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REVIEW ARTICLE
Year : 2002  |  Volume : 19  |  Issue : 1  |  Page : 4-8
 

Mitrofanoff procedure: A versatile method of continent catheterisable urinary diversion


Department of Urology & Kidney Transplantation, Institute of Kidney Diseases and Transplantation Sciences, B.J. Medical College & Civil Hospital Campus, Asarwa, Ahmedabad, India

Correspondence Address:
Tejanshu P Shah
65- B, Swastik Society, Navrangpura, Ahmedabad
India
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   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 2014 Aug 22];19:4-8. Available from: http://www.indianjurol.com/text.asp?2002/19/1/4/21073



   Introduction Top


The creation of continence mechanism that utilized the flap-valve principle was first introduced by Dr. P. Mitro­fanoff (1980) [1] 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). [2] The operative technique is straightforward and has been equally successful in many different hands (Monfort et al 1983). [3]

Hodges, A.M. (1994) [4] 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 Top


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 Top


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 Top


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 Top


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). [5] 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). [6]

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) [7] 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) [8] 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). [9]

The continence rate in the present series was excellent (100%) and close to that reported by Sumfest et al (1993), [10] Elder et al (1992), [11] and Monfort et al (1984). [3]

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). [12] 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 Top


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 Top

1.Mitrofanoff P. Cystostomie continent trans-appendiculaire dansle traitement des vessies neurologiques. Chir Pediatric 1980; 21: 297.   Back to cited text no. 1    
2.Duckett JW, Synder HM. Continent Urinary diversion : Variations on the Mitrofanoff principle. J Urol 1986: 135: 58-62.  Back to cited text no. 2    
3.Monfort G, Guys JM, Lacombe M. Appendicovesicostomy : an al­ternative urinary diversion in the child. Eur Urol 1984; 10: 361-3.  Back to cited text no. 3    
4.Hodges AM. The Mitrofanoff urinary diversion for complex vesi­covaginal fistulae : experience from Uganda. BJU International 1999; 84: 436-439.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Lapides J, Dionko AC, Gould FR, Lowe BS. Further observations on self-catheterization. J Urol 1976; 116: 169-71.  Back to cited text no. 5    
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.  Back to cited text no. 6    
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.  Back to cited text no. 7    
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.  Back to cited text no. 8  [PUBMED]  
9.Cromie WJ, Barada JH, Weingarten JL: Cecal tubularization: Lengthening technique for creation of catheterizable conduit. Urol­ogy 1991; 37: 41.  Back to cited text no. 9    
10.Sumfest JM, Burns MW, Mitchell ME. The Mitrofanoff principle in urinary reconstruction. J Urol 1993; 150: 1875-7.  Back to cited text no. 10  [PUBMED]  
11.Elder JS. Continent appendicocolostomy : A variation of the Mitrofanoff principle in pediatric urinary tract reconstruction. J Urol 1992; 148: 117-9.  Back to cited text no. 11  [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.  Back to cited text no. 12    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1]



 

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    Abstract
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    Technique
    Results
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