A new extra-abdominal channel alternative to the mitrofanoff principle: experimental and preliminary clinical experience

INTRODUCTION: The appendix is the gold-standard channel for the Mitrofanoff principle in pediatric urology, but the search for alternatives is justified considering it may not be available or preferably used for colonic stomas (Malone antegrade continence enema). The aim of this study is to report on technical feasibility of a new approach for creating catheterizable channels in a rabbit model and to present our preliminary clinical experience. MATERIAL AND METHODS: We configured a tube from two rectangular skin flaps 1x4 cm opposite each other in the middle line of the lower inferior abdomen. The channel was anastomosed to the bladder dome with embedding sutures to create a valvular mechanism. The experimental study consisted of 12 rabbits, divided in 4 groups according to the sacrifice schedule at 2, 4, 8 and 12 weeks. At 30th postoperative day, an urodynamic evaluation was performed to record continence of the stoma. A histological analysis of the specimens stained with hematoxylin-eosin, Masson trichrome and Picrosirius red was also done in group 2 (sacrifice at 4 weeks postoperatively). We used this method in 3 patients with congenital non-neurogenic bladder disease presenting with massive residual volumes without compliance deficits. RESULT: The technique proved feasible in all animals, 9 of 12 could be easily catheterized and underwent urodynamic study. No stoma leakage was observed in 7 animals at high bladder pressures (> 50 cm H20) and only 2 animals had some leakage at 40 cm H20. Urodynamics performed through the stoma showed urethral leakage at 20 cm H20, therefore demonstrating the efficacy of the valvular mechanism. Histological analysis confirmed good integration between the tube and the bladder. Mean follow-up of the clinical series (3 patients) was 7.2 months. Two patients remained continent up to 4 hours, whereas 1 patient had some leakage after 2 hours. CONCLUSION: We were able to confirm feasibility of a new extra-abdominal...

Derivações urinárias continentes na criança / Continent urinary diversion in children

O tratamento da incontinência urinária na criança, particularmente da bexiga neurogênica, representa um grande desafio para o cirurgião ou urologista pediátrico. Antigamente, dispunha-se apenas de derivações cutâneas incontinentes para se preservar a função renal dessas crianças. Aos poucos, foram surgindo inovações, como o cateterismo limpo intermitente, em 1971, a cistostomia continente transapendicular ou principio de Mitrofanoff, em 1980, o enema anterógrado continente ou procedimento de Malone, em 1990, a técnica de Monti, em 1997. Todo esse arsenal terapêutico contribuiu muito para a melhoria do tratamento das crianças com bexiga neurogênica, tanto do ponto de vista social, mantendo-as continentes, quanto do ponto de vista renal, com preservação do trato urinário superior. Este trabalho pretende revisar as derivações continentes existentes na criança, discutindo aspectos ligados às suas indicações, à técnica cirúrgica e às suas complicações.

Treatment of urinary incontinence caused by spina bifida in children represents an enormous challenge to the pediatric urologist. In the past, cutaneous diversion was the only option to treat these children. Starting in 1971 with clean intermittent catheterization, new therapeutical modalities appeared, such as the Mitrofanoff principle (1980), the Malone procedure (1990) and the Monti principie (1997). These advances have changed dramatically the treatment of children with neurogenic bladder by achieving dryness and preservation of upper urinary, tract. This study intended to review the techniques of cominem diversion in children, with special attention to its indications, surgical aspects and complications.

Continent Urinary Diversion Using the Split Cuff Nipple Mitrofanoff Stoma / 대한비뇨기과학회지

PURPOSE: The Mitrofanoff continent catheterizable stoma is a useful technique in continent reconstruction. Continence is dependent on the formation of a valve mechanism usually in the form of a submucosal tunnel. This mechanism requires careful dissection of the appendix mesentery and may not be appropriate in small bowel pouches, The split cuff nipple technique has been used effectively for ureteral reimplantation into bowel segments, This paper describes the successful combination of these techniques to provide a continent catheterizable stoma. MATERIALS AND METHODS: Five patients(6 cases) have undergone split cuff nipple stoma formation. Appendix was used in 5 cases and ileum was used in 1 case. Underlying disease were 3 bladder cancers and 2 spinal cord injuries. Reservoir was made using 3 patients ileum, 1 right colon and 1 ileocolon. In 3 cases the appendix was brought out through the umbilicus and in another 3 cases the stoma was formed in the right iliac fossa. CONCLUSIONS: The split cuff nipple appendix stoma provides a simple and reliable continent stoma technique, overcoming some of the complexities of reimplantation of the intact appendix. The technique may be suitable for other narrow tubes, mainly the stapled small bowel or gastric tube.