- Email: [email protected]
APPENDICOVESICOSTOMY: THE MITROFANOFF PROCEDURE—A 15-YEAR PERSPECTIVE
0022-5347/00/1636-1922/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 163, 1922–1926, June 2000 Printed in U.S.A.
APPENDICOVESICOSTOMY: THE MITROFANOFF PROCEDURE—A 15-YEAR PERSPECTIVE CONSTANTINE F. HARRIS, CHRISTOPHER S. COOPER,* JOEL C. HUTCHESON AND HOWARD M. SNYDER, III From the Division of Pediatric Urology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
ABSTRACT
Purpose: Appendicovesicostomy was introduced in the United States in 1982 at our hospital. It has become the most popular alternate continence channel for catheterization. We reviewed the experience of 1 surgeon with appendicovesicostomy during a 15-year period. Materials and Methods: We retrospectively reviewed the operative reports and clinical records of 50 consecutive patients in whom appendicovesicostomy was performed by 1 surgeon between 1982 and 1998. The underlying diagnosis was myelomeningocele in 31 cases, bladder exstrophy in 6, the prune-belly syndrome in 2, posterior urethral valves in 2 and other disorders in 10. Mean patient age at surgery was 13.1 years (range 4 months to 25 years) and mean followup was 4.3 years (range 3 months to 16.3 years). Results: Of the 50 patients 96% continue to catheterize the appendicovesicostomy. Stomal stenosis developed in 5 cases (10%) and other complications included stricture and appendiceal perforation in 2 each. Eight patients (16%) required appendicovesicostomy revision at a median of 7.3 months (range 1 month to 5.8 years) after the initial procedure. Median time to revision for stomal stenosis was 13 months (range 1 month to 5.8 years). Appendicovesicostomy continence was achieved in 49 patients (98%). Conclusions: Our series demonstrates the successful long-term outcome and durability of appendicovesicostomy in children. Careful adherence to technique at initial surgery helps ensure a high long-term success rate. KEY WORDS: appendix, urinary diversion, cystostomy, abnormalities, bladder
In 1980 Mitrofanoff proposed implanting the appendix into the bladder as a catheter conduit.1 In 1982 appendix was initially used in the United States as a catheterizable channel in children at our hospital.2 Since then, others at many institutions have reported performing appendicovesicostomy using the Mitrofanoff principle in the pediatric population2– 8 and it has become the most widely used alternative continence mechanism in the world. Appendicovesicostomy has been performed in patients with exstrophy and epispadias who are reluctant to perform intermittent catheterization due to a sensitive urethra. It is also useful in the spina bifida population in which urethral access may be difficult due to obesity or wheelchair dependence. The success of appendicovesicostomy has led to its widespread use with good early followup.3, 4, 7, 9 Minimal complications have been reported. The most common complication is stomal stenosis. In a large series of 100 patients using various conduits Woodhouse and MacNeily reported a stomal stenosis rate of 24%.9 Other complications include appendiceal necrosis, stricture and stomal incontinence. We report our long-term followup of 50 consecutive patients in whom appendicovesicostomy was performed by 1 surgeon (H. M. S.). MATERIALS AND METHODS
We reviewed the hospital records and clinical outcome of 28 males and 22 females who underwent appendicovesicostomy as part of continent bladder reconstruction between 1982 and 1998. Followup was defined as the interval between surgery
and the most recent urology visit. All procedures were performed by 1 surgeon (H. M. S.). Appendicovesicostomy was performed via a midline or Pfannenstiel incision. The midline incision curved around the umbilicus, leaving enough fascia lateral to the umbilicus to permit closure away from the appendicovesicostomy stoma located in the depths of the umbilicus. The cecum was widely mobilized, so that the base of the intact appendix reached the umbilicus. This mobilization prevents stretching of the vascular pedicle to the appendix. By mobilizing the cecum the appendix was easily placed to the umbilicus or elsewhere on the abdominal wall. Since the appendiceal blood supply is at the end of the superior mesenteric artery, it has great mobility. By moving the appendix with the cecum there was no need to separate widely the appendix from the cecum, which in turn protected the appendiceal blood supply. After the peritoneum was removed from the bladder dome the ability of the bladder to reach the umbilicus was tested by traction on the bladder dome. When the bladder reached the umbilicus, it was opened along the anterior surface, usually to the left of the midline, permitting the right side of the bladder to be more easily stretched to the umbilicus. This incision also facilitated access to the opened bladder for sigmoid cystoplasty, which was the most common type of intestinal augmentation done. The bladder was virtually always stretched to reach the umbilicus, especially when the bladder was opened on the left side, permitting a flap to be stretched on the right side to reach the umbilicus. Additional mobility was gained as necessary by incising the left side of the bladder wall transversely. Leaving a portion of the cephalad anterior bladder wall intact as a cap permitted manual elevation from inside the bladder toward the umbilicus (fig. 1). The site of the bladder hiatus was identified and enlarged enough to admit a finger easily. The path of the intended
Accepted for publication January 14, 2000. * Requests for reprints: Division of Pediatric Urology, Children’s Hospital of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, Iowa 522421089. 1922
1923
DURABILITY OF APPENDICOVESICOSTOMY
FIG. 1. Leaving anterior cap of bladder facilitates manual positioning of bladder against anterior abdominal fascia. Reprinted with permission.4
appendiceal tunnel was identified and injected submucosally with mixed lidocaine and epinephrine at a ratio of 1:100,000. The path of the appendix was off of the midline to prevent future urethral catheterization via the appendicovesicostomy. When the trigone was sensate, the appendiceal path was directed so that catheterization would not irritate the trigone. Mucosal flaps were broadly elevated around the hiatus and along the intended path of the appendix before the bladder was fixed to the abdominal wall. The umbilical stoma was created with a U-shaped skin flap incision in the depth of the umbilicus from the 3 to 9 o’clock positions. The flap was sharply elevated from the fascia to which it was adherent. The fascia was opened vertically and wide enough for a finger to be inserted from below to ensure no compression of the appendiceal mesentery. The appendiceal mesentery was minimally separated at the cecal junction to expose the cecal wall. The appendix was harvested by obtaining a small cuff of cecum (fig. 2). In the rare situation in which the appendix was less than 5 cm. a strip of cecum a few cm. long was tubularized to lengthen the appendix. The cecal end of the appendix was brought through the
fascial and umbilical opening, and spatulated to interdigitate with the skin flap of the bottom of the umbilicus, taking care to avoid the mesentery. The appendix was approximated to the edges of the umbilical skin with multiple interrupted absorbable 5-zero polyglactin sutures placed at 2 to 3 mm. intervals, taking solid bites of the full thickness of the appendix. This skin-to-appendix anastomosis was facilitated by creating it before attaching the appendix to the bladder so that anastomosis was constructed above the skin level (fig. 3, A). After creation of the appendicovesicostomy stoma the appendix was passed through the bladder hiatus and pulled down, causing the stoma to disappear into the depth of the umbilicus (fig. 3, B). The bladder was manually elevated to the umbilicus and fixed to the fascia on the lateral side of the umbilicus with 4, 2-zero sutures so that the hiatus in the bladder and fascia were aligned (fig. 4). With several more polypropylene sutures the medial and anterior aspects of the hiatus were reattached to the abdominal wall. A gap in the fixing sutures remained along the posterior side to avoid compressing the appendiceal mesentery. During the attachment of the bladder to the abdominal wall a lubricated feeding tube was repeatedly passed into the appendix to ensure that no obstructing edge of fascia or bladder wall was created to interfere with later catheterization. The appendix was stretched to the distal end of the mucosal trough, helping to ensure a long flap valve and straight appendix for catheterization. Fixation of the appendix at the umbilicus and distal to the detrusor provides a straight conduit and helps to avoid kinks in the appendiceal course. Kinking of the appendix as it traverses the abdominal fascia or bladder wall may lead to catheter deflection with resultant distortion and sacculation of the appendix, which may in turn lead to subsequently difficult catheterization. The distal appendix was amputated and the bladder end was spatulated for 3 to 4 mm. to prevent stenosis by wound contracture at the distal anastomosis of the appendix to the bladder. The distal appendix was attached with 2 or 3 interrupted polyglycolic or polyglycolic acid sutures, catching a solid bite of the detrusor muscle at the edge of the apical incision in the mucosa. The back wall of the appendix was sutured to the detrusor in several places as necessary to relieve tension and help to maintain the position of the appendix in the trough. Care was taken not to rotate the appendix with these sutures, which would have created a mucosal fold in the appendix capable of interfering with catheterization. The mucosal flaps were approximated over the appendix. With appendicovesicostomy complete catheterization was repeated to ensure a smooth course. When planned bladder augmentation was done last. A 10Fr polyethylene catheter remained in the appendix as a stent for 3 weeks. A suprapubic tube was routinely used. Three weeks after surgery a cystogram was performed and then appendicovesicostomy catheterization was started with a 12Fr polyethylene catheter. Long-term catheterization was done with a 12 or 14Fr catheter, which has a blunter tip than a 10Fr catheter. The suprapubic tube was removed after catheterization was reliably established. Bladder ultrasound in the office assessed the efficacy of catheterization by measuring post-catheterization residual urine volume. RESULTS
FIG. 2. A, appendix is isolated with small cuff of cecum. B, care is taken to preserve vasculature. Reprinted with permission.4
Mean patient age at surgery was 13.1 years (range 4 to 25). Followup ranged from 3 months to 16.3 years (average 51 months or 4.3 years). The underlying diagnosis varied, including myelomeningocele in 31 cases and bladder exstrophy in 6 (table 1). The preferred site of stomal placement was at the umbilicus in 40 patients, of whom 4 with exstrophy underwent neo-umbilicus creation. In the other 10 patients the catheter-
1924
DURABILITY OF APPENDICOVESICOSTOMY
FIG. 3. A, appendix is sutured to everted umbilical skin flap with feeding tube entering appendix. B, after completion of stoma traction on distal appendiceal aspect results in appendicovesicostomy hidden in umbilicus.
FIG. 4. A, appendix with feeding tube inserted via umbilical stoma traverses fascial and bladder openings. Sutures fix bladder wall to anterior abdominal fascia along lateral side of hiatus. Note bladder lumen. Reprinted with permission. B, appendix (A), feeding tube (B), bladder wall (C) anterior abdominal fascia (D) and bladder lumen (E).
TABLE 1. Underlying diagnoses Diagnosis
No. Pts.
Neurogenic bladder with or without myelomeningocele Exstrophy with or without epispadias Prune-belly syndrome Posterior urethral valves Imperforate anus Hinman syndrome Other Total No.
34 7 2 2 2 1 2 50
izable stoma was placed elsewhere on the abdominal wall. After the umbilicus the most common site was the right lower quadrant. A total of 48 patients (96%) continue to use the appendicovesicostomy, although 1 male with an underlying diagnosis of posterior urethral valves no longer uses it. In this case dysfunctional voiding improved and catheterization was no longer necessary. Another patient had diffuse fibrosis of the appendix after 2 years of use and subsequently a catheterizable stoma was reconstructed from tapered ileum. Stomal stenosis developed in only 5 patients (10%) at a median of 13 months (range 1 to 69). In most cases it developed within 1.5 years after surgery but in 1 case stomal stenosis occurred 5.8 years later. Of the 5 patients with stenosis 4 had an umbilical stoma and 1 had a right lower quadrant abdominal wall stoma. All cases were successfully treated with Y-V plasty. Two patients had appendiceal stricture 3 and 18 months postoperatively, respectively, at the appendicovesical junction, which was believed to be due to inadequate appendiceal spatulation. Each patient required open operative revision and subsequently catheterized the appendicovesicostomy without difficulty.
The appendix was perforated in 2 patients who performed catheterization. In 1 female the bladder pulled away from the anterior abdominal wall 19 months postoperatively. This patient later had difficult catheterization due to a fascial shelf at the base of the umbilicus that directed the catheter poorly and required fascial incision to ease catheterization. In the other patient the appendix was perforated by traumatic catheterization and a small false passage developed, requiring surgical revision. Other postoperative complications included difficult catheterization due to a mucosal tear within the appendix in 1 case, which resolved after stenting with a 12Fr polyethylene catheter. Two patients underwent surgical revision for prolapsed mucosa at the appendicovesicostomy stoma 6 and 7 months, respectively, after appendicovesicostomy. Overall 8 patients (16%) underwent at least 1 appendicovesicostomy revision, of whom 4 required 2 or more revisions during followup. Except for 1 case complications necessitating surgical appendiceal revision developed within the initial 1.5 years postoperatively. Median time to the initial revision was 7.3 months (range 1 month to 5.8 years). Only 1 girl with a history of myelomeningocele, a closed bladder neck and multiple previous bladder perforations reported dampness at the stomal site despite frequent catheterization. Five other patients complained of intermittent leakage with bladder over distention or intermittent leakage at night. Leakage in these cases was controlled by increasing the frequency of catheterization to every 3 hours during the day in 2 and 2 times nightly in 1 as well by the recommendation to decrease fluid intake before bedtime. The remaining 2 patients reported only a few episodes of intermittent leakage and no changes were made in treatment.
1925
2 (4)
6/36 1/50 0 Not provided
1
1/26 0 0
5/19 (26) 0 3/41 (7) 2/26 13/54 (24) 4/25 7/66 (11) 6/36 (17) Not provided 12/57 (21) 8/50 (16) 0/19 0
1/19 0 1/25 0 0 0
Not provided Not provided Median 7 Not provided Not provided 15.4 Not provided
13 5/50 (10)
49/50
(98)
Not provided Not provided 13/41 (32) 0 Not provided 5/28 (18) 5/66 (8) 2/43 (5) 6/50 (12) 56/57 (98) 7 (14) (100) Not provided Not provided 25/26 (96) 49/54 (91) 25/25 (100) 48/48 (100) Not provided Not provided Not provided
4/19 (21) 0 3/41 (7) 4/26 (15) 24/100 (24) 4/25 (16) 6/48 (13) 3/36 (8) 5/50 (10)
13 (2–45) 17 (6–29) 38.4 (6–96) 28.8 (2–72) 30 (2–98) 29 (6–63) 36 36 (0.5–78) 62.4 (1–122) 30.5 52 (3–196) Median Mean Mean Mean Median Mean Mean Mean Mean Mean Mean 10.1 (1–19) 9 (4–15) 13 (5–25) 11 (3–31) 29.3 (13.6–82.3) 8.7 (18 mos.–18.6 yrs.) 8.8 (3 days–20 yrs.) 10 (3–21) 13.7 (3–38) 11 (2–23) 13.1 (4–25)
Age (range)* References
19 Mean Dykes et al3 14 Mean Keating et al4 25 Median Duckett and Lotfi10 26 Mean Sumfest et al5 54 Median Woodhouse and MacNeily9 25 Mean Jayanthi et al12 48 Mean Van Savage et al6 36 Mean Suzer et al7 17 Mean Kaefer et al13 57 Mean Cain et al11 Current series 50 Mean * Given in years unless indicated otherwise.
Mean Mos. to Stenosis No. Stenosis/ Total No. (%) Mos. Followup (range) No. With Appendix
TABLE 2. Published reports of appendicovesicostomy
Appendiceal Stomal Continence
Stones
Necrosis
No. Pts./Total No. (%)
Stricture
Revision
DURABILITY OF APPENDICOVESICOSTOMY DISCUSSION
In 1980 Mitrofanoff initially reported successful use of the appendix as a continent catheterizable stoma.1 Since then many others have shown that the Mitrofanoff procedure is effective.3– 6, 10, 11 Mitrofanoff originally used appendix or ureter as the catheterizable channel, while others used ileum, a fallopian tube, cecum or stomach.7–9 Published series indicate appendicovesicostomy stomal stenosis rates of 7% to 24% at a mean followup of 13 to 38.4 months (table 2).3–7, 9 –13 In our series the incidence of stomal stenosis was 10% at a mean followup of 52 months. The mean of 13 months to stomal stenosis is similar to that in other published series (table 2).3–7, 9 –13 Stomal stenosis is generally considered to be an early complication of appendicovesicostomy but in our series 1 patient had stomal stenosis initially after 69 months of followup. Others also reported late stomal stenosis at 649 and 717 months. We believe that our technique of placing the stoma at the umbilicus and interdigitating a U-shaped flap of skin into a spatulated appendix minimizes the incidence of stomal stenosis. The technique developed at our hospital was described by Keating et al.4 Mobilization of the cecum and the root of the mesentery, and avoiding dissection that separates the appendix from the cecum should decrease injury to the appendiceal vascular supply, stenosis and stricture. Hitching the bladder to the abdominal wall and creating an umbilical stoma decrease the necessity for a long appendix. This technique also decreases the length of extravesical appendix as well as the likelihood of appendiceal kinking. Frequent catheterization of the appendix throughout the operative procedure helps to ensure an easily catheterizable appendix postoperatively. Stricture of the appendicovesical junction developed in only 2 patients. This complication was believed to be due to inadequate spatulation. Preservation of the blood supply by wide mobilization of the cecum prevents ischemic stricture. The flap-valve mechanism at the appendicovesical junction provides excellent continence at the stoma. Stomal continence rates of 93%9 to 100%12 have been reported in the literature. Only 1 patient in our series noticed wetness at the stomal site that was worse at night. In our series it was not necessary to revise the flap valve mechanism in any patient. Six patients have been catheterizing the appendix multiple times daily regularly for at least 8 years and only 2 no longer use the appendix for catheterization, which was due to appendicovesicostomy failure in 1.
CONCLUSIONS
Our review of 50 cases of appendicovesicostomy with longterm followup demonstrates the successful long-term outcome and durability of this technique. Surgical revision for complications associated with the appendix was necessary in 16% of patients. Adherence to a technique that emphasizes ease of catheterization intraoperatively, wide mobilization of the cecum to preserve vascularity and fixation of the bladder to the anterior abdominal wall helps to ensure long-term success.
REFERENCES
1. Mitrofanoff, P.: Cystostomie continent trans-appendiuclaire dans le traitement des vessies neurologiques. Chir Pediatr, 21: 297, 1980 2. Duckett, J. W. and Snyder, H. M., III.: Continent urinary diversion: variations on the Mitrofanoff principle. J Urol, 136: 58, 1986 3. Dykes, E. H., Duffy, P. G. and Ransley, P. G.: The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children. J Pediatr Surg, 26: 535, 1991
1926
DURABILITY OF APPENDICOVESICOSTOMY
4. Keating, M. A., Rink, R. C. and Adams, M. C.: Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J Urol, 149: 1091, 1993 5. Sumfest, J. M., Burns, M. W. and Mitchell, M. E.: The Mitrofanoff principle in urinary reconstruction. J Urol, 150: 1875, 1993 6. Van Savage, J. G., Khoury, A. E., McLorie, 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 7. Suzer, O., Vates, T. S., Freedman, A. L. et al: Results of the Mitrofanoff procedure in urinary tract reconstruction in children. Br J Urol, 79: 279, 1997 8. Kaefer, M. and Retik, A. B.: The Mitrofanoff principle in continent urinary reconstruction. Urol Clin North Am, 24: 795, 1997 9. Woodhouse, C. R. and MacNeily, A. E.: The Mitrofanoff princi-
10. 11.
12.
13.
ple:expanding upon a versatile technique. Br J Urol, 74: 447, 1994 Duckett, J. W. and Lotfi, A.: Appendicovesicostomy (and variations) in bladder reconstruction. J Urol, 149: 567, 1993 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 Jayanthi, V. R., Churchill, B. M., McLorie, G. A. et al: Concomitant bladder neck closure and Mitrofanoff diversion for the management of intractable urinary incontinence. J Urol, part 2, 154: 886, 1995 Kaefer, M., Tobin, M. S., Hendren, W. H. et al: Continent urinary diversion: the Children’s Hospital experience. J Urol, 157: 1394, 1997
Vol. 163, 1922–1926, June 2000 Printed in U.S.A.
APPENDICOVESICOSTOMY: THE MITROFANOFF PROCEDURE—A 15-YEAR PERSPECTIVE CONSTANTINE F. HARRIS, CHRISTOPHER S. COOPER,* JOEL C. HUTCHESON AND HOWARD M. SNYDER, III From the Division of Pediatric Urology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
ABSTRACT
Purpose: Appendicovesicostomy was introduced in the United States in 1982 at our hospital. It has become the most popular alternate continence channel for catheterization. We reviewed the experience of 1 surgeon with appendicovesicostomy during a 15-year period. Materials and Methods: We retrospectively reviewed the operative reports and clinical records of 50 consecutive patients in whom appendicovesicostomy was performed by 1 surgeon between 1982 and 1998. The underlying diagnosis was myelomeningocele in 31 cases, bladder exstrophy in 6, the prune-belly syndrome in 2, posterior urethral valves in 2 and other disorders in 10. Mean patient age at surgery was 13.1 years (range 4 months to 25 years) and mean followup was 4.3 years (range 3 months to 16.3 years). Results: Of the 50 patients 96% continue to catheterize the appendicovesicostomy. Stomal stenosis developed in 5 cases (10%) and other complications included stricture and appendiceal perforation in 2 each. Eight patients (16%) required appendicovesicostomy revision at a median of 7.3 months (range 1 month to 5.8 years) after the initial procedure. Median time to revision for stomal stenosis was 13 months (range 1 month to 5.8 years). Appendicovesicostomy continence was achieved in 49 patients (98%). Conclusions: Our series demonstrates the successful long-term outcome and durability of appendicovesicostomy in children. Careful adherence to technique at initial surgery helps ensure a high long-term success rate. KEY WORDS: appendix, urinary diversion, cystostomy, abnormalities, bladder
In 1980 Mitrofanoff proposed implanting the appendix into the bladder as a catheter conduit.1 In 1982 appendix was initially used in the United States as a catheterizable channel in children at our hospital.2 Since then, others at many institutions have reported performing appendicovesicostomy using the Mitrofanoff principle in the pediatric population2– 8 and it has become the most widely used alternative continence mechanism in the world. Appendicovesicostomy has been performed in patients with exstrophy and epispadias who are reluctant to perform intermittent catheterization due to a sensitive urethra. It is also useful in the spina bifida population in which urethral access may be difficult due to obesity or wheelchair dependence. The success of appendicovesicostomy has led to its widespread use with good early followup.3, 4, 7, 9 Minimal complications have been reported. The most common complication is stomal stenosis. In a large series of 100 patients using various conduits Woodhouse and MacNeily reported a stomal stenosis rate of 24%.9 Other complications include appendiceal necrosis, stricture and stomal incontinence. We report our long-term followup of 50 consecutive patients in whom appendicovesicostomy was performed by 1 surgeon (H. M. S.). MATERIALS AND METHODS
We reviewed the hospital records and clinical outcome of 28 males and 22 females who underwent appendicovesicostomy as part of continent bladder reconstruction between 1982 and 1998. Followup was defined as the interval between surgery
and the most recent urology visit. All procedures were performed by 1 surgeon (H. M. S.). Appendicovesicostomy was performed via a midline or Pfannenstiel incision. The midline incision curved around the umbilicus, leaving enough fascia lateral to the umbilicus to permit closure away from the appendicovesicostomy stoma located in the depths of the umbilicus. The cecum was widely mobilized, so that the base of the intact appendix reached the umbilicus. This mobilization prevents stretching of the vascular pedicle to the appendix. By mobilizing the cecum the appendix was easily placed to the umbilicus or elsewhere on the abdominal wall. Since the appendiceal blood supply is at the end of the superior mesenteric artery, it has great mobility. By moving the appendix with the cecum there was no need to separate widely the appendix from the cecum, which in turn protected the appendiceal blood supply. After the peritoneum was removed from the bladder dome the ability of the bladder to reach the umbilicus was tested by traction on the bladder dome. When the bladder reached the umbilicus, it was opened along the anterior surface, usually to the left of the midline, permitting the right side of the bladder to be more easily stretched to the umbilicus. This incision also facilitated access to the opened bladder for sigmoid cystoplasty, which was the most common type of intestinal augmentation done. The bladder was virtually always stretched to reach the umbilicus, especially when the bladder was opened on the left side, permitting a flap to be stretched on the right side to reach the umbilicus. Additional mobility was gained as necessary by incising the left side of the bladder wall transversely. Leaving a portion of the cephalad anterior bladder wall intact as a cap permitted manual elevation from inside the bladder toward the umbilicus (fig. 1). The site of the bladder hiatus was identified and enlarged enough to admit a finger easily. The path of the intended
Accepted for publication January 14, 2000. * Requests for reprints: Division of Pediatric Urology, Children’s Hospital of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, Iowa 522421089. 1922
1923
DURABILITY OF APPENDICOVESICOSTOMY
FIG. 1. Leaving anterior cap of bladder facilitates manual positioning of bladder against anterior abdominal fascia. Reprinted with permission.4
appendiceal tunnel was identified and injected submucosally with mixed lidocaine and epinephrine at a ratio of 1:100,000. The path of the appendix was off of the midline to prevent future urethral catheterization via the appendicovesicostomy. When the trigone was sensate, the appendiceal path was directed so that catheterization would not irritate the trigone. Mucosal flaps were broadly elevated around the hiatus and along the intended path of the appendix before the bladder was fixed to the abdominal wall. The umbilical stoma was created with a U-shaped skin flap incision in the depth of the umbilicus from the 3 to 9 o’clock positions. The flap was sharply elevated from the fascia to which it was adherent. The fascia was opened vertically and wide enough for a finger to be inserted from below to ensure no compression of the appendiceal mesentery. The appendiceal mesentery was minimally separated at the cecal junction to expose the cecal wall. The appendix was harvested by obtaining a small cuff of cecum (fig. 2). In the rare situation in which the appendix was less than 5 cm. a strip of cecum a few cm. long was tubularized to lengthen the appendix. The cecal end of the appendix was brought through the
fascial and umbilical opening, and spatulated to interdigitate with the skin flap of the bottom of the umbilicus, taking care to avoid the mesentery. The appendix was approximated to the edges of the umbilical skin with multiple interrupted absorbable 5-zero polyglactin sutures placed at 2 to 3 mm. intervals, taking solid bites of the full thickness of the appendix. This skin-to-appendix anastomosis was facilitated by creating it before attaching the appendix to the bladder so that anastomosis was constructed above the skin level (fig. 3, A). After creation of the appendicovesicostomy stoma the appendix was passed through the bladder hiatus and pulled down, causing the stoma to disappear into the depth of the umbilicus (fig. 3, B). The bladder was manually elevated to the umbilicus and fixed to the fascia on the lateral side of the umbilicus with 4, 2-zero sutures so that the hiatus in the bladder and fascia were aligned (fig. 4). With several more polypropylene sutures the medial and anterior aspects of the hiatus were reattached to the abdominal wall. A gap in the fixing sutures remained along the posterior side to avoid compressing the appendiceal mesentery. During the attachment of the bladder to the abdominal wall a lubricated feeding tube was repeatedly passed into the appendix to ensure that no obstructing edge of fascia or bladder wall was created to interfere with later catheterization. The appendix was stretched to the distal end of the mucosal trough, helping to ensure a long flap valve and straight appendix for catheterization. Fixation of the appendix at the umbilicus and distal to the detrusor provides a straight conduit and helps to avoid kinks in the appendiceal course. Kinking of the appendix as it traverses the abdominal fascia or bladder wall may lead to catheter deflection with resultant distortion and sacculation of the appendix, which may in turn lead to subsequently difficult catheterization. The distal appendix was amputated and the bladder end was spatulated for 3 to 4 mm. to prevent stenosis by wound contracture at the distal anastomosis of the appendix to the bladder. The distal appendix was attached with 2 or 3 interrupted polyglycolic or polyglycolic acid sutures, catching a solid bite of the detrusor muscle at the edge of the apical incision in the mucosa. The back wall of the appendix was sutured to the detrusor in several places as necessary to relieve tension and help to maintain the position of the appendix in the trough. Care was taken not to rotate the appendix with these sutures, which would have created a mucosal fold in the appendix capable of interfering with catheterization. The mucosal flaps were approximated over the appendix. With appendicovesicostomy complete catheterization was repeated to ensure a smooth course. When planned bladder augmentation was done last. A 10Fr polyethylene catheter remained in the appendix as a stent for 3 weeks. A suprapubic tube was routinely used. Three weeks after surgery a cystogram was performed and then appendicovesicostomy catheterization was started with a 12Fr polyethylene catheter. Long-term catheterization was done with a 12 or 14Fr catheter, which has a blunter tip than a 10Fr catheter. The suprapubic tube was removed after catheterization was reliably established. Bladder ultrasound in the office assessed the efficacy of catheterization by measuring post-catheterization residual urine volume. RESULTS
FIG. 2. A, appendix is isolated with small cuff of cecum. B, care is taken to preserve vasculature. Reprinted with permission.4
Mean patient age at surgery was 13.1 years (range 4 to 25). Followup ranged from 3 months to 16.3 years (average 51 months or 4.3 years). The underlying diagnosis varied, including myelomeningocele in 31 cases and bladder exstrophy in 6 (table 1). The preferred site of stomal placement was at the umbilicus in 40 patients, of whom 4 with exstrophy underwent neo-umbilicus creation. In the other 10 patients the catheter-
1924
DURABILITY OF APPENDICOVESICOSTOMY
FIG. 3. A, appendix is sutured to everted umbilical skin flap with feeding tube entering appendix. B, after completion of stoma traction on distal appendiceal aspect results in appendicovesicostomy hidden in umbilicus.
FIG. 4. A, appendix with feeding tube inserted via umbilical stoma traverses fascial and bladder openings. Sutures fix bladder wall to anterior abdominal fascia along lateral side of hiatus. Note bladder lumen. Reprinted with permission. B, appendix (A), feeding tube (B), bladder wall (C) anterior abdominal fascia (D) and bladder lumen (E).
TABLE 1. Underlying diagnoses Diagnosis
No. Pts.
Neurogenic bladder with or without myelomeningocele Exstrophy with or without epispadias Prune-belly syndrome Posterior urethral valves Imperforate anus Hinman syndrome Other Total No.
34 7 2 2 2 1 2 50
izable stoma was placed elsewhere on the abdominal wall. After the umbilicus the most common site was the right lower quadrant. A total of 48 patients (96%) continue to use the appendicovesicostomy, although 1 male with an underlying diagnosis of posterior urethral valves no longer uses it. In this case dysfunctional voiding improved and catheterization was no longer necessary. Another patient had diffuse fibrosis of the appendix after 2 years of use and subsequently a catheterizable stoma was reconstructed from tapered ileum. Stomal stenosis developed in only 5 patients (10%) at a median of 13 months (range 1 to 69). In most cases it developed within 1.5 years after surgery but in 1 case stomal stenosis occurred 5.8 years later. Of the 5 patients with stenosis 4 had an umbilical stoma and 1 had a right lower quadrant abdominal wall stoma. All cases were successfully treated with Y-V plasty. Two patients had appendiceal stricture 3 and 18 months postoperatively, respectively, at the appendicovesical junction, which was believed to be due to inadequate appendiceal spatulation. Each patient required open operative revision and subsequently catheterized the appendicovesicostomy without difficulty.
The appendix was perforated in 2 patients who performed catheterization. In 1 female the bladder pulled away from the anterior abdominal wall 19 months postoperatively. This patient later had difficult catheterization due to a fascial shelf at the base of the umbilicus that directed the catheter poorly and required fascial incision to ease catheterization. In the other patient the appendix was perforated by traumatic catheterization and a small false passage developed, requiring surgical revision. Other postoperative complications included difficult catheterization due to a mucosal tear within the appendix in 1 case, which resolved after stenting with a 12Fr polyethylene catheter. Two patients underwent surgical revision for prolapsed mucosa at the appendicovesicostomy stoma 6 and 7 months, respectively, after appendicovesicostomy. Overall 8 patients (16%) underwent at least 1 appendicovesicostomy revision, of whom 4 required 2 or more revisions during followup. Except for 1 case complications necessitating surgical appendiceal revision developed within the initial 1.5 years postoperatively. Median time to the initial revision was 7.3 months (range 1 month to 5.8 years). Only 1 girl with a history of myelomeningocele, a closed bladder neck and multiple previous bladder perforations reported dampness at the stomal site despite frequent catheterization. Five other patients complained of intermittent leakage with bladder over distention or intermittent leakage at night. Leakage in these cases was controlled by increasing the frequency of catheterization to every 3 hours during the day in 2 and 2 times nightly in 1 as well by the recommendation to decrease fluid intake before bedtime. The remaining 2 patients reported only a few episodes of intermittent leakage and no changes were made in treatment.
1925
2 (4)
6/36 1/50 0 Not provided
1
1/26 0 0
5/19 (26) 0 3/41 (7) 2/26 13/54 (24) 4/25 7/66 (11) 6/36 (17) Not provided 12/57 (21) 8/50 (16) 0/19 0
1/19 0 1/25 0 0 0
Not provided Not provided Median 7 Not provided Not provided 15.4 Not provided
13 5/50 (10)
49/50
(98)
Not provided Not provided 13/41 (32) 0 Not provided 5/28 (18) 5/66 (8) 2/43 (5) 6/50 (12) 56/57 (98) 7 (14) (100) Not provided Not provided 25/26 (96) 49/54 (91) 25/25 (100) 48/48 (100) Not provided Not provided Not provided
4/19 (21) 0 3/41 (7) 4/26 (15) 24/100 (24) 4/25 (16) 6/48 (13) 3/36 (8) 5/50 (10)
13 (2–45) 17 (6–29) 38.4 (6–96) 28.8 (2–72) 30 (2–98) 29 (6–63) 36 36 (0.5–78) 62.4 (1–122) 30.5 52 (3–196) Median Mean Mean Mean Median Mean Mean Mean Mean Mean Mean 10.1 (1–19) 9 (4–15) 13 (5–25) 11 (3–31) 29.3 (13.6–82.3) 8.7 (18 mos.–18.6 yrs.) 8.8 (3 days–20 yrs.) 10 (3–21) 13.7 (3–38) 11 (2–23) 13.1 (4–25)
Age (range)* References
19 Mean Dykes et al3 14 Mean Keating et al4 25 Median Duckett and Lotfi10 26 Mean Sumfest et al5 54 Median Woodhouse and MacNeily9 25 Mean Jayanthi et al12 48 Mean Van Savage et al6 36 Mean Suzer et al7 17 Mean Kaefer et al13 57 Mean Cain et al11 Current series 50 Mean * Given in years unless indicated otherwise.
Mean Mos. to Stenosis No. Stenosis/ Total No. (%) Mos. Followup (range) No. With Appendix
TABLE 2. Published reports of appendicovesicostomy
Appendiceal Stomal Continence
Stones
Necrosis
No. Pts./Total No. (%)
Stricture
Revision
DURABILITY OF APPENDICOVESICOSTOMY DISCUSSION
In 1980 Mitrofanoff initially reported successful use of the appendix as a continent catheterizable stoma.1 Since then many others have shown that the Mitrofanoff procedure is effective.3– 6, 10, 11 Mitrofanoff originally used appendix or ureter as the catheterizable channel, while others used ileum, a fallopian tube, cecum or stomach.7–9 Published series indicate appendicovesicostomy stomal stenosis rates of 7% to 24% at a mean followup of 13 to 38.4 months (table 2).3–7, 9 –13 In our series the incidence of stomal stenosis was 10% at a mean followup of 52 months. The mean of 13 months to stomal stenosis is similar to that in other published series (table 2).3–7, 9 –13 Stomal stenosis is generally considered to be an early complication of appendicovesicostomy but in our series 1 patient had stomal stenosis initially after 69 months of followup. Others also reported late stomal stenosis at 649 and 717 months. We believe that our technique of placing the stoma at the umbilicus and interdigitating a U-shaped flap of skin into a spatulated appendix minimizes the incidence of stomal stenosis. The technique developed at our hospital was described by Keating et al.4 Mobilization of the cecum and the root of the mesentery, and avoiding dissection that separates the appendix from the cecum should decrease injury to the appendiceal vascular supply, stenosis and stricture. Hitching the bladder to the abdominal wall and creating an umbilical stoma decrease the necessity for a long appendix. This technique also decreases the length of extravesical appendix as well as the likelihood of appendiceal kinking. Frequent catheterization of the appendix throughout the operative procedure helps to ensure an easily catheterizable appendix postoperatively. Stricture of the appendicovesical junction developed in only 2 patients. This complication was believed to be due to inadequate spatulation. Preservation of the blood supply by wide mobilization of the cecum prevents ischemic stricture. The flap-valve mechanism at the appendicovesical junction provides excellent continence at the stoma. Stomal continence rates of 93%9 to 100%12 have been reported in the literature. Only 1 patient in our series noticed wetness at the stomal site that was worse at night. In our series it was not necessary to revise the flap valve mechanism in any patient. Six patients have been catheterizing the appendix multiple times daily regularly for at least 8 years and only 2 no longer use the appendix for catheterization, which was due to appendicovesicostomy failure in 1.
CONCLUSIONS
Our review of 50 cases of appendicovesicostomy with longterm followup demonstrates the successful long-term outcome and durability of this technique. Surgical revision for complications associated with the appendix was necessary in 16% of patients. Adherence to a technique that emphasizes ease of catheterization intraoperatively, wide mobilization of the cecum to preserve vascularity and fixation of the bladder to the anterior abdominal wall helps to ensure long-term success.
REFERENCES
1. Mitrofanoff, P.: Cystostomie continent trans-appendiuclaire dans le traitement des vessies neurologiques. Chir Pediatr, 21: 297, 1980 2. Duckett, J. W. and Snyder, H. M., III.: Continent urinary diversion: variations on the Mitrofanoff principle. J Urol, 136: 58, 1986 3. Dykes, E. H., Duffy, P. G. and Ransley, P. G.: The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children. J Pediatr Surg, 26: 535, 1991
1926
DURABILITY OF APPENDICOVESICOSTOMY
4. Keating, M. A., Rink, R. C. and Adams, M. C.: Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J Urol, 149: 1091, 1993 5. Sumfest, J. M., Burns, M. W. and Mitchell, M. E.: The Mitrofanoff principle in urinary reconstruction. J Urol, 150: 1875, 1993 6. Van Savage, J. G., Khoury, A. E., McLorie, 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 7. Suzer, O., Vates, T. S., Freedman, A. L. et al: Results of the Mitrofanoff procedure in urinary tract reconstruction in children. Br J Urol, 79: 279, 1997 8. Kaefer, M. and Retik, A. B.: The Mitrofanoff principle in continent urinary reconstruction. Urol Clin North Am, 24: 795, 1997 9. Woodhouse, C. R. and MacNeily, A. E.: The Mitrofanoff princi-
10. 11.
12.
13.
ple:expanding upon a versatile technique. Br J Urol, 74: 447, 1994 Duckett, J. W. and Lotfi, A.: Appendicovesicostomy (and variations) in bladder reconstruction. J Urol, 149: 567, 1993 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 Jayanthi, V. R., Churchill, B. M., McLorie, G. A. et al: Concomitant bladder neck closure and Mitrofanoff diversion for the management of intractable urinary incontinence. J Urol, part 2, 154: 886, 1995 Kaefer, M., Tobin, M. S., Hendren, W. H. et al: Continent urinary diversion: the Children’s Hospital experience. J Urol, 157: 1394, 1997