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Background: the Mitrofanoff appendicovesicostomy provides a catheterizable submucosal tunnel between umbilicus and bladder (or neobladder). In patients with a closed bladder neck, the Mitrofanoff channel is the only way to access the bladder. We describe our case of a 17 year-old girl with a Mitrofanoff appendicovesicostomy and a previous surgical closure of the bladder neck and who developed a large bladder clot due to hematuria after a surgical cystolithotomy in an augmented bladder; Methods: after an unsuccessful trans-appendicovesicostomy bladder washing, the endoscopic evaluation was performed using a 14 Ch rigid cystoscope and surrounded by its own urethral sheath. The clot was progressively fragmented through the cystoscope under direct vision. Clot fragments were aspirated to obtain a complete evacuation; Results: the urethral sheath prevented damages to the appendicovesicostomy, allowing at the same time repeated accesses of the cystoscope into the neobladder and ensuring the procedural success. The postoperative period was uneventful, and the neobladder catheter was removed after two days. Neither channel stenosis nor anastomosis dehiscence nor incontinence were reported after five months; Conclusions: the use of urethral sheath 14 Ch through an appendicovesicostomy preserves both the stoma and the channel, making possible endoscopic procedures such as blood clot evacuation into the neobladder.

Bilateral single system ectopic ureters are a rare entity in paediatric urology. We report a girl child with bilateral single system ectopic ureters with right system opening into the vagina, who presented at 3.5 years with continuous dribbling of urine & a small capacity bladder. Renal scans and MRI were done which indicated bilateral single system ectopic ureters with hydroureteronephrosis. We managed her surgically by a right nephro-ureterectomy, bladder augmentation, left ureteric reimplantation and Mitrofanoff. Post op patient had acute on chronic renal failure, stabalised by haemodialysis. It is a rare presentation if managed promptly can prevent renal replacement therapy.

Bladder stone formation is common in patients with augmented urinary bladder. In this case, we have applied minimally invasive technique through the existing appendicovesicostomy. After dilating the Mitrofanoff channel with dilators, we used 6.4/7.9 semirigid ureteroscope with pneumatic lithotripsy to fragment the stone. 20 Fr chest drain was introduced into the augmented bladder over the ureteroscope and all fragments were sucked out, rendering the patient stone free. Operating through the existing Mitrofanoff urinary diversion with ureteroscope along with judicious use of suction can be an excellent cost effective and minimally traumatic method of rendering the patient stone free.

Aim: Some children require long-term drainage of the bladder but do not tolerate clean intermittent catheterisation (CIC) urethrally. We aimed to compare long term suprapubic catheter (SPC) drainage vs Mitrofanoff conduit (allowing CIC) by comparing the survival of the drainage methods and rates of urinary tract infection (UTI)., Method: Retrospective review of a single surgeon's experience (2007-2023). Data collection included diagnosis, age at procedures, date of surgery, date of most recent follow-up and date and reason for unplanned surgery. For SPCs, initial insertion of SPC and then conversion to a Foley catheter under GA was taken as normal (event free survival) and only further operations were counted as complication events. For Mitrofanoffs, any subsequent operation was counted as a complication. Data were given as a number (%) or median (interquartile range) as appropriate. Data analysed by Fisher exact and Mann-Whitney U-test. Kaplan Meier (KM) survival of drainage routes was compared, P < 0.05 taken as significant., Results: There were 45 patients (n = 86 SPC episodes) compared to 108 patients (n = 110 Mitrofanoff procedures). Data were available in 73 SPC episodes and 109 Mitrofanoff episodes, including 3 redo procedures (one from another centre). There was no difference in gender (SPC group, 67 % male vs. Mitrofanoff group, 77 %; N.S.). There was no difference in age at procedure [7.5 (2.9-11.5) years vs 8.3 (5.9-11.4) years respectively; N.S.) KM comparison showed that Mitrofanoff have a better event-free survival than SPC (91 % vs 52 % at 1 year; 80 % vs. 13 % at 5 years; P < 0.0001). Paired data showed a significant (86 %) reduction in rate of UTI with conversion from SPC to Mitrofanoff drainage in 15 patients; SPC: 0.13 (0-0.46) UTIs/month vs subsequent Mitrofanoff: 0.02 (0-0.08) UTI/month, P = 0.04)., Conclusion: SPCs had a much higher rate of unplanned surgery than Mitrofanoffs, creating a considerable unplanned burden of care for families and clinical staff. For long-term bladder drainage CIC via a Mitrofanoff conduit should be considered in preference to SPC where urethral CIC is not possible., (Copyright © 2024. Published by Elsevier Inc.)

Abstract Background Chronic catheterization remains the only attractive option in specific circumstances, especially in neurologically impaired patients. Complications produced by the indwelling catheters, like patulous urethra and bladder neck destruction, usually lead to severe incontinence and significant nursing difficulties. Here, we describe a rare case, a urinary bladder opening representing massive and extensive destruction of the urethra and bladder sphincter due to an indwelling catheter. Case presentation We present a 46-year-old paraplegic woman complaining of recurrent febrile urinary tract infections and severe urinary incontinence. She suffered from persistent malodorous urine and skin breakdowns from constant urine leakage. The vaginal examination revealed extensive destruction of the urethra and a 10 cm opening permitting the urinary bladder wall to prolapse into the vagina. The patient underwent a combined surgical approach; a transvaginal bladder closure with anterior colporrhaphy and a Mitrofanoff procedure to ensure a continent stoma for future clean intermittent self-catheterization (CISC). The patient is compliant with CISC and, remains continent twelve years after surgery. Conclusion This case demonstrates that in the era of CISC, there are still neurologically impaired females suffering from rare but critical adverse effects of indwelling catheters. The urethra and bladder neck erosion represent a demanding treatment assignment. The Mitrofanoff procedure for continent stoma and the transvaginal closure of urinary bladder opening produced a lifesaving potential treatment.

Over the last half century, significant improvements in health outcomes for individuals with spinal cord injury (SCI) and growing recognition those women with SCI can become pregnant. However, pregnancy must be rated as high risk and requires multidisciplinary medical care as higher rate of complication compare to general population. Most of published literature grouped all patients with lower urinary tract reconstruction (LUTR) like exstrophy–epispadias complex, spina bifida, interstitial cystitis urogenital sinus or fistula, but our article is focusing in the childbearing SCI women who undergone cutaneous continent urinary diversion (CCUD) with mitrofanoff procedure. We report two cases of three successful pregnancies in this population.

Purpose of review: The purpose of this review is to (1) summarize the current literature on the use of occupational therapy services to facilitate self-catheterization and self-management skills in pediatric patients with neurogenic bladder, and (2) propose how occupational therapists can partner with urologists to improve surgical decision-making for lower urinary tract reconstruction, specifically the implementation of continent catheterizable channels in pediatric populations. Topics include occupational therapy, self-catheterization training, toileting independence, lower urinary tract reconstruction, continent catheterizable stoma, and urinary incontinence. Recent findings: Recent evidence indicates the use of occupational therapists to train pediatric patients with neurogenic bladder on self-catheterization is beneficial, and can lead to more efficient outcomes. There is a lack of literature detailing the frequency and duration, of occupational therapy treatment for needed toileting independence. There is also a lack of literature on standardization of surgical indications for a continent catheterizable channel. No available studies describe methods that exhaust or standardize urethral self-catheterization training prior to surgical intervention for increased independence. There is limited data on predictive factors and recommended timelines to initiate self-catheterization. No studies have explored occupational therapy evaluations as part of pre-operative assessment for independent bladder management via catheterizable channels. Summary: Emerging evidence supports and promotes the collaboration of occupational therapists and healthcare providers to enhance the management of neurogenic bladder and self-catheterization. Further studies are needed to evaluate the use of occupational therapists in urologic practice, with the aim of prioritizing independence and quality of life. [ABSTRACT FROM AUTHOR]

Introduction: Cutaneous stoma stenosis represents a frequent complication associated with continent catheterizable channel, often necessitating recurrent patients' consultation, hospital admission, and repetitive surgical interventions. Management strategies encompass dilatation, incision, and, in case of refractory stenosis, invasive surgical revision., Objectives: In this study, we aimed to assess the efficacy of buccal mucosa graft as an alternative therapeutic approach for managing cutaneous catheterizable channel stenosis., Methods: We conducted a retrospective analysis of all patients referred to our two specialized tertiary reconstructive urology centers due to continent catheterizable cutaneous channel stenosis between January 2015 and June 2023. The study cohort comprises patients who had undergone either a Mitrofanoff, an ileal continent catheterizable channel (Monti or Casal) or a Malone antegrade colonic enema procedure (MACE), all of whom exhibited stoma stenosis., Results: We identified 14 patients who underwent a total of 15 buccal mucosa graft augmentation repairs for stenosis. Following a mean follow-up duration of 30months, 11 out of 15 procedures (73%) demonstrated successful outcomes. Notably, no complication was observed, except in the 4 cases classified as failures. These failures were attributed to either stenosis recurrence (3 cases) or fleshy bud persistence (1 case). Importantly, patients did not report any concerns regarding esthetic or functional complains., Conclusions: Buccal mucosa graft emerges as a minimally invasive alternative for repairing continent catheterizable channel stenosis, yielding a promising success rate and an exceptionally low incidence rate of complications., Level of Evidence: III., (Copyright © 2024. Published by Elsevier Masson SAS.)

Introduction: Robot-assisted Laparoscopic Appendicovesicostomy (RALAPV) is increasingly performed as a minimally invasive alternative to the open appendicovesicostomy (OPAV), but questions remain regarding the efficacy of the RALAPV compared to OPAV., Objective: To assess and compare outcomes for non-augmented RALAPV to the open surgical approach., Materials and Methods: An IRB approved prospective registry was retrospectively examined to abstract all patients who underwent APV without augment between 2012 and 2023. Baseline demographics, intra and post-operative characteristics, and long-term outcomes were aggregated and compared. P-values were two sided and a p-value <0.05 was considered statistically significant., Results: 52 children were identified, 19 (36.5%) OAPV and 33 (63.5%) RALAPV. The median age at surgery was 8.5 years for OAPV and 9.3 years for RALAPV (p = 0.29). Longer operative time was noted in the RALPAV group (346 min vs 289 min, p = 0.04), with a lower estimated blood loss (5 cc vs 30 cc, p = 0.003), shorter median length of hospital stay (4 days vs 5 days, p = 0.07), and lower IV morphine administration (0.04 mg/kg/d vs 0.09 mg/kg/d, p = 0.01). Similar surgical reintervention rate was seen in both cohorts (42% OAPV vs 36% RALAPV, p = 0.77). At the end of follow-up, continence was achieved in 18 (95%) OAPV and 33 (100%) RALAPV patients (p = 0.37) CONCLUSIONS: RALAPV shows comparable success to patients who underwent OPAV procedures. The longer follow-up interval for OPAV highlights minimally invasive surgery as a recent adoption., Competing Interests: Conflict of interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

A small proportion of patients with EB develop genitourinary disorders, which can nevertheless have a major impact on their morbidity. We present the case of a 7-year-old boy with junctional EB who presented with dysuria and lower back pain caused by bladder lithiasis complicating posterior urethral stenosis, surgical management, and postoperative outcomes.

Despite theadvancements in surgical reconstructive techniques for bladder exstrophy-epispadias complex, urinary incontinence represents a major problem that affects the quality of life. Bladder augmentation associated to Mitrofanoff external continent urinary diversion (ECUD) constitute for some surgeon the best solution for the management of bladder exstrophyallowing to achieve continence and to preserve renal function.

Background: Chronic catheterization remains the only attractive option in specific circumstances, especially in neurologically impaired patients. Complications produced by the indwelling catheters, like patulous urethra and bladder neck destruction, usually lead to severe incontinence and significant nursing difficulties. Here, we describe a rare case, a urinary bladder opening representing massive and extensive destruction of the urethra and bladder sphincter due to an indwelling catheter.Case Presentation: We present a 46-year-old paraplegic woman complaining of recurrent febrile urinary tract infections and severe urinary incontinence. She suffered from persistent malodorous urine and skin breakdowns from constant urine leakage. The vaginal examination revealed extensive destruction of the urethra and a 10 cm opening permitting the urinary bladder wall to prolapse into the vagina. The patient underwent a combined surgical approach; a transvaginal bladder closure with anterior colporrhaphy and a Mitrofanoff procedure to ensure a continent stoma for future clean intermittent self-catheterization (CISC). The patient is compliant with CISC and, remains continent twelve years after surgery.Conclusion: This case demonstrates that in the era of CISC, there are still neurologically impaired females suffering from rare but critical adverse effects of indwelling catheters. The urethra and bladder neck erosion represent a demanding treatment assignment. The Mitrofanoff procedure for continent stoma and the transvaginal closure of urinary bladder opening produced a lifesaving potential treatment. [ABSTRACT FROM AUTHOR]

To allow patients with bladder and bowel dysfunctions to achieve social continence, continent catheterizable channels (CCCs) are effective alternatives to intermittent self-catheterization and enema. We aimed to describe our progressive advancement from open to robotic construction of CCCs, reporting outcomes and comparing the two approaches. We retrospectively reviewed electronic medical records of pediatric patients who underwent construction of CCCs between 2008 and 2019. The inclusion criteria were age ≤18 yr, and CCCs with or without bladder augmentation or bladder neck surgery. We compared open versus robotic approaches for demographics, and intra- and postoperative outcomes; operative time was calculated as incision-to-closure time. Channels performed were appendicovesicostomy (APV), Monti with tapered ileum, and antegrade colonic enema (ACE). A Monti channel with tapered ileum was preferred to a spiral Monti or double Monti, as it has more robust blood supply and it was performed only with an open approach. The primary outcome was success rate, defined as postoperative stomal continence. Stomal incontinence was defined as the presence of urine leakage noted by caregivers or patients and confirmed by the surgeon. Secondary outcomes were stomal stenosis (supra- and subfascial), incontinence, need for surgical revision, and surgical site infection. A total of 69 patients were included in the study, with 35 open and 34 robotic procedures. The robotic approach showed a significant decrease in length of hospital stay (LOS) compared with the open approach. Six primary subfascial revisions were performed in five patients––three Monti, two ACE, and one APV. Continence rates were 91.4% and 91.2% for open and robotic approaches, respectively. Robotic surgery for CCCs showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, LOS, and time to full diet, and better cosmesis. Robotic surgery for continent catheterizable channels showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Bladder dysfunction is a consequence of serious urologic conditions that must be addressed effectively and expeditiously in order to prevent all consequences associated with chronic high-pressure voiding, such as renal function deterioration. In order to allow patients to achieve social continence, intermittent self-catheterization is an option. The use of a continent catheterizable channel (CCC) decreases the discomfort associated with urethral catheterization, as well as complications due to repeated trauma, such as urethral strictures and false passages. In this study, we aimed to describe our progressive advancement from open to robotic performance of CCCs, reporting and comparing outcomes between the two approaches. The types of channel performed were appendicovesicostomy, Monti with tapered ileum, and/or antegrade colonic enema without cecum imbrication. A Monti channel with tapered ileum was preferred to a spiral Monti or double Monti, as it has more robust blood supply. Our results showed that robotic surgery for CCCs had acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, length of hospital stay, time to full diet, and better cosmesis. As more surgeons implement the use of a robotic platform into their practice, optimization of surgical steps for CCCs will further reduce the operative time, making this already safe and effective approach a more sustainable operative modality. [ABSTRACT FROM AUTHOR]

Objectives: The objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life., Materials and Methods: We studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients' quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis., Results: A total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence., Discussion: The experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Anastomosis of catheterising channels (Mitrofanoff and ACE) to the skin can be a challenge. The Kelly VV plasty is a straightforward solution but has been described only as a point of technique. We used the previously described method with minor modification. The technique has been used in 14 patients, including 9 children and 5 adults for Mitrofanoff,ACE and Monti channels. At a median follow-up of 25 months all patients continue to catheterise; none have required revision surgery. The Kelly VV plasty is a potentially robust solution to the problem of skin anastomosis; technique merits wider adoption and evaluation., Competing Interests: Conflict of interest We have no disclosures., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

The Mitrofanoff procedure has enhanced practical management of urinary incontinence over the past 20 years by means of an abdominal stoma catheterisation for patients suffering from neuropathic bladder. This procedure has been modified when there is no viable appendix to enable similar tubularisation and conduit formation from parts of the gastrointestinal tract, also known as the Monti technique. While ileum is more consistently used in a Monti procedure, in this particular case a Meckel's Diverticulum (MD) lent for an alternative option. Herein, this case report allows us to demonstrate the use of a MD as a viable option if and when the opportunity allows, in the absence of appendicular tissue.

Aims: This study aims to describe our surgical technique and report our preliminary experience with laparoscopic ileal or appendicovesicostomy in adult patients with neurogenic bladder caused by spinal cord injury. Subjects and Methods: From January 2014 to March 2017, seven patients were submitted to an appendicovesicostomy under Mitrofanoff procedure and two patients to an ileovesicostomy under Yang-Monti procedure by laparoscopy. Clinical indications were patients with a history of neurogenic bladder secondary to spinal cord pathology, with proper dexterity and willing to have a more accessible continent derivation. Surgical steps include: (1) identification and mobilization of appendix; (2) ligation of appendix' base; (3) endoloop reinforcement of proximal end; (4) silicon catheter insertion in appendix' lumen; (5) mesoappendix dissection; (6) Retzius space opening; (7) posterior bladder dissection; (8) anterior transcutaneous bladder dome fixation; (9) vertical midline detrusor incision; (10) opening of bladder mucosa; (11) excision and espatulation of appendix tip; (12) appendico vesical anastomosis; and (13) exteriorization of appendix through umbilicus and creation of catheterizable stoma. In the two patients submitted to a Yang-Monti diversion, the ileum reconfiguration and calibration was done extracorporeally. One patient had simultaneous bladder augmentation. Results: The mean follow-up was 21.5 ± 11.9 months. The mean operative time was 161 min (123–220). There was no conversion to laparotomy and no need of postoperative blood transfusion. The mean hospitalization length was 4 days. No early postoperative complication was registered. Late postoperative complications were: one surgical stoma revision, one false-passage (solved by transient catheterization), and one bladder stone (solved by endoscopic approach). All patients are continent. Conclusions: This series presents our laparoscopic technique for continent urinary diversions, showing that it is feasible and safe in adult patients with neurogenic bladder.

Over the last half century, significant improvements in health outcomes for individuals with spinal cord injury (SCI) and growing recognition those women with SCI can become pregnant. However, pregnancy must be rated as high risk and requires multidisciplinary medical care as higher rate of complication compare to general population. Most of published literature grouped all patients with lower urinary tract reconstruction (LUTR) like exstrophy–epispadias complex, spina bifida, interstitial cystitis urogenital sinus or fistula, but our article is focusing in the childbearing SCI women who undergone cutaneous continent urinary diversion (CCUD) with mitrofanoff procedure. We report two cases of three successful pregnancies in this population. [ABSTRACT FROM AUTHOR]

We describe the case of a bladder exstrophy–epispadias complex (BEEC), in which a “split” appendix was used simultaneously as a posterior urethral replacement (for strictured Mitchell's repair) as well as a Mitrofanoff channel. Split appendix had been used before for simultaneous Mitrofanoff and Malone's antegrade contrast enema channels to manage neurogenic bladder and bowel. To the best of our knowledge, this is the first reported case for the use of split appendix for urethral reconstruction in a child with BEEC.

Aims: This study aims to describe our surgical technique and report our preliminary experience with laparoscopic ileal or appendicovesicostomy in adult patients with neurogenic bladder caused by spinal cord injury. Subjects and Methods: From January 2014 to March 2017, seven patients were submitted to an appendicovesicostomy under Mitrofanoff procedure and two patients to an ileovesicostomy under Yang-Monti procedure by laparoscopy. Clinical indications were patients with a history of neurogenic bladder secondary to spinal cord pathology, with proper dexterity and willing to have a more accessible continent derivation. Surgical steps include: (1) identification and mobilization of appendix; (2) ligation of appendix' base; (3) endoloop reinforcement of proximal end; (4) silicon catheter insertion in appendix' lumen; (5) mesoappendix dissection; (6) Retzius space opening; (7) posterior bladder dissection; (8) anterior transcutaneous bladder dome fixation; (9) vertical midline detrusor incision; (10) opening of bladder mucosa; (11) excision and espatulation of appendix tip; (12) appendico vesical anastomosis; and (13) exteriorization of appendix through umbilicus and creation of catheterizable stoma. In the two patients submitted to a Yang-Monti diversion, the ileum reconfiguration and calibration was done extracorporeally. One patient had simultaneous bladder augmentation. Results: The mean follow-up was 21.5 ± 11.9 months. The mean operative time was 161 min (123–220). There was no conversion to laparotomy and no need of postoperative blood transfusion. The mean hospitalization length was 4 days. No early postoperative complication was registered. Late postoperative complications were: one surgical stoma revision, one false-passage (solved by transient catheterization), and one bladder stone (solved by endoscopic approach). All patients are continent. Conclusions: This series presents our laparoscopic technique for continent urinary diversions, showing that it is feasible and safe in adult patients with neurogenic bladder. [ABSTRACT FROM AUTHOR]

Objective: Mitrofanoff procedure has been employed commonly as bladder draining tool in patients unable to do clean intermittent self catheterization through native urethera. Single centre experience of pediatric age group patients undergoing Mitrofanoff procedure has been presented here. Material and methods: It was a retrospective study of 29 children who underwent continent catheterizable conduit (CCC), from January 2009 till March 2017. Charts were reviewed for age, gender, presenting complaints, need for augmentation cystoplasty, Mitrofanoff channel source such as appendix or ileal patch, duration of surgery in minutes, hospital stay in days, per operative and postoperative complications. Preoperative evaluation of the children was done by doing complete blood picture, serum electrolytes, and renal function tests. Radiological evaluation included ultrasound kidney,ureter and bladder, voiding cystourethrography, urodynamic analysis and a nuclear renal scan with 99m Technetium dimercapto-succinic acid or MAG-3 scan. The abdominal end of the conduit was brought through the abdominal wall, and a stoma was fashioned by the V-quadrilateral-Z technique. Results: Twenty nine children having mean age of 9.54±4.88 years underwent CCC. There were 19 males (65.51%) and 10 females (34.48%). Children who underwent CCC included 18 children having neurogenic bladder, 2 cases of urethral trauma/stricture 3 patients with history of posterior uretheral valve and 6 patients with exstrophy bladder. Augmentation cystoplasty plus mitrofanoff was done in 18 children while only mitrofanoff in 11 children. Stuck catheter was seen in one patient which was removed successfully via normal urethral route under general anesthesia. Stomal stenosis in first year was noted in 4 patients (13.79%). Conclusion: Continent catheterizable conduit based on Mitrofanoff principle have durable outcome over long term follow up in terms of urinary continence and complications. [ABSTRACT FROM AUTHOR]

In the past two decades, technology has advanced to augment an already minimally-invasive approach in laparoscopic surgery. Robotic-assisted laparoscopic platforms have now evolved to its 4th-generation product: a single-port system, first cleared through the FDA for urologic procedures last year. A single, 2.5 cm incision allows for placement of a port that admits a fully-wristed camera as well as three fully-wristed instruments, all controlled by the surgeon at the console. We sought to document the feasibility of the single-port (SP) robotic platform in the first clinical series of pediatric patients, reporting use of this system for dismembered pyeloplasty and Mitrofanoff. Secondary aims were to report intraoperative details and perioperative outcomes. Seven patients underwent surgery using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). Six patients, two girls and 4 boys, were diagnosed with ureteropelvic junction obstruction and underwent SP robotic-assisted dismembered pyeloplasty while one male patient with neurogenic bladder underwent SP robotic-assisted Mitrofanoff procedure. Patient's ages ranged from 22 months to 14 years. A 2.5-cm incision was made within the Pfannenstiel line in HIdES fashion for the pyeloplasties, while the previous gastrostomy tube site was used for the Mitrofanoff. Through this incision a 25-mm multichannel port was placed. The 12 × 10-mm articulating robotic camera and two 6-mm articulating robotic instruments were utilized. All surgeries were completed successfully through the single port without intraoperative complications, need for separate ports, or conversion. Median operative time was 120 min, and all patients were dismissed in less than 24 h, taking only acetaminophen and ibuprofen for pain control. There was no issue with instrumentation in older patients; however, shorter working distance in the 22-month-old pyeloplasty limited wristing of the instruments. We report the first cases utilizing the SP robotic platform in children. Despite their smaller size and limited workspace, we had no issues with instrument clashing or triangulation in older patients, completing the procedures in a similar timeframe as multiport robotic platforms. Use of the SP platform is not recommended if working distance will be < 10 cm from the end of the port as instrument movement is prohibitive. The HIdES approach of placing the port in the Pfannenstiel line gave additional working distance and kept the incision below the swimsuit line for excellent cosmesis (Figure 1). Further study with additional cases will compare this approach with standard multiport robotics to analyze and compare operative data and outcomes. [ABSTRACT FROM AUTHOR]

Background: In 1980, Mitrofanoff described the creation of an appendicovesicostomy for continent urinary diversion. This procedure greatly facilitates clean intermittent catheterisation in patients with neurogenic bladder. The purpose of our study was to determine the clinical efficacy of the laparoscopic Mitrofanoff catheterisable stoma for children and adolescents with spina bifida. Materials and Methods: Review of hospital records revealed that 11 children with spina bifida underwent a laparoscopic Mitrofanoff procedure with at least 1-year of follow-up. A four-port transperitoneal laparoscopic approach was used to create a Mitrofanoff appendicovesicostomy. The child was followed-up in the urology clinic at 6 weeks, 3 months, 6 months, 1-year, and then semiannually after that. Questionnaires were administered to determine, from the children′s perspective, the level of satisfaction with catheterisation and the psychosocial implications of catheterisation before and after the creation of the Mitrofanoff continent catheterisable stoma. Results: Of the 11 children, six were female, and five were male. The mean age at presentation to Paediatric urological services was 11 × 3.22 years. Overall the mean operative time was 144.09 × 17.00 min. Mean estimated blood loss was 37.36 × 11.44 cc. None of the cases needed conversion to open. Patient satisfaction with their catheterisation was measured at 2.18 × 0.98 preoperatively, Post-operatively, this improved to 4.27 × 0.46. Statistical analysis using paired t-test showed significance with P < 001. Conclusions: Laparoscopic Mitrofanoff catheterisable stoma is feasible in children with spina bifida and is associated with reasonable outcome with early recovery, resumption of normal activities and excellent cosmesis.

Background Effective bladder emptying by clean intermittent catheterization for children with severe bladder dysfunction is critical for renal preservation and social integration. Use of a continent catheterizable conduit (CCC) as urethral alternative procedure provides effective bladder drainage. However, it brings a substantive maintenance. Methods Retrospective review of the indications and long-term outcomes of 54 patients with a Mitrofanoff procedure in a single center over a 20-year period (1995–2015). Results Indications of CCC include 21 neurogenic bladders, 12 patients with epispadias/exstrophy, 13 bladder outlet obstruction, 6 malignancies and 2 cloaca. Median age at surgery was 8.3 years (4 months–20 years). The appendix was used in 76% of cases. Most frequently encountered complication was stomal stenosis (n = 17/34, 50%), occurring at median time of 9 months (2 months–13 years). The other complications were: leakage in 9 (26.5%); conduit stricture in 5 (14.7%), angulation of the conduit in 2 (5.8%) and prolapse in one (3%). Operative revision was encountered by 33 (61%) patients, the majority in the first 2 years. Median follow-up was 4.3 years (3 months–16 years). Conclusions CCC has a high incidence of complication. It has to be used only when the native urethra is not suitable for catheterization. Carers, patients and families must be prepared to deal with both the complexity of index conditions and the complications of this procedure. [ABSTRACT FROM AUTHOR]

Background/Purpose Reconstruction of microbladders is a difficult surgical challenge: How can a neobladder be recreated when > 90% of the new bladder is augmented patch, and how can a Mitrofanoff conduit be anastomosed when the native bladder is so tiny? This series describes microbladders secondary to anuria and/or diversion that required augmentation. This was done using a de-tubularized ileal segment, and because of the small size of the native bladder, Mitrofanoff anastomosis was performed to the bowel patch (using a novel “Keel Procedure”). Methods Our surgical experience in reconstruction of microbladders was reviewed: pre and post augmentation capacity, compliance and maximum detrusor pressure were compared. The success of the Mitrofanoff anti-reflux technique is described. Data are given as median (interquartile range) and compared by Wilcoxon paired rank test. Results 10 patients, median bladder capacity pre-op 10 (9–20) mls were reconstructed. The follow up time is 2.7 years (2.2–4.2). Post-op bladder capacity increased 16-fold to 167 (114–281) mls, P < 0.01. Compliance significantly improved from 1.7 (0.3–4.8) to 14.3 (4.1–66.3) mls/cmH 2 O, P < 0.05. Maximum detrusor over-activity decreased from 27 (7–120) to 12.5 (8–26) cmH 2 O, (N.S. P = 0.3). Videourodynamics confirmed a leak in 2 patients, leading to incorporation into the technique of a non-absorbable seromuscular suture to provide long-term robustness to the antireflux procedure. Conclusion Bladder augmentation in microbladders is possible, and a functional Mitrofanoff procedure with a continent anti-reflux procedure can be created using the “Birmingham keel technique” implanting the Mitrofanoff into the augment patch, with 80% success (similar to published results for conventional anastomosis to native bladders). Level of evidence Level IV. [ABSTRACT FROM AUTHOR]

Since the original description of the trans-appendicular continent cystostomy by Mitrofanoff in 1980, a variety of techniques have been described for creating a continent catheterisable channel leading to the bladder, which avoids the native urethra. The Mitrofanoff principle involves the creation of a conduit going into a low pressure reservoir, which can emptied through clean intermittent catheterization through an easily accessible stoma. A variety of tissue segments have been used for creating the conduit, but the two popular options in current urological practice remain the appendix and Yang-Monti transverse ileal tube. The Mitrofanoff procedure has an early reoperation rate for bleeding, bowel obstruction, anastomotic leak or conduit breakdown of up to 8% and the most common long-term complication noted is stomal stenosis resulting in difficulty catheterizing the conduit. However, in both pediatric and adult setting, reports imply that the procedure is durable although it is associated with an overall re-operation rate of up to 32% in contemporary series. Initial reports of laparoscopic and robotic-assisted Mitrofanoff procedures are encouraging, but long-term outcomes are still awaited.

Introduction: The Mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder. It creates a conduit to the bladder through which patients with a sensitive, absent, or traumatized urethra can perform clean intermittent catheterization (CIC) easily. We report our experience with complete laparoscopic Mitrofanoff appendicovesicostomy to promote a catheterizable abdominal stoma. Materials and Methods: A 4-port transperitoneal approach was used to create a complete laparoscopic Mitrofanoff appendicovesicostomy. Results: Six children with a mean age of 12.8 years (range 9-16 years) underwent laparoscopic Mitrofanoff appendicovesicostomy. Mean operative time was 139.6 min and Mean estimated blood loss was 46 cc. No cases of urinary leaks were noted. There have been no cases of either stomal stenosis or appendicovesical stenosis noted. Conclusions: Pure laparoscopic Mitrofanoff appendicovesicostomy is feasible and is associated with reasonable outcome with early recovery, resumption of normal activities and excellent cosmesis.

Objective To report the long-term complications of continent cutaneous urinary diversion(CCUD) in spinal cord injured(SCI) patients unable to perform intermittent self-catheterization(ISC) through the urethra. Materials and Methods Between July 2001 and January 2012, adult SCI patients with a neurogenic bladder who underwent CCUD according to Mitrofanoff's/Monti's/Casale's principle were enrolled. A concomitant supratrigonal and augmentation enterocystoplasty were performed because of refractory detrusor overactivity or low bladder compliance. Early postoperative complications were reported according to Clavien-Dindo classification. Long-term complications, stomal and urethral continence, renal function, urodynamic parameters and quality-of-life were assessed. Results Overall, 29 consecutive SCI patients were included, median age 35 years (IQR 26-46). Median follow-up time was 66 months (IQR 50-80). Two post-operative severe complications (grade III-IV) were reported. One patient had a stomal stenosis and another patient a tube stenosis. Both were treated by dilation. Two patients developed fistulae between the tube and the skin and required a surgical treatment. Three patients had bladder stones managed with endoscopy. Two patients had remnant stress urine leakage through the urethra, which was treated surgically: one received periurethral balloons(ACTTM) and one a tension-free vaginal tape. Creatinine clearance remained stable postoperatively. Urodynamic parameters were significantly improved. At last follow-up, 100% of patients had a catheterizable continent stoma and urethral continence was achieved in 96%. An improvement of quality-of-life was reported by 90% of patients. Conclusions CCUD allowed these patients to keep ISC as a voiding pattern and to be continent without any appliance. The main complications were related to the tube and to bladder enlargement; thus, annual monitoring is required. Neurourol. Urodynam. 35:1046-1050, 2016. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

The use of robotic approaches has permeated the field of urology with continued advances in pediatric urology. Increasingly, more complex urologic procedures are being performed using a minimally invasive approach. The goal is to deliver at least equivalent long-term outcomes while minimizing the morbidity classically associated with open approaches. The robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy with (RALIMA) or without (RALMA) ileocystoplasty represents the forefront of reconstructive pediatric urology. Select centers have demonstrated the safety and efficacy of these procedures. We review the indications, preoperative preparations, operative techniques, outcomes, current controversies, and future directions of RALMA and RALIMA. [ABSTRACT FROM AUTHOR]

Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis. It is generally performed to eliminate the risk of future appendicitis. The risks and benefits of incidental appendectomy during various operations in children have been debated for over a century, but need to be revisited in light of innovations in medical practice, including minimally invasive surgery, improved imaging techniques, and use of the appendix as a tubular conduit for reconstruction. A detailed review was undertaken of the techniques, pathology, risks of appendectomy, utility of the appendix, and incidental appendectomy in the treatment of specific pediatric medical conditions. A comprehensive literature search was performed, and retrieved results were reviewed for relevance to the topic. The decision to perform a pediatric incidental appendectomy relies on informed consideration of the individual patient's co-morbid conditions, the indication for the initial operation, the future utility of the appendix, and the risk of future appendiceal pathology. The discussion includes a variety of situations and comorbid conditions that may influence a surgeon's decision to perform incidental appendectomy. [ABSTRACT FROM AUTHOR]

We describe the case of a bladder exstrophy–epispadias complex (BEEC), in which a "split" appendix was used simultaneously as a posterior urethral replacement (for strictured Mitchell's repair) as well as a Mitrofanoff channel. Split appendix had been used before for simultaneous Mitrofanoff and Malone's antegrade contrast enema channels to manage neurogenic bladder and bowel. To the best of our knowledge, this is the first reported case for the use of split appendix for urethral reconstruction in a child with BEEC. [ABSTRACT FROM AUTHOR]