Mitrofanoff Conduit Research Articles

Clean Intermittent Catheterisation via a Mitrofanoff Is Superior to Long Term Suprapubic Catheters for Bladder Drainage

AimSome 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). MethodRetrospective 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. ResultsThere 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). ConclusionSPCs 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.

Transurethral laser lithotripsy using the Mitrofanoff urethral conduit for bladder stones: a case report

BackgroundThe Mitrofanoff (appendicovesicostomy) procedure is a contraindicated urinary modification that maintains urinary continence by forming a flap-valve mechanism at the site of anastomosis between the appendage and bladder wall, which is used as a guide for urinary drainage. This technique has been used by intermittent self-catheterization patients who have difficulty voiding from the native urethra or in cases where voiding from the abdominal wall would improve quality of life. However, the risk of stone formation is high due to intermittent urinary catheterization using the Mitrofanoff conduit urethrostomy as a conduit.Case presentationThe patient was a 22-year-old Asian-Japanese woman. At 6 years of age, she underwent bilateral vesicoureteral reflux surgery, Mitrofanoff urethrostomy using the appendix, abdominal wall plication, and vaginoplasty using the ileum. During follow-up, ultrasound performed due to persistent pain during urinary drainage revealed a 26 mm bladder stone. We performed ureteroscopic lithotripsy 6Fr using ureteral access sheath and made lithotripsy using Ho: YAG laser, then successfully removed the target stone.ConclusionsWe report a case of transurethral laser lithotripsy using the Mitrofanoff urethral conduit for bladder stones. Using with ureteral access sheath made lithotripsy and retrieved ureteral stone more effective.

Augmentation cystoplasty in children with stages III and IV chronic kidney disease secondary to neurogenic bladder

ObjectiveThis study examines the outcome of augmentation cystoplasty (AC) in children with stages III and IV chronic kidney disease (CKD) secondary to neurogenic bladder in which transplantation was not imminent. MethodsHospital records of all children with CKD stages III and IV who underwent AC between 2008 and 2017 were retrieved to study outcome and complications including estimated glomerular filtration rate (eGFR, National Kidney Foundation Calculator), somatic growth (percentiles, compared with population data), and febrile urinary tract infections (fUTIs) requiring admission. Statistical analysis was performed using R. ResultsAC was performed in 13 children with CKD stages III and IV (10 girls; median 8.0 years) with median follow-up of 51 months. Patients had incontinence (10/13), reflux (7/13), and hydronephrosis (13/13) despite antimuscarinics and intermittent catheterization. Bladder capacity was 74% of expected and median compliance was 5 mL/cm H20 (inter-quartile range 4 mL/cm H20). All underwent ileocystoplasty (25 cm bowel). One each had nephrectomy and mitrofanoff conduit. All had resolution of incontinence. One had acute kidney injury that recovered. Initial eGFR at presentation (24 mL/min/1.73 m2) improved with conservative management alone (52 mL/min/1.73 m2, p=0.004). This improved further 1 year following AC (61 mL/min/1.73 m2, p=0.036) with stable function at 7 years. There was improvement in somatic growth, hydronephrosis, and fUTI despite no ureteric re-implantation. ConclusionAC carries acceptable morbidity in children with CKD stages III and IV secondary to neurogenic bladder. Surgery is effective with improvements in continence, eGFR, somatic growth, and propensity for fUTIs. Ureteric re-implantation might not be necessary.

Cystolitholapaxy for a Large Bladder Calculi Using Semi-Rigid Ureteroscope through the Mitrofanoff Stoma

Bladder calculi are a common long-term complication of enterocystoplasty. Increasingly, mini-invasive techniques are taking the place of open cystolithotomy in the management of this patient category. Options include extra-coropreal lithotripsy, endoscopic management, percutaneous or combined technique using both endoscopic and laparoscopic approaches. Reports of Mitrofanoff cystolitholapaxy are rare and are not free from complications, the challenge is to obtain a free stone patient without compromising or the continence mechanism or inducing a mucosal lesion that could lead to the stenosis of the conduit. We report the case of a large neobladder calculi managed endoscopically using semi-rigid ureteroscope, which allowed a complete stone cleansing without damage to the Mitrofanoff conduit.

Use of a Modified Continent Ileovesicostomy in Adults with Prior Enterocystoplasty

Background/Aims: To describe our initial experience with a novel modification of the Mitrofanoff conduit technique utilizing the Yang-Monti ileovesicostomy and the serosa lined extramural tunnel of the T-pouch to create a continent catheterizable stoma in patients with a prior enterocystoplasty. Methods: A 14 cm segment of bowel was harvested, and the distal 4 cm was divided and reconfigured utilizing the Yang-Monti technique. The remaining segment was folded into a U and secured with a serosal basting stitch. Half of the Yang-Monti tube is laid in the trough of the U-shaped segment and secured. Next, the U-shaped segment was incised along the anti-mesenteric border for the length of the tube. The newly created flaps adjacent to the tube was then laid over the tube and sutured together completing the serosa lined tunnel. The entire patch was anastomosed to a cystostomy through the previous enterocystoplasty. Finally, the proximal end of the tube was brought through the umbilicus and matured as a stoma. Results: Two patients with prior enterocystoplasties underwent the procedure described above. At follow-up of 18 and 24 months, both patients reported excellent continence. To date, there have been no revisions or significant complications. Conclusion: The construction of continent catheterizable stoma in adults with prior history of enterocystoplasty presents many technical challenges. The combination of the Yang-Monti ileovesicostomy and the extramural tunnel of the T-pouch provides an effective option for creating a continent catheterizable stoma in adults with prior history of enterocystoplasty.

Treatment of bladder lithiasis using a percutaneous approach in a patient with Mitrofanoff conduit.

Treatment of bladder lithiasis using a percutaneous approach in a patient with Mitrofanoff conduit.

Bladder augmentation in anuric/defunctioned microbladders and a novel antireflux mechanism for Mitrofanoff anastomosis to the ileal patch

Background/PurposeReconstruction 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”). MethodsOur 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. Results10 patients, median bladder capacity pre-op 10 (9–20) mls were reconstructed. The follow up time is 2.7years (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/cmH2O, P<0.05. Maximum detrusor over-activity decreased from 27 (7–120) to 12.5 (8–26) cmH2O, (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. ConclusionBladder 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 evidenceLevel IV.

Complications after bladder augmentation in children.

Bladder augmentation is an effective surgical procedure for increasing bladder capacity and reducing pressure on the urinary system. It is indicated for patients with anomalies such as spina bifida, myelomeningocele, urethral valve and bladder exstrophy, who progress with low tolerance of medication. This was a retrospective study conducted on pediatric patients submitted to bladder augmentation from 2000 to 2011. 34 patients aged 4 to 17 years were submitted to bladder augmentation, 30 of them with an ileal loop and 4 with a ureter.A continent urinary shunt was performed in 16 patients, the Mitrofanoff conduit was associated in 15, and the Macedo technique was used in one. Mean follow-up was 34.35 months (1 to 122 months). Mean creatinine was 1.5 ng/ml (0.4 to 7.5 ng/ml) preoperatively and 1.78 ng/ml postoperatively. Three patients required a renal transplant during follow-up. There was improvement or resolution of vesicoureteral reflux in 83.5% of the kidneys on the right and in 75% on the left. Bladder capacity increased, on average, from 152.5 ml to 410 ml. The main complications were vesical lithiasis in 3 patients and conduit perforation in one. Bladder augmentation showed good results in this series, preserving renal function in most of the patients.

Vesico-cutaneous fistula: A simple method for continent urinary diversion

IntroductionPatients with lower urinary tract anomalies or neurogenic disorders often suffer from voiding difficulties. Clean intermittent catheterization (CIC) is effective for bladder drainage; however, this is often painful. Transurethral catheterization is also impossible in patients with urethral stricture. A Mitrofanoff conduit may solve some of these problems, but a few disadvantages have been reported, including: difficult surgical techniques and frequent operative complications. A vesicostomy is easy to perform but persistent urine leak over the abdomen and diaper rash can be annoying. A better way to achieve continent urinary diversion is indicated. MethodBetween December 01 1998 and December 31 2013, six patients underwent a vesico-cutaneous fistula for CIC. The etiologies included urethral stricture (n = 2) and neurogenic bladder (n = 4). The fistula was created at the bladder dome with only the muscle layer of the bladder sutured to the skin. A Foley catheter was left in place for at least two weeks to prevent stoma stricture. After removing the Foley catheter, regular CIC from the fistula was performed every 2 h during the daytime with a Fr. 10–12 feeding tube, depending on the patient's age. Further stenting during the night in the first six months was necessary to prevent early closure of the fistula. Patients were followed with periodic renal ultrasonography, blood tests and urinalysis in the outpatient department. ResultsFollow-up ranged from 6 months to 16 years. All patients showed improvements in hydronephrosis. Decreased UTI frequency was seen in five patients. Renal function was normal in five patients, whilst the other suffered from chronic renal failure preoperatively. Only one patient had occasional mild urine leakage from the stoma at night, which was once in two weeks. No patient experienced painful or difficult catheterization and CIC becomes easy, even by young children. ConclusionsThe vesico-cutaneous fistula is a simple, effective and tolerable method for CIC. It may be a substitute for or a transition to a Mitrofanoff conduit in some patients.

Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients?

ObjectiveAlthough renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC. Materials and methodsBetween 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups. ResultsMean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m2 in the AC group and 88.17 ± 28.20 ml/min/m2 in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years). ConclusionsBladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.

Renal Transplant Outcome in Children with an Augmented Bladder

Objective: Studies evaluating renal transplant (RT) outcome in children who underwent an augmentation cystoplasty (AC) are contradictory and the current knowledge is based on studies with a limited number of patients. The aim of this study is to compare RT outcome between children who underwent AC and those without augmentation.Patients and methods: A total of 20p who underwent an AC prior to the RT (12 with ureter and 8 with intestine) were enrolled in the study and were compared to a control group of 24p without AC, transplanted in the same time period (1991–2011). Data including; age at transplant, allograft source, urological complications, urinary tract infections (UTI) incidence, the presence of VUR, and patient and graft survival were compared between the groups.Results: Mean age at RT and mean follow-up were 9.7 vs. 7.9 years and 6.9 vs. 7.9 years in the AC group and control group, respectively (NS). The graft originated in living donors for 60% of AC patients and 41.6% of the control RT patients. The rate of UTI were 0.01 UTI/patient/year and 0.004 UTI/patient/year in the augmented group and controls, respectively (p = 0.0001). In the AC group of 14p with UTIs, 10 (71%) had VUR and 5p out of 8 (62.5%) in the control group had VUR. In the AC group, of the 7p with ≥3 UTIs, 3 (43%) were non-compliant with CIC and the incidence of UTIs was not related with the type of AC or if the patient did CIC through a Mitrofanoff conduit or through the urethra. Graft function at the end of study was 92.9 ± 36.85 ml/min/m2 in the AC group and 88.17 ± 28.2 ml/min/m2 in the control group (NS). Graft survival at 10 years was also similar 88% in the AC group and 84.8% in controls. In the AC group 3p lost their grafts and 5 in the control group with respective mean follow-up of 10.6 ± 4.3 and 7.1 + 4.7 years.Conclusion: There are no significant differences in the RT outcome between children transplanted with AC or without. However, recurrent UTIs are more frequent in the former group and these UTIs are related with non-compliance with CIC or the presence of VUR but, even so, UTIs will not lead to impaired graft function in most of the patients.

Multiple Stones in Atypical Heterotopic Reservoir in a Patient with Renal Transplant: Endourologic Resolution

Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity. Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence. We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones. preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted. No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported. In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

UP-03.090 Endoscopic Extraction of Bladder Lithiasis Through a Mitrofanoff Continent Diversion: A New Surgical Procedure

Bladder-stone formation is common problem following continent urinary diversion with augmentation cystoplasty. We describe a minimally invasive technique using electro hydraulic vesicolithotripsy via a Mitrofanoff conduit.

Using Mitrofanoff's principle and Monti's technique as a surgical option for bladder augmentation with a continent stoma: a case report

IntroductionHydronephrosis, reflux and renal failure are serious complications that occur in patients with neurogenic bladder associated with myelomeningocele. When the bladder compliance is lost, it is imperative to carry out surgery aimed at reducing bladder storage pressure. An ileocystoplasty, and for patients not suitable for intermittent catheterization, using the Mitrofanoff principle to form a continent stoma and the subsequent closure of the bladder neck, can be used. We report here, for the first time to the best of our knowledge, an association between two previously described techniques (the Mitrofanoff principle and the technique of Monti), that can solve the problem of a short appendix in obese patients.Case presentationA 33-year-old male Caucasian patient with myelomeningocele and neurogenic bladder developed low bladder compliance (4.0 mL/cm H2O) while still maintaining normal renal function. A bladder augmentation (ileocystoplasty) with continent derivation principle (Mitrofanoff) was performed. During surgery, we found that the patient's appendix was too short and was insufficient to reach the skin. We decided to make an association between the Mitrofanoff conduit and the ileal technique of Monti, through which we performed an anastomosis of the distal stump of the appendix to the bladder (with an antireflux valve). Later, the proximal stump of the appendix was anastomosed to an ileal segment of 2.0 cm that was open longitudinally and reconfigured transversally (Monti technique), modeled by a 12-Fr urethral catheter, and finally, the distal stump was sutured at the patient's navel.After the procedure, a suprapubic cystostomy (22 Fr) and a Foley catheter (10 Fr) through the continent conduit were left in place. The patient had recovered well and was discharged on the tenth day after surgery. He remained with the Foley catheter (through the conduit) for 21 days and cystostomy for 30 days. Six months after surgery he was continent with good bladder compliance without reflux and fully adapted to catheterization through the navel.ConclusionThe unpublished association between the Mitrofanoff and Monti techniques is feasible and a very useful alternative in urologic cases of derivation continent in which the ileocecal appendix is too short to reach the skin (i.e., in obese patients).

The continent, catheterizable abdominal conduit in adult urological practice

To report a large, single-centre experience with a continent, catheterizable abdominal conduit in adult patients. We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13-year period. Data on surgical procedure, complications and final outcome were collected and analysed. The mean age of the patients was 38.4 years and mean follow-up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent. Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long-term follow-up.

Robot-Assisted Mitrofanoff and Malone Antegrade Continence Enema Reconstruction Using Divided Appendix

Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children with varying pathologic conditions. To manage double incontinence or the combination of wetting and severe constipation, a Mitrofanoff conduit and a channel for antegrade continence enema is constructed using the appendix by open surgery. We present a video of the first case of robot-assisted laparoscopy for simultaneous reconstruction of a continent urinary diversion using the Mitrofanoff principle and a Malone antegrade continent enema using the divided appendix.

Use of button in the bladder and bowel

Purpose To present our technique for the use of the MICKEY button in the bladder and bowel. Material and methods Our practice is to use the button extensively for bladder drainage in selected indications and also for the ACE for the last five years. We use the button exclusively for the ACE whilst leaving the appendix for the mitrofanoff conduit when indicated. Results Our video will demonstrate the techniques involved in these situations. We have large experience with the ACE button either inserted by colonoscope or by open technique. The cystostomy button has been very effective providing a socially and cosmetically acceptable method of bladder drainage as a temporary measure in selected indications. When we come to reconstructive surgery, we have the appendix available in majority of cases and the ACE is achieved with the help of a button. Conclusions The button is a useful device not just for the stomach for feeding but also a good alternative for bladder drainage and the ACE procedure. The appendix is put to better use in the bladder for reconstructive surgery.

Single percutaneous access for endoscopic extraction of lithiasis after intestinocystoplasty

Purpose Bladder-stone formation is a common problem following augmentation cystoplasty. Urological management is controversial. We describe a minimally invasive technique using electrohydraulic vesicolithotripsy via a single percutaneous access. Material and methods Between 1998 and 2004, 10 percutaneous extractions of bladder calculi were performed in seven patients with bladder augmentation. Prior bladder enlargement was performed for neuropathic bladder dysfunction in four cases and bladder exstrophy in three cases. The procedure involved percutaneous placement of a 10- or 12-mm laparoscopic trocar, after which the airtightness valve of the trocar was removed. A rigid nephroscope allowed direct visualization of calculi. Stones were fragmented with electrohydraulic lithotripsy when necessary. Removal of the fragments was by grasping forceps or basket. Vigorous, warmed-saline bladder irrigation eliminated residual fragments. Results The technique was successful in all cases, resulting in controlled bladder-stone-free status and no surgical complications. The only complication was hypothermia linked to prolonged operation time, inadequate warmed-saline irrigation and lack of waterproof sheets. Conclusions Percutaneous vesicolithotripsy was highly successful and easy to perform, without being restricted by size and number of calculi. The continence mechanism of a reconstructed urethra or Mitrofanoff conduit should not be compromised. As recurrent stone formation is expected in children with augmented bladder, this technique appears to be suitable for bladder calculi removal during the long-term follow-up of multioperated patients.

Renal Transplantation in Children With Augmentation Enterocystoplasty

Introduction We report our experience with renal transplantation in patients with severe bladder dysfunction who underwent prior augmentation cystoplasty. Patients and methods Among 58 pediatric patients, three underwent bladder augmentation prior to renal transplantation. The patients’ ages at transplantation were 10, 13, and 17. The etiologies of bladder dysfunction were posterior urethral valves in two patients and contracted bladder in one patient. Vesicoureteral reflux was concomitantly present in three patients. Pretransplant ileocystoplasty was created in two patients and gastrocystoplasty in one patient. All patients received kidneys from cadaveric donors and were treated with calcineurin-based immunosuppressive therapy. Results The patients had normal renal function without hydronephrosis of the transplanted kidney at 13, 22, 49 months follow-up. No patients had morbidity due to technical complications. All the patients were continent. Two of three patients required clean intermittent catheterization from a Mitrofanoff conduit, while one patient spontaneously voids without significant residual urine. Urinary tract infections observed in two patients were successfully treated without any permanent deterioration in graft kidney function. Conclusions Our data suggest that augmentation cystoplasty is a safe and effective option to treat patients with end-stage renal disease undergoing kidney transplantation. Experience of the transplantation team with a qualified pediatric urologist is essential due to the potentially high risk of surgical complications during the long term management of these patients.

Use of the Mitrofanoff principle in urinary tract reconstruction: Experience with 122 children

<b>Purpose: </b> Use of the Mitrofanoff principle is a valuable adjunct to many reconstructive urological procedures in the pediatric age group requiring clean intermittent catheterization (CIC) especially if the urethra is not easily catheterizable. We present our experience with 122 children and analyze the results of this operation. <br><b> Materials and Methods: </b> 133 Mitrofanoff channels (100 appendicular, 31 ureteric and 2 Monti) were constructed in 122 children (93 boys and 29 girls) of mean age 6.3 years over the period from 1997 to 2005. The procedure was part of the reconstructive procedure in patients of neurogenic bladder (n=44), exstrophy-epispadias (n=40), posterior Urethral valve (n=30), and other diseases (n=8). Additional procedures included augmentation cystoplasty (n=90) and bladder neck procedure (n=46).<br><b> Results: </b> Mean follow-up was 2.6 years in 109 patients. Overall results were satisfactory. Major complication rates with the Mitrofanoff conduit using appendicular and ureteric channels were 7.4 % in and 25.8%, respectively, most of the ureteric channels due to non-use, there being alternate channels for catheterization. Only six (4.5%) children required re-operation for significant problems with the Mitrofanoff conduit: revision of stoma due to stenosis or kinking (n=4) and closure of stoma due to troublesome leak (n=2). Children and parents were satisfied with the results of the operation and the majority was compliant with regular CIC. All children were socially well accepted and those above 6 years of age were attending regular school. <br><b> Conclusions: </b> The Mitrofanoff procedure is a feasible and acceptable option, with a low complication rate, for use as part of complex urinary reconstruction in a developing country. Patient education, family motivation, and cost reduction are important factors for success.