mitrofanoff procedure - royal college of obstetricians and ... · mitrofanoff procedure...

Mitrofanoff Procedure

• 1980 Mitrofanoff reported use of appendix to attain continence in 16 children

• Produced a continent catheterizable vesicostomy stoma

• Implanted appendix into bladder wall via a subepithelial antirefluxing tunnel

• In conjunction with closure of the bladder neck


• Originally intended for children with

adequate bladder capacity without

functional urethral access

• Modified to include bladder augmentation

when small capacity poorly compliant

bladders (Weisgerber)

• Duckett & Snyder (1986) ileocecal reservoir

with appendiceal stoma


• Technique:

– Appendix mobilized on mesentery preserving

blood supply

– Bladder neck transected and closed unless

external sphincter is competent (pop off valve)

– Appendix implanted into 4 - 5 cm subepithelial

tunnel

– Bladder augmentation used when capacity

limited


• Technique:

– Bladder is anchored to anterior abdominal wall

to ensure ease of catheterization

– Appendix base is exteriorized and sutured to

skin

– Appendix intubated with 12F catheter for 2

weeks


• Indications for Mitrofanoff

– Intractable incontinence due to:

• Neuropathic Bladder

– Spinal Dysraphism

– Spinal Neuroblastoma

• Genitourinary Malformations

– Imperforated Anus

– Cloacal Anomalies

– Exstrophy - Epispadias Complex


• Mitrofanoff reviewed long term results with

continent vesicostomies minimum 15 year

follow-up in 23 patients. 20 appendices, 2

ureter, 1 bladder tube

• Bladder augmentation 2 simultaneously, 8

later secondary procedure

• 5 patients had vesicoureteric reflux


• Results:

– 1 death - post op infection - VP Shunt infection

– No metabolic disorders, malignancy, or

perforation

– 5 leakage bladder neck

– Renal deterioration - 10 - enterocystoplasty 6,

urinary diversion 4

– Bladder stones - 5 - 2 prior augmentation


• Results:

– Stomal complications - stenosis or leakage

requiring revision - 11 and 1 noncontinent

diversion after revision

– After 10 years complications rare

– 16 patients stable and 6 noncontinent diversion


• Results do not appear ideal, complications

occurred early during learning phase, no

diversions necessary since 1984

• Procedure that has a lasting efficiency


• Reservoir complications - upper tract

deterioration early on in 4 and 1 due to

bladder calculi and slight upper tract change

• After 1982 - 5 bladder augmentation with

ileal segment - normalized upper tracts

• 1 case progressive renal deterioration, died

in end stage renal disease not compliant

with catheterization


• Bladder Neck Recanalization - Repeat

procedure in 5 of 21 persistent leakage

• Vesicoureteral Reflux often due to high

vesical pressure, usually requires augment

and or ureteral reimplantation

• Bladder Lithiasis usually requires open

cystolithotomy as bladder neck closed


• Small bowel obstruction -5 due to adhesions

in 2 and volvulus around vascular pedicle in

3

• Appendix necrosis 1 complete (obesity) and

one partial

• Stomal stenosis - 9 - 10 dilatations and 14

revisions


• Continence achieved in >90 in most

published series independent of whether

appendix, ureter, or tapered ileum is used

• Stomal stenosis 12-30 % simple dilatation

may work, often need surgical revision,

injection triamcinolone may help, V flap

advancement into stoma appears to decrease

incidence


• Bladder reconstruction necessary when poor

capacity, poor compliance and potential for

upper tract deterioration exists

• Augmentation provides increased capacity

and may be performed with catheterizable

channels to facilitate bladder emptying


• No ideal substitute for bladder augment

• Enterocystoplasty associated with• infection perforation

• mucous production intestinal obstruction

• electrolyte abnormalities lithiasis

• potential carcinogenicity


• Principle extrapolated to create continent

stomas using:• Distal ureter (Weingarten & Cromie)

• Fallopian Tube (Woodhouse et al)

• Tapered ileum (Monti et al)

• Bladder wall (Rink et al)

• Cecostomy (Malone)


• Demucosalized augments without urothelial

preservation results in fibrosis of the

augment and/or re-growth of the intestinal

mucosa and its inherent problems


• Demucosalized gastric patch with urothelial

preservation prevents acid secretion and the

resultant hematuria dysuria syndrome and

alkalosis

• Auto-augmentation with detrusorrhaphy

with peritoneal covering of urothelium has

not led to improvement of bladder

compliance or capacity


• In patients with intractable fecal

incontinence, the Mitrofanoff principle may

be used to construct a continent conduit to

the bowel (MACE) to administer enemas in

an antegrade fashion into the cecum to clean

out the large bowel to attain continence

• Appendix , ileum, or cecostomy button have

been used


• Using the MACE procedure fecal

incontinence rates and satisfaction has been

reported approaching 100

• In patients with both fecal and urinary

incontinence, we usually use the appendix

for the cecostomy and use a small piece of

ileum for the vesicostomy


• Monti described use of a transversely

retubularized short segment of ileum for the

Mitrofanoff stoma in those patients without

an appendix or those requiring both a

MACE stoma as well as a continent

vesicostomy


• Successful outcome of the Mitrofanoff

procedure relies upon careful surgical

technique and attention to detail

• Postoperative nursing care is essential,

catheters are left indwelling 3 - 4 weeks to

ensure proper healing of the stomas

• Elevation of the catheter tubing 25 cm

above the bladder assures urothelial

adherence to the demucosalized augment


• Such procedures have revolutionized the

lives of many of our patients as they are

now quite independent,dry,and clean

• We are far from free of complications and

several patients have required revisions of

their stomas and bladder neck closures

• In addition we have had to revise 6

vesicostomies for urine leaks


• Our urinary continence rate is 100% after

vesicostomy and bladder neck revisions

• Several patients are still having

catheterization problems which we will

have to correct

• Overall we are encouraged to continue with

the use of the Mitrofanoff Procedure

mitrofanoff procedure - royal college of obstetricians and ... · mitrofanoff procedure...

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