|Year : 2002 | Volume
| Issue : 1 | Page : 4-8
Mitrofanoff procedure: A versatile method of continent catheterisable urinary diversion
Tejanshu P Shah, Kiritpal Vishana, Prakash Ranka, Himanshu Shah, Rajesh Choudhary
Department of Urology & Kidney Transplantation, Institute of Kidney Diseases and Transplantation Sciences, B.J. Medical College & Civil Hospital Campus, Asarwa, Ahmedabad, India
Tejanshu P Shah
65- B, Swastik Society, Navrangpura, Ahmedabad
| Abstract|| |
Objective: Our aim is reappraisal of Mitrofanoff principle in a wide array of diverse clinical situations like pelvic tumors, myelodysplasia, irreparably damaged urethra and sphincters and with total bladder substitution.
Materials and Methods: 24 patients underwent the construction of a continent catheterisable stoma based on the Mitrofanoff principle between February 1990 to December 2000 for various etiologies. Youngest patient was 4 years old and the oldest patient was 54 years of age. The conduit was constructed using appendix in all patients.
Results: Stomal continence was achieved in all 24 patients (100%). Difficulty in catheterisation was most frequent late complication encountered in 4 patients (16.6%). 3 patients (12.45%) developed stones in reservoir
Conclusions: Mitrofanoff procedure is a versatile technique. The extension of this principle can provide continence mechanism to variety of patients, with or without total or partial substitution of bladder, in whom there is no usable urethra or sphincter or both.
Keywords: Mitrofanoff Principle; Urinary Tract Reconstruction; Urinary Diversion
|How to cite this article:|
Shah TP, Vishana K, Ranka P, Shah H, Choudhary R. Mitrofanoff procedure: A versatile method of continent catheterisable urinary diversion. Indian J Urol 2002;19:4-8
|How to cite this URL:|
Shah TP, Vishana K, Ranka P, Shah H, Choudhary R. Mitrofanoff procedure: A versatile method of continent catheterisable urinary diversion. Indian J Urol [serial online] 2002 [cited 2015 Mar 6];19:4-8. Available from: http://www.indianjurol.com/text.asp?2002/19/1/4/21073
| Introduction|| |
The creation of continence mechanism that utilized the flap-valve principle was first introduced by Dr. P. Mitrofanoff (1980)  In last two decades, since his initial report, the procedure that bears his name has been utilized successfully to provide continent catheterisable stoma to patients with neuropathic bladder dysfunction, exstrophy epispadias complex, pelvic malignancies and boys with posterior urethral valve and prune-belly syndrome.
The extensions of Mitrofanoff principle have permitted the continent reconstruction of the lower urinary tract in a wide variety of situations (Duckett and Synder, 1986).  The operative technique is straightforward and has been equally successful in many different hands (Monfort et al 1983). 
Hodges, A.M. (1994)  reported Mitrofanoff urinary diversion in 7 women with severe persistent incontinence due either to complex VVF or severe bladder and urethral destruction or stress incontinence, in whom all other attempts to restore continence had failed.
We herein report our experience with continent catheterisable stoma based on the Mitrofanoff principle with an endeavor to explore the utility of this versatile procedure in different subsets of patients.
| Materials and Methods|| |
Mitrofanoff urinary diversion was performed in 24 patients (13 males and 11 females) between February 1990 and December 2000. 16 patients had myelodysplasia and neurogenic bladder, 4 adult patients had untreated exstrophy epispadias complex with squamous metaplasia which required cystectomy plus total bladder substitution. One female patient had neurofibromatosis of pelvis and perineum. Two male patients had undergone multiple failed attempts at urethroplasty following traumatic rupture of posterior urethra [Figure - 1]. One female patient had urethral avulsion following fracture pelvis with multiple failed attempts at repair. The youngest patient was 4 years old and the oldest patient was 54 years of age [Table - 1].
Pre-operative evaluation included intravenous pyelogram to assess upper tract functioi. whereas a voiding cystourethrogram was done to assess the presence or absence of vesico-urethral reflux. Urodynamic evaluation was done to determine functional bladder capacity, bladder compliance and outlet resistance at the bladder neck so as to make rational treatment decisions.
| Technique|| |
4 patients with adult exstrophy and squamous metaplasia underwent cystectomy and substitution cytoplasty with Mitrofanoff procedure [Figure - 2]. Concomitant augmentation cytoplasty was done in 5 cases of neurogenic bladder, closure of bladder neck was done in 9 patients with neurogenic bladder.
In all patients, appendix was used as the conduit for self-catheterisation, adding a tubularised strip of caecum (2 cases) to provide additional conduit length. Bladder was used as a urinary reservoir in 20 patients. In 4 patients Mainz I (Ileo-caeco-colonic pouch) was the reservoir. A submucosal tunnel was created in the bladder or reservoir. The appendix on its intact vascularized pedicle was reversed and inserted into it or implanted in continuity with Mainz I pouch. A stoma was constructed at a convenient point in the right iliac fossa. To ensure a short straight conduit the bladder adjacent to the entrance of appendix was secured to the abdominal wall.
A well-lubricated 10 or 12F catheter was kept in conduit during implantation and during different degrees of bladder filling, to ensure a smooth curve and easy catheterization. After bladder closure, bladder was filled through suprapubic tube to test the competency of the flapvalve mechanism and leakage. Postoperatively, suprapubic cystostomy tube and 8-10 F catheter (stented across the continent efferent tube) were left indwelling.
A cystogram or pouchogram was performed after 2 weeks [Figure - 3]. In the absence of leak, the stent was removed and patient was taught how to catheterize stoma. Suprapubic tube was removed once the patient could demonstrate proficiency in CSIC. IVU was performed during follow-up to assess upper tract function [Figure - 4].
| Results|| |
Stomal continence was achieved in all 24 patients (100%). Out of 24 patients, 4 (16.6%) encountered difficulty in catheterization. 1 of these patients had mild stomal stenosis and was benefited by intermittent dilation whereas 2 patients (8%) required surgical revision for stomal stenosis. 1 patient had endoscopic incision followed by indwelling 10 F catheter for one week. Stoma] prolapse, conduit stenosis or necrosis occurred in none of the patients. Therefore, the overall revision rate was 8%. 3 patients (12.45%) developed stones, which were effectively removed by percutaneous method, as stone burden was low. Mean follow-up was 4 years (range 6 months to 10 years).
| Discussion|| |
Augmentation cystoplasty and CSIC in combination is a safe and acceptable method for bladder emptying and achieving continence in children with neurogenic bladder (Lapides et al, 1976).  However, there are limitations to the successful use of CSIC. Many patients with neurogenic bladder dysfunction lack the manual dexterity required to catheterize the urethra adequately. Many boys with intact urethral sensation are reluctant to instrument their native urethra as they find it unpleasant.
Obese females also face difficulty in catheterizing their native urethra. Severe congenital or orthopaedic anomalies, leg braces and wheelchair dependence also impair catheterization. Construction of continent catheterizable abdominal stoma based on Mitrofanoff principle has been successful in these patients.
The Mitrofanoff neourethra concept has been proved to be extremely versatile. The neourethra has been implanted into bladder, colon, and stomach with equal efficiency (Sheldon and Gilbert 1992). 
The type of reservoir is, therefore, irrelevant.
The vermiform appendix, if available, is found to be the best choice to construct the conduit. It has a good vascular pedicle. Its wall is compliant and thin enough to allow easy submucosal implantation. Sozer et al (1997)  also concluded that the complication rate is lower when appendix is used as compared to non-appendicular conduits. They found difficulty in catheterization of the conduit in 25% of patients when appendix was used and in 86% of patients when appendix was not used. In the present series difficulty in catheterization was encountered in 16% of patients. It has been shown that the appendix has a leak point pressure upto 50 cm. H 2 O (Marshal et al, 1995)  and this can contribute to the continence mechanism of the Mitrofanoff conduit.
If the appendix is not of adequate length, a segment of caecum may be taken with the appendix and tubularized to extend the proximal end of the conduit (Cromie et al 1991). 
The continence rate in the present series was excellent (100%) and close to that reported by Sumfest et al (1993),  Elder et al (1992),  and Monfort et al (1984). 
Urolithiasis was another common complication. Daily irrigation of the bladder to avoid excessive mucus accumulation and stone formation has been shown to be effective (Ruiz et al, 1996).  Albeit all patients were advised to perform daily irrigation of reservoir nonetheless 3 patients (12.45%) developed stones.
In the present series, Mitrofanoff procedure was offered to 2 male patients with pelvic fracture and rupture urethra who had undergone multiple failed attempts at urethroplasty. This subset of patients has a marked social impact on their quality of life owing to prolonged suprapubic diversion with its attendant complications. The Mitrofanoff urinary diversion is a viable option in this group of patients. Both our patients have tolerated this procedure very well and are now contented. Therefore, urinary diversion in these patients should not be taken as a defeat by the genito-urinary surgeon. Rather in the best interest of the patient eventually the experienced surgeon must admit when all attempts to obtain continence have failed and consider Mitrofanoff diversion which still leaves an option open for further urethral reconstruction in future. Similarly, Mitrofanoff urinary diversion was offered to a female with fracture pelvis in whom attempts at urethral repair failed. We deem that in this setting of irreparable urethral damage, Mitrofanoff diversion is a well-tolerated and very successful procedure.
4 patients in the present series had exstrophy of bladder who were untreated in childhood because of socio-economic reasons and attained adulthood. Biopsy of their bladders showed squamous metaplasia and early premalignant changes. These patients underwent cystectomy and total bladder substitution by Mainz I pouch (Ileo-caeco-ascending colonic pouch) and appendix was used in continuity creating submucosal tunnel in caecwn to provide continent catheterizable conduit.
| Conclusions|| |
Mitrofanoff principle is applicable to a wide array of diverse clinical situations. In patients with neurogenic bladder, myelodysplasia and pelvic neoplasia the procedure is used to provide catheterisable conduit as an alternative to urethral catheterization. It is also useful with total bladder substitution (Mainz I pouch) to provide continent mechanism. Mitrofanoff principle has permitted the continent reconstruction of the lower urinary tract when a patient has no usable urethra or urethral sphincters. Hence, this versatile procedure can be of significant benefit to patients with urethral injuries in whom multiple attempts at urethroplasty have failed. This procedure makes such patients tubeless, renders them continent and allows them to return to normal social activities.
Appendix appears to be the best source for reconstructing the conduit with excellent stoma] continence (100%). We envisage that Mitrofanoff diversion is a well-tolerated, very successful and simple procedure. However, pre-operative counseling regarding the need for life-long CSIC and irrigation of reservoir is mandatory, where augmentation or substitution cystoplasty was done.
| References|| |
|1.||Mitrofanoff P. Cystostomie continent trans-appendiculaire dansle traitement des vessies neurologiques. Chir Pediatric 1980; 21: 297. |
|2.||Duckett JW, Synder HM. Continent Urinary diversion : Variations on the Mitrofanoff principle. J Urol 1986: 135: 58-62. |
|3.||Monfort G, Guys JM, Lacombe M. Appendicovesicostomy : an alternative urinary diversion in the child. Eur Urol 1984; 10: 361-3. |
|4.||Hodges AM. The Mitrofanoff urinary diversion for complex vesicovaginal fistulae : experience from Uganda. BJU International 1999; 84: 436-439. [PUBMED] [FULLTEXT]|
|5.||Lapides J, Dionko AC, Gould FR, Lowe BS. Further observations on self-catheterization. J Urol 1976; 116: 169-71. |
|6.||Sheldon CA, Gilbert A. Use of the appendix for urethral reconstruction in children with congenital anomalies of the bladder. Surgery 1992; 112: 805-812. |
|7.||Sozer O, Vates TS, Freedman AL. Results of the Mitrofanoff procedure in urinary tract reconstruction in children. British Journal of Urology 1997: 79: 279-282. |
|8.||Marshall IY, Bissada NK. Study of unaltered in situ appendix as a native continence mechanism : Cadaveric and clinical correlation. J Invest Surg 1995; 8: 147-52. [PUBMED] |
|9.||Cromie WJ, Barada JH, Weingarten JL: Cecal tubularization: Lengthening technique for creation of catheterizable conduit. Urology 1991; 37: 41. |
|10.||Sumfest JM, Burns MW, Mitchell ME. The Mitrofanoff principle in urinary reconstruction. J Urol 1993; 150: 1875-7. [PUBMED] |
|11.||Elder JS. Continent appendicocolostomy : A variation of the Mitrofanoff principle in pediatric urinary tract reconstruction. J Urol 1992; 148: 117-9. [PUBMED] |
|12.||Ruiz E, Castellan M, Anichiarico J, Puigdevall JC, Denes ED, Badiola FIR Prevention of bladder lithiasis after bladder augmentation in children. J Urol 1996; 485'A, abstract 700. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1]