Intermittent Self-Catheterization by Quadriplegic Patients Via a Catheterizable Mitrofanoff Channel

Purpose

Neurogenic bladder due to cervical spinal cord injury is often best managed by clean intermittent catheterization. Limited upper extremity function makes patients with quadriplegia dependent on caregivers for clean intermittent catheterization. The Mitrofanoff umbilical appendicovesicostomy provides easy access to the bladder in patients with all types of access difficulty. We evaluated the Mitrofanoff umbilical appendicovesicostomy in 7 patients with quadriplegia.

Materials and Methods

Four men and 3 women with cervical spinal cord injury underwent the Mitrofanoff umbilical appendicovesicostomy with appendix (5) or ileum (2).

Results

All patients are continent and able to self-catheterize via the umbilical stoma. In 1 patient with an ileal Mitrofanoff umbilical appendicovesicostomy umbilical incontinence was repaired surgically and stomal stenosis developed in 1, which required stomal revision. All patients use the stoma regularly. Four patients have moved out of care facilities and are living more independently.

Conclusions

The Mitrofanoff catheterizable channel is a valuable option for bladder management in patients with quadriplegia. Clean intermittent self-catheterization allows these patients independent function and facilitates their return to productive lives outside care facilities.     

FAVORABLE EXPERIENCE WITH A SIMPLE TECHNIQUE TO CREATE A CONCEALED UMBILICAL STOMA

Purpose

After using different sites for continent urinary diversion stomas the umbilicus became the preferred site. Experience with a simple technique to place the continent diversion stoma at the umbilical site is reported.

Materials and Methods

Cutaneous continent urinary diversion was performed in 95 patients with placement of the stoma at the umbilical site. A triangular skin flap is elevated to the right of the umbilicus a 1 cm. piece of the umbilical scar is excised and the apex of the skin flap is anastomosed to the spatulated appendix, tapered ileum or gastric tube.

Results

All patients had satisfactory cosmetic results, 3 required simple revision and 4 needed dilation. These 7 patients as well as all others easily catheterized the urinary pouch.

Conclusions

This simple technique results in good cosmesis and it is associated with a minimal need for stomal revision.     

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Combined Mitrofanoff and Antegrade Continence Enema Procedures for Urinary and Fecal Incontinence

Purpose

Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children undergoing major reconstructive urological operations. To treat double incontinence or the combination of wetting and severe constipation, we constructed a Mitrofanoff conduit and a channel for antegrade continence enemas in 18 patients between 1989 and 1995. We review the underlying pathological conditions, various surgical techniques and outcomes of these operations.

Materials and Methods

Underlying abnormalities mainly included spinal lesions, bladder exstrophy, imperforate anus and various cloacal anomalies. Patient age ranged from 2 to 18 years (average 8.4). In 13 patients both procedures were done simultaneously. The appendix was used to construct the antegrade continence enema channel in 8 cases and the Mitrofanoff channel in 5. It was long enough to be divided and used for both procedures in 2 cases but it was missing or unsuitable in 3. Alternative antegrade continence enema conduits were cecal flap in 7 patients and ileum in 1, while the ureter, ileum and detrusor tube were used to establish Mitrofanoff channels in 5, 5 and 1, respectively. Stomas were constructed according to the V-flap or V. Z. Q. technique and situated in close proximity in the right lower abdominal quadrant in 13 cases.

Results

Convalescence was uneventful except for 1 abscess near an antegrade continence enema stoma. Ten patients needed dilation or minor revisions due to difficulty in catheterizing the antegrade continence enema (5), Mitrofanoff (3) or both conduits (2). Subsequently 3 patients underwent repeat operations for reconstruction of 2 antegrade continence enema channels (cecal flap and ileum) and 1 detrusor tube Mitrofanoff channel. Currently 15 patients are dry on regular clean intermittent catheterization using 10 to 12F catheters. Outcomes of the antegrade continence enema channels are satisfactory in 15 patients who are clean or rarely soil. Failure occurred in 1 patient with severe constipation necessitating colostomy and 2 (1 noncompliant who stopped catheterizing regularly) in whom the channels subsequently closed.

Conclusions

Synchronous construction of antegrade continence enema and Mitrofanoff channels is successful in the majority of doubly incontinent patients. Selection of patients with high motivation is important to obtain satisfactory results.     

THE MITROFANOFF PROCEDURE IN PAEDIATRIC URINARY TRACT RECONSTRUCTION

Methods : Between 1991 and 1996, 23 children underwent urinary tract reconstruction of varying complexity together with a continent diversion according to the Mitrofanoff principle. The appendix was used in 14 patients and the ureter in seven. Two patients had previously had an appendicectomy and the ureters were not suitable. One had a catheterizable channel made from an isolated segment of colon and the other had a detrusor tube constructed. Background : Urinary tract reconstruction is required in many congenital and some acquired urological conditions in childhood. The majority are managed by clean intermittent catheterization (CIC), for which purpose the appendix or other tubular structure may be used to provide a continent catheterizable abdominal stoma. Results : Twelve patients with an appendix conduit, six with a ureteric conduit, and one with a colonic tube are continent, although the latter has had some problems with stomal stenosis. All manage CIC with comfort, the older children doing the procedure themselves. One appendix conduit has stomal incontinence and another was inadvertently divided during renal transplantation. The detrusor tube strictured and was removed. Conclusions : A continent abdominal stoma using the Mitrofanoff principle gives reliable results in children and is well tolerated. It should be considered in the management of children undergoing urinary tract reconstruction when CIC is necessary. The appendix is eminently suitable for this purpose but the ureter provides a satisfactory alternative in selected cases. When neither is available, alternative techniques for constructing a catheterizable continent channel may be considered.     

Minimizing Stomal Stenosis in Appendicovesicostomy Using the Modified Umbilical Stoma

Purpose

We describe creation of a modified umbilical stoma as part of continent urinary diversion using appendicovesicostomy.

Materials and Methods

Umbilical stomas were created using the eversion-inversion principle in 25 patients undergoing appendicovesicostomy.

Results

Mean followup was 3 years. Cosmesis of the umbilical stoma was good in all cases. Stomal stenosis required surgical revision in 8 percent of cases.

Conclusions

We recommend our modified umbilical stomal technique for appendicovesicostomy because it allows good cosmesis without compromising stomal function.     

Serosal lined extramural tunnel (Ghoneim) principle in the creation of a catheterizable channel in bladder augmentation

PURPOSE: The flap valve mechanism is often the preferred technique for creating a continent catheterizable channel in bladder reconstruction. The umbilicus is usually the preferred site for stomal placement. However, it is not always possible to bring the conduit to the umbilicus when creating the flap valve mechanism at the bladder level. To prevent this problem, we applied the Ghoneim technique to construct the flap valve mechanism during ileal bladder augmentation. MATERIALS AND METHODS: A total of 10 patients (7 boys and 3 girls) 5 to 17 years old underwent ileocystoplasty in combination with an appendiceal Mitrofanoff procedure as a catheterizable channel. The U-shaped ileal segment was anastomosed to the bivalve native bladder, leaving redundant bowel on the right side. The musculomucosal edges of the redundant bowel were sutured together, forming the posterior wall of the tunnel. The appendix was positioned onto the musculomucosal suture line, and the proximal end was anastomosed to the reservoir with an advancement suture. The ileal segment was then imbricated over the appendix by interrupted silk sutures, forming a serosal lined extramural tunnel. The stoma was placed at the depth of the umbilicus. RESULTS: The underlying diagnoses included mylomeningocele (8) and posterior urethral valve (2). Mean followup time was 12.5 months (range 7 to 21). All patients were continent, and there were no stoma related complications such as stenosis or difficult catheterization. CONCLUSIONS: The Ghoneim technique creates an effective continence mechanism and allows the conduit to reach the umbilicus easily.     

The continent, catheterizable abdominal conduit in adult urological practice

OBJECTIVE

To report a large, single‐centre experience with a continent, catheterizable abdominal conduit in adult patients.

PATIENTS AND METHODS

We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13‐year period. Data on surgical procedure, complications and final outcome were collected and analysed.

RESULTS

The mean age of the patients was 38.4 years and mean follow‐up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent.

CONCLUSIONS

Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long‐term follow‐up.     

Editorial comment

We experienced two cases of neurogenic bladder in which clean intermittent catheterization (CIC) had been performed since early childhood. In both cases, CIC had not provided adequate voiding control and incontinence persisted. According to the Mitrofanoff Principle, we used the appendix as a catheterizable conduit, which was constructed to the umbilicus.     

The appendix as a conduit for antegrade continence enemas in patients with anorectal malformations: lessons learned from 163 cases treated over 18 years

Introduction

The antegrade continence enema (ACE) has been shown to be a safe and effective method for managing fecal incontinence in the pediatric population. The purpose of this study was to examine our experience with the ACE procedure using the appendix as a catheterizable conduit in children with anorectal malformations (ARMs).

Methods

We reviewed the charts of all patients who underwent an ACE procedure using the appendix as a catheterizable conduit between January 1992 and January 2010. Preoperative diagnosis (ARM type), operative details, functional outcomes, and postoperative complications were assessed. Technical modifications over time included selective cecoplication, implementation of the umbilical V-V appendicoplasty technique, and laparoscopy for cecal mobilization.

Results

Mean age was 9.9 ± 0.6 years, and 67% were male. The most common preoperative diagnosis was rectourethral fistula in boys (39%) and persistent cloaca in girls (61%). Forty-five complications occurred in 41 patients with an overall incidence of 25.6% (stricture, 18%; leakage, 6%; prolapse, 4%; intestinal obstruction, 0.6%). The incidence of stomal leakage was lower in patients when a cecoplication was performed (2.9% [4/138] vs 29.4% [5/17]; P < .01), and the incidence of stricture was lower in patients when the umbilical anastomosis was created using the V-V appendicoplasty technique (11% [11/100] vs 30% [18/60]; P < .01). Successful management of incontinence was reported by 96% of all patients.

Conclusions

The ACE procedure using the umbilical V-V appendicoplasty provides an effective and cosmetically superior means for bowel management in children with ARMs. The rate of late complications is not insignificant however, and preventative strategies should focus on careful operative technique and ensuring compliance with catheterization protocols well past the initial postoperative period.     

Continent catheterizable conduits: which stoma, which conduit and which reservoir?

OBJECTIVE: To assess the outcome of the various methods used in creating continent catheterizable conduits. PATIENTS AND METHODS: The case notes were reviewed from 89 patients who underwent the formation of 112 continent catheterizable conduits. RESULTS: Sixty-five conduits were Mitrofanoff and 47 were antegrade colonic enema (ACE); 21 patients had both. At a mean follow-up of 34 months, 95 (85%) conduits were still in use. There was no difference in complications between the Mitrofanoff and ACE conduits; 109 (97%) conduits were continent and stomal stenosis occurred 35 (31%). There was no significant difference relating to the conduit used, the reservoir, the stoma type or the stoma site. Only 39% of patients required no revisional surgery. CONCLUSION: Although urinary and fecal continence can be achieved in most patients there is a high burden of complications and revisional surgery. All patients should be counselled accordingly.     

Long-term followup and outcome of continent catheterizable vesicocstomy using the Rink modification

PURPOSE: Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. RESULTS: Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. CONCLUSIONS: Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.     

Use of the mitrofanoff principle in urinary reconstruction

Summary The Mitrofanoff principle for continent reconstruction of the lower urinary tract may be summarized as: 1) the use of a narrow catheterizable conduit (appendix or ureter) brought to the skin; 2) anti-refluxing connection of the conduit for catheterization to the reservoir to provide continence; 3) a large low pressure leak-proof urine storage reservoir (bladder, augmented bladder, or colon segment); 4) anti-refluxing connection of the upper urinary tract to the reservoir; 5) effective complete emptying of the reservoir by clean intermittent catheterization. Our experience with eight successful cases is reviewed.     

Urinary Reconstruction Using Appendix as a Urinary and Catheterizable Conduit in 12 Patients

Background The appendix vermiformis can. provide an excellent urinary conduit or a catheterizable outlet in continent urinary reservoirs in selected cases. We report our clinical experience using the appendix in urinary reconstruction in adult patients.
Methods A total of 12 patients underwent urinary reconstruction using the appendix. The indications were pelvic malignancies except for 1 patient with neurogenic bladder and difficulty in self-catheterization via urethra. The appendix was used as a catheterizable conduit in 8 patients, and as a urinary conduit in 4 patients. The in situ submucosally embedded method was used in 6 patients and the Mitrofanoff method was used in 2 patients. Follow-up ranged from 3 to 41 months (mean, 22).
Results Early complications occurred in 3 patients (wound infection, false passage and intestinal anasotomotic leak). Late complications occurred in 3 (slight hydronephrosis, ileus, stomal stenosis). Emergent colostomy and pouchstomy with resection of the appendix was performed in the patient with anastomotic leak. The isoperistaltic Kock nipple valve was reconstructed for continence in this case. Prolonged ileus in 1 patient was treated by open surgery. Other complications were managed conservatively. End results were excellent in 8 patients, good in 3, and poor in 1.
Conclusions The appendix can be used advantageously as an outlet of continent urinary reservoirs or for a urinary conduit when the ureter is too short to reach the skin. Complete continence and easy catheterization can be obtained, and the appendix construction can be used as a urinary conduit instead of the ileal conduit in poor risk patients.     

Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas

OBJECTIVE: To evaluate the impact of various factors that might ultimately influence the stoma complication rate associated with the construction of a continent catheterizable urinary (CCU) and Malone antegrade colonic enema (MACE) stoma in children. PATIENTS AND METHODS: Retrospectively, we reviewed our experience in patients who had a CCU and/or MACE stoma reconstructed at our institution from 1992 to 2003. Diagnosis, type of stoma constructed (CCU vs MACE), single vs dual stomas, stomal site, conduit material (appendix, split appendix, Monti-Yang or ureter), sex, age, patient mobility and body mass index, race and concomitant surgery (e.g. bladder augmentation with or without bladder neck reconstruction) were evaluated for stoma-related complications. In all, 109 patients (64 males and 45 female), with a mean (sd, range) age of 8.6 (5.7, 2-37) years, had 151 stomas constructed during the period of analysis, comprising 56 CCU only, 11 MACE only and 42 (84 stomas) both simultaneously. RESULTS: The mean (range) follow-up was 48 (6-144) months. The primary diagnoses were neurogenic bladder in 60 (55%), bladder exstrophy/epispadias in 17 (16%) and posterior urethral valves in 11 (9%) patients. The umbilicus was the primary site for the CCU stoma in 88 of 98 (90%) cases, while the right lower quadrant was the primary site for MACE in 46 of 53 (87%). After surgery complete stomal continence was provided in 95 of 98 (97%) CCU stoma, whereas the MACE was successful in 52 of 53 (99%). The stoma-related complications included stenosis in 27, leakage in eight, false passage in four, atrophy in two, keloid in one, and breakdown of the stoma in two. Individually, only greater age and a primary diagnosis of neurogenic bladder were independent risk factors associated with an increased rate of stomal complications and higher incidence of revision (P < 0.05). CONCLUSION: Stomal complications are extremely common whether CCU or MACE stomas are constructed individually or together. Nevertheless, despite the need for revision, the high stoma continence rate supports their use. Greater age at surgery and a primary diagnosis of neurogenic bladder were associated with a significant increase in the stoma-related complications and the need for revision.     

Continent Gastric Tube: New Techniques and Long-Term Followup

Purpose

The successful use of stomach for bladder augmentation and substitution is well documented. Gastric tissue has been used more recently to create continent catheterizable tubes. We describe 2 new techniques of gastric tube construction, and report our long-term followup of catheterizable gastric tubes in children and adults undergoing complex urinary tract reconstruction.

Materials and Methods

A retrospective chart review of 6 male and 4 female patients 5 to 43 years old was done. Primary diagnoses included bladder exstrophy, cloacal exstrophy, rhabdomyosarcoma and neurogenic bladder. Five patients underwent gastrocystoplasty with simultaneous creation of a continent gastric tube from the anterior gastric flap. In 2 patients who had undergone previous gastrocystoplasty a continent gastric tube was created from an anterior flap raised from the existing gastric bladder. Isolated gastric tubes were constructed in 3 patients.

Results

Followup ranged from 2 to 9 years (median 3.5). All patients demonstrated easy reliable catheterization. One patient required revision of the proximal end of the tube for incontinence. At followup all tubes were continent. Complications occurred only in flush or protuberant stomas, and resolved after stomal revision with recessed skin flaps.

Conclusions

Several techniques can be used to create a continent gastric tube. Long-term followup reveals reliable catheterization and good continence rates. Recession of the gastric tube stoma with a skin flap prevents peristomal complications.     

MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

Purpose

We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion.

Materials and Methods

Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed.

Results

Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion).

Conclusions

Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Orthotopic urethral substitution in female patients using the mitrofanoff principle

PURPOSE: We present our experience with orthotopic urethral substitution in female patients using the Mitrofanoff principle. MATERIALS AND METHODS: We performed orthotopic urethral substitution using the Mitrofanoff principle in 18 female patients 1 to 29 years old (mean age 10). The conduit was constructed with appendix in 13 cases, tapered ileum in 4 and fallopian tube in 1. The etiology of incontinence included exstrophy in 8 patients, neurogenic bladder in 3, urogenital sinus in 3, and bilateral ectopic ureter, ectopic ureterocele, the prune-belly syndrome and post-cystectomy undiversion in 1 each. RESULTS: Mean followup was 29 months (range 9 to 72). A total of 16 patients achieved continence following a program of clean intermittent catheterization. There were 2 unsuccessful operations. In 1 case the appendix become ischemic and in 1 a vesicoperineal fistula developed. One patient catheterizes every 2 hours to avoid leakage. Catheterization was temporarily difficult in 5 patients, of whom 2 had an appendiceal and 3 had a tapered ileal conduit. Two patients with an ileal conduit have had chronic difficult catheterization. CONCLUSIONS: Orthotopic replacement of the urethra using the Mitrofanoff principle is suitable in highly select female patients who need continent diversion or a catheterizable conduit but who will not accept an abdominal stoma. It is particularly suited to patients in whom exstrophy reconstruction has failed.     

Long-Term Results of Lower Urinary Tract Reconstruction With the Ceco-Appendiceal Unit

Purpose

We report long-term results in 11 patients born with bladder exstrophy who underwent lower urinary tract reconstruction using a ceco-appendiceal unit.

Materials and Methods

Four boys and 2 girls underwent lower urinary tract reconstruction using an unaltered ceco-appendiceal unit. In 2 boys and 1 girl the bladder was replaced with a reservoir of terminal ileum, cecum and ascending colon, and the appendix was used as an orthotopic neourethra. In another 2 boys and 1 girl the bladder was augmented, while the appendix was used to create a stoma to the umbilicus. In 5 patients in whom the ceco-appendiceal sphincteric mechanism. Four patients underwent augmentation with the appendix brought out as an umbilical stoma, and in 1 the bladder was replaced and the appendix was used as a neourethra.

Results

Six patients in whom the ceco-appendiceal junction was unaltered and 5 in whom it was plicated remain continent 5 to 11 and 2 to 7 years postoperatively, respectively. In the initial patient urinary incontinence developed due to high intraluminal pressure, which resolved after detubularization of the urinary reservoir. Another patient underwent revision of the abdominal stoma.

Conclusions

The ceco-appendiceal unit may be used for continent lower urinary tract reconstruction. Ceco-appendiceal junction competence can be tested intraoperatively and the sphincteric mechanism may be reinforced as necessary. The appendix may be ectopically or orthotopically placed and used for intermittent catheterization.     

A high easy-to-treat complication rate is the price for a continent stoma

OBJECTIVE: To evaluate the conduit-related complications and their treatment in Mitrofanoff continent urinary diversion and antegrade colonic enema (ACE) procedures. PATIENTS AND METHODS: The files of 53 patients (18 men and 35 women) in whom 58 continent stomas were created were retrospectively reviewed. Gender, age, age at the time of surgery, underlying disease, concomitant surgery, abdominal position of the stoma, follow-up, complications and treatment were assessed. The mean (sd) age at the time of surgery was 19 (13) years; 30 patients were aged <15 years and the mean follow-up was 2.8 (1.9) years. Fifty-three continent vesicostomy-type Mitrofanoff stomas were constructed and five ACE procedures performed. Forty-five stomas were in the umbilicus and 13 on the abdominal wall. For 45 conduits the appendix was used; in the other 13 a transverse tubularized ileal segment according to Monti was created. RESULTS: There were stoma-related complications in 19 patients (36%), with 27 in all and stomal stenosis accounting for more than half. Five patients had urinary leakage. The median time to the first complication was 9 months. Multiple regression analysis showed that gender and stoma location were the only significant determinants of the complication/follow-up ratio. Women had more complications than men and umbilical stomas fared worse than those on the abdominal wall. Age, underlying disease and type of stoma were not significantly related to the complication/follow-up ratio. The complication was treated by one procedure in 13 patients; four needed two and two needed three surgical revisions. Most complications were relatively easy to treat, i.e. dilatation in five, endoscopic incision in one, re-anastomosis in four, Y-V plasty in seven, a new channel in two, reimplantation in three, a bladder cuff in two for stomal leakage, and abdominoplasty in two. Only one stoma had to be abandoned. CONCLUSION: The complication rate for continent small-diameter stoma is high. However, most complications are relatively easy to treat. Despite these complications, patient satisfaction remains high.