SIMULTANEOUS MALONE ANTEGRADE CONTINENT ENEMA AND MITROFANOFF PRINCIPLE USING THE DIVIDED APPENDIX: REPORT OF A NEW TECHNIQUE FOR PREVENTION OF STOMA COMPLICATIONS

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We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level. Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique). All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1. The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.