In the past, the primary indication for bladder reconstruction was for
upper urinary tract preservation. In the era of aggressive use of
anticholinergics and intermittent catheterization in young patients,
the more common indication for a Mitrofanoff channel is for urinary
continence and convenient, independent bladder management for the
patient. All patients should undergo a trial of CIC to demonstrate
that they are reliable and able to comply with a daily routine prior
to bladder reconstruction.
– IV abx (cefoxitin now, flagyl on call)
– All patients are admitted the day before surgery for intravenous
antibiotics to sterilize the urinary tract and for a mechanical and
antibiotic bowel preparation.
– This is in particular important for patients with
ventriculoperitoneal shunts, who have a risk of shunt infection.
– Potential sites for stomal location should be determined
preoperatively, with the patient in the sitting and supine position.
1. Surgical exposure is usually obtained through a midline
transabdominal incision that is carried around the umbilicus to leave
enough fascia to close the abdomen without compromising an umbilical
stoma. A lower transverse Pfannenstiel incision will also allow
adequate exposure for both bladder augmentation and the Mitrofanoff
stoma in thin patients.
1a. Laparoscopic mobilization of the right colon and isolation of the
appendix has been described, which allows a smaller lower-abdominal
incision without the concern of inadequate exposure.
2. A 2.5- to 3-cm segment of intestine is harvested with a
well-vascularized segment of mesentery. If ileal augmentation is
planned, the Monti-Yang segment can be easily harvested from the
distal end of the segment with a shared mesentery.
2a. When the Monti channel does not provide adequate length to reach
the abdominal stomal site, then two Monti tubes can be reconfigured
and connected (double monti)
3. The ileal segment is opened on the antimesenteric side. It can be
opened slightly off the midline to provide a longer segment for
implanting into the bladder.
4. The opened segment is then retubularized transversely in two layers
over a 14 Fr catheter.
5. The bowel mucosa is approximated with running 5-0 or 6-0 absorbable
sutures and the muscular layer is closed with running or interrupted
4-0 absorbable sutures
6. The stomal end is not closed initially, providing wide spatulation
of the antimesenteric side of the tube for later stomal anastomosis.
7. The technique of implanting the tube into the bladder and creating
a stoma is identical to that for mitrofanoff appendicovesicostomy
A 12 Fr catheter is left across the channel for 3 weeks before
initiating intermittent catheterization.