The fallow mitrofanoff

Abstract

Background: Treatment of severe congenital dysfunctional bladders often requires bladder drainage to maintain low bladder pressure, thus preserving renal function. Although clean intermittent catheterization is the ideal choice, this can be especially challenging in the younger pediatric population or in children with neurological impairment. Alternatives such as incontinent vesicostomy, long-term suprapubic catheterization, or button cystostomy exist, but these are rarely very long-term options.

Objective: The objective of this study is to report the authors' experience with children who underwent a 'fallow' Mitrofanoff, meaning an appendicovesicostomy in which an indwelling catheter was placed for several months or years, allowing for bladder emptying several times a day, until the child was ready for clean intermittent catheterization (CIC).

Study design: All patients who underwent a Mitrofanoff appendicovesicostomy with or without concomitant bladder augmentation, for whom there was a significant delay (≥6 months) between surgery and implementation of CIC, were reviewed. In all these cases, the child showed obvious opposition to CIC. An indwelling catheter was left in place, with a stopper allowing for bladder emptying 5-6 times a day as would happen with CIC. The catheter was changed once a week until CIC was implemented. Complications including febrile urinary tract infections (fUTIs) during the fallow period and complications including leakage or stenosis during the CIC period were noted.

Results: The series includes 10 patients (7 boys and 3 girls), aged a median 41 ± 34 months (range: 23-144) at the time of the appendicovesicostomy (6 posterior urethral valves and 4 non-neurogenic neurogenic bladders). All underwent classic appendicovesicostomies. The delay before full implementation of CIC was a median 29.5 ± 24 months (range: 6-72). During the fallow period, 3 patients presented fUTIs. The catheter was closed, allowing for bladder drainage 4-6 times a day. There were no episodes of leakage from the Mitrofanoff or stomal stenosis during the fallow period or CIC period. Mean follow-up since the appendicovesicostomy is 66 ± 33 months and since initiation of CIC is 26 ± 26 months (range: 4-94).

Discussion: For children who require bladder drainage, an appendicovesicostomy can be performed even if CIC is not initiated immediately and be used as a suprapubic catheter or button cystostomy. When the child is ready, CIC can be initiated without need for further surgery and without risk for the conduit. The limitations of this study include its retrospective nature and the low number of patients.

Conclusion: A Mitrofanoff appendicovesicostomy can be performed in a child requiring long-term bladder drainage and in whom classic CIC is not possible, even if CIC is not initiated immediately.

Keywords: Appendicovesicostomy; Bladder drainage; Cystostomy.