Monti Technique Research Articles

Whole ureter replacement with Yang–Monti principle: successful treatment of challenging conditions

No clear consensus has been reached on the reconstruction of long-segment or total ureter discontinuation. Here we present our experience using the Yang-Monti technique in total ureter reconstruction. This study was a single-center retrospective study of patients who underwent Yang-Monti ileal whole ureter reconstruction (from the ureteropelvic junction[UPJ] to the ureterovesical junction). Data were collected on patients' baseline characteristics, stricture etiology, the time interval between insult and surgical repair, pre/postoperative serum creatinine, estimated glomerular filtration rate (eGFR), split renal function, complications during admission and follow-ups, and the indwelling durations of JJ tubes and nephrostomy tubes, if presented. Seven patients underwent Yang-Monti ileal ureter reconstruction in 2010-2020 at our hospital. One of the patients underwent single-session bilateral ureter repair. Radiation therapy-related fibrosis and degloving injury were the most common etiologies for ureter injury. The median interval between ureter insult and operation was 8months. The median follow-up was 36.7months. The average operation time was 11.4h, and the average blood loss was 273ml. Postoperatively, no significant differences were found in serum creatinine, eGFR, or split renal function. As for postoperative complications, two patients experienced ileus and were treated conservatively. One patient had UPJ stenosis, which resolved after re-anastomosis surgery 11months later. Metabolic acidosis or electrolyte imbalance was not reported. We found that ileal replacement of total ureteral loss using the Yang-Monti principle is effective and durable. This is the largest cohort study conducted with more than 2years of follow-up.

Simultaneous placement of fecal and urinary continent channel stomas in the umbilicus: Single-center experience

In patients with urinary continent channel (UCC) and Malone Antegrade Continent Enema (MACE) procedures, two separate abdominal stomas are needed. The umbilicus is a preferred site for single channel stomas given the ability to conceal the stoma. However, there are no studies describing outcomes of both stomas being created in the umbilicus. We aimed to describe our experience in patients who underwent UCC and MACE stomas both placed in the umbilicus. A retrospective review from 2009 to 2020 was performed in our institution for patients who underwent the creation of UCC and MACE stomas simultaneously in the umbilicus. The variation in the technique involves two V-skin shaped flaps in the umbilicus; the MACE and UCC stomas are delivered from both flaps and placed at the right and left side respectively. Patients with greater than 3 months of follow-up were included in the study. There were 17 patients identified with the median age of 13.5 years and a median follow-up of 32.8 months. The mean BMI percentile was 89.5%. Monti technique and split appendix with cecal extension were utilized in 8 (47.1%) and 7 (41.2%) patients respectively and 13 (76.5%) patients required concurrent urological procedures. All channel-related complications occurred within a mean time of 15.7 months. Skin-level stenosis in the MACE occurred in 5 (29.4%) events, and all were successfully managed by placing an indwelling catheter for up to two weeks. There were 2 (11.8%) complications related to UCC, which required subfascial minor surgical revision. The rate of patients with symptomatic UTI decreased 35.3% postoperatively, and no new onset of UTI occurred in patients without a prior history of UTI. During follow-up, all patients remained dry between CIC, however one had occasional leakage related to delay in catheterization. Total fecal continence was achieved in 14 (82.3%) patients. Additionally, 3 (16.6%) patients experienced improvement in fecal continence with sporadic soiling episodes. Placement of UCC and MACE stomas in the umbilicus demonstrate a percentage of complication of 7/34 (20.6%) with only 2 patients requiring surgical intervention, comparable to the standard. UTI rate decreased in patients with a prior history of UTI. We believe the patients' perspective and degree of satisfaction will fully determine the benefits of this technique. Simultaneous UCC and MACE stomas placed at the umbilicus showed good functional outcomes and similar complication rates to traditional approach where stomas were placed separately in the abdominal wall.

Case report: A case of neoadjuvant immunotherapy in combination with the Yang–Monti technique for the treatment of ureteral carcinoma after radical cystectomy and left radical nephroureterectomy

Recurrence of urothelial carcinoma in a patient with solitary kidney is always a clinical challenge. In the immune checkpoint inhibitor era, neoadjuvant immunotherapy in combination with the Yang–Monti technique might be a good option for the patient with a high-risk tumor when kidney-sparing surgery for renal function preservation is desired. We report the case of a 74-year-old man with solitary kidney who was diagnosed with recurrence of urothelial carcinoma in the right ureter. He was initially deemed unfit for segmental resection of the ureter. Neoadjuvant immunotherapy with tislelizumab was performed in this patient with a partial response to urothelial carcinoma. He underwent segmental resection of the ureter with negative margins, and the ureteral defect was bridged by modified ileal replacement, which is the Yang–Monti technique. This patient has remained disease-free with adequate kidney function for longer than 18 months.

V01-09 ROBOTIC-ASSISTED CONTINENT CUTANEOUS DIVERSION: FEASIBILITY OF A ROBOTIC SPIRAL MONTI TECHNIQUE IN A PATIENT WITH INCOMPLETE EMPTYING

INTRODUCTION AND OBJECTIVE:The spiral Monti technique to continent cutaneous urinary diversion allows for maximal length of the catheterizable channel without multiple anastomoses that increase the...

Ureteral Avulsion during Semirigid Ureteroscopy: A Single-Centre Experience.

Aims The aim of the study is to present our experience with the management of ureteral avulsions following semirigid ureteroscopy for ureteral stones. This is one of the largest series reported so far. Methods and Materials It is a retrospective and observational study done at Sri Ramachandra Institute of Higher Education and Research over the last 18 years. Results There were seven cases of ureteral avulsion following semirigid ureteroscopy. All patients were males with a mean age of 35.7 years. All had impacted stones, with proximal ureteric location in 6 patients and distal ureteric location in 1 patient. Five cases had two-point avulsions with loss of entire ureter. Two cases had one-point avulsion: one distal ureteric and the other mid-ureteric. Of the five cases with whole length ureteral avulsion, four were managed by classical ileal replacement of ureter and the the fifth case was managed by ileal replacement of ureter by the Yang–Monti technique. Of the two cases with one-point avulsion, one was managed by uretero-neocystostomy and the other by uretero-ureterostomy. All the patients had successful outcome. Conclusions Even though rare, ureteral avulsion can potentially happen especially when dealing with impacted ureteric stones. Being conscious of the possible occurrence of this serious complication during any difficult ureteroscopy and exercising utmost care during the procedure are important preventive measures. However, this catastrophe can be successfully managed by either immediate definitive repair or in a staged manner.

Self-perception, quality of life and ease of catheterization in patients with continent urinary diversion with the mitrofanoff principle.

ABSTRACTPurpose:Continent urinary diversion (CUD) with the Mitrofanoff principle stands as an alternative to urethral catheterization by a route other than the urethra. The aim of the study was to determine self-perception of health-related quality of life (HRQoL), ease of catheterization and global and cosmetic outcomes in patient’s dependent on Mitrofanoff catheterization.Materials and methods:Records of all patients who underwent CUD with the Mitrofanoff principle between 2012 to 2018 were reviewed. Data were collected and analysed retrospectively from medical charts. We assessed HRQoL with the EuroQol EQ-5D-3L questionnaire, cosmetic and global satisfaction with a questionnaire designed by the reconstructive urology board and ease of catheterization with a Likert questionnaire adapted from the Intermittent Catheterization Difficulty Questionnaire (ICDQ) validated in patients reliant on retrograde CIC.Results:A total of 25 patients requiring CUD with the Mitrofanoff principle between 2012 and 2018 were assessed, the group was composed mainly of: appendiceal conduits 18 patients (72%) and 7 ileal conduits (Yang-Monti) and three of those requiring Casale (Monti Spiral) and 1 a double Monti technique. Median follow-up was 57 months, median age was 30 years. Visual Analogue Scale (VAS) of the EQ-5D-3L reported a Global health score of 86.5%. Fifty nine percent of the patients had no pain or bleeding with catheterizations. Regarding global satisfaction and cosmetic perception 91% were satisfied with their CUD.Conclusions:CUD is associated with good HRQoL, global satisfaction, ease and painless catheterization, adequate self-perception of cosmetic outcomes and a low complication rate, remaining a safe and viable option.

A modified Monti procedure using a Meckel's diverticulum

Abstract 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.

PD41-07 SELF-PERCEPTION, QUALITY OF LIFE AND EASE OF CATHETERIZATION IN PATIENTS WITH CONTINENT URINARY DIVERSION WITH THE MITROFANOFF PRINCIPLE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (PD41)1 Apr 2020PD41-07 SELF-PERCEPTION, QUALITY OF LIFE AND EASE OF CATHETERIZATION IN PATIENTS WITH CONTINENT URINARY DIVERSION WITH THE MITROFANOFF PRINCIPLE Julian Chavarriaga*, German Patino, Maria Ocampo, Nicolas Fernandez, Jaime Perez, and John Bolivar Julian Chavarriaga*Julian Chavarriaga* More articles by this author , German PatinoGerman Patino More articles by this author , Maria OcampoMaria Ocampo More articles by this author , Nicolas FernandezNicolas Fernandez More articles by this author , Jaime PerezJaime Perez More articles by this author , and John BolivarJohn Bolivar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000921.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Continent urinary diversion (CUD) with the Mitrofanoff principle stands as an alternative to urethral Catheterization by a route other than the urethra when the urethra could not be used or for a patient who will need clean intermittent Catheterization (CIC) lifelong. The aim of the study was to determine self-perception of health related quality of life (HRQoL), ease of Catheterization and global and cosmetic outcomes in patients reliant on Mitrofanoff catheterization for bladder emptying. METHODS: Cross-sectional study that aims to describe HRQoL with the EuroQol EQ-5D-3L questionnaire, Cosmetic and global satisfaction with a questionnaire designed by the reconstructive urology board and ease of catheterization with a Likert questionnaire adapted from the Intermittent Catheterization Difficulty Questionnaire (ICDQ) validated in patients reliant on retrograde CIC. Records of all patients requiring CUD with the Mitrofanoff principle by three surgeons were reviewed, and data regarding sociodemographic characteristics, complications, diagnosis and follow up were collected from patient medical records. RESULTS: A total of 25 patients requiring CUD with the Mitrofanoff principle between 2012 and 2018, the group was composed mainly of appendiceal conduits 18 patients (72%) and 7 ileal conduits (Yang-Monti) and three of those requiring Casale (Monti Spiral) and 1 a Double Monti technique. Median follow up was 57 months with an Interquartile Range (IQR) of 9-84 months, median age was 30 years with an IQR of 5-76 years. Visual Analogue Scale (VAS) of the EQ-5D-3L reported a Global health score of 86.5%. 59% of the patients had no pain or bleeding with catheterization. Regarding Global satisfaction and cosmetic perception 91% were satisfied with their CUD, 95% would recommend this procedure to a friend and 64% were satisfied with the cosmetic appearance of their stoma. CONCLUSIONS: CUD with the Mitrofanoff its associated with good HRQoL, global satisfaction, ease and painless Catheterization, adequate self-perception of cosmetic outcomes and a low complication rate, remaining a safe and viable option for patients reliant on CIC and who´s urethra could not be used for micturition or retrograde catheterization. To our Knowledge this is the first study that reports all these outcomes in this setting, with follow up, up to 84 months. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e823-e823 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Julian Chavarriaga* More articles by this author German Patino More articles by this author Maria Ocampo More articles by this author Nicolas Fernandez More articles by this author Jaime Perez More articles by this author John Bolivar More articles by this author Expand All Advertisement PDF downloadLoading ...

Yang–Monti ileal ureter reconstruction

Objective. The aim of this study was to present experience with ureteral reconstruction using the Yang–Monti technique with reconfigured ileal segments. Material and methods. Between 2006 and 2010, five patients underwent complete unilateral ureteral substitution with the Yang–Monti technique, whereby short segments of ileum were incised paramesenterically, joined and transversely tubularized to form a neoureter of suitable length and cross-sectional diameter to bridge large ureteral defects. The causes of the ureteral defects were strictly iatrogenic. Two of the five patients were reconstructed acutely, while the others were repaired after 3–5 months with a nephrostomy diversion in the intervening period. Results. Four of the five patients had patent neoureters, while one sustained a stricture, necessitating permanent double-J stenting. Mean follow-up was 41 months (range 13–62 months). Split renal function for two of the patients was markedly reduced but notably with no elevation in creatinine or apparent loss of renal function. Three of the five patients had immediate postoperative urinary leakage at the proximal anastomosis, necessitating drainage, prolonged double-J stenting and/or nephrostomy diversion. Conclusion. In cases of ureteral defects deemed too extensive for traditional reconstruction techniques such as the psoas hitch and/or Boari flap, the technique demonstrated here, using reconfigured ileal segments, is a viable alternative to nephrectomy and autotransplantation. Acute reconstruction within 24 h after the ureteral lesion is also feasible. In general, care must be taken to avoid urinary leakage, particularly at the proximal anastomosis, which may result in prolonged hospitalization and double-J stenting. The protocol should include frequent follow-up to avoid long-term loss of renal function.

Monti's Principle in the Treatment of Congenital Uterovesical Fistula

Congenital uterovesical fistula is rare and generally associated with genital tract abnormalities derived from mullerian ducts or urogenital sinus. Management is usually challenging, and it involves vaginal reconstruction. A 15-year-old female patient presented with a 2-year history of cyclical hematuria. Investigation revealed a bicornuate uterus and complete vaginal agenesis associated with congenital uterovesical fistula. The fistula was repaired, and a neovagina was created using Monti's technique. Postoperative recovery was uneventful with normal voiding and initiation of regular menstruation through the neovagina. We discuss the options of vaginal reconstruction and stress the advantages of the technique used in this case.

Application of the Monti channel in female adult with urethral injuries in pelvic trauma

<em>Objective</em>. To report 3 cases using the Monti ileovesicostomy as a continent catheterizable stoma in women with post-traumatic resulted in loss of the urethra. <em>Materials and Methods</em>. Between April and November 2010, the Monti technique was performed as a reconstructive procedure in 3 female patients at our institution. All cases had history of posterior urethral defect, two motor vehicle accidents, and one pelvic crush injury. Channels were created by transversely reconfigured segment of ileum. The 3 patients age was 20, 41, and 43 years. Indications, technique, complications and outcomes are reported below. <em>Results</em>. Three patients were undergone for transversely re-tubularized ileal segment urinary reconstruction. All of them were evaluated from 5 to 12 months postoperatively. All patients’ postoperative visits to our outpatient gynecological clinic about 3, 6 and 12 months respectively after Monti ileovesicostomy operation revealed no dehiscence, necrosis, stenosis or perforation of the tube. All performed catheterization through the conduit without difficulty. <em>Conclusion</em>. The Monti ileovesicostomy is a new technique for creation of a continent catheterizable stoma. Based on our data, Monti procedure seems to be a valuable technique in patients with complicated urethral defect who cannot be managed with routine urethroplastic techniques. This reconstruction provides another option for a diversion technique in patients with irreparable urethral damage. However, evaluation whether it can be extensively developed still need more investigations with larger number of patients by long-term follow up.

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).

Monti’s procedure as an alternative technique in complex urethral distraction defect

Pelvic fracture urethral distraction defect is usually managed by the end to end anastomotic urethroplasty. Surgical repair of those patients with post-traumatic complex posterior urethral defects, who have undergone failed previous surgical treatments, remains one of the most challenging problems in urology. Appendix urinary diversion could be used in such cases. However, the appendix tissue is not always usable. We report our experience on management of patients with long urethral defect with history of one or more failed urethroplasties by Monti channel urinary diversion. From 2001 to 2007, we evaluated data from 8 male patients aged 28 to 76 years (mean age 42.5) in whom the Monti technique was performed. All cases had history of posterior urethral defect with one or more failed procedures for urethral reconstruction including urethroplasty. A 2 to 2.5 cm segment of ileum, which had a suitable blood supply, was cut. After the re-anastomosis of the ileum, we closed the opened ileum transversely surrounding a 14-16 Fr urethral catheter using running Vicryl sutures. The newly built tube was used as an appendix during diversion. All patients performed catheterization through the conduit without difficulty and stomal stenosis. Mild stomal incontinence occurred in one patient in the supine position who became continent after adjustment of the catheterization intervals. There was no dehiscence, necrosis or perforation of the tube. Based on our data, Monti's procedure seems to be a valuable technique in patients with very long complicated urethral defect who cannot be managed with routine urethroplastic techniques.

Une technique modifiée de cystostomie continente avec iléocystoplastie d’agrandissement : à propos d’une série de 32 patients

To evaluate the functional outcomes and quality of life of adult's disabled motor with neurogenic bladders, who had undergone a continent catheterizable vesicostomy with ileocystoplasty permitting a systematic implantation of the stoma at the umbilicus without closure of the bladder neck. Between 2004 and 2006, 32 adults with neurogenic bladder who underwent Mitrofanoff continent catheterizable vesicostomy with ileocystoplasty were evaluated with the "Qualiveen" and a local satisfaction questionnaire. The median age was 42.2 years. The neurological diagnoses were: spinal cord injury (26), spina bifida (two) and multiple sclerosis (four). The cystostomies were conducted with appendix (17) and the ileum according Monti's technique (15). The stomas were conducted in 29 cases at the umbilicus. The 31 patients were followed up for a mean of 21.6 months. The continence rate was 86%. The satisfaction with functional result and aesthetic of the stoma was of 88% and 92%. Capacity to self catheterize increased from 64% to 88%. Thirty-three percent of stoma stenosis was noted and 36% of patients underwent a reintervention including 25% for stenosis. The results of this study have demonstrated that the ileocystoplasty with umbilical continent vesicostomy fullfill with treatment objective's of patients with neurogenic bladder: restoration of continence and improved quality of life by granting them social life.

Transverse Colon for Continent Urinary Diversion: Experimental Study Comparing Two Techniques

Patients who have undergone pelvic radiotherapy can develop urinary complications such as actinic cystitis or fistulas and ultimately need urinary diversion, for which several techniques have been described. The purpose of this experimental study was to compare 2 different types of continent urinary diversion with the colonic pouch. Sixteen dogs of both sexes, weighing 20-25 kg were divided into 3 groups: the pilot group consisted of 6 dogs used to standardize the technique. Group 1 consisted of 5 dogs that underwent the Monti technique to construct the conduit and the Abol-Eneim technique to promote continence. The final group, group 2, consisted of 5 dogs that underwent the intussusception technique for continence. In both techniques the same length of colon was used (20 cm). Urodynamic evaluation was performed at postoperative day 30. The compliance of the reservoir was similar among the groups. The capacity of the reservoir was greater and the continence mechanism was more effective in group 1. The length of the conduit was also longer in group 1. In group 2, the intussusception's mechanism was totally lost in 1 dog and partially in 2. The technique performed in group 1 allowed for the construction of a reservoir with greater capacity and the continence mechanism proved to be more efficient than in group 2. The length of the conduit was significantly greater in group 1.

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

Objective Continent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang–Monti) and site of implantation (augmentation vs. native bladder) on outcome. Patients and methods A retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon). Results There were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang–Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang–Monti CCC ( P = 0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder ( P = 0.3). The majority of revisions were at skin level. Conclusions Although there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.

83 Cystoscopic injection of polydimethylsiloxane to treat mitrofanoff channel leakage ‐ is it effective?

Introduction: Leakage of urine via the Mitrofanoff channel is a difficult clinical problem. We report use of injections of Polydimethylsiloxane as a bulking agent to cure this problem.Methods: We performed 21 Polydimethylsiloxane implantations in the leaking Mitrofanoff channels in 14 women at a tertiary referral centre. Analysis of improvement in leakage was done at six‐weeks. Patients with partial or no improvement in leakage were re‐injected. Twelve bladders were neuropathic treated with augmentation ileo‐cystoplasty and Mitrofanoff and two were overactive. Double Monti technique was used in nine and appendix in five.Results: The mean age was 45 years (range 26–60), with a mean follow up of 11 months (range 2–29). The mean volume injected was 2.78 ml. (range 0.5–5). Multiple implantations were required in 4. Leakage stopped in 4/14 patients requiring only one injection. Partial improvement was seen in 3 patients. In seven no improvement was seen after an average of two injections (range 1–4). Urinary diversion was performed in two while three have had revision of Mitrofanoff channel.Conclusions: Injection of bulking agent like Polydimethylsiloxane was successful in 28.5% of patients, and partially successful in 21.4% patients. Half the patients (7/14) found no benefit from the procedure.

Clinical applications of the monti procedure as a continent catheterizable stoma

Objectives. Monti et al. recently described a technique for the construction of a continent catheterizable conduit using short segments of small bowel in a canine model. We review our experience with 25 adult and pediatric patients in whom the Monti procedure was used in their reconstructive efforts. Methods. Since October 1995, 25 patients (13 males and 12 females), aged 4 to 67 years (median 29), underwent the construction of 29 catheterizable stomas with a short (2.5 cm) segment of bowel following the Monti technique. Twenty-seven tubes were created as urinary stomas and two as part of the Malone antegrade continent enema procedure (MACE). Continence is based on the Mitrofanoff flap valve mechanism. Tubes were created when the appendix was unavailable as part of urinary reconstructive efforts or after exenterative oncologic surgery of the lower urinary tract. Tubes were created using ileum (24) and sigmoid colon (5). Ten tubes (34.5%) were done in combination with a simultaneous bowel patch in the same pedicle for bladder augmentation. Tubes were implanted in the ileum (13), bladder (9), sigmoid colon (3), stomach (1), and descending colon (1). The two tubes created to do a MACE procedure were anastomosed into the cecum. Double tubes were necessary in 7 adult patients for adequate length. The length of the tubes varied from 6 to 14 cm. Results. Follow-up ranged between 3 and 26 months (mean 13). One adult patient (4%) with bladder cancer died of myocardial infarction 14 days postoperatively. Three patients (12%) received a new Monti tube because of ischemic stenosis of the tube. All of them were continent at a follow-up of 1, 6, and 20 months, respectively. Two patients (8%) experienced leakage through the stoma, requiring additional procedures and pharmacologic manipulation to become continent. All patients used intermittent catheterization through the stoma without problems. Conclusions. Although the appendix remains the tissue of choice, the Monti procedure has substantial advantages over other efferent catheterizable tubes, including the need for a very short segment of bowel (2.5 cm), adequate lumen size (16F to 18F), length, reliable blood supply, and the versatility to combine with a simultaneous bowel patch in the same pedicle for bladder augmentation.

Refashioned short bowel segments for the construction of catheterizable channels (the Monti procedure): early clinical experience.

We report the early results of a new surgical procedure to construct a catheterizable stoma from a small segment of bowel according to the Monti technique. Since November 1996, 4 male and 4 female patients with a mean age of 14 years have undergone the Monti procedure in association with other reconstructive efforts. Indications included the unavailability of appendix because of concomitant ACE Malone appendicocecostomy in 2 patients, atretic appendixes in 3, previous appendectomy in 2 and technical difficulties during appendix isolation in 1. In no patient was small bowel used instead of a suitable appendix. Other simultaneous surgical procedures included bladder augmentation in 4 patients in whom the bowel tube and patch for augmentation were created with the same mesenteric pedicle (ileum in 3 and sigmoid colon in 1). Followup ranged from 3 to 11 months (mean 7). No patient has had difficulty with catheterization or any other problems related to the stoma. In 2 patients stomal leakage required additional procedures and pharmacological manipulation. The appendiceal Mitrofanoff procedure remains the technique of choice for the construction of catheterizable continent stomas. In the absence of a suitable appendix a catheterizable bowel conduit based on the Monti technique appears to be the best alternative in our early experience. The short segment of bowel required for conduit construction, excellent blood supply throughout its length, and the possibility of developing the tube and bowel patch for simultaneous augmentation from the same pedicle are some of the clear advantages of this technique.

REFASHIONED SHORT BOWEL SEGMENTS FOR THE CONSTRUCTION OF CATHETERIZABLE CHANNELS (THE MONTI PROCEDURE): EARLY CLINICAL EXPERIENCE

Purpose We report the early results of a new surgical procedure to construct a catheterizable stoma from a small segment of bowel according to the Monti technique. Materials and Methods Since November 1996, 4 male and 4 female patients with a mean age of 14 years have undergone the Monti procedure in association with other reconstructive efforts. Indications included the unavailability of appendix because of concomitant ACE Malone appendicocecostomy in 2 patients, atretic appendixes in 3, previous appendectomy in 2 and technical difficulties during appendix isolation in 1. In no patient was small bowel used instead of a suitable appendix. Other simultaneous surgical procedures included bladder augmentation in 4 patients in whom the bowel tube and patch for augmentation were created with the same mesenteric pedicle (ileum in 3 and sigmoid colon in 1). Results Followup ranged from 3 to 11 months (mean 7). No patient has had difficulty with catheterization or any other problems related to the stoma. In 2 patients stomal leakage required additional procedures and pharmacological manipulation. Conclusions The appendiceal Mitrofanoff procedure remains the technique of choice for the construction of catheterizable continent stomas. In the absence of a suitable appendix a catheterizable bowel conduit based on the Monti technique appears to be the best alternative in our early experience. The short segment of bowel required for conduit construction, excellent blood supply throughout its length, and the possibility of developing the tube and bowel patch for simultaneous augmentation from the same pedicle are some of the clear advantages of this technique.