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The Catheterizable Content Urinary Stomas in Pediatric Population - our experince in 8 cases

Iulia Straticiuc-Ciongradi¹,², I. Sarbu¹,², Elena Tarca¹,², Doina Nedelcu², R. Russu³, S. G. Aprodu¹,²

¹“Gr. T. Popa” University of Medicine and Pharmacy

²Department of Pediatric Surgery, “Sf. Maria” Children’s Hospital

³Department of Pediatric Nephrology, “Sf. Maria” Children’s Hospital, Iasi, Romania

 

Abstract

Purpose: Continent appendicovesicostomy, described by Mitrofanoff in 1980, is widely used in patients with voiding dysfunction with indication for clean intermittent catheterization to provide an easier way. Our aim was to evaluate the outcome and complications of catheterizable continent urinary stomas.

Methods: Retrospective record review of all patients operated in our department with urinary continent stomas, within the last 8 years.

Results: 8 cases were operated during that time and they all received Mitrofanoff stomas, with the use of the appendix. The diagnoses were: posterior urethral valves (n=2), neurologic bladder (myelomeningoceles) (n=3), bladder exstrophy (n=1), severe posttraumatic urethral stenosis (n=1), neurogenlike bladder (n=1). The mean age at operation was 6.7 years. The implantation of urinary stomas was into the native bladder in 7 patients and into the intestinal segment of an augmented bladder in 1 case. The location of the stoma was umbilical in 2 cases and in the right lower quadrant of the abdomen in 6. When an extra-umbilical location was chosen, skin flaps were used. Excellent esthetic and functional results were achieved in 6 (75%) of the 8 stomas, which were continent and easy to catheterize. One of the children underwent a second surgical procedure on account of difficult catheterization due to umbilical stoma opening stenosis. One neurologic patient is still incontinent and will need further bladder neck surgery. All the cases have improved or maintained their renal function stable.

Conclusions: Catheterizable continent urinary stomas achieve the goals of urinary continence, renal function preservation and independence in most patients, with a low complication rate.

Key words: Mitrofanoff procedure, urinary stoma, urinary incontinence, appendicostomy

 

Correspondence

Iulia Straticiuc-Ciongradi
Department of Pediatric Surgery
“Sf. Maria” Children’s Hospital
Str. Vasile Lupu Nr.62, Iasi, Romania
E-mail : This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel : 040745314628

 

Introduction

The continent urinary bypass technique described by Mitrofanoff in 1980 [1] has revolutionized urinary tract reconstruction procedures in both adult and pediatric urology. Thus, the Mitrofanoff principle involves the use of an intestinal conduit, either the appendix or a molded intestinal segment [2], designed to drain the urine from the bladder via a cutaneous opening. Although it was initially meant for the treatment of neurologic bladder cases, in time, the Mitrofanoff principle has proven useful alone or in association with other cystoplasty procedures in various other cases requiring efficient urinary bladder draining (posterior urethral valve, exstrophyepispadias complex, etc). There are numerous advantages to continent urinary stomas and they include: urinary incontinence prevention in patients who are unable to catheterize themselves on the urethra, accurate bladder emptying in the retentionist bladder, etc. The authors share their experience regarding the use of Mitrofanoff continent urinary stomas in 8 pediatric patients.

Material and method

A retrospective review of the medical records of the patients that underwent surgical Mitrofanoff procedures between 2005 and 2012 was done. We identified 8 such cases whose etiology included: posterior urethral valves (2 cases), neurologic bladder (myelomeningoceles) (3 cases), bladder exstrophy (1 case), neurogen-like bladder (1 case) and severe posttraumatic urethral stenosis due to several previous surgical procedures (1 case). There were 7 male patients (87%) and one female patient (13%), whose mean age at the time of the operation was 6.7 years (between 4.5 and 8 years).

The surgical procedure followed the stages described by the Mitrofanoff technique, which involves appendix preparation, urinary bladder preparation and anti-reflux appendix implantation through a submucous path (fig. 1), transparietal appendix path preparation. No procedures on the bladder neck were performed in any of the cases. In all the cases the appendix was used to create the continent stoma. In 2 cases (25%) the cutaneous opening was located in the patient’s navel (25%) and in the other 6 cases (75%) the right iliac fossa was preferred, using a “V-Z” skin flap (fig. 2). In one of the patients with posterior urethral valve, the Mitrofanoff procedure was accompanied by a bladder augmentation procedure (ileocystoplasty).

Figure 1: Appendicular stoma implantation in the bladder

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Figure 2: Cutaneous opening done using a “V-Z” skin flap

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All the patients had a stoma calibration catheter placed in the opening for six weeks, at the end of which, they came back to the hospital to have their drainage catheters removed and start their daily catheterizations. The catheterizations were done every 3 to 4 hours throughout the day in all the patients. A night drainage probe was placed in the stoma in the patients with neurologic bladder due to myelomeningoceles and in the patient with retentionist “neurogen-like” bladder.

Results

Excellent esthetic and functional results were achieved in 6 of the 8 stomas, which were continent and easy to catheterize (fig. 3). None of the patients had uncontrolled urine loss through the stoma. The catheterizations were considered acceptable by the families and patients in all cases. Although, according to the literature, an umbilical stoma location is better tolerated by patients, especially by those confined to wheelchairs, in our group, both umbilical and right iliac fossa stomas were equally well tolerated by the patients.

Figure 3: Mitrofanoff umbilical stoma

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About 2 months after having undergone the first surgical procedure, one of the patients required another plasty operation to correct the umbilical stoma opening stenosis. The patient’s postoperative evolution was good.

We would also like to mention the persistence of involuntary urine loss in a patient suffering from neurologic baldder due to myelomeningocele. The patient’s state was only ameliorated by intermittent catheterization and he will require another surgical procedure on the bladder neck.

The patients’ postoperative follow-up lasted 55 months on the average (between 98 and 12 months). A single male patient with posterior urethral valve suffered from febrile episodes due to urinary tract infections. Since the patient lived in an orphanage, we considered this to be a urinary infection risk factor. We noticed that the renal function remained constant after we started performing daily catheterization, including in one of the patients with posterior urethral valve who had a degree of renal failure before surgery.

Discussions

Continent urinary bypasses done by various surgical procedures are recommended in many conditions, both in adult urology and especially in pediatric urology. In addition to the classical indications related to the need of intermittent catheterizations performed several times a day in various cases of retentionist or incontinent bladder, we were able to use the Mitrofanoff stoma in the case of a patient with severe posttraumatic posterior urethral stenosis in whom the previous repeated attempts of urethra calibration had failed [3].

A Mitrofanoff procedure is considered successful if an easily catheterizable continent conduct is achieved. Thus, a continent stoma may be achieved by creating an adequate intravesical path and by using an anti-reflux technique, while maintaining a 5:1 ratio between the length of the submucous tunnel where the appendix will be placed and its diameter [4]. Most of the intestinal conduct complications occur in its cutaneous opening, although cases of fibrosis, necrosis, volvulus or even appendix perforation have also been described in literature. 12.5% of the patients in our group experienced cutaneous opening stenosis, whereas in literature this percentage is up to 31% [5, 6]. Although the only case of stenosis in our group occurred in an open umbilical stoma, this location and the use of skin flaps for stomas located in the right lower quadrant of the abdomen are factors that reduce the risk of stenosis. Also, the use of “V-Z” or “V-Q-Z” skin flaps will result in an improved esthetic appearance and in lower prolapsed intestinal mucosa or stenosis rates [7]. This is why we used skin flaps in all of the patients in whom the intestinal conduct was opened in the right iliac fossa, with good results.

Conclusions

Although our study group included only eight patients, we think that our success rates, complications and evolution were similar to those reported in literature by research conducted on large populations. We think that continent urinary stomas achieved by surgery are extremely important for preserving the renal function, for ensuring the continence and independence in a significant number of pediatric patients who suffer from different inborn or acquired conditions that also associate incontinence or retentionist bladder.

 

 

 

References

1. Mitrofanoff P. Cystostomie continente transappendiculaire dans le traitement des vessies neurologiques. Chirurgie Pediatrique, vol.21, no.4, 297-306.

2. Monti PR, Lara RC, Dutra MA, Carvalho JR. New techniques for construction of efferent conduits based on the Mitrofanoff principle. Urology 1997;49:112e5

3. Boemers T, Schimke C. ColpoeWrap: a new continence procedure. BJU Int 2004;93(Suppl. 2):27e8.

4. FurnessPD,MalonePSJ,BarqawiA,KoyleMA.TheMitrofanoff principle. Innovativeapplicationsincontinenturinarydiver- sion. ContempUrol;2003:30e45.

5. McAndrew HF, Malone PSJ. Continent catheterizable conduits: which stoma, which conduit and which reservoir? BJU Int 2002;98:86e9.

6. Clark T, Pope CJ, Adams MC, Wells N, Brock JW. Factors that influence outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive procedures in children. J Urol 2002;168:1537e40.

7. Landau EH ,Gofrit ON ,Cipele H, Hardak B, Duvdevani M, PodeD et al. Superiority of the VQZ over the tubularized skin flap and the umbilicus for continent abdominal stoma in children. JUrol2008;180(Suppl.4):1761e5.