Hubbry Logo
Mitrofanoff procedureMitrofanoff procedureMain
Open search
Mitrofanoff procedure
Community hub
Mitrofanoff procedure
logo
8 pages, 0 posts
0 subscribers
Be the first to start a discussion here.
Be the first to start a discussion here.
Mitrofanoff procedure
Mitrofanoff procedure
Mitrofanoff procedure
View on Wikipedia
from Wikipedia
Mitrofanoff procedure
The appendix is used in the Mitrofanoff procedure. The appendix is used to connect the umbilicus to the urinary bladder. The blood supply of the appendix is preserved.[1]
Other namesMitrofanoff appendicovesicostomy

The Mitrofanoff procedure, also known as the Mitrofanoff appendicovesicostomy, is a surgical procedure in which the appendix is used to create a conduit, or channel, between the skin surface and the urinary bladder.[2] The small opening on the skin surface, or the stoma, is typically located either in the navel or nearby the navel on the right lower side of the abdomen.[3] Originally developed by Professor Paul Mitrofanoff in 1980, the procedure represents an alternative to urethral catheterization[4] and is sometimes used by people with urethral damage or by those with severe autonomic dysreflexia.[5] An intermittent catheter, or a catheter that is inserted and then removed after use, is typically passed through the channel every 3–4 hours[6] and the urine is drained into a toilet or a bottle.[6] As the bladder fills, rising pressure compresses the channel against the bladder wall, creating a one-way valve that prevents leakage of urine between catheterizations.[3]

Description of procedure

[edit]

A surgeon creates a small channel using the appendix or in the absence of the appendix, a piece of small bowel.[3] When bowel is used instead of appendix, it is called a Monti procedure.[7] One end of the channel is sewn to the skin, creating an opening on the surface called a stoma.[3] The other end of the channel is sewn to the bladder and a flap valve of tissue is created to prevent leakage from the stoma between catheterizations.[3] Sometimes, the bladder is enlarged with bowel tissue to enable greater urine storage in an additional procedure called bladder augmentation.[3] The Mitrofanoff procedure is different from an indwelling catheter placement because the catheter is removed from the channel between urine drainage events.[5] Some people with Mitrofanoff channels can also void urethrally, while others catheterize exclusively.

Relation to MACE

[edit]

The Malone antegrade continence enema (MACE), used to treat fecal incontinence, is like the Mitrofanoff procedure as it uses the Mitrofanoff principle and, thus, can be considered an analogous procedure.[8] As fecal and urinary incontinence frequently co-exist, a MACE is often created at the same time as a continent catheterizable urinary conduit.[8]

Relation to Monti procedure

[edit]

If the appendix is not available, due to appendectomy, or unusable for another reason, the Monti procedure is done.[9]

Relation to bladder augmentation and neobladder construction

[edit]

If the bladder is not sufficiently large, some people may need a bladder augmentation at the same time as a Mitrofanoff.[10] Augmentation enlarges the bladder, making it possible to hold more urine and prevent backflow into the kidneys.[10] This is usually done with one's own bowel tissue and typically bowel tissue produces mucus.[10] Hence, regular washouts are usually required.[11] Because bowel tissue aids in absorption, its use for an augmentation may result in metabolic imbalance and result in the need to monitor vitamin B12, bicarbonate, and chloride.[11] If bowel tissue is used to create an entirely new bladder, the resulting reservoir to hold urine is called a neobladder.[12] Neobladders are usually created in instances of bladder removal.[11]

History

[edit]

The concept of clean intermittent catheterization via the urethra was widely introduced by Jack Lapides when he published a seminal paper on the subject in 1972.[13] Clean intermittent catheterization provides an alternative to the sterile technique and allows individuals to self-catheterize after washing their hands, without the need for medical professionals and sterile equipment.[13] In 1980, Professor Paul Mitrofanoff described a "trans-appendicular continent cystostomy," the technique that would later be named for him.[14] Mitrofanoff's concept revolutionized clean intermittent catheterization because it allows urine to be drained via a route other than the urethra.[14] However, the Mitrofanoff procedure was slow to be adopted until a pediatric resident named Marc Cendron translated Mitrofanoff's French language paper for the well-known pediatric urologist Dr. John Duckett Jr.[15] in Philadelphia.[14] The Mitrofanoff procedure is sometimes performed along with bladder neck closure,[16] but Duckett advised against the closure of the bladder neck.[14] Today, the Mitrofanoff procedure can be performed robotically or using laparoscopic techniques and it paved the way for the creation of other urinary conduits using fallopian tubes, ureters, and segments of bowel, as in the Monti procedure.[14]

Indications

[edit]

The Mitrofanoff procedure is typically performed as an alternative for people who experience painful urethral catheterization and has been particularly useful for females.[5] It is also used in people with neurogenic bladder dysfunction, urethral trauma, and spinal cord injuries.[5] The procedure is sometimes recommended for those with spinal cord injuries who have severe autonomic dysreflexia.[5] Wheelchair users who cannot use a toilet independently or who struggle to catheterize independently may get a Mitrofanoff to gain greater control over their care.[17] For people who would otherwise leak via the urethra, the Mitrofanoff channel can provide continence and enable them to stop using diapers.[17] Other conditions for which the procedure may be appropriate include urethral cancer, congenital absence of a urethra, Prune Belly syndrome, sacral agenesis, and traumatic loss of urethra from a gunshot.[18] Appropriate candidates are prepared to commit to a lifetime of followup care.[18]

Contraindications

[edit]

People who have high pressure bladders, meaning their bladder pressure increases significantly with small increments of fluid, are not good candidates for the procedure due to the risk of damage to the kidneys.[19] Also contraindicated are those who cannot hold large volumes of urine without refluxing into the kidneys.[3] The procedure is not recommended for people with poor hand function, especially those without access to reliable assistance.[13]

Presurgical testing

[edit]

People who have been determined to be candidates for a Mitrofanoff surgery will need to undergo a variety of presurgical tests.[20] Testing often includes blood tests such as a complete blood count, a basic metabolic panel, and an assessment of cystatin c.[20] Additionally, urodynamic testing and a kidney bladder ultrasound are typically performed to assess characteristics of the urinary tract prior to surgery.[20] The urodynamics test should be done within 2 years prior to the procedure and the ultrasound within 1 year.[20] Prior to surgery, the bowels are typically cleared with a routine called bowel prep.[20] Bowel prep can be performed at home the 1–2 days before surgery or in some instances, occurs in a hospital before the operation.[20] Bowel prep may require magnesium citrate drink to empty the colon.[21] Bowel prep is done to reduce infection risk.[22]

Recovery from surgery and life with a Mitrofanoff

[edit]

Hospitalization and learning to use the channel

[edit]

The Mitrofanoff procedure is a major surgery and typically requires inpatient hospitalization for 5–7 days.[23] Initially, eating and drinking by mouth is not permitted and fluids are delivered intravenously for a few days.[24] Progression to a regular diet can be accomplished, starting with the consumption of clear fluids.[24] After the surgery, a tube is placed in the newly created channel to keep it open while it heals.[25] A tube is typically also placed in the urethra or through a suprapubic opening to ensure full urine drainage and to rest the bladder during recovery.[25] The tubes are generally removed and the channel is ready to use with intermittent catheters in 4–6 weeks,[25] provided that a medical professional first instructs on how to catheterize.[23] Depending on one's neurological status, a person with a Mitrofanoff may or may not feel the sensation to urinate.[26] Full recovery time varies from person to person and ranges from 3–12 months.[27]

Types of catheters

[edit]

There are three major types of intermittent catheters used with a Mitrofanoff.[28] Intermittent catheters are used to drain the bladder at regular intervals.[28] The three types are:

  • Non-coated: can be used with a lubricant[28]
  • Hydrophilic: need to be activated with water by following the product instructions[28]
  • Pre-lubricated: these come already soaked in lubricant[28]

Dietary considerations

[edit]

People with Mitrofanoff channels should eat a balanced diet that is high in fiber, including a recommended 5 servings of fruits and vegetables daily.[29] Drinking plenty of fluids is recommended to flush out the kidneys and bladder and to lessen the chance of urinary tract infection.[29] Recommended fluid intake is 2-3 liters of water a day, resulting in the production of healthy urine that is light in color.[29] Most people with Mitrofanoff channels can drink alcohol in moderation provided that they follow a regular catheterization schedule to avoid overfilling the bladder.[29]

Sex and pregnancy

[edit]

Sexual activity is typically avoided for six weeks postoperatively. It is possible to have a healthy pregnancy after Mitrofanoff surgery, but the pregnancy should be monitored closely by a urologist. A cesarean section may be considered. In individuals with a conduit made from bowel tissue, a standard pregnancy test will not be accurate in most instances; pregnancy can instead be confirmed by a blood test. Male fertility is typically unaffected.[25][5]

Exercise and physical activity

[edit]

For 2–3 weeks after surgery, extra care should be taken to prevent trauma to the surgical area.[30] For this time period, physical education and activities such as bicycle riding are not advisable.[30] It is possible to play sports with a Mitrofanoff, but high contact sports such as rugby are typically not advised.[25] Light exercise following surgery can facilitate recovery; though specific exercise recommendations generally require consultation with a medical professional.[29]

Bladder washouts

[edit]

Bladder washouts are performed to prevent build up of mucus and debris that can lead to urinary tract infection and increase the chance of a bladder stone.[31] Bladder stones can stop the bladder from emptying completely during catheterization and cause infection.[26] Those with an augmented bladder are more likely than those with a native bladder to require washouts.[26] A washout, also called an irrigation,[31] is performed by pushing saline or sterile water into the channel using a syringe connected to a catheter.[31] The water is pulled back out when the syringe is withdrawn and the process is repeated until the mucus is cleared.[31] Certain foods and drinks such as dairy products and soft drinks (soda) can increase mucus production.[31] The frequency of bladder washouts is dictated by medical advice.[31]

Annual follow up testing

[edit]

People with Mitrofanoff channels can expect a lifetime of annual testing to evaluate their urological health.[5] These tests may include:

  • a scan of the bladder, kidneys, and ureters[5]
  • a cystoscopy, an examination of the bladder using a camera[5]
  • blood tests to check the kidney and liver[5]

Risks and complications

[edit]

Every surgery has some risks. Some possible complications are:

  • Bladder stones: Bladder stones are hardened masses of minerals usually form when the bladder has not emptied properly or mucus has built up.[32] Left untreated, bladder stones can cause infection.[32]
  • Stenosis: Stenosis of the channel occurs when it becomes narrower, making it difficult to pass a catheter.[11] Additional surgery may be required to ensure the safe insertion of a catheter.[11] If the bladder cannot be emptied via the urethra and the catheter cannot enter the channel, it is a medical emergency.[5]
  • Leaking: Leakage of urine may occur from the stoma, particularly if the channel becomes stretched and the valve preventing such leaks fails to self- seal.[5] Bladder spasms, painful contractions of the bladder, can cause leakage from the stoma or the urethra[30] and may need to be treated with medication called an antispasmodic.[33]
  • Urinary tract infections: Urinary tract infections can be a concern in people who use catheters due to incomplete emptying or catheter contamination from the hands.[25] They can be prevented with proper fluid intake and careful hand hygiene.[11]

References

[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Mitrofanoff procedure

View on Grokipedia
from Grokipedia
The Mitrofanoff procedure, also known as appendicovesicostomy, is a surgical technique that repurposes the appendix (or a segment of the if the appendix is unavailable) to create a continent catheterizable channel connecting the to a on the lower , enabling intermittent self-catheterization for urine drainage while minimizing leakage. First described by French pediatric urologist Paul Mitrofanoff in 1980 based on cases performed between 1976 and 1979, the procedure addresses challenges in managing neurogenic bladders by providing a reliable, valve-like conduit that relies on the natural anti-reflux properties of tunneled bowel segments. It is primarily indicated for patients with refractory —often due to conditions like , , or myelomeningocele—as well as congenital anomalies such as , , or posterior urethral valves, and in some adults with severe urethral strictures or bladder outlet obstruction. During the , performed under general and typically lasting 3 to 5 hours, the appendix is mobilized, one end is tunneled submucosally into the posterior wall (usually 3-4 cm) to create a flap-valve mechanism that prevents urinary and incontinence, and the other end is brought through the to form a , often placed at or near the umbilicus for easy access. If the appendix is absent or unsuitable, alternatives like the Monti or Yang-Monti technique use reconfigured to form the conduit. The procedure may be combined with augmentation cystoplasty to increase capacity in cases of poor compliance or high-pressure storage. Postoperatively, patients remain hospitalized for 5 to 7 days, with indwelling catheters in the and sometimes a suprapubic site for 3 to 4 weeks to allow healing; self-catheterization training begins around 6 weeks, requiring 4 to 6 daily sessions and periodic mucus irrigation to prevent buildup. Long-term success is high, with continence rates reported between 79% and 100% in pediatric series and 66% to 100% in adults, though complications such as (typically 10% to 50% in long-term studies), false passages, or need for revision (around 20%) occur and necessitate lifelong follow-up with annual evaluations. Advances in minimally invasive approaches, including laparoscopic and robotic-assisted techniques, have reduced recovery time and morbidity in select patients since the early .

Overview and Description

Procedure Fundamentals

The Mitrofanoff procedure is a continent catheterizable urinary diversion that employs a tunneled conduit, typically the appendix, to form a channel from a skin stoma to the , allowing for intermittent self-catheterization to empty the . This technique, first described by Paul Mitrofanoff in 1980, addresses challenges in patients with neurogenic or other conditions impairing urethral catheterization. The anatomical principle centers on creating a reliable mechanism through submucosal tunneling of the conduit into the wall, which establishes a flap- effect; as pressure rises, the tunnel compresses the conduit against the mucosa, preventing passive leakage while permitting straightforward insertion for drainage. This design ensures continence without reliance on external appliances, mimicking a functional one-way . Key benefits include substantial improvements in for individuals unable to perform urethral catheterization, marked reduction in , and protection of renal function through regular, complete bladder emptying that mitigates risks of and infection. Patients often report greater independence and comfort compared to traditional indwelling catheters or diapers. Basic components encompass strategic stoma placement, usually at the umbilicus or lower , to optimize accessibility, , and ease of use in daily activities. The conduit length is ideally 10-15 cm to balance reach without kinking or excessive mobility, and it integrates seamlessly with a low-pressure reservoir—often the native or an augmented segment—to maintain safe intravesical pressures and prevent upper urinary tract complications.

Normal vs. Post-Procedure Urinary Drainage Pathway

  • Normal Pathway: Urine produced by the kidneys travels via the ureters to the , where it is stored until voluntary contraction of the expels it through the under control.
  • Post-Procedure Pathway: With the typically closed or non-functional, accumulates in the reservoir until a is inserted through the abdominal , traversing the tunneled conduit directly into the for complete drainage, thereby bypassing the native urethral route. This intermittent ensures continence and efficient emptying without continuous flow.
The Mitrofanoff procedure is frequently combined with the Malone antegrade continence enema (MACE) in patients with dual urinary and , utilizing the same appendiceal conduit divided to create separate channels for urinary drainage and colonic irrigation, thereby optimizing tissue use and surgical efficiency in a single operation. This synchronous approach has demonstrated high success rates, with continence achieved in the majority of cases when the appendix measures at least 9 cm, allowing for reliable mesothelial separation without compromising vascular supply. When the appendix is unavailable or inadequate, the Monti procedure serves as an adaptation to the Mitrofanoff principle, employing a short segment of reconfigured into a longer conduit through transverse tubularization, often enhanced by the Yang-Monti spiral configuration to extend length while preserving continence via the valve mechanism. This bowel-based alternative maintains the core continence mechanism of the Mitrofanoff by creating a catheterizable channel with adequate length for placement, particularly beneficial in pediatric or obese patients requiring greater conduit reach. Integration with bladder augmentation, or enterocystoplasty, is common to address low bladder capacity and high pressures, where the Mitrofanoff conduit functions as the catheterizable outlet for the enlarged reservoir formed by incorporating ileal or colonic segments into the bladder wall, thus achieving both volume expansion and reliable emptying. In post-cystectomy settings, the Mitrofanoff is incorporated into neobladder construction as the efferent limb of a urinary diversion, tunneling the conduit into an orthotopic or heterotopic pouch to enable intermittent catheterization while avoiding external appliances. Among conduit tissues, the appendix remains preferred due to its ideal length, robust vascularity, and natural anti-reflux properties when imbricated into the mucosa, outperforming alternatives in long-term continence rates. Bowel segments, such as used in Monti adaptations, offer versatility but carry higher risks of metabolic complications and compared to the appendix, while ureteral segments provide a narrower caliber with lower closure pressures, making them suitable only when other options are limited and often yielding slightly inferior functional outcomes.

History and Development

Origins and Initial Description

The Mitrofanoff procedure was developed by French pediatric urologist Paul Mitrofanoff in 1976 to address persistent challenges in managing pediatric neurogenic , particularly in cases where urethral access for clean intermittent catheterization was impractical or impossible, such as in boys or children with anatomical obstructions. The innovation drew inspiration from the established efficacy of unsterile self-catheterization in girls with neurogenic , which had shown minimal septic complications, and from prior surgical concepts utilizing the appendix as a conduit substitute, akin to ureteral reimplantation techniques to prevent . This approach aimed to create a reliable, alternative for emptying via an abdominal , combined with bladder neck closure to ensure low-pressure storage and voluntary catheterization. The procedure's first applications occurred starting in October 1976 at the Hôpital Clocheville in Tours, , targeting children with neurogenic bladders primarily arising from myelomeningocele (). Between 1976 and 1979, Mitrofanoff performed the trans-appendicular continent cystostomy on 16 pediatric patients, with 13 achieving total continence and excellent functional outcomes despite minor issues like urinary infections or vesicorenal reflux in some cases. These early successes, representing an approximately 81% initial continence rate among the selected cohort, highlighted the procedure's potential, though five cases failed due to inadequate capacity, necessitating conversion to incontinent cutaneous diversions. Subsequent extensions further demonstrated adaptability in complex congenital urologic conditions. Mitrofanoff's foundational description appeared in a 1980 publication titled "Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques," published in Chirurgie Pédiatrique. This paper detailed the surgical technique, rationale, and outcomes of the initial series, establishing the as a cornerstone for continent urinary diversion and inspiring widespread adoption in . Long-term followup of these pioneering cases, reported two decades later, confirmed sustained continence in approximately 73% of patients, with revisions addressing complications like or leakage, underscoring the procedure's enduring impact.

Evolution and Modern Variations

Following its initial description in , the Mitrofanoff procedure saw widespread adoption in pediatric urology during the and , particularly for managing neurogenic bladders in children with conditions such as and . Refinements during this period focused on optimizing placement, with umbilical and lower quadrant sites becoming preferred to improve accessibility and reduce cosmetic concerns, achieving continence rates of 79-100% in long-term series. Anti-reflux mechanisms were enhanced through submucosal tunneling techniques, minimizing while maintaining conduit patency. In the 2000s, innovations emphasized minimally invasive approaches to decrease surgical morbidity and recovery time. Laparoscopic techniques were introduced, allowing complete intracorporeal construction of the appendicovesicostomy with mean operative times around 140 minutes and low complication rates in initial pediatric cohorts. Robotic-assisted variants followed, utilizing systems like da Vinci to enhance precision in pediatric cases, with preliminary series reporting minimal blood loss (under 50 cc on average) and hospital stays of about 5 days. Concurrently, the Monti-Yang technique emerged as a key alternative for patients lacking a suitable appendix, involving reconfiguration of ileal segments into a conduit while preserving the continence principle, thus expanding applicability. Advancements from the to have further diversified the procedure, incorporating seromuscular tunnels for improved anti-reflux in laparoscopic and robotic settings, which facilitate secure conduit implantation with reduced leakage risks. Tissue-engineered conduits, seeded with autologous micrografts on scaffolds, have entered preclinical and early clinical trials, demonstrating enhanced epithelialization and vascularization in animal models as a potential non-autologous option to avoid gastrointestinal complications. Adult applications have grown, particularly post-radical for , where heterotopic ileal reservoirs with Mitrofanoff conduits achieve complete continence in 3 months and pouch capacities of 250-370 ml, with low early morbidity. Long-term patency has improved, with studies indicating revision rates as low as 18% in select series. A single-center study analyzing laparoscopic Mitrofanoff over 18 years confirmed its feasibility and favorable outcomes in pediatric patients. The procedure's global spread has been notable in developing countries, where it offers cost-effective management amid limited access to disposable supplies. A 2020 single-center Indian study over 10 years confirmed its reliability, achieving 98% stomal continence in 51 pediatric patients and significant renal function stabilization, despite challenges like reuse. Key publications include a review in the Indian Journal of Urology outlining the Mitrofanoff principle and its variations, and recent 2024 analyses on robotic implementations highlighting sustained efficacy in pediatric populations.

Indications and Patient Selection

Primary Indications

The Mitrofanoff procedure is primarily indicated for patients with neurogenic bladder disorders, such as those resulting from , , or myelomeningocele, which lead to impaired bladder emptying, high-pressure storage, or incontinence that cannot be managed through urethral catheterization. These conditions often necessitate lifelong clean intermittent catheterization (CIC), and the procedure provides a reliable continent stoma to facilitate this. In cases of congenital anomalies, the procedure is suitable for individuals with , , or posterior urethral valves, where anatomical defects cause difficulties with urethral access or result in recurrent urinary tract infections and poor function. These anomalies typically present in infancy or , making the Mitrofanoff a key intervention to enable effective management. For acquired conditions, indications include post-radiation urethral strictures, neurogenic bladder secondary to , or failed prior urinary diversions that compromise quality of life through intractable incontinence or catheterization challenges. Such scenarios often arise from trauma, treatment, or progressive neurological diseases, where alternative management options have been exhausted. The procedure is most commonly performed in pediatric patients aged 2 to 18 years, particularly those with congenital or early-onset neurogenic issues, though its use has expanded in adults to improve independence and in cases of or chronic bladder dysfunction. Adult applications emphasize long-term continence and ease of self-catheterization, with success rates supporting its role in rehabilitation. Patient selection prioritizes those requiring lifelong CIC due to urethral inaccessibility, with adequate bladder capacity (or planned augmentation cystoplasty) to ensure low-pressure storage and prevent complications like vesicoureteral reflux. Ideal candidates demonstrate sufficient manual dexterity and motivation for stoma care, as assessed by a multidisciplinary team.

Contraindications and Exclusion Criteria

The Mitrofanoff procedure, a form of continent , carries specific absolute contraindications that preclude its performance due to unacceptably high risks of perioperative morbidity or failure of the continent mechanism. These include uncorrectable , which increases the likelihood of uncontrollable intraoperative or postoperative bleeding, as well as active untreated , which can lead to severe or conduit contamination during . Additionally, non-compliance with or inability to adhere to a clean intermittent catheterization (CIC) regimen represents an absolute barrier, as the procedure relies on reliable patient or self-catheterization to maintain continence and prevent reservoir overdistension. Relative contraindications involve conditions that elevate risks but may not entirely rule out the procedure if benefits outweigh potential complications following multidisciplinary evaluation. A short of less than five years is often considered relative, particularly in patients with advanced malignancies or comorbidities where long-term conduit maintenance cannot be justified. Severe bowel disease, such as , limits conduit creation or threatens anastomotic integrity due to inflammation or poor tissue healing, rendering it a relative exclusion unless alternative non-bowel options are viable. In pediatric cases, inadequate caregiver support for lifelong CIC training and management similarly weighs against proceeding, as it compromises postoperative success. Anatomic factors can also contraindicate the standard appendicovesicostomy approach. Absence of the appendix, combined with unsuitable bowel segments for alternative conduits (e.g., due to prior resections or inadequate length/), prevents creation of a reliable catheterizable channel. Similarly, a small capacity that is not amenable to augmentation cystoplasty poses a challenge, as it risks high-pressure or incontinence without a low-pressure . Patient-specific factors further influence suitability. Obesity complicates stoma placement and access for catheterization, increasing and risks, though it is typically relative and manageable with optimization. Psychological barriers, including , poor motivation, or anxiety related to self-catheterization, can undermine adherence and are relative contraindications requiring psychological assessment.

Preoperative Preparation

Diagnostic Testing

Preoperative diagnostic testing for the Mitrofanoff procedure is essential to assess candidacy, evaluate and upper urinary tract function, and identify any anatomical abnormalities that could influence surgical planning. These evaluations help confirm the need for and potential concomitant augmentation by measuring compliance, capacity, and pressure dynamics, while also screening for renal impairment or . Testing is tailored to the 's underlying condition, such as neurogenic or congenital anomalies, and typically includes a combination of , and assessments. Urodynamic studies form a cornerstone of the preoperative evaluation, providing detailed insights into , capacity, compliance, and detrusor function to determine the necessity of the procedure and augmentation. These studies involve filling the with fluid while measuring pressures via catheters, often combined with to visualize voiding dynamics and detect involuntary contractions or poor compliance that could lead to upper tract damage if unaddressed. In pediatric patients with neurogenic , urodynamics are particularly critical for identifying high- storage that contraindicates native urethral catheterization, guiding the decision for a catheterizable channel like the Mitrofanoff. Imaging modalities are employed to delineate urinary tract , assess for , and evaluate . Renal and pelvic is routinely performed pre- and post-void to measure size, parenchymal thickness, residual volume, and wall thickness, offering a non-invasive initial screen for upper tract dilation. Voiding cystourethrogram (VCUG) is used to detect , diverticula, and outlet obstruction, providing dynamic views during filling and emptying. In select cases, particularly in children, dimercaptosuccinic acid (DMSA) evaluates renal cortical scarring and differential function, while (MRI) may be reserved for complex or spinal dysraphism to assess neural elements. Renal function tests are vital to gauge overall health and metabolic status prior to . Serum and estimated (eGFR) quantify renal clearance, while panels detect imbalances, such as hyperchloremic in patients with prior bowel-based urinary reconstructions or diversions. screens for or , and analysis with culture ensures sterile conditions to minimize perioperative risks. These laboratory assessments, often supplemented by 24-hour collection for volume and clearance, help stratify patients at risk for postoperative renal deterioration. Cystoscopy allows direct visualization of the mucosa, , and ureteral orifices to identify trabeculation, tumors, strictures, or unsuitable sites for conduit implantation. Performed under , it facilitates if needed and confirms capacity and compliance observed on urodynamics. This endoscopic evaluation is especially important in patients with prior interventions or suspected . When bladder augmentation is anticipated, additional assessments include bowel preparation evaluation, potentially via or barium enema in older patients to rule out or neoplasms in the proposed bowel segment. Allergy screening for contrast agents, anesthetics, and antibiotics is conducted through detailed history review to prevent intraoperative reactions, aligning with standard preoperative protocols for major urologic .

Patient Counseling and Optimization

Patient counseling for the Mitrofanoff procedure begins with a thorough discussion of , emphasizing the procedure's goals of establishing a reliable continent catheterizable channel to facilitate clean intermittent catheterization (CIC) while preserving renal function and achieving urinary continence. Patients and families are educated on the necessity of lifelong CIC training, typically initiated preoperatively through simulations or demonstrations by specialized nursing staff, to ensure proficiency in insertion and maintenance. Realistic expectations are set regarding potential revisions, with lifetime revision rates reported between 10% and 60%, with some paediatric series indicating 50-60% due to issues such as or incontinence, underscoring the importance of long-term follow-up. Psychological preparation is integral, particularly for pediatric and adolescent patients, where multidisciplinary teams comprising urologists, psychologists, and stoma care nurses address concerns related to alterations from the abdominal and the transition to self-catheterization. Supportive interventions, including counseling sessions focused on and , help mitigate anxiety and improve health-related , with studies indicating high satisfaction rates post-procedure when emotional needs are proactively managed. The AUA (2021) and EAU (2024) guidelines advocate for shared in neurogenic bladder management, recommending continent diversions like the Mitrofanoff for those unable to perform urethral CIC, while incorporating psychological evaluations to optimize outcomes and considering factors such as accessibility for patients with or . Preoperative optimization strategies aim to reduce surgical risks and enhance recovery, including counseling to improve and pulmonary function, as well as for obese patients to minimize anesthetic complications. UTI prophylaxis with perioperative antibiotics is standard to prevent infectious morbidity, particularly in patients with underlying neurogenic . For cases involving combined bladder augmentation, mechanical bowel is employed to clear the and reduce contamination risks. In pediatric settings, family involvement is emphasized through hands-on CIC training for caregivers, fostering realistic expectations of 90-95% continence success rates while preparing for potential adjustments in daily routines.

Surgical Technique

Standard Appendicovesicostomy

The standard appendicovesicostomy, also known as the Mitrofanoff procedure, involves using the appendix to create a catheterizable urinary channel from the bladder to the , enabling reliable intermittent catheterization while minimizing urine leakage. This technique relies on the appendix's natural valvular properties, enhanced by surgical tunneling, to achieve continence. The procedure is typically performed in an open fashion, though minimally invasive exist. Preoperatively, the site is marked to ensure easy access, commonly at the umbilicus for optimal positioning and cosmetic results. A Pfannenstiel or lower midline incision is then made to provide access to the and ileocecal region. The appendix is carefully isolated and mobilized, with preservation of the mesoappendix to maintain its blood supply; a (typically 12-14 Fr) is passed through the appendix intraoperatively to confirm patency and facilitate flushing of the conduit. For implantation, an incision is created on the posterior wall, followed by submucosal tunneling of the appendix tip into the , aiming for a tunnel length of 3-4 cm to achieve a 5:1 length-to-diameter ratio, which is critical for the anti-reflux mechanism and continence. The appendiceal orifice is then anastomosed to the mucosa and secured to the muscular layer with absorbable sutures. If urethral diversion is required for complete isolation, the is divided at this stage. The proximal end of the appendix is exteriorized through the premarked site and matured by imbricating the surrounding skin and cecal serosa with sutures, such as 3-0 silk or , to promote healing and valve competence. The operation generally requires 3-5 hours, depending on complexity, and is frequently combined with augmentation cystoplasty to increase bladder capacity in patients with poor compliance. Laparoscopic adaptations of the procedure have been reported since the early 2000s, offering reduced recovery time in select cases. A key technical consideration is thorough intraoperative of the conduit to verify unobstructed flow and remove any debris.

Alternative Conduit Options

When the appendix is unavailable due to prior , congenital absence, inadequate length, or other anatomical issues, alternative tissues are selected to form the catheterizable conduit in the Mitrofanoff procedure. Patient-specific factors such as overall bowel health, conduit caliber for easy catheterization (typically 14-18 ), and the need for anti-reflux mechanisms guide the choice, prioritizing tissues that maintain continence while minimizing surgical complexity. Small bowel segments, particularly , are the most common alternatives, often reconfigured using the Monti procedure to create a longer, narrower conduit from short detubularized segments. In this technique, 2-3 cm ileal segments are harvested, opened longitudinally, and retubularized in a spiral or serpentine fashion to form a 12-18 cm tube with a small suitable for intermittent catheterization; this configuration also incorporates an anti-reflux flap-valve mechanism when tunneled into the . The Yang-Monti variation, a transverse ileal tube, further optimizes length and reach for patients with short . Ureteral segments can serve as conduits in select cases, such as when a dilated (mega)ureter is present, allowing direct use of native tissue with predictable behavior and an extraperitoneal approach to reduce morbidity. Gastric patches or pedicled gastric tubes are rarer options for patients with limited bowel availability, providing a continent channel but carrying risks of skin breakdown from secreted .00018-5/pdf) Other created channels include cecal or ileocecal flaps, where a flap from the is tubularized and tunneled to form the conduit, often combined with VQZ plasty for the external to enhance cosmetic outcomes and prevent . Recent advancements in minimally invasive approaches have explored serosal or peritoneal-lined tunnels for extravesical implantation, offering reduced risks in robotic-assisted procedures. Compared to the standard appendicovesicostomy, bowel-based alternatives like the Monti procedure achieve similar continence rates of 85-95%, with stomal continence around 92-97% across series, though they introduce higher metabolic risks such as electrolyte imbalances (e.g., from ileal absorption) due to prolonged urine-bowel contact. Ureteral and gastric options generally have lower metabolic complications but may require more precise patient selection to ensure adequate length and compliance.

Postoperative Recovery

Hospital Stay and Initial Catheterization

Following the Mitrofanoff procedure, patients typically remain hospitalized for 5 to 10 days to allow for close monitoring of the surgical site, including assessments for potential leaks or obstructions in the newly created conduit. This duration facilitates initial recovery, with , urine output, and wound integrity evaluated regularly to ensure stability before transition to home care. Pain is managed postoperatively through methods such as epidural infusions of local anesthetics and analgesics or (PCA) with intravenous opioids like , transitioning to oral medications as tolerated. Early ambulation is encouraged within the first 24 to 48 hours to reduce the risk of deep vein thrombosis (DVT) and promote gastrointestinal recovery. An indwelling is placed in the Mitrofanoff conduit and sometimes a suprapubic , remaining in place for 3-4 weeks to promote healing. A cystogram is performed around 3 weeks to check for leaks before starting clean intermittent catheterization (CIC), with training typically beginning 4-6 weeks post-surgery using 8-12 French hydrophilic catheters, including gentle saline irrigation as needed to clear clots or and maintain patency. Stoma care begins immediately in the hospital, emphasizing local hygiene with soap and water or mild wipes to prevent infection, while avoiding undue tension on the site to support healing. Patients and caregivers are educated on recognizing early signs of issues, such as difficulty passing the catheter suggesting a false passage, prompting prompt medical evaluation. Discharge occurs once the patient demonstrates proficiency in CIC technique, remains afebrile without signs of infection, and shows adequate oral intake and mobility; for pediatric cases, home nursing support is often arranged to reinforce training and monitor progress. Since around 2015, incorporation of enhanced recovery after surgery (ERAS) protocols in pediatric has optimized these elements, such as multimodal pain control and early feeding, often reducing hospital stays to 4 to 7 days without increasing complications.

Long-term Daily Management

Patients undergoing the Mitrofanoff procedure typically perform clean intermittent catheterization (CIC) 4 to 6 times per day to empty the bladder, aiming to drain volumes of 300 to 400 mL to avoid overdistension and maintain continence. Hydrophilic-coated single-use catheters are commonly recommended due to their pre-lubricated design, which facilitates easier insertion through the and reduces the risk of urinary tract infections (UTIs) compared to uncoated options, although reusable catheters may be suitable for select patients with proper protocols. Dietary management emphasizes a high-fiber intake, including at least five portions of fruits and daily, to prevent , which can exacerbate bladder spasms or stomal issues. Adequate hydration is essential, with recommendations of 1.5 to 2 liters of per day to promote clear and reduce buildup or stone formation, while avoiding bladder irritants such as , carbonated beverages, fruits, , and excessive dairy products that may increase production or UTI risk. Lifestyle integration post-healing allows for normal activities, including without restrictions after approximately 4 to 6 weeks, with the easily covered using tape or clothing for discretion. is generally safe following the procedure, though close urological monitoring is advised to detect potential stomal stenosis or UTIs, as evidenced by successful cases managed with routine catheterization adjustments. Exercise, including contact sports, is permissible with protective padding or belts over the stoma to prevent trauma. Bladder maintenance involves regular saline washouts, often daily or as needed based on production, using a 50 mL to instill and aspirate saline through the until the fluid runs clear, helping to prevent blockages, , or stone formation particularly in augmented bladders. For patients with recurrent UTIs, low-dose prophylaxis is recommended to reduce frequency, with agents selected based on prior sensitivities and monitored for resistance. Psychosocial support plays a key role in long-term adaptation, with patient and family involvement in support groups facilitating adjustments for , work, and daily independence; recent studies as of 2024 indicate that approximately 83% of patients experience improved and greater autonomy in self-management following the procedure.

Complications and Risks

Early Postoperative Issues

Early postoperative issues following the Mitrofanoff procedure primarily encompass complications arising within the first 30 to 90 days after , often related to surgical site , urinary drainage, and systemic responses. complications are common, including infections at incision or sites occurring in approximately 5-10% of cases, as well as dehiscence and formation, which contribute to morbidity in 2-10% of patients. Anastomotic leaks, manifesting as urine extravasation, affect 2-5% of patients and typically require management through percutaneous drainage or, in severe cases, reoperation to prevent further complications such as . Catheter-related problems in the immediate postoperative period include the formation of false tracts due to difficult initial catheterization, as well as transient incontinence resulting from at the site, which usually resolves with conservative measures like adjusted catheterization techniques. Systemic issues may involve postoperative , reported in up to 13% of cases in small series, fever secondary to urinary tract infections (incidence around 10%), and, when bowel segments are used as alternative conduits, from electrolyte imbalances. Overall, the early reoperation rate reaches up to 8%, driven by , obstruction, or the aforementioned leaks and breakdowns, according to comprehensive reviews.

Late Complications

Late complications of the Mitrofanoff procedure, which typically emerge months to years after , primarily involve the catheterizable conduit and associated urinary tract changes, often necessitating interventions to maintain functionality. , a narrowing at the skin-level , occurs in 10-30% of cases and is frequently managed with serial dilations, local injections (achieving up to 82% success), or surgical revisions such as V-Y plasty. Conduit-related issues, including strictures (incidence 5-15%), false passages during catheterization (up to 30%), and incontinence (0.9-19.5%), arise from scarring, inadequate tunneling length, or tissue remodeling, and may require endoscopic resection, tunnel lengthening, or bulking agent injections for resolution. Calculi formation within the conduit or , reported in up to 25% of Mitrofanoff cases, stems from production by the appendiceal tissue and urinary stagnation, preventable through meticulous protocols and antireflux tunneling techniques. Infections and (VUR) represent significant delayed risks, with new-onset VUR affecting up to 30% of patients, often attributable to incomplete antireflux mechanisms or chronic from intermittent catheterization. These can lead to upper tract deterioration in approximately 43% of long-term cases if unmanaged, underscoring the importance of prophylactic antibiotics and regular imaging surveillance. In procedures combined with bladder augmentation using bowel segments (e.g., ileocystoplasty), metabolic disturbances such as occur in about 15% of patients due to reabsorption and loss, managed via oral alkalinizing agents like . Malignancy risk in augmented bladders is rare, with a probability of 0-5.5% over long-term follow-up (mean latency 19 years), primarily at the entero-urinary , though incidence remains below 1% in most series and requires vigilant endoscopic monitoring beyond 10 years post-surgery. Long-term data from 20-year follow-ups indicate overall revision rates of 28-48% for conduit-related problems, with conversion to non-continent diversion required in a minority of cases (e.g., 4-10%); however, advancements in surgical techniques, such as optimized submucosal tunneling and design (e.g., rosebud configuration), have reduced these rates in recent cohorts to under 30%. Prevention emphasizes lifelong urologic follow-up, including annual and metabolic panels, to mitigate progression of these chronic issues.

Outcomes and Follow-up

Success Rates and Efficacy

The Mitrofanoff procedure demonstrates high efficacy in achieving urinary continence, with reported rates of 79-100% in pediatric populations and up to 96% in adults across multiple series. Daytime continence is typically achieved in 90-95% of cases, while nighttime continence ranges from 80-90%, often assessed through patient reports of pad usage or dryness with regular catheterization. These outcomes are supported by long-term follow-up data, where stomal continence remains stable in the majority of patients, though minor leakage may occur in 5-10% requiring adjunctive measures. Renal function outcomes are generally favorable, with stabilization or improvement observed in approximately 85% of patients based on urodynamic evaluations and serum markers such as and . In a cohort of 51 pediatric patients, 78% experienced stabilized renal parameters postoperatively, with significant reductions in levels (p<0.01), particularly beneficial for those with preexisting impairment from neurogenic conditions. This preservation is attributed to reliable low-pressure emptying via clean intermittent catheterization, reducing risk compared to indwelling catheters. Quality-of-life metrics indicate high patient and satisfaction, with 80-90% reporting substantial improvements in daily activities and in pediatric series. Surveys reveal that 83% of families perceive enhanced overall well-being, including better school integration and reduced reliance on caregivers, alongside 88-96% global satisfaction rates with continence management. These gains are linked to fewer urinary tract infections relative to urethral catheterization, though long-term adherence to catheterization protocols is essential.00512-X/fulltext) Long-term efficacy is evidenced by conduit patency exceeding 80% at 10 years, with 82% of channels remaining functional at 126 months in aggregated pediatric and adult data. Post-2010 adult series confirm durability, with 91% continence maintained at 2.5 years in large cohorts, though revision rates of 8-32% underscore the need for vigilant monitoring. Systematic reviews of over 200 neuro-urological patients affirm these findings, highlighting the procedure's role in sustained bladder management despite potential stenoses.

Routine Monitoring and Revision

Routine monitoring following the Mitrofanoff procedure is essential for preserving renal function and conduit patency, involving regular assessments to detect early signs of complications such as or . Annual evaluations typically include renal to screen for , urinalysis to identify infections or abnormalities, and serum measurement to monitor function. is performed every 2-3 years to inspect the conduit for structural integrity, including checks for mucosal changes or narrowing. Follow-up frequency is more intensive in the initial postoperative period, with quarterly visits in the first year to assess healing and catheterization tolerance, transitioning to annual evaluations thereafter, guided by patient-reported symptoms such as difficulty catheterizing or leakage. Indications for revision surgery include conduit , often managed initially with balloon dilation before surgical intervention; incontinence due to inadequate tunneling, addressed by re-tunneling; and stone formation, typically treated via endoscopic removal. Revision rates range from 15-25% by 10 years, with minimally invasive techniques, such as endoscopic or laparoscopic approaches, preferred when feasible to reduce morbidity. Long-term surveillance requires a multidisciplinary approach, involving urologists for conduit management and nephrologists for renal complications, with integration of for remote monitoring since 2020 to enhance accessibility and compliance.

References

  1. https://pubmed.ncbi.nlm.nih.gov/7408090/
  2. https://my.clevelandclinic.org/health/treatments/23535-mitrofanoff-procedure
  3. https://www.childrenscolorado.org/doctors-and-departments/departments/urology/tests-services/mitrofanoff-procedure/
  4. https://pmc.ncbi.nlm.nih.gov/articles/PMC6342573/
  5. https://journals.lww.com/urol/fulltext/2022/07000/technical_aspects_and_outcome_review_of_continent.2.aspx
  6. https://pmc.ncbi.nlm.nih.gov/articles/PMC11674903/
  7. https://www.sciencedirect.com/topics/medicine-and-dentistry/mitrofanoff-appendicovesicostomy
  8. https://pmc.ncbi.nlm.nih.gov/articles/PMC3822348/
  9. https://www.nationwidechildrens.org/specialties/urology/procedures/mitrofanoff
  10. https://my.clevelandclinic.org/health/articles/21197-urinary-system
  11. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Mitrofanoff_stoma/
  12. https://pubmed.ncbi.nlm.nih.gov/11371987/
  13. https://pubmed.ncbi.nlm.nih.gov/9186357/
  14. https://pmc.ncbi.nlm.nih.gov/articles/PMC3038960/
  15. https://www.urologynews.uk.com/features/features/post/the-mitrofanoff-procedure-a-continent-revolution
  16. https://pmc.ncbi.nlm.nih.gov/articles/PMC3822346/
  17. https://pubmed.ncbi.nlm.nih.gov/7609203/
  18. https://pubmed.ncbi.nlm.nih.gov/11371985/
  19. https://pmc.ncbi.nlm.nih.gov/articles/PMC5498164/
  20. https://journals.lww.com/indianjurol/fulltext/2013/29040/reconstructing_the_lower_urinary_tract__the.10.aspx
  21. https://pmc.ncbi.nlm.nih.gov/articles/PMC3339781/
  22. https://pubmed.ncbi.nlm.nih.gov/19683730/
  23. https://pmc.ncbi.nlm.nih.gov/articles/PMC3830905/
  24. https://www.nature.com/articles/s41598-024-72876-0
  25. https://pmc.ncbi.nlm.nih.gov/articles/PMC10570455/
  26. https://pmc.ncbi.nlm.nih.gov/articles/PMC6127530/
  27. https://www.researchgate.net/publication/396454500_LAPAROSCOPIC_MITROFANOFF_PROCEDURE_IN_CHILDREN_FEASIBILITY_AND_OUTCOME_ANALYSIS_OVER_18_YEARS_IN_A_SINGLE_CENTRE
  28. https://www.ijpediatrics.com/index.php/ijcp/article/download/3260/2158/12181
  29. https://www.mdpi.com/2227-9067/11/12/1442
  30. https://www.chop.edu/conditions-diseases/neurogenic-bladder
  31. https://www.urologynews.uk.com/media/7848/urojf18-mitrofanoff.pdf
  32. https://craighospital.org/resources/mitrofanoff-procedure
  33. https://www.liebertpub.com/doi/10.1089/end.2017.0720
  34. https://pmc.ncbi.nlm.nih.gov/articles/PMC4739983/
  35. https://emedicine.medscape.com/article/443916-periprocedure
  36. https://pmc.ncbi.nlm.nih.gov/articles/PMC4955412/
  37. https://www.gosh.nhs.uk/conditions-and-treatments/procedures-and-treatments/bladder-augmentation-and-mitrofanoff/
  38. https://www.urologynews.uk.com/media/15960/urojf18-mitrofanoff-update.pdf
  39. https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Paediatric-Urology-2024.pdf
  40. https://www.auanet.org/guidelines-and-quality/guidelines/adult-neurogenic-lower-urinary-tract-dysfunction
  41. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Mitrofanoff.pdf
  42. https://www.pediatricsurgical.com/wp-content/uploads/2025/02/Mitrofanoff-.pdf
  43. https://www.sciencedirect.com/science/article/pii/S0090429599000461
  44. https://pmc.ncbi.nlm.nih.gov/articles/PMC3418024/
  45. https://www.auajournals.org/doi/10.1097/01.ju.0000164747.90562.59
  46. https://karger.com/eur/article/24/1/103/130785/Pedicled-Gastric-Tube-as-a-Catheterising-Conduit
  47. https://www.auajournals.org/doi/pdf/10.1016/j.juro.2008.04.070
  48. https://www.auajournals.org/doi/pdf/10.1016/j.juro.2011.01.027
  49. https://pmc.ncbi.nlm.nih.gov/articles/PMC9472303/
  50. https://www.sciencedirect.com/science/article/pii/S1477513125000087
  51. https://pmc.ncbi.nlm.nih.gov/articles/PMC3822347/
  52. https://www.childrenshealthireland.ie/documents/1555/Urology-Mitrofanoff-Bladder-Neck-Procedure-2020.pdf
  53. https://www.gillettechildrens.org/your-visit/patient-education/after-bladder-augmentation-with-mitrofanoff-procedure
  54. https://www.childrensmn.org/educationmaterials/childrensmn/article/15963/mitrofanoff-discharge-instructions/
  55. https://pubmed.ncbi.nlm.nih.gov/35995660/
  56. https://archive.org/stream/manualzilla-id-6109516/6109516_djvu.txt
  57. https://nurses.uroweb.org/wp-content/uploads/EAUN-Guideline-Urethral-intermittent-catheterisation-in-adults-2024.pdf
  58. https://www.mitrofanoffsupport.org.uk/healthy-living
  59. https://www.bbuk.org.uk/wp-content/uploads/2016/12/Discussing-Mitrofanoff-Final-Draft.pdf
  60. https://www.researchgate.net/publication/6755262_Pregnancy_in_a_woman_with_a_continent_appendicovesicostomy_A_case_report
  61. https://pubmed.ncbi.nlm.nih.gov/40918795/
  62. https://www.mitrofanoffsupport.org.uk/living-with-a-mitrofanof
  63. https://pmc.ncbi.nlm.nih.gov/articles/PMC6105581/
  64. https://pubmed.ncbi.nlm.nih.gov/39506412/
  65. https://www.auajournals.org/doi/10.1097/01.ju.0000061761.24504.47
  66. https://www.jpurol.com/article/S1477-5131%2822%2900270-4/pdf
  67. https://europepmc.org/article/med/32929409
  68. https://sci-can.ca/blog/what-mitrofanoff-procedure-and-it-worth-it
  69. https://punsonline.org/multimedia/files/2013/Bladder-Augmentations-Mitrofanoffs-and-Maces.pdf
  70. https://www.jpurol.com/article/S1477-5131(22)00003-1/fulltext
  71. https://pubmed.ncbi.nlm.nih.gov/25867054/
  72. https://onlinelibrary.wiley.com/doi/10.1002/nau.23213
  73. https://secipe.org/coldata/upload/revista/2024_37-4_172.pdf
  74. https://pubmed.ncbi.nlm.nih.gov/24679888/
  75. https://pubmed.ncbi.nlm.nih.gov/10799230/
  76. https://www.researchgate.net/publication/11966269_The_Mitrofanoff_procedure_20_years_later
  77. https://pmc.ncbi.nlm.nih.gov/articles/PMC7301090/
Add your contribution
Related Hubs
User Avatar
No comments yet.