MyPACS.net: Radiology Teaching Files > Case 6865486

previously visited MITROFANOFF BLADDER RECONSTRUCTION
Contributed by: Dr Phillip Silberberg, Children's Hospital Omaha, Radiologist, Omaha Childrens, Creighton University and UNMC, Nebraska, USA.
Patient: male
History: Patient post severe high grade urethral obstruction secondary to urethral valves.
Images:[small]larger

Fig. 1: VCUG. Catheter passing through the Mitrofanoff.

Fig. 2: VCUG. small amount of contrast within bladder trigone, most post urethra. patient unable to void.

Fig. 3: VCUG shows large bladder diverticulum with contrast exiting via the Mitofanoff.

Fig. 4: Post Void VCUG shows residual contrast with the modified Mitrofanoff.

Fig. 5: VCUG Post Void shows catheter passing through the modified Mitrofanoff used to facilitae continence compared with a simple vesicostomy.
Findings: Modified Mitrofanoff procedure where the bladder wall was utilized for construction of a tube extending from the bladder to the anterior abdominal wall. A diverticulum is seen on both sides of the bladder. Patient unable to void due to past history of severe post urethral valve and failed surgery which could not be repaired sufficiently
Diagnosis: .
Discussion: Mitrofanoff Procedure for Incontinence

General:

The Mitrofanoff procedure involves construction of vesicostomy to the abdominal wall, typically to the umbilicus, that allows for catheterization of the bladder for alleviation of incontinence and bladder pressure.  The procedure was originally described by Mitrofanoff in 1980.  Many conduits have been used to create the tract for introduction of the catheter into the bladder.  Originally, the procedure was performed using the appendix; now in addition to the appendix, ureteral segments, portions of the native bladder, segments of small or large bowel and stomach, as well as fallopian tubes have been employed for formation of the catheter conduit. 

Continence of the conduit is based on the Mitrofanoff principle in which pressure elevation within the reservoir (the bladder) is transmitted to a supple, small-diameter conduit, resulting in compression of the lumen against the firmer wall of the storage reservoir.

Indications:

The Mitrofanoff procedure is an excellent alternative continence mechanism for patients with incontinence due to a variety of different pathologies including neurogenic bladder with or without spina bifida, extrophy of the bladder, epispadias, patients with failed surgery for posterior urethral valves and post signifcant pelvic surgery or radiation for treatment of malignancies.  This can also be an effective procedure for wheelchair bound patients, morbidly obese patients, or those whom require but lack lack the dexterity for urethral catheterization.
 
Preoperative Considerations:

Patients should have an abdominal series as well as a IV pyelogram and voiding cystourethrogram to evaluate for any malformations or the presence of vesicourethral reflux which may complicate the surgery and postoperative coarse.  In addition, compliance, capacity and spasticity of the bladder should also be evaluated.

Operative Considerations:

The type of conduit must determined, with the appendix and the ureter being the most common.  In addition, whether to preserve the native bladder, augment the native reservoir or create a new reservoir using bowel must be considered based on studies performed preoperatively.  In some instances a procedure to increase resistance at the native bladder neck outlet may be required to prevent urethral incontinence postoperatively.

Postoperative Management:

A stent within the conduit is left in place for seven to days post-op, and removed following a cystogram demonstrating the absence of any leakage.  Catheterization is then performed by the patient or caretaker every four to six hours.  For patients with bowel segment conduits, irrigation should be performed each time the conduit is catheterized.

Results and Complications:

This procedure has been shown to be effective treatment in the majority of cases.  Complications include stomal stenosis, leakage, stricture and necrosis.  In addition, conduit perforation can occur.  Most of these complications will require revision of the procedure.  Post revision results are often good.  Urolithiasis is  a reported complication with this procedure, and this has been treated percutaneously in some instances.  Complications are reported more frequently when conduit other than the appendix is utilized.
References:

References:

Harris CF, Cooper CS, Hutcheson JC, Snyder HM.  "Appendicovesicostomy: The Mitrofanoff procedure--a 15-year prospective."  Journal of Urology. (2000) 163(6): 1922-1926.
Kaefer M, Retik AB.  "The Mitrofanoff procedure in continent urinary reconstruction."  Urologic Clinics of North America.  (1997) 24(4): 795-811.

Contributed by:

Corey Zetterman, Medical Student, Creighton University Medical School, Omaha, NE

Dr. Phillip Silberberg, Omaha Children’s Hospital, Creighton University and UNMC, Omaha, NE
Comments:
No comments posted.
Additional Details:

Case Number: 6865486Last Updated: 04-02-2007
Anatomy: Genitourinary (GU)   Pathology: Congenital
Modality: GUAccess Level: Readable by all users
Keywords: vesicostomy appendix bladder augmentation

The reader is fully responsible for confirming the accuracy of this content.
Text and images may be copyrighted by the case author or institution.
You can help keep MyPACS tidy: if you notice a case which is not useful (e.g. a test case) or inaccurate, please contact us.