Mitrofanoff Procedure

Overview

The Mitrofanoff procedure helps individuals with certain conditions drain urine from their bladder via a surgically created opening in the abdomen. During this procedure, surgeons use the appendix to create a channel that connects the bladder to a stoma on the abdominal wall. To urinate, a catheter (a flexible tube) is inserted through the stoma into the bladder. Developed by Professor Paul Mitrofanoff in 1976, this procedure is also known as appendicovesicostomy or continent urinary diversion.

The bladder

As a component of your urinary system, your bladder aids in the removal of waste and toxins from your body through urine. Usually, when you urinate, you go through these steps:

• Your kidneys produce urine and filter pollutants from your blood.
• Urine enters your bladder through tiny tubes called ureters.
• Urine is stored in your bladder, a muscular organ shaped like a balloon, until you feel the need to urinate.
• Your bladder empties urine into the urethra, a tube.

The appendix

The appendix, located in the lower-right abdomen and connecting to the upper part of the large intestine (colon), is still under investigation regarding its exact function. Some studies propose that it produces mucus that supports beneficial gut bacteria, which help with digestion and recovery from digestive issues like diarrhea.

During the Mitrofanoff procedure, healthcare providers use the appendix to create a channel for urine drainage from the bladder to the abdominal wall. However, if the appendix is not available due to removal from appendicitis, surgeons can use a segment of the small intestine instead. This intestinal segment is repurposed to form a channel between the bladder and the abdominal wall, known as a Monti or Monti-Yang channel, named after the surgeons who developed this technique.

Reasons for undergoing the procedure

A Mitrofanoff allows for self-catheterization, where you use an intermittent catheter through a self-sealing abdominal opening.

Throughout the day, you will undergo the following:

• To access your bladder, insert a flexible tube called a catheter through your Mitrofanoff tunnel and stoma.
• Empty the urine into a collection container or toilet using the catheter.
• After the bladder has emptied, remove the catheter. The stoma shuts by itself.

Certain birth defects can impact a child’s nervous system, resulting in a condition known as neurogenic bladder. This condition affects a child’s ability to control their bladder muscles.

Some children are born with congenital urinary anomalies. Examples include bladder exstrophy or cloacal exstrophy, where the abdominal wall fails to form correctly, allowing the bladder to protrude through an opening between the pubic bones. This results in the bladder developing inside-out and being exposed externally (exstrophy).

Other conditions that may necessitate a Mitrofanoff procedure include:

• Spina bifida
• Cerebral palsy
• Spinal cord damage
• Sacral agenesis, or the absence of a portion of the lower spine

A Mitrofanoff may be necessary for adults if they have:

• Colorectal (colon) cancer, prostate cancer, or bladder cancer.
• Problems with bladder control, such as severe incontinence.
• Cystitis, or inflammation of the bladder.
• Neurogenic bladders brought on by neurological conditions such as Parkinson’s disease or multiple sclerosis.
• Spinal tumors, paralysis, or trauma to the spinal cord.
• Stroke.

Risks

Around 2 out of 10 individuals who undergo a Mitrofanoff procedure may require revision surgery years later to address issues such as narrowing (stenosis) or deterioration of the Mitrofanoff tunnel. In some cases, the stoma may cease to seal properly after catheterizations, resulting in urine leakage that can be corrected with a revision surgery.

Since the appendix continues to produce mucus despite its altered role, regular cleaning (irrigation) of the tunnel is necessary. Your doctor will instruct you on how to perform this procedure. Irrigation can affect electrolyte levels in your blood, which are essential for maintaining fluid balance in the body. Regular blood tests can detect any electrolyte imbalance.

Other risks associated with bladder surgery include:

• Bleeding.
• Bladder cancer and calculi (bladder stones).
• Significant intestinal (bowel) blockage.
• Infections, such as persistent Urinary Tract Infections (UTIs).

 Before the procedure

To reduce the danger of infection, make sure your intestines are as empty as possible before the surgery. You should adhere to the advice given by your doctor, which may include:

• Fasting (drinking only clear beverages).
• Finishing a colon cleansing.

During the procedure

Since a Mitrofanoff is performed under general anesthesia, you are unconscious throughout the process.

Throughout the process, your doctor:

• Creates a cut on your abdomen.
• Extracts your big intestine’s appendix.
• Joins the appendix at one end to a tiny bladder incision and the other end to a smaller abdominal incision (the stoma).
• Forms a valve at the point where your bladder and appendix meet. In order to stop leaks, this valve closes as your bladder fills with pee.
• Creates a tiny incision beneath the stoma to allow the suprapubic tube—the first catheter—to be inserted straight into your bladder. In order to give your bladder time to heal, this temporary catheter allows urine to drain into a collection bag outside of your body.
• To allow urine to flow easily from your kidneys into your bladder, tiny tubes called ureteral stents may be inserted into your ureters. (Not all patients require ureteral stents.)
• Uses dissolving stitches to seal the main surgical incision site while your bladder recovers.

After the procedure

In the hospital, you can stay for up to a week recovering. Following surgery, you might:

• To give your intestines time to recover, receive Intravenous (IV) fluids for a few days and refrain from eating solid meals.
• Spend a day or two lying flat in bed. You should not sit up, but you can move your legs and roll from side to side.
• To prevent the Mitrofanoff tunnel from closing, insert a catheter. After the procedure, this catheter is left in place for up to four weeks. Together with the suprapubic tube, you take it home.
• If required, have another treatment to remove the ureteral stents in six to eight weeks.
• When self-catheterization begins, ask your doctor to remove the Mitrofanoff catheter and the suprapubic tube. It is taken out in your provider’s office. It won’t need to be removed by another procedure.

Outcome

A few weeks following the treatment, you might feel like this:

• Hematuria (blood in the urine).
• Severe spasms of the muscles (bladder spasms).

To relax your bladder muscle and reduce spasms, you can take medications and painkillers. You’ll also need to return to your doctor’s office in about six weeks for instructions on how to perform self-catheterization.

The majority of Mitrofanoff recipients have long, healthy lives. You can swim and engage in physical activity (though you might want to stay away from certain contact sports). Women and those assigned female at birth with a Mitrofanoff syndrome can conceive and bear children healthily with the correct medical attention.

Following the surgery, your doctor will monitor the functioning of your urinary system. Every year, you’ll take exams like these:

• Blood tests to assess liver, kidney, and electrolyte levels.
• A cystoscopy, which shows the interior of the bladder.
• Ultrasounds of the kidneys and pelvis.
• Urinary tract, bladder, and kidney X-rays.