Appendicovesicostomy

Appendicovesicostomy

Mitrofanoff procedure or Appendicovesicostomy is a surgical method applied to form a continent catheterizable channel connecting the skin surface with the urinary bladder. The appendix (or occasionally a different bowel segment) is a conduit, through which patients are able to empty the bladder, by using intermittent catheterization using a small stoma on the abdomen.

This surgery is usually required in patients that are unable to catheterize via the urethra or individuals that have a severe bladder dysfunction.

Appendicovesicostomy procedure

Appendicovesicostomy closes the urethra and opens up a continent catheterizable canal between the bladder and the skin surface with the appendix so that the catheter is no longer sent into the urethra but through a small abdominal stoma.

Preoperative Preparation

• The use of general anaesthesia takes place.
• Pelvis and abdomen are dressed and covered.
• The current bladder compliance, capacity, and anatomy are evaluated.
• In case, augmentation and bladder neck repair (simultaneously) are to be performed.

Appendix Identification and Mobilization

• Incision is done at the lower abdomen (Pfannenstiel or midline).
• The appendix is found and separated with due consideration of the blood supply.

In case the appendix is too short or missing, it could be substituted with:

• Monti channel (ileal tube)
• Reconfigured ureter (rare)

Training the Bladder to the Channel

• Bladder is perforated or a tiny hole is made on the surface of the bladder.
• Tunneled submucosal anti-reflux is formed.
• This is to make sure urine does not pass through stoma.
• Tunneling is traditionally performed on the bladder dome or anterior wall.

Appendix Attached to Bladder

• The tip of the appendix is left free to make stoma.
• The terminal of the appendix is sewn to the bladder opening.
• One connects to a secure and watertight connection.
• The appendix is then inserted via the anti-reflux tunnel to be continuous.

The Stoma Making (Skin Opening)

• The other terminal of the appendix is taken to the abdominal wall.

Preferred stoma locations:

• Umbilicus (cosmetic, hidden)
• Right lower abdomen
• This is done by creating a small hole in a circle and suturing the appendix to the skin.
• To avoid narrowing, the channel is matured.

Catheter Placement

• A catheter is retained in the channel over a number of weeks (10-12 Fr).
• There is another catheter that can be temporarily introduced into the urethra.
• This provides healing and avoids impediment.

Abdominal Closure

• It has a closed abdomen, which is layered.
• Dressings are applied.
• Irrigation of the bladder after surgery could be applied (particularly the bowel segments are employed).

Postoperative Measures: Immediately

• Hospital stay: 4–7 days.
• Until follow-up, catheter is left.
• Stoma care education commences.
• Training on catheterization begins subsequent to healing (typically 2-3 weeks).

Appendicovesicostomy complications

Appendicovesicostomy is a successful method of continent catheterizable urinary drainage, but the channel and stoma may experience a number of complications with time. Follow-up in the long term is necessary since a significant number of patients need minor or major revisions.

Postoperative Complications: Early-Stages

• Wound Infection
• UTI
• Bleeding
• Mucus Discharge
• Urine Leakage
• Stomal Edema

Complications over time

• Stomal Stenosis (Narrowing)
• Channel Stenosis / Stricture
• False Passage Formation
• Stomal Leakage (Incontinence)
• Channel Prolapse
• Catheterization Difficulties
• Urinary Calculi (Stones)
• Recurrent UTIs
• Unsolved bowel problems
• Channel Failure

Appendicovesicostomy recovery

Post-operative management of appendicovesicostomy (Mitrofanoff procedure) encompasses the healing of the stoma, stoma stabilization and education of the patient or caregiver in intermittent catheterization. It requires several weeks to be completely adapted.

Hospital Stay

• Typical stay: 4–7 days
• Patients can remain longer when combined procedures (e.g., augmentation cystoplasty) are performed.

Postoperative care is to be provided immediately

Catheter Management

Patients usually have:

• A catheter in the Mitrofanoff channel (10-14 Fr) left in place 2-3 weeks.
• In some cases, a urethral catheter is often used concurrently, at the choice of the surgeon.
• The channel catheter enables the healing and avoids stenosis.

Bladder Irrigation

• Mucus may clog and therefore gentle irrigation with saline may be necessary in case:
• Bowel segments were used (Monti).
• Augmentation of the bladder was done.

Pain Management

• Mostly mild or moderate pain which is managed by oral medications.

Surveillance of Early Complications

• Leakage around the stoma
• Infection or redness
• Having trouble with catheter flow.
• Fever or UTI symptoms

Stoma Care

• Keep the stoma clean and dry.
• Light redness is normal, intense redness, discharge or edema requires reconsideration.
• Close-fitting garments or the tightness of the stoma should be avoided.
• Stoma maturation time: 2 -4 weeks.

Catheterization Training (CIC Training)

When it begins

• Typically begins 2-3 weeks of surgery, when healing is sufficient.
• A medical practitioner educates on the introduction of the catheter using the channel.

Frequency

• After every 3-4 hours, according to the bladder capacity.
• The frequency of night catheterization is dependent on the performance of the bladder.

Technique

• Clean lubricated catheter.
• Insertion gently to prevent false passages or trauma.
• Always make sure that the bladder is empty, in order to minimize UTIs.

Activity Restrictions

• 4-6 weeks of no heavy lifting.
• The same should apply to children who should not be engaged in sports or rough playing.
• Normal walking is promoted.
• DO NOT SWIM once the stoma is healed.

Follow-Up Appointments for Patients

• The initial follow-up would be 10 to 14 days following the operation. 
• Removal of catheters and catheterization trial using the channel occurs at around 2-3 weeks.

Follow-up is necessary on a regular basis on:

• Stenosis detection
• Channel function
• UTI monitoring
• Bladder pressure assessment (assess of neurogenic bladder present)

Long-term Recovery and Adaptation

Stoma Stability

• The stoma is stable after 6-8 weeks.
• The channel remains patented by continued catheterization.

Channel Maintenance

• Catheterization should be routine, failure to which it may lead to narrowing.
• There are patients who need periodical dilation or stoma stretching.

Lifestyle Adjustments

• The process provides autonomy whereby nurses catheterize themselves.
• The children tend to switch to self-CIC following training.

Pediatric appendicovesicostomy

Pediatric appendicovesicostomy is a continent catheterizable channel surgery, which is done on children with an inability to empty the bladder normally or safely. It involves the use of appendix to establish a small opening between the bladder and the skin so that the child (or care giver) can empty the bladder with the help of a catheter.

It has a profound positive effect on continence, independence and quality of life of children with chronic bladder issues.

Indications in Children

• The most common indications for pediatric patients to undergo this procedure are:

Neurogenic Bladder 

• Most common cause

Seen in children with:

• Spina bifida
• Spinal cord injuries
• Tethered cord syndrome

Congenital Urogynacological Diseases

• Exstrophy-epispadias complex
• Cloacal anomalies
• The aftermath of posterior urethral valves following repeat operations.

Challenging Urethral Catheterization

• Urethral strictures
• Severe scarring
• Urethral malformations

Children with Life Long Clean Intermittent Catheterization (CIC) Need

• It has the ability to provide a stable, long-term access route.

Best hospital for appendicovesicostomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Appendicovesicostomy (Mitrofanoff procedure) is a very superior method, which offers a continent, predictable, and convenient pathway of emptying the bladder, particularly to those patients who are unable to catheterize the bladder via the urethra. The procedure has a high chance of enhancing the quality of life, independence and continence in both children and adults. The surgery is not only associated with long term functional success, but the surgery also demands close postoperative care, regular catheterization and regular follow ups to check against complications like stenosis, leakages or infections. Through appropriate training and management, the greater number of patients can attain stable bladder control and excellent channel functioning over many years.

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FAQ

1. Is this operation permanent? 

• Yes it is a long term reconstructive surgery. The new channel is established for lifelong use.

2. What is the usual location for the stoma?

• For access, usually at the umbilicus as they cosmetic reasons or right lower abdomen.

3. Will the child/adult be continent once the procedure is done?

• Yes. The channel is otherwise continence from urinary leak between catheterizations by anti-reflux tunnel constructed in the bladder.

4. Is the appendix always available as a conduit?

• No. When the appendix is too short or unavailable, other options like a Monti channel (ileal tube) come into consideration.

5. Will there be any revisions later on?

• Maybe 10 to 20% of patients may require revisions minor or major due to stenosis or changes of channel over many years(one out of five).

6. Is the procedure safe for children? 

• Yes. It is widely performed in pediatric urology and has excellent long term outcomes provided follow-up is maintained.

7. Can the stoma be seen?

• When it is brought through the umbilicus it is usually minimally visible and is cosmetically acceptable.