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THE MITROFANOFF PROCEDURE: 20 YEARS LATER
0022-5347/01/1656-2394/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 2394 –2398, June 2001 Printed in U.S.A.
THE MITROFANOFF PROCEDURE: 20 YEARS LATER ` S LIARD, EMMANUELLE SE ´ GUIER-LIPSZYC, ANNE MATHIOT AGNE
AND
PAUL MITROFANOFF
From the Department of Pediatric Surgery, University Hospital Charles Nicolle, Rouen, France
ABSTRACT
Purpose: We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup. Materials and Methods: Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux. Results: One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion. Conclusions: The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency. KEY WORDS: cystostomy, follow-up studies, bladder
The continent cystostomy technique was first described by Mitrofanoff in 1980.1 This method allows an alternative procedure when difficulties occur with transurethral catheterization and is now largely used throughout the world for various indications. We assess the long-term evolution of and outcome of the first patients treated with continent cystostomy. MATERIALS AND METHODS
We retrospectively reviewed the records of all patients who underwent continent cystotomy between 1976 and 1984 with a followup of at least 15 years. All operations were performed by the same surgeon (P. M.). A total of 23 cystostomies were performed on 15 boys and 8 girls for neuropathic bladders. Mean patient age at surgery was 8 years (range 3 to 16) and mean followup was 20 years (range 15 to 23). One patient died 3 months after surgery. The neurological lesions myelomeningocele (2 associated with an anorectal malformation in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation with anorectal malformation and sacral agenesis in 1. Clean intermittent catheterization failed in all cases, mostly related to urine leakage. The appendix was
used as a catheterizable conduit in 20 cases, the lower segment of 1 ureter in 2 and a bladder tube in 1. The continent conduit was always brought out to the right lower abdominal quadrant. Closure of the bladder neck was performed in 21 cases (16 times during the same procedure and 5 times secondarily because of persistent urethral leakage). Enterocystoplasty was done during the same procedure in 2 cases and at a later stage in 8. For each patient complications related to the bladder reservoir, continent conduit or other problem and their evolution were reviewed. RESULTS
A 3-year-old girl died in 1977 due to a severe infection of the ventriculoperitoneal valve 3 months after continent cystostomy with closure of the bladder neck (table 1). Immediate conversion to cutaneous urinary diversion associated with cystectomy was required because of high vesical pressure and upper tract dilatation. The most severe complications were those due to a high vesical pressure. Reservoir complications. Upper Tract Deterioration: Ten patients presented with upper tract deterioration after continent cystostomy in 1979, at the beginning of our experience
2394
28
32
30
31
27
28
34
28
27
26
11
12
13
14
15
16
17
18
19
20
27
27
10
23
28 27
8 9
29
24
7
26
37
6
21
Dead
5
22
40 28 26 32
1 2 3 4
Case No.
11 (1984)
10 (1984)
12 (1983)
7 (1981)
8 (1981)
8 (1980)
13 (1979)
6 (1978)
5 (1978)
9 (1978)
8 (1978)
10 (1978)
6 (1978)
5 (1978)
5 (1977) 5 (1977)
6 (1977)
14 (1977)
3 (1977)
16 (1976) 5 (1977) 3 (1977) 9 (1977)
Pt. Age at Current Continent Pt. Age Cystostomy (yr.)
Appendix
Bladder tube Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Ureter Appendix
Appendix
Appendix
Appendix
Appendix Appendix Appendix Ureter
Conduit
Bladder neck closure, bladder augmentation 0
Bladder neck closure Bladder neck closure Bladder neck closure 0 Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure, bladder augmentation Bladder neck closure Bladder neck closure 0
0 0 0 0
Associated Procedure
9 Mos.
2 Yrs.
4 Mos. 3 Mos. 4 Mos.
Interval to Secondary Bladder Neck Closure
Ileal loop (3 yrs.)
Ileal loop (1 yr.)
Ileocecal loop (5 yrs.)
Ileal loop (10 yrs.)
Ileal loop (10 yrs.)
Ileal loop (4 yrs.)
Ileal loop (10 yrs.)
Sigmoid loop (14 yrs.)
Secondary Bladder Augmentation (interval)
Bilat.
Lt, ureteroureterostomy (3 yrs.)
Lt.
Lt., reimplantation (4 mos.)
Bilat.
Secondary Reflux (interval)
2
3
1
1
2
No. Bladder Neck Recanalization
TABLE 1. Results of surgery
Yes
Yes
Yes
Yes
Yes
Yes Yes
Yes renal insufficiency Yes
Yes
Upper Tract Deterioration
6, 7, 11 Yrs.
18 Mos.
5 Yrs.
5 Yrs.
12, 20 Yrs.
Interval to Bladder Lithiasis
5 Yrs.
9 Yrs.
6 Yrs.
2 Yrs.
2 Yrs.
1 Yr.
2 Yrs.
Interval to Cutaneous Diversion
3, 4, 5, 7 Yrs.
1, 4, 6, 9 Yrs.
10, 18 Mos.
2, 6 Yrs.
9 Times
5, 14, 16 Yrs.
Twice for leakage
16, 23 Yrs.
23 Yrs.
1 Yr. 19 Yrs.
Interval to Stomal Revision
MITROFANOFF PROCEDURE
2395
2396
MITROFANOFF PROCEDURE
with continent cystostomy, which led to conversion to cutaneous urinary diversion in 4 and 2 years after the initial surgery in 3 (cases 2, 7 and 8). In case 17 the cutaneous diversion was performed elsewhere because of bladder lithiasis associated with slight upper tract deterioration. None of these 4 patients had had prior conduit catheterization problems. After 1982, 5 patients underwent bladder augmentation with an ileal segment which improved or normalized the upper tracts. Case 6 had progressive deterioration of renal function in the first years of life before continent cystostomy. He was lost to followup for 10 years and seen again with end stage renal failure because he was poorly compliant with catheterizations. Sigmoid cystoplasty was performed 14 years after the continent cystostomy followed by kidney transplantation. Bladder Neck Recanalization: Repeat procedure was required in 5 of 21 patients who underwent bladder neck closures due to persistent leakage. In 3 patients revision of bladder neck closure failed, 1 had successful perineal closure after 2 failed attempts, 1 (case 6) required 2 repeat surgeries and 1 (case 23) required concomitant bladder augmentation. Vesicoureteral Reflux: Vesicoureteral reflux was diagnosed in 10 patients before continent cystostomy. Ureteral reimplantation was performed before cystostomy in 5 patients and afterward because of persistent reflux with upper tract deterioration (case 7). In 5 patients reflux developed after continent cystostomy. In case 4 reimplantation was performed early simultaneously with secondary bladder neck closure. In case 11 unilateral reflux was treated with ureteroureterostomy but persistent deterioration of the upper tract led to augmentation. In 2 cases reflux was managed conservatively with resolution after subsequent bladder augmentation. In case 2 permanent diversion was performed 6 years after continent cystostomy due to severe bilateral reflux with upper tract deterioration. These different complications due to high vesical pressure led to cutaneous urinary diversion in 6 of 7 cases in the first years of our experience. Bladder Lithiasis: In 5 patients bladder stones developed between 18 months to 20 years postoperatively. Only 2 patients had had prior bladder augmentation with an ileal segment. All were treated surgically with open cystolithotomy. Single recurrence in 1 patient and twice in another required endoscopic stone extraction through the conduit and through a small vesicostomy. Small Bowel Obstruction: Intestinal obstruction occurred in 5 patients after continent cystostomy. Causes of obstruction included simple intestinal adhesion in cases 6 and 17 at 1 and 2 years postoperatively, and volvulus around the vascular pedicle of the ileocystoplasty in cases 11, 13 and 19. No metabolic disorder or bladder rupture was observed. Catheterizable conduit complications (table 2). Appendix Necrosis: A male patient with a neuropathic bladder due to myelomeningocele was not included in this series because of perioperative appendix necrosis. This patient was obese and continent cystostomy could not be done. Case 16 presented with partial necrosis at the base of the appendix requiring revision 1 day postoperatively with the appendix preserved. Persistent stomal leakage led to multiple revisions of the continent cystostomy and eventually conversion to an ileocecal conduit associated with a bladder augmentation 5 years
TABLE 2. Stomal complications and evolution with time in 11 patients
Stomal dilatation Surgical revision of the stoma Revision of the intravesical implantation
0–5 Yrs.
5–10 Yrs.
10–15 Yrs.
More Than 15 Yrs.
4 6
4 6
0 2
2 0
4
0
0
3
after the initial surgery. Definitive cutaneous diversion was done 9 years after the initial surgery due to persistent leakage. Stomal Leakage: Persistent leakage required 7 revisions of the appendicovesicostomy junction in 5 patients. These revisions were performed either early in the postoperative period or late in followup. In 1 patient reimplantation of the appendix was necessary twice because of persistent leakage. Leakage persisted despite the 2 revisions, and 4 years after initial surgery an artificial sphincter was inserted around the appendix under the stoma, which was kept for 3 years. After extraction and cutaneous plasty of the stoma rare nocturnal leakage still persists. In case 4 cystostomy was performed using a nonreimplanted ureter. Leakage occurred 18 years later and stopped after reimplantation of the ureter. Case 6 had a terminal renal insufficiency without diuresis. The appendicovesicostomy became obstructed and required revision after 23 years to make it functional before kidney transplantation. Stomal Stenosis: Stenosis was observed in 9 patients due to catheterization difficulties. Treatment strategies included 10 dilations and 14 simple surgical revisions. At the beginning of 2000, 16 patients still have a functional continent cystostomy. Of the patients 7 never had a stomal complication and 15 still benefit from continent cystostomy (dryness, easy self-catheterization). One patient has nocturnal intermittent stomal leakage. Seven patients did not require additional revision in the last 10 years and 4 never underwent additional surgery since the initial operation. One patient (case 18) gave birth by cesarean section to a child in good health 16 years after continent cystostomy. She had no catheterization problem during pregnancy. DISCUSSION
To our knowledge, we report the longest followup in the literature. Most series have approximately 5 years of followup,2, 3 with the maximum being 10 years.4 Before the early 1980s the concept of a low pressure reservoir was not established, and the children who underwent such surgery did not have bladder augmentation. We had hoped that bladder neck closure would allow sufficient bladder capacity without creating upper tract deterioration. Eventually high vesical pressure led to major bladder reservoir complications. Cutaneous urinary diversion was required in 6 cases due to upper tract dilatation and renal function deterioration. Currently, these patients would have undergone bladder augmentation, and cutaneous diversion would not be the sole option. Bladder replacement by enterocystoplasty was first described in adults at the end of the last century for bladder tuberculosis or tumor.5 Bladder augmentation was performed frequently after 1950 by Couvelaire who used an ileal loop to reconstruct tuberculosis small bladders.6 In the pediatric population in which the main indication was neuropathic bladder, bladder augmentation had poor results mainly due to difficulties in bladder voiding. Bladder augmentation became common in children only after the introduction of intermittent catheterization by Lapides et al.7 Much later, confronted with persistent urethral leakage or upper tract deterioration, reflux and urinary infections, the concept of a low pressure reservoir emerged.8, 9 Presently, in most series bladder augmentation is done concomitantly with continent cystostomy.2, 3, 10, 11 Thus, continence is obtained without danger to the upper tract. Bladder neck closure was almost systematically done concomitantly with continent cystostomy to avoid urethral leakage. However, high vesical pressure led to bladder neck recanalization, while patients with a primary or secondary bladder augmentation did not have bladder neck recanalization or had no more urethral leakage. Currently bladder neck
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MITROFANOFF PROCEDURE
closure is not systematically performed. Bladder augmentation is done to obtain a low pressure reservoir. Bladder neck plasty is proposed to minimize residual leakage, which can be done by urethral lengthening procedure,12 rectus fascial sling13–20 or wraparound sling.21 Some still propose bladder neck closure during the same operation which makes the procedure longer.22, 23 However, with continent cystostomy associated with bladder augmentation the risk of recanalization should be much lower than 25% as observed by Mollard.24 For boys revision for secondary closure can be particularly difficult. Plasty of the bladder neck has an uncertain result in most series using a rectus fascial sling or wraparound sling. Thus, we often propose immediate bladder neck closure. For girls secondary closure can be easily done by a perineal approach.25 Endoscopic transurethral injections26 or implantable microballoons27 can also achieve continence. Thus, the bladder neck is left open, representing a useful pop-off mechanism.28 –30 Evolution of vesicoureteral reflux remains uncertain even after construction of a continent low pressure reservoir. Chances of spontaneous resolution after bladder augmentation are high.31 Our cases 9 and 15 had reflux after continent cystostomy which resolved after augmentation. Nevertheless, reflux can persist and revision for ureteral reimplantation can be difficult and uncertain. If the bladder neck has been closed, endoscopic treatment cannot be done, which is why we prefer to perform ureteral reimplantation before continent cystostomy when reflux exists in these neuropathic bladders. It has the double advantage of definitively ruling out reflux and allows if necessary use of the reimplanted ureter as a continent conduit for continent cystostomy. Reflux appeared 18 years later in case 4 treated with transureteral cystostomy and the ureter had not been reimplanted. Bladder stones can develop in all types of neuropathic bladders. In our series stones mostly formed in nonaugmented bladders. In a recent article Barroso et al reported identical observations, concluding that the main risk factor is intermittent catheterization and the incidence of stones is not influenced by enterocystoplasty.32 They reported a slightly higher rate of stones in the continent cystostomy group but the difference was not statistically significant in the urethral catheterization group. Treatment of these stones usually consists of open cystolithotomy. It enables removal of large stones in 1 piece without fragmentation and, thus, lowers the risk of recurrence in case fragments remain in recesses or irregularities of the augmented bladder.33 Endoscopic treatment can also be used through the urethra or conduit.34 –36 Pregnancy can be considered in women treated with continent cystostomy.37–39 In our series 1 patient with a stoma in the lower abdominal quadrant had no problem related to intermittent catheterization or enterocystoplasty during pregnancy. The risk of the appendix and its pedicle being stretched during pregnancy would probably be increased with an umbilical stoma. Kidney transplantation is possible with continent cystostomy insofar as the reservoir is a low pressure reservoir.40, 41 In our series there was 1 case of kidney transplantation performed after bladder augmentation with no catheterization or reservoir problems. Intestinal obstructions by volvulus due to enterocystoplasty have not been described in the literature. We have previously reported these complications in a recent article.42 Continence achieved with a Mitrofanoff tube is usually higher than 90% in most published series.43– 48 These good results are independent of whether appendix, ureter or Monti tube is used as the conduit. Stomal leakage can occur despite a low pressure reservoir, and treatment consists of revision of the tube implantation in the bladder. Another solution consists of placing an artificial sphincter around the tube to achieve stomal continence, while allowing intermittent cath-
eterization.49 However the latter option remains unsatisfactory and has been used only once on a temporary basis. Conduit stenosis, particularly at the stoma, has been reported in 12% to 30% of cases.2, 3, 50 Simple dilation can be enough but often recurrence leads to surgical revision. Injections of triamcinolone around the stoma have recently been proposed with good results.51 Various techniques have been described to prevent stenosis at the level of the stoma including V flap advancement and VQZ plasty.52 In our experience maintaining an exteriorized small cuff of cecal mucosa appeared to be the optimal prevention. The umbilical site for the stoma has cosmetic advantages but could lead to bigger risks of stenosis.53 We have no experience with this choice of stomal location. Complications related to the conduit are most frequent during the first years following continent cystostomy. However, these complications can occur in the long term, as seen in several of our cases. Body habitus modifications appearing at adult age and development of obesity may represent risk factors to conduit complications. CONCLUSIONS
Our results may appear modest compared to published series with more recent experience, which can be related to the development of a novel approach and to the current much more systematic bladder augmentation. All 16 cystostomies in this series and all those performed at our institution since 1985 remain functional. We conclude that this technique is an important improvement for the management of pediatric neuropathic bladder and various pathological conditions requiring intermittent catheterization, such as bladder exstrophy, cloacal exstrophy and valve bladder. The long followup of our series demonstrates that continent cystostomy is a procedure with lasting efficiency. REFERENCES
1. Mitrofanoff, P.: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir Pediatr, 21: 297, 1980 2. Harris, C. F., Cooper, C. S., Hutcheson, J. C. et al: Appendicovesicostomy: the Mitrofanoff procedure—a 15-year perspective. J Urol, 163: 1922, 2000 3. Cain, M. P., Casale, A. J., King, S. J. et al: Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children’s Hospital. J Urol, 162: 1749, 1999 4. Fischwick, J. E., Gough, D. C. S. and O’Flynn, K. J.: The Mitrofanoff procedure: does it last? BJU Int, 85: 496, 2000 5. Mickulicz, J.: Zur operation der angeborenen blasenspalte. Zentralbl Chir, 21: 641, 1899 6. Couvelaire, R.: La petite vessie des tuberculeux ge´nito-urinaries; essai de classification, place et variantes des cystointestinoplasties. J Urol (Paris), 56: 381, 1950 7. Lapide`s, J., Diokno, A. C., Silber, S. J. et al: Clean intermittent self-catheterization in the treatment of urinary tract disease. J Urol, 107: 458, 1972 8. Mitchell, M. E.: The role of bladder augmentation in undiversion. J Pediatr Surg, 16: 790, 1981 9. Mitchell, M. E., Kulb, T. B. and Backes, D. J.: Intestinoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction. J Urol, 136: 288, 1986 10. Woodhouse, C. R. J. and Macneily, A. E.: The Mitrofanoff principle: expanding upon a versatile technique. Br J Urol, 74: 447, 1994 11. Sumfest, J. M., Burns, M. W. and Mitchell, M. E.: The Mitrofanoff principle in urinary reconstruction. J Urol, 150: 1875, 1993 12. Mollard, P., Mouriquand, P. and Joubert, P.: Urethral lengthening for neurogenic urinary incontinence (Kropp’s procedure): results of 16 cases. J Urol, 143: 95, 1990 13. Gormley, E. A., Bloom, D. A., McGuire, E. J. et al: Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol, part 2, 152: 822, 1994
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14. Koff, S. A.: A technique for bladder neck reconstruction in exstrophy: the cinch. J Urol, part 2, 144: 546, 1990 15. Bauer, S. B., Peters, C. A., Colodny, A. H. et al: The use of rectus fascia to manage urinary incontinence. J Urol, 142: 516, 1989 16. Raz, S., McGuire, E. J., Ehrlich, R. M. et al: Fascial sling to correct male neurogenic sphincter incompetence: the McGuire/ Raz approach. J Urol, 139: 528, 1988 17. Herschorn, S. and Radomski, S. B.: Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence. J Urol, 147: 434, 1992 18. Elder, J. S.: Periurethral and puboprostatic sling repair for incontinence in patients with myelodysplasia. J Urol, 144: 434, 1990 19. Decter, R. M.: Use of the fascial sling for neurogenic incontinence: lessons learned. J Urol, part 2, 150: 683, 1993 20. Walker, R. D., Flack, C. E., Hawkins-Lee, B. et al: Rectus fascial wrap: early results of a modification of the rectus fascial sling. J Urol, part 2, 154: 771, 1995 21. Kurzrock, E. A., Lowe, P. and Brian, E.: Bladder wall pedicle wraparound sling for neurogenic urinary incontinence in children. J Urol, 155: 305, 1996 22. Hensle, T. W., Kirsch, A. J., Kennedy, W. A. et al: Bladder neck closure in association with continent urinary diversion. J Urol, 154: 883, 1995 23. Khoury, A. E., Agarwal, S. K., Bagli, D. et al: Concomitant modified bladder neck closure and Mitrofanoff urinary diversion. J Urol, 162: 1746, 1999 24. Mollard, P.: Longterm results of incontinence surgery in neuropathic bladder. In: Long-term Outcome in Pediatric Surgery and Urology. Edited by M. Stringer, K. Oldham, E. Howard et al. London: W. B. Saunders Co., pp., 579 –586, 1998 25. Ziuman, L.: Transvaginal approach. In: Atlas of Pediatric Urologic Surgery. Edited by F. Hinman. Philadelphia: W. B. Saunders Co., pp. 301–302, 1994 26. Guys, J. M., Simeoni-Alias, J., Fakhro, A. et al: Use of polydimethylsiloxane for endoscopic treatment of neurogenic urinary incontinence in children. J Urol, 162: 2133, 1999 27. Pycha, A., Klingler, C. H., Haitel, A. et al: Implantable microballoons: an attractive alternative in the management of intrinsic sphincter deficiency. Eur Urol, 33: 469, 1998 28. Kaefer, M. and Retik, A. B.: The Mitrofanoff principle in continent urinary reconstruction. Urol Clin North Am, 24: 795, 1997 29. Kaefer, M., Tobin, M. S., Hendren, W. H. et al: Continent urinary diversion: the Children’s Hospital experience. J Urol, 157: 1394, 1997 30. Duckett, J. W.: (Editorial comment). J Urol, 156: 1794, 1996 31. Krishna, A. and Gough, D. C.: Evaluation of augmentation cystoplasty in childhood with reference to vesico-ureteric reflux and urinary infection. Br J Urol, 74: 465, 1994 32. Barroso, U., Jednak, R., Fleming, P. et al: Bladder calculi in children who perform clean intermittent catheterization. BJU Int, 85: 879, 2000 33. Blyth, B., Ewalt, D. H., Duckett, J. W. et al: Lithogenic properties of enterocystoplasty. J Urol, 148: 575, 1992
34. Palmer, L. S., Franco, I., Reda, E. F. et al: Endoscopic management of bladder calculi following augmentation cystoplasty. Urology, 44: 902, 1994 35. Cohen, T. D. and Streem, S. B.: Minimally invasive endourologic management of calculi in continent urinary reservoirs. Urology, 43: 865, 1994 36. Roth, S., Van Halen, H., Semjonow, A. et al: Percutaneous pouch lithotripsy in continent urinary diversions with narrowed Mitrofanoff conduit. Br J Urol, 73: 316, 1994 37. Fenn, N., Barrington, J. W. and Stephenson, T. P.: Clam enterocystoplasty and pregnancy. Br J Urol, 75: 85, 1995 38. Hatch, T. R., Steinberg, R. W. and Davis, L. E.: Successful term delivery by cesarean section in a patient with a continent ileocecal urinary reservoir. J Urol, 146: 1111, 1991 39. Mundy, A. R.: Continent urinary reconstruction and reproductive function. Scand J Urol Nephrol, suppl., 142: 129, 1992 40. Francis, D. M. and Millar, R. J.: Renal transplantation using a continent ileocecal urinary reservoir as a bladder substitute. Transplantation, 53: 937, 1992 41. Heritier, P., Perraud, Y., Relave, M. H. et al: Renal transplantation and Koch pouch: a case report. J Urol, 141: 595, 1989 42. Bertschy, C., Bawab, F., Liard, A. et al: Enterocystoplasty complications in children: a study of 30 cases. Eur J Pediatr Surg, 10: 30, 2000 43. King, L. R.: Continent urinary diversion in children: the American experience. Scand J Urol Nephrol, suppl., 142: 85, 1992 44. Khair, L. R., Azmy, A. F., Carachi, R. et al: Continent urinary diversion using Mitrofanoff principle in children with neurogenic bladder. Eur J Pediatr Surg, suppl, 3: 8, 1993 45. Ramanan, V., Kapoor, R., Srinadh, E. S. et al: Mitrofanoff principle for continent urinary diversion. Urol Int, 58: 108, 1997 46. Suzer, O., Freedman, A. L., Smith, C. A. et al: Results of the Mitrofanoff procedure in urinary tract reconstruction in children. Br J Urol, 79: 279, 1997 47. Sylora, J. A., Gonzalez, R., Vaughn, M. et al: Intermittent selfcatheterization by quadriplegic patients via a catheterizable Mitrofanoff channel. J Urol, 157: 48, 1997 48. Mollard, P., Gauriau, L., Bonnet, J. P. et al: Continent cystostomy (Mitrofanoff procedure) for neurogenic bladder in children and adolescent (56 cases: long-term results). Eur J Pediatr Surg, 7: 34, 1997 49. Mitrofanoff, P., Bonnet, O., Annoot, M. P. et al: Continent urinary diversion using an artificial urinary sphincter. Br J Urol, 70: 26, 1992 50. Duckett, J. W. and Lofti, A. H.: Appendicovesicostomy (and variations) in bladder reconstruction. J Urol, 149: 567, 1993 51. Snodgrass, W.: Triamcinolone to prevent stenosis in Mitrofanoff stomas. J Urol, 161: 928, 1999 52. Fitzgerald, J., Malone, M. J., Gaertner, R. A. et al: Stomal construction, complications and reconstruction. Urol Clin North Am, 24: 729, 1997 53. Van Savage, J. G., Khoury, A. E., Mac Lorie, G. A. et al: Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol, 156: 1794, 1996
Vol. 165, 2394 –2398, June 2001 Printed in U.S.A.
THE MITROFANOFF PROCEDURE: 20 YEARS LATER ` S LIARD, EMMANUELLE SE ´ GUIER-LIPSZYC, ANNE MATHIOT AGNE
AND
PAUL MITROFANOFF
From the Department of Pediatric Surgery, University Hospital Charles Nicolle, Rouen, France
ABSTRACT
Purpose: We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup. Materials and Methods: Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux. Results: One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion. Conclusions: The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency. KEY WORDS: cystostomy, follow-up studies, bladder
The continent cystostomy technique was first described by Mitrofanoff in 1980.1 This method allows an alternative procedure when difficulties occur with transurethral catheterization and is now largely used throughout the world for various indications. We assess the long-term evolution of and outcome of the first patients treated with continent cystostomy. MATERIALS AND METHODS
We retrospectively reviewed the records of all patients who underwent continent cystotomy between 1976 and 1984 with a followup of at least 15 years. All operations were performed by the same surgeon (P. M.). A total of 23 cystostomies were performed on 15 boys and 8 girls for neuropathic bladders. Mean patient age at surgery was 8 years (range 3 to 16) and mean followup was 20 years (range 15 to 23). One patient died 3 months after surgery. The neurological lesions myelomeningocele (2 associated with an anorectal malformation in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation with anorectal malformation and sacral agenesis in 1. Clean intermittent catheterization failed in all cases, mostly related to urine leakage. The appendix was
used as a catheterizable conduit in 20 cases, the lower segment of 1 ureter in 2 and a bladder tube in 1. The continent conduit was always brought out to the right lower abdominal quadrant. Closure of the bladder neck was performed in 21 cases (16 times during the same procedure and 5 times secondarily because of persistent urethral leakage). Enterocystoplasty was done during the same procedure in 2 cases and at a later stage in 8. For each patient complications related to the bladder reservoir, continent conduit or other problem and their evolution were reviewed. RESULTS
A 3-year-old girl died in 1977 due to a severe infection of the ventriculoperitoneal valve 3 months after continent cystostomy with closure of the bladder neck (table 1). Immediate conversion to cutaneous urinary diversion associated with cystectomy was required because of high vesical pressure and upper tract dilatation. The most severe complications were those due to a high vesical pressure. Reservoir complications. Upper Tract Deterioration: Ten patients presented with upper tract deterioration after continent cystostomy in 1979, at the beginning of our experience
2394
28
32
30
31
27
28
34
28
27
26
11
12
13
14
15
16
17
18
19
20
27
27
10
23
28 27
8 9
29
24
7
26
37
6
21
Dead
5
22
40 28 26 32
1 2 3 4
Case No.
11 (1984)
10 (1984)
12 (1983)
7 (1981)
8 (1981)
8 (1980)
13 (1979)
6 (1978)
5 (1978)
9 (1978)
8 (1978)
10 (1978)
6 (1978)
5 (1978)
5 (1977) 5 (1977)
6 (1977)
14 (1977)
3 (1977)
16 (1976) 5 (1977) 3 (1977) 9 (1977)
Pt. Age at Current Continent Pt. Age Cystostomy (yr.)
Appendix
Bladder tube Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Ureter Appendix
Appendix
Appendix
Appendix
Appendix Appendix Appendix Ureter
Conduit
Bladder neck closure, bladder augmentation 0
Bladder neck closure Bladder neck closure Bladder neck closure 0 Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure Bladder neck closure, bladder augmentation Bladder neck closure Bladder neck closure 0
0 0 0 0
Associated Procedure
9 Mos.
2 Yrs.
4 Mos. 3 Mos. 4 Mos.
Interval to Secondary Bladder Neck Closure
Ileal loop (3 yrs.)
Ileal loop (1 yr.)
Ileocecal loop (5 yrs.)
Ileal loop (10 yrs.)
Ileal loop (10 yrs.)
Ileal loop (4 yrs.)
Ileal loop (10 yrs.)
Sigmoid loop (14 yrs.)
Secondary Bladder Augmentation (interval)
Bilat.
Lt, ureteroureterostomy (3 yrs.)
Lt.
Lt., reimplantation (4 mos.)
Bilat.
Secondary Reflux (interval)
2
3
1
1
2
No. Bladder Neck Recanalization
TABLE 1. Results of surgery
Yes
Yes
Yes
Yes
Yes
Yes Yes
Yes renal insufficiency Yes
Yes
Upper Tract Deterioration
6, 7, 11 Yrs.
18 Mos.
5 Yrs.
5 Yrs.
12, 20 Yrs.
Interval to Bladder Lithiasis
5 Yrs.
9 Yrs.
6 Yrs.
2 Yrs.
2 Yrs.
1 Yr.
2 Yrs.
Interval to Cutaneous Diversion
3, 4, 5, 7 Yrs.
1, 4, 6, 9 Yrs.
10, 18 Mos.
2, 6 Yrs.
9 Times
5, 14, 16 Yrs.
Twice for leakage
16, 23 Yrs.
23 Yrs.
1 Yr. 19 Yrs.
Interval to Stomal Revision
MITROFANOFF PROCEDURE
2395
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MITROFANOFF PROCEDURE
with continent cystostomy, which led to conversion to cutaneous urinary diversion in 4 and 2 years after the initial surgery in 3 (cases 2, 7 and 8). In case 17 the cutaneous diversion was performed elsewhere because of bladder lithiasis associated with slight upper tract deterioration. None of these 4 patients had had prior conduit catheterization problems. After 1982, 5 patients underwent bladder augmentation with an ileal segment which improved or normalized the upper tracts. Case 6 had progressive deterioration of renal function in the first years of life before continent cystostomy. He was lost to followup for 10 years and seen again with end stage renal failure because he was poorly compliant with catheterizations. Sigmoid cystoplasty was performed 14 years after the continent cystostomy followed by kidney transplantation. Bladder Neck Recanalization: Repeat procedure was required in 5 of 21 patients who underwent bladder neck closures due to persistent leakage. In 3 patients revision of bladder neck closure failed, 1 had successful perineal closure after 2 failed attempts, 1 (case 6) required 2 repeat surgeries and 1 (case 23) required concomitant bladder augmentation. Vesicoureteral Reflux: Vesicoureteral reflux was diagnosed in 10 patients before continent cystostomy. Ureteral reimplantation was performed before cystostomy in 5 patients and afterward because of persistent reflux with upper tract deterioration (case 7). In 5 patients reflux developed after continent cystostomy. In case 4 reimplantation was performed early simultaneously with secondary bladder neck closure. In case 11 unilateral reflux was treated with ureteroureterostomy but persistent deterioration of the upper tract led to augmentation. In 2 cases reflux was managed conservatively with resolution after subsequent bladder augmentation. In case 2 permanent diversion was performed 6 years after continent cystostomy due to severe bilateral reflux with upper tract deterioration. These different complications due to high vesical pressure led to cutaneous urinary diversion in 6 of 7 cases in the first years of our experience. Bladder Lithiasis: In 5 patients bladder stones developed between 18 months to 20 years postoperatively. Only 2 patients had had prior bladder augmentation with an ileal segment. All were treated surgically with open cystolithotomy. Single recurrence in 1 patient and twice in another required endoscopic stone extraction through the conduit and through a small vesicostomy. Small Bowel Obstruction: Intestinal obstruction occurred in 5 patients after continent cystostomy. Causes of obstruction included simple intestinal adhesion in cases 6 and 17 at 1 and 2 years postoperatively, and volvulus around the vascular pedicle of the ileocystoplasty in cases 11, 13 and 19. No metabolic disorder or bladder rupture was observed. Catheterizable conduit complications (table 2). Appendix Necrosis: A male patient with a neuropathic bladder due to myelomeningocele was not included in this series because of perioperative appendix necrosis. This patient was obese and continent cystostomy could not be done. Case 16 presented with partial necrosis at the base of the appendix requiring revision 1 day postoperatively with the appendix preserved. Persistent stomal leakage led to multiple revisions of the continent cystostomy and eventually conversion to an ileocecal conduit associated with a bladder augmentation 5 years
TABLE 2. Stomal complications and evolution with time in 11 patients
Stomal dilatation Surgical revision of the stoma Revision of the intravesical implantation
0–5 Yrs.
5–10 Yrs.
10–15 Yrs.
More Than 15 Yrs.
4 6
4 6
0 2
2 0
4
0
0
3
after the initial surgery. Definitive cutaneous diversion was done 9 years after the initial surgery due to persistent leakage. Stomal Leakage: Persistent leakage required 7 revisions of the appendicovesicostomy junction in 5 patients. These revisions were performed either early in the postoperative period or late in followup. In 1 patient reimplantation of the appendix was necessary twice because of persistent leakage. Leakage persisted despite the 2 revisions, and 4 years after initial surgery an artificial sphincter was inserted around the appendix under the stoma, which was kept for 3 years. After extraction and cutaneous plasty of the stoma rare nocturnal leakage still persists. In case 4 cystostomy was performed using a nonreimplanted ureter. Leakage occurred 18 years later and stopped after reimplantation of the ureter. Case 6 had a terminal renal insufficiency without diuresis. The appendicovesicostomy became obstructed and required revision after 23 years to make it functional before kidney transplantation. Stomal Stenosis: Stenosis was observed in 9 patients due to catheterization difficulties. Treatment strategies included 10 dilations and 14 simple surgical revisions. At the beginning of 2000, 16 patients still have a functional continent cystostomy. Of the patients 7 never had a stomal complication and 15 still benefit from continent cystostomy (dryness, easy self-catheterization). One patient has nocturnal intermittent stomal leakage. Seven patients did not require additional revision in the last 10 years and 4 never underwent additional surgery since the initial operation. One patient (case 18) gave birth by cesarean section to a child in good health 16 years after continent cystostomy. She had no catheterization problem during pregnancy. DISCUSSION
To our knowledge, we report the longest followup in the literature. Most series have approximately 5 years of followup,2, 3 with the maximum being 10 years.4 Before the early 1980s the concept of a low pressure reservoir was not established, and the children who underwent such surgery did not have bladder augmentation. We had hoped that bladder neck closure would allow sufficient bladder capacity without creating upper tract deterioration. Eventually high vesical pressure led to major bladder reservoir complications. Cutaneous urinary diversion was required in 6 cases due to upper tract dilatation and renal function deterioration. Currently, these patients would have undergone bladder augmentation, and cutaneous diversion would not be the sole option. Bladder replacement by enterocystoplasty was first described in adults at the end of the last century for bladder tuberculosis or tumor.5 Bladder augmentation was performed frequently after 1950 by Couvelaire who used an ileal loop to reconstruct tuberculosis small bladders.6 In the pediatric population in which the main indication was neuropathic bladder, bladder augmentation had poor results mainly due to difficulties in bladder voiding. Bladder augmentation became common in children only after the introduction of intermittent catheterization by Lapides et al.7 Much later, confronted with persistent urethral leakage or upper tract deterioration, reflux and urinary infections, the concept of a low pressure reservoir emerged.8, 9 Presently, in most series bladder augmentation is done concomitantly with continent cystostomy.2, 3, 10, 11 Thus, continence is obtained without danger to the upper tract. Bladder neck closure was almost systematically done concomitantly with continent cystostomy to avoid urethral leakage. However, high vesical pressure led to bladder neck recanalization, while patients with a primary or secondary bladder augmentation did not have bladder neck recanalization or had no more urethral leakage. Currently bladder neck
2397
MITROFANOFF PROCEDURE
closure is not systematically performed. Bladder augmentation is done to obtain a low pressure reservoir. Bladder neck plasty is proposed to minimize residual leakage, which can be done by urethral lengthening procedure,12 rectus fascial sling13–20 or wraparound sling.21 Some still propose bladder neck closure during the same operation which makes the procedure longer.22, 23 However, with continent cystostomy associated with bladder augmentation the risk of recanalization should be much lower than 25% as observed by Mollard.24 For boys revision for secondary closure can be particularly difficult. Plasty of the bladder neck has an uncertain result in most series using a rectus fascial sling or wraparound sling. Thus, we often propose immediate bladder neck closure. For girls secondary closure can be easily done by a perineal approach.25 Endoscopic transurethral injections26 or implantable microballoons27 can also achieve continence. Thus, the bladder neck is left open, representing a useful pop-off mechanism.28 –30 Evolution of vesicoureteral reflux remains uncertain even after construction of a continent low pressure reservoir. Chances of spontaneous resolution after bladder augmentation are high.31 Our cases 9 and 15 had reflux after continent cystostomy which resolved after augmentation. Nevertheless, reflux can persist and revision for ureteral reimplantation can be difficult and uncertain. If the bladder neck has been closed, endoscopic treatment cannot be done, which is why we prefer to perform ureteral reimplantation before continent cystostomy when reflux exists in these neuropathic bladders. It has the double advantage of definitively ruling out reflux and allows if necessary use of the reimplanted ureter as a continent conduit for continent cystostomy. Reflux appeared 18 years later in case 4 treated with transureteral cystostomy and the ureter had not been reimplanted. Bladder stones can develop in all types of neuropathic bladders. In our series stones mostly formed in nonaugmented bladders. In a recent article Barroso et al reported identical observations, concluding that the main risk factor is intermittent catheterization and the incidence of stones is not influenced by enterocystoplasty.32 They reported a slightly higher rate of stones in the continent cystostomy group but the difference was not statistically significant in the urethral catheterization group. Treatment of these stones usually consists of open cystolithotomy. It enables removal of large stones in 1 piece without fragmentation and, thus, lowers the risk of recurrence in case fragments remain in recesses or irregularities of the augmented bladder.33 Endoscopic treatment can also be used through the urethra or conduit.34 –36 Pregnancy can be considered in women treated with continent cystostomy.37–39 In our series 1 patient with a stoma in the lower abdominal quadrant had no problem related to intermittent catheterization or enterocystoplasty during pregnancy. The risk of the appendix and its pedicle being stretched during pregnancy would probably be increased with an umbilical stoma. Kidney transplantation is possible with continent cystostomy insofar as the reservoir is a low pressure reservoir.40, 41 In our series there was 1 case of kidney transplantation performed after bladder augmentation with no catheterization or reservoir problems. Intestinal obstructions by volvulus due to enterocystoplasty have not been described in the literature. We have previously reported these complications in a recent article.42 Continence achieved with a Mitrofanoff tube is usually higher than 90% in most published series.43– 48 These good results are independent of whether appendix, ureter or Monti tube is used as the conduit. Stomal leakage can occur despite a low pressure reservoir, and treatment consists of revision of the tube implantation in the bladder. Another solution consists of placing an artificial sphincter around the tube to achieve stomal continence, while allowing intermittent cath-
eterization.49 However the latter option remains unsatisfactory and has been used only once on a temporary basis. Conduit stenosis, particularly at the stoma, has been reported in 12% to 30% of cases.2, 3, 50 Simple dilation can be enough but often recurrence leads to surgical revision. Injections of triamcinolone around the stoma have recently been proposed with good results.51 Various techniques have been described to prevent stenosis at the level of the stoma including V flap advancement and VQZ plasty.52 In our experience maintaining an exteriorized small cuff of cecal mucosa appeared to be the optimal prevention. The umbilical site for the stoma has cosmetic advantages but could lead to bigger risks of stenosis.53 We have no experience with this choice of stomal location. Complications related to the conduit are most frequent during the first years following continent cystostomy. However, these complications can occur in the long term, as seen in several of our cases. Body habitus modifications appearing at adult age and development of obesity may represent risk factors to conduit complications. CONCLUSIONS
Our results may appear modest compared to published series with more recent experience, which can be related to the development of a novel approach and to the current much more systematic bladder augmentation. All 16 cystostomies in this series and all those performed at our institution since 1985 remain functional. We conclude that this technique is an important improvement for the management of pediatric neuropathic bladder and various pathological conditions requiring intermittent catheterization, such as bladder exstrophy, cloacal exstrophy and valve bladder. The long followup of our series demonstrates that continent cystostomy is a procedure with lasting efficiency. REFERENCES
1. Mitrofanoff, P.: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir Pediatr, 21: 297, 1980 2. Harris, C. F., Cooper, C. S., Hutcheson, J. C. et al: Appendicovesicostomy: the Mitrofanoff procedure—a 15-year perspective. J Urol, 163: 1922, 2000 3. Cain, M. P., Casale, A. J., King, S. J. et al: Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children’s Hospital. J Urol, 162: 1749, 1999 4. Fischwick, J. E., Gough, D. C. S. and O’Flynn, K. J.: The Mitrofanoff procedure: does it last? BJU Int, 85: 496, 2000 5. Mickulicz, J.: Zur operation der angeborenen blasenspalte. Zentralbl Chir, 21: 641, 1899 6. Couvelaire, R.: La petite vessie des tuberculeux ge´nito-urinaries; essai de classification, place et variantes des cystointestinoplasties. J Urol (Paris), 56: 381, 1950 7. Lapide`s, J., Diokno, A. C., Silber, S. J. et al: Clean intermittent self-catheterization in the treatment of urinary tract disease. J Urol, 107: 458, 1972 8. Mitchell, M. E.: The role of bladder augmentation in undiversion. J Pediatr Surg, 16: 790, 1981 9. Mitchell, M. E., Kulb, T. B. and Backes, D. J.: Intestinoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction. J Urol, 136: 288, 1986 10. Woodhouse, C. R. J. and Macneily, A. E.: The Mitrofanoff principle: expanding upon a versatile technique. Br J Urol, 74: 447, 1994 11. Sumfest, J. M., Burns, M. W. and Mitchell, M. E.: The Mitrofanoff principle in urinary reconstruction. J Urol, 150: 1875, 1993 12. Mollard, P., Mouriquand, P. and Joubert, P.: Urethral lengthening for neurogenic urinary incontinence (Kropp’s procedure): results of 16 cases. J Urol, 143: 95, 1990 13. Gormley, E. A., Bloom, D. A., McGuire, E. J. et al: Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol, part 2, 152: 822, 1994
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14. Koff, S. A.: A technique for bladder neck reconstruction in exstrophy: the cinch. J Urol, part 2, 144: 546, 1990 15. Bauer, S. B., Peters, C. A., Colodny, A. H. et al: The use of rectus fascia to manage urinary incontinence. J Urol, 142: 516, 1989 16. Raz, S., McGuire, E. J., Ehrlich, R. M. et al: Fascial sling to correct male neurogenic sphincter incompetence: the McGuire/ Raz approach. J Urol, 139: 528, 1988 17. Herschorn, S. and Radomski, S. B.: Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence. J Urol, 147: 434, 1992 18. Elder, J. S.: Periurethral and puboprostatic sling repair for incontinence in patients with myelodysplasia. J Urol, 144: 434, 1990 19. Decter, R. M.: Use of the fascial sling for neurogenic incontinence: lessons learned. J Urol, part 2, 150: 683, 1993 20. Walker, R. D., Flack, C. E., Hawkins-Lee, B. et al: Rectus fascial wrap: early results of a modification of the rectus fascial sling. J Urol, part 2, 154: 771, 1995 21. Kurzrock, E. A., Lowe, P. and Brian, E.: Bladder wall pedicle wraparound sling for neurogenic urinary incontinence in children. J Urol, 155: 305, 1996 22. Hensle, T. W., Kirsch, A. J., Kennedy, W. A. et al: Bladder neck closure in association with continent urinary diversion. J Urol, 154: 883, 1995 23. Khoury, A. E., Agarwal, S. K., Bagli, D. et al: Concomitant modified bladder neck closure and Mitrofanoff urinary diversion. J Urol, 162: 1746, 1999 24. Mollard, P.: Longterm results of incontinence surgery in neuropathic bladder. In: Long-term Outcome in Pediatric Surgery and Urology. Edited by M. Stringer, K. Oldham, E. Howard et al. London: W. B. Saunders Co., pp., 579 –586, 1998 25. Ziuman, L.: Transvaginal approach. In: Atlas of Pediatric Urologic Surgery. Edited by F. Hinman. Philadelphia: W. B. Saunders Co., pp. 301–302, 1994 26. Guys, J. M., Simeoni-Alias, J., Fakhro, A. et al: Use of polydimethylsiloxane for endoscopic treatment of neurogenic urinary incontinence in children. J Urol, 162: 2133, 1999 27. Pycha, A., Klingler, C. H., Haitel, A. et al: Implantable microballoons: an attractive alternative in the management of intrinsic sphincter deficiency. Eur Urol, 33: 469, 1998 28. Kaefer, M. and Retik, A. B.: The Mitrofanoff principle in continent urinary reconstruction. Urol Clin North Am, 24: 795, 1997 29. Kaefer, M., Tobin, M. S., Hendren, W. H. et al: Continent urinary diversion: the Children’s Hospital experience. J Urol, 157: 1394, 1997 30. Duckett, J. W.: (Editorial comment). J Urol, 156: 1794, 1996 31. Krishna, A. and Gough, D. C.: Evaluation of augmentation cystoplasty in childhood with reference to vesico-ureteric reflux and urinary infection. Br J Urol, 74: 465, 1994 32. Barroso, U., Jednak, R., Fleming, P. et al: Bladder calculi in children who perform clean intermittent catheterization. BJU Int, 85: 879, 2000 33. Blyth, B., Ewalt, D. H., Duckett, J. W. et al: Lithogenic properties of enterocystoplasty. J Urol, 148: 575, 1992
34. Palmer, L. S., Franco, I., Reda, E. F. et al: Endoscopic management of bladder calculi following augmentation cystoplasty. Urology, 44: 902, 1994 35. Cohen, T. D. and Streem, S. B.: Minimally invasive endourologic management of calculi in continent urinary reservoirs. Urology, 43: 865, 1994 36. Roth, S., Van Halen, H., Semjonow, A. et al: Percutaneous pouch lithotripsy in continent urinary diversions with narrowed Mitrofanoff conduit. Br J Urol, 73: 316, 1994 37. Fenn, N., Barrington, J. W. and Stephenson, T. P.: Clam enterocystoplasty and pregnancy. Br J Urol, 75: 85, 1995 38. Hatch, T. R., Steinberg, R. W. and Davis, L. E.: Successful term delivery by cesarean section in a patient with a continent ileocecal urinary reservoir. J Urol, 146: 1111, 1991 39. Mundy, A. R.: Continent urinary reconstruction and reproductive function. Scand J Urol Nephrol, suppl., 142: 129, 1992 40. Francis, D. M. and Millar, R. J.: Renal transplantation using a continent ileocecal urinary reservoir as a bladder substitute. Transplantation, 53: 937, 1992 41. Heritier, P., Perraud, Y., Relave, M. H. et al: Renal transplantation and Koch pouch: a case report. J Urol, 141: 595, 1989 42. Bertschy, C., Bawab, F., Liard, A. et al: Enterocystoplasty complications in children: a study of 30 cases. Eur J Pediatr Surg, 10: 30, 2000 43. King, L. R.: Continent urinary diversion in children: the American experience. Scand J Urol Nephrol, suppl., 142: 85, 1992 44. Khair, L. R., Azmy, A. F., Carachi, R. et al: Continent urinary diversion using Mitrofanoff principle in children with neurogenic bladder. Eur J Pediatr Surg, suppl, 3: 8, 1993 45. Ramanan, V., Kapoor, R., Srinadh, E. S. et al: Mitrofanoff principle for continent urinary diversion. Urol Int, 58: 108, 1997 46. Suzer, O., Freedman, A. L., Smith, C. A. et al: Results of the Mitrofanoff procedure in urinary tract reconstruction in children. Br J Urol, 79: 279, 1997 47. Sylora, J. A., Gonzalez, R., Vaughn, M. et al: Intermittent selfcatheterization by quadriplegic patients via a catheterizable Mitrofanoff channel. J Urol, 157: 48, 1997 48. Mollard, P., Gauriau, L., Bonnet, J. P. et al: Continent cystostomy (Mitrofanoff procedure) for neurogenic bladder in children and adolescent (56 cases: long-term results). Eur J Pediatr Surg, 7: 34, 1997 49. Mitrofanoff, P., Bonnet, O., Annoot, M. P. et al: Continent urinary diversion using an artificial urinary sphincter. Br J Urol, 70: 26, 1992 50. Duckett, J. W. and Lofti, A. H.: Appendicovesicostomy (and variations) in bladder reconstruction. J Urol, 149: 567, 1993 51. Snodgrass, W.: Triamcinolone to prevent stenosis in Mitrofanoff stomas. J Urol, 161: 928, 1999 52. Fitzgerald, J., Malone, M. J., Gaertner, R. A. et al: Stomal construction, complications and reconstruction. Urol Clin North Am, 24: 729, 1997 53. Van Savage, J. G., Khoury, A. E., Mac Lorie, G. A. et al: Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol, 156: 1794, 1996