34 Continent Catheterizable Channels

427 34 Continent Catheterizable Channels Yunus Söylet Contents in both children and adults, such as ARM, spina bifida, sacral agenesis, exstrophy complex, postradia- 34.1 Introduction . 427 tion cystitis, complex vesicovaginal fistulae, posterior 34.2 Indications . 427 urethral valves, prune-belly syndrome, cerebral palsy, 34.3 The Mitrofanoff Procedure . 428 sacrococcygeal teratoma, spinal-cord injury, perineal 34.3.1 Technical Details . 428 trauma, Hirschsprung’s disease, intractable consti- 34.4 The MACE Procedure . 430 pation, and different types of urethral failures, or in 34.4.1 Technical Details . 431 patients with perineal colostomy after rectal resec- 34.5 The Stoma Technique and Associated Problems . 432 tion [6–19]. In the original description of Mitrofanoff 34.6 Postoperative Management . 434 and antegrade colonic enema (ACE) procedures, the 34.7 Results . 435 conduit of choice is the appendix. In conditions in References . 435 which the appendix is not available, tubular struc- tures such as the ureter, fallopian tube, Meckel’s diverticulum, and the vas deferens, or tubes created from the ileum, colon, stomach, bladder, rectus 34.1 Introduction abdominis muscle, and prepuce can be used to create a Mitrofanoff channel. Ileal tubes are most commonly The concept of clean intermittent catheterization and preferred if the appendix is not available. The use of its efficacy in emptying urinary reservoirs was first in- the other organs except the ureters and bladder tubes troduced by Lapides in 1972 and is accepted as the first are either sporadic or experimental (Table 34.1) [20– step in the use of continent catheterizable channels 37]. (CCC). Subsequent important progress in CCC in- In ARM, the ACE procedure is used with two in- cludes performance of the first continent cystostomy dications: the treatment of fecal incontinence and/or by Mitrofanoff in the 1980s, acknowledgment of low- the treatment of postoperative intractable consti- pressure reservoirs from the beginning of the 1980s, pation and developing megarectum/megacolon in recognition of the importance and efficacy of colonic which conservative management frequently fails [38]. washouts in the management of fecal continence, and The presence of sacrospinal anomalies in ARM can the first continent cecostomy performed by Malone also lead to both urinary and fecal incontinence [39– in 1990 [1–4]. CCC are used in anorectal malforma- 42]. In this group of patients, the Mitrofanoff prin- tions (ARM) for problems involving the gastrointes- ciple is used to provide urinary continence. In some tinal and/or urinary systems. The aim is to overcome fecal and urinary incontinence concomitantly. These circumstances also lead to competition for the appendix, since this has been the favored channel for both Table 34.1 Organs used in the construction of continent chan- the Malone’s antegrade colonic enema (MACE) and nels using the Mitrofanoff principle Mitrofanoff procedures. These limitations have lead Tubular organs Tubularized organs to the creation of new techniques for these channels Appendix Ileum [5]. Ureter Colon Fallopian tubes Stomach 34.2 Indications Bladder Prepuce The Mitrofanoff and MACE procedures are widely Rectus abdominis muscle used alone or in combination for different problems 428 Yunus Söylet patients with combined incontinence, the ACE and dix is anastomosed to the bladder with an antirefl ux Mitrofanoff procedures are used together. technique, there is no leak from the abdominal wall orifi ce, thus it is a continent vesicostomy. In this procedure, a catheter is advanced through a conduit to 34.3 The Mitrofanoﬀ Procedure empty the urinary reservoir in a clean and intermittent fashion. Th e Mitrofanoff procedure is also known as continent appendicovesicostomy according to the Mitrofanoff principle. Th e two indications for continent vesicos- 34.3.1 Technical Details tomy in ARM are the same as those for incontinent intestinal conduits: management of urinary inconti- In the majority of cases a Mitrofanoff channel is con- nence and preservation of renal function. ARM pa- structed through a midline infraumbilical incision. tients usually have neurogenic bladders secondary to If the patient will only have a continent vesicostomy sacrospinal anomalies. In a small group of patients constructed, the right laterovesical space is deeply that have urethral injury secondary to their ARM re- freed before opening the peritoneum. Th e cecum construction, the Mitrofanoff procedure may be help- and appendix are explored and the pedicle vessels ful in the long-lasting management of urethral stric- of the appendix are carefully mobilized. Th e appen- ture. Th is is the third indication for the Mitrofanoff dix is excised from the cecum with a cecal wall cuff . procedure, and has been reported in the management Th e aim in leaving the cecal cuff on the appendix is of urethral problems [43]. Th e Mitrofanoff procedure to enable a wide anastomosis on the abdominal wall. as the pioneer of CCC has helped to defi ne the pri- Once the cecal defect is closed, the tip of the appen- mary principles of these channels. Since the appendix is opened obliquely, the lumen is irrigated with Fig. 34.1 (A–D) Submucous tunnel technique into the U-fl ap of thick-walled bladder for creating a Mitrofanoff channel 34 Continent Catheterizable Channels 429 an antiseptic solution, and the patency of the lumen In the majority of patients, augmentation cysto- is checked with a catheter. If the bladder has a small plasty is a part of this surgery. Augmentation pro- capacity and thick wall (as it has most of the time), vides a low-pressure reservoir, while the Mitrofanoff a U-shaped fl ap should be raised cranially for en- channel aids in emptying the reservoir regularly. Th e trance. With the help of this fl ap, the appendix can bladder neck should be constructed or closed so that be anastomosed to the bladder through a long tun- it does not leak. It has been shown in many cases that nel (Fig. 34.1). Th e tunnel should at least be 2.5–3 cm even though vesicoureteric refl ux may exist in the long. Once the conduit–bladder anastomosis is com- system, the creation of a low-pressure reservoir and pleted, if no further procedures such as bladder aug- guaranteeing regular emptying of the system will lead mentation, bladder-neck reconstruction, or ureteric to disappearance of the refl ux. Th us, in many patients reimplantation are necessary, the bladder is closed with small bladders and limited space for a ureteric and the conduit is anastomosed either to the right reimplantation, the reimplantation should not be car- lower quadrant or to the umbilicus. In the literature, ried out and morbidity is avoided [45]. two cases have been reported to have their appendix In patients with urethral injuries as a result of located into the left lower quadrant due to previous ARM repair, if a long and complicated management stomas created in the right lower quadrant. In these is necessary, or if autoaugmentation is indicated for cases the cecum and the ascending colon were widely a diff erent underlying pathology, it is appropriate to mobilized, the appendiceal vessels were dissected up construct an appendicovesicostomy without opening to their origin from the superior mesenteric artery, the bladder. In the extravesical Mitrofanoff technique and the conduit was moved to the left through a de- that we use in our patients, the abdomen is entered fect created in the bowel mesentery and anastomosed through a lower-abdominal midline incision, the to the left abdominal wall [44]. right laterovesical space is opened, and a Lich-Gre- Fig. 34.2 (A–D) Extravesical Mitrofanoff technique 430 Yunus Söylet goire-like extramucosal tunnel is created in the right Minimally invasive techniques, although not posterolateral wall of the bladder. The mucosa is en- widely popularized, have been used in the construc- tered close to the bladder neck and an appendicovesi- tion of continent urinary channel surgery. The first costomy performed. The seromuscular layer is closed laparoscopic appendiceal–vesical anastomosis with a with sutures, the tunnel is completed, and the appen- flap-valve mechanism has been reported by Hsu and dix is anastomosed to the skin (Fig. 34.2). In cases Shortliffe [57]. There is also a case report on laparo- where the appendix is not available or has been used scopic removal of a nonfuctioning kidney and anas- for the MACE procedure, the Mitrofanoff channel is tomosis of the distal ureter to the skin as a continent most commonly created using the Monti technique channel in a patient who had previously undergone [46]. Although this technique was described by Monti a ureteric reimplantation due to vesicoureteric reflux in 1997 [47], it was also described by Yang in 1993 [58]. [48]. When Yang reported this technique, however, he focused on the use of a needle as an aid for reimplants into the small bowel submucosa. In the Monti tech- 34.4 The MACE Procedure nique a 2.5-cm segment of the small bowel is detubu- larized longitudinally and retubularized transversally. Bowel management is necessary in the majority of A 2.5-cm segment of bowel provides a tube size of ARM in the postoperative period. Fecal incontinence about 18–20 Fr. The length of the Monti tube is de- in some patients and intractable constipation in termined by the diameter of the bowel segment. The others are the main problems. Initially, conservative length will be at least 8 cm when the ileum is used measures including aggressive potty training, dietary and 10–12 cm when the colon is used. The transverse management, different medications, daily retrograde tubularization should be carried out first with muco- enemas, and biofeedback therapy in suitable patients sal apposition and then with a second row of serosal are used to overcome these complications.

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