmoid colon (5). Ten tubes (34.5%) were done in combination with a simultaneous bowel patch in the same pedicle for bladder augmentation. Tubes were implanted in the ileum (13), bladder (9), sigmoid colon (3), stomach (1), and descending colon (1). The two tubes created to do a MACE procedure were anastomosed into the cecum. Double tubes were necessary in 7 adult patients for adequate length. The length of the tubes varied from 6 to 14 cm.

RESULTS

Follow-up ranged between 3 and 26 months (mean 13). One adult patient (4%) with bladder cancer died of myocardial infarction 14 days postoperatively. Three patients (12%) received a new Monti tube because of ischemic stenosis of the tube. All of them were continent at a follow-up of 1, 6, and 20 months, respectively. Two patients (8%) experienced leakage through the stoma, requiring additional procedures and pharmacologic manipulation to become continent. All patients used intermittent catheterization through the stoma without problems.

CONCLUSIONS

Although the appendix remains the tissue of choice, the Monti procedure has substantial advantages over other efferent catheterizable tubes, including the need for a very short segment of bowel (2.5 cm), adequate lumen size (16F to 18F), length, reliable blood supply, and the versatility to combine with a simultaneous bowel patch in the same pedicle for bladder augmentation.

Initial experience using a catheterizable ileovesicostomy (Monti procedure) in children

OBJECTIVES

To present a review of our experience using the recently described Monti ileovesicostomy as an alternative to appendicovesicostomy as a continent catheterizable stoma in children.

METHODS

Between January and December 1997, a Monti ileovesicostomy was performed as part of a reconstructive procedure in 13 children. Mean patient age was 1 1 years, and diagnosis included neurogenic bladder in 11 patients, cloacal exstrophy in 1, and cloacal anomaly in 1 patient. Simultaneous bladder augmentation was performed in 10 children, bladder neck reconstruction or closure in 7, and Malone antegrade continent enema (MACE) in 4.

RESULTS

All 13 patients have continent stomas (100%) and catheterize the Monti ileovesicostomy without difficulty. Mean follow-up was 7 months (range 1 to 14), and there have been no stomal problems or postoperative complications attributed to the ileal channel.

CONCLUSIONS

The Monti ileovesicostomy is a new technique for creation of a continent catheterizable stoma and has allowed preservation of the appendix for the MACE procedure, providing an additional option in patients with an absent or inadequate appendix. Early results of this technique for pediatric reconstruction have been excellent.

Refashioned short bowel segments for the construction of catheterizable channels (the Monti procedure): early clinical experience

PURPOSE

We report the early results of a new surgical procedure to construct a catheterizable stoma from a small segment of bowel according to the Monti technique.

MATERIALS AND METHODS

Since November 1996, 4 male and 4 female patients with a mean age of 14 years have undergone the Monti procedure in association with other reconstructive efforts. Indications included the unavailability of appendix because of concomitant ACE Malone appendicocecostomy in 2 patients, atretic appendixes in 3, previous appendectomy in 2 and technical difficulties during appendix isolation in 1. In no patient was small bowel used instead of a suitable appendix. Other simultaneous surgical procedures included bladder augmentation in 4 patients in whom the bowel tube and patch for augmentation were created with the same mesenteric pedicle (ileum in 3 and sigmoid colon in 1).

RESULTS

Followup ranged from 3 to 11 months (mean 7). No patient has had difficulty with catheterization or any other problems related to the stoma. In 2 patients stomal leakage required additional procedures and pharmacological manipulation.

CONCLUSIONS

The appendiceal Mitrofanoff procedure remains the technique of choice for the construction of catheterizable continent stomas. In the absence of a suitable appendix a catheterizable bowel conduit based on the Monti technique appears to be the best alternative in our early experience. The short segment of bowel required for conduit construction, excellent blood supply throughout its length, and the possibility of developing the tube and bowel patch for simultaneous augmentation from the same pedicle are some of the clear advantages of this technique.

Construction of continent catheterizable urinary conduit from an isolated segment of colon

BACKGROUND

Continent urinary diversion may be necessary in a range of urological abnormalities. In circumstances where the standard techniques are not possible, alternative innovative techniques may be used.

METHODS

In a female patient with bladder exstrophy, a continent diversion was recommended. The appendix was not available, the ureters were not suitable and a continent stoma was fashioned from an isolated segment of colon.

RESULTS

The stoma proved to be continent, although it was somewhat stenotic. However, clean intermittent catheterization maintained its patency.

CONCLUSIONS

A continent catheterizable stoma may be constructed from a segment of colon. The technique may be considered when other well recognized methods are not feasible.

The Mitrofanoff procedure in paediatric urinary tract reconstruction

BACKGROUND

Urinary tract reconstruction is required in many congenital and some acquired urological conditions in childhood. The majority are managed by clean intermittent catheterization (CIC), for which purpose the appendix or other tubular structure may be used to provide a continent catheterizable abdominal stoma.

METHODS

Between 1991 and 1996, 23 children underwent urinary tract reconstruction of varying complexity together with a continent diversion according to the Mitrofanoff principle. The appendix was used in 14 patients and the ureter in seven. Two patients had previously had an appendicectomy and the ureters were not suitable. One had a catheterizable channel made from an isolated segment of colon and the other had a detrusor tube constructed.

RESULTS

Twelve patients with an appendix conduit, six with a ureteric conduit, and one with a colonic tube are continent, although the latter has had some problems with stomal stenosis. All manage CIC with comfort, the older children doing the procedure themselves. One appendix conduit has stomal incontinence and another was inadvertently divided during renal transplantation. The detrusor tube strictured and was removed.

CONCLUSIONS

A continent abdominal stoma using the Mitrofanoff principle gives reliable results in children and is well tolerated. It should be considered in the management of children undergoing urinary tract reconstruction when CIC is necessary. The appendix is eminently suitable for this purpose but the ureter provides a satisfactory alternative in selected cases. When neither is available, alternative techniques for constructing a catheterizable continent channel may be considered.

Transverse retubularized ileum: early clinical experience with a new second line Mitrofanoff tube

PURPOSE

Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique.

MATERIALS AND METHODS

From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube.

RESULTS

Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization.

CONCLUSIONS

With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.

Transversely tubularized ileal segments for the Mitrofanoff or Malone antegrade colonic enema procedures: the Monti principle

OBJECTIVE

To assess the use of a transverse tubularized segment(s) of ileum in the Mitrofanoff or Malone antegrade colonic enema (MACE) procedures.

PATIENTS AND METHODS

Eleven patients in three centres underwent the formation of a continent conduit to bowel (MACE, eight patients) and/or bladder (Mitrofanoff, four) using either a single segment of transverse tubularized ileum (10 patients) or two segments of ileum anastomosed and tubularized into a single conduit (two).

RESULTS

Within a follow-up of 8 weeks to 6 months, all conduits were continent and catheterized easily. One stomal stenosis required a revision procedure.

CONCLUSION

This method for forming a continent catheterizing conduit, based on the Mitrofanoff principle, appears to be effective and is recommended in cases where the appendix cannot be used or where a second conduit is required.

Urodynamically based modification of Mitrofanoff procedure

This paper reviews our experience with the Mitrofanoff principle as applied in eight patients. Of four patients with post-traumatic urethral stricture, three required the appendix as continent catheterizable conduit, with a modified appendicovesical anastomosis technique-that is, without a submucosal tunnel- and in one patient, the remnant ureter of a previous simple nephrectomy was used. Of the four remaining patients, one with a hypotonic bladder and three with urethral stricture, a complete laparoscopic approach was used to perform the same modified Mitrofanoff procedure with the appendix. With a mean follow-up of 19.5 months, all patients were completely dry. Only three patients had persistently positive urine cultures, but without evidence of renal function impairment. The modified direct appendicovesical anastomosis technique reduces the operative time, has a lower complication rate, and allows us to use a laparoscopic approach with the resulting benefits of a minimally invasive surgical procedure. As shown in urodynamic tests, urinary continence is preserved.

Female bladder exstrophy

Bladder exstrophy is one of the most challenging congenital urinary tract abnormalities. Apart from the open bladder the patient also has various other abnormalities, including urogenital, musculoskeletal and anorectal defects. The size of the exstrophic bladder varies from patient to patient. In the female the clitoris to bifid and the vagina is anteriorly placed. In this paper various aspects of female bladder exstrophy are reviewed in detail, including incidence, etiology, anatomy and clinical features, together with early, medium-term and long-term surgical management. The aim is to achieve a functional bladder closure, although some patients are better off with a urinary diversion. Considering the complexity of the urogenital problems and the surgical management thereof, all patients require lifelong follow-up.

New techniques for construction of efferent conduits based on the Mitrofanoff principle

Presently, urinary diversion with continence mechanisms based on the Mitrofanoff principle is frequently used. For its construction, the critical issue is related to the choice of efferent conduit; the most widely used are the appendix and the tapered ileum. Here, we present two alternative techniques for construction of tubes applicable to the same function. Ten dogs underwent operations with two different types of tubes constructed through transversal tubularization of small segments of ileum. These tubes were implanted in the bladder. The dogs were followed up for 30 days, during which all were continent. Their tubes were easily catheterized. The techniques described met the criteria defined for an efferent tube to be used according to the Mitrofanoff principle.

Concealed umbilical stoma: description of a modified technique

PURPOSE

We describe a technique for creating a concealed umbilical stoma.

MATERIALS AND METHODS

The base of the umbilicus is used as a superiorly based skin flap that is incorporated into the spatulated stoma. Six patients have undergone diversion using this technique. The stoma was constructed from appendix in 4 cases, stomach in 1 and tapered ileum in 1.

RESULTS

All patients achieved an easily catheterizable hidden umbilical stoma, are dry on clean intermittent catheterization and have had no stomatitis or peristomal hernia.

CONCLUSIONS

This technique for creating a concealed umbilical stoma preserves the native appearance of the umbilicus and combines a superior cosmetic result with an easily catheterizable stoma.