Mitrofanoff procedure

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.

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]

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]

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]

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]

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]