Ileovesicostomy Monti

Ileovesicostomy Monti

Ileovesicostomy refers to a urinary diversion whereby a piece of the ileum (small intestine) is joined to the bladder to form a low-pressure outlet of the urine. It is usually applied in the case of severe bladder dysfunction or neurogenic bladder when the catheterization via the urethra is impossible.

It provides unstopped urinary drainage by means of stoma on the abdominal wall which enhances the emptying of bladder and decreases the pressure on the kidneys.

Monti Procedure (Catheterizable Channel)

The Monti procedure is a type of channel reconstruction technique of the continents that is catheterizable. A small strip of the ileum is incised, re-tubularized to a hollow and connected to the bladder. The other end is connected into the abdominal wall in the form of a stoma.

It facilitates clean intermittent catheterization (CIC) via the stoma by use of a small catheter.

The Monti method is also adopted in cases whereby the appendix cannot be utilized in a Mitrofanoff appendicovesicostomy.

Monti ileovesicostomy procedure

In Monti ileovesicostomy a short length of ileum is made into a catheterizable small passage (Monti tube) and attached to the bladder, the other part being exited as a stoma on the abdominal wall.

It provides:

• A continent catheterizable channel.
• Another option to the Mitrofanoff in the absence of an appendix or when it is inappropriate.
• Quality access to a catheter approach to clean intermittent catheterization (CIC).
• Kidney protection through the facilitation of low-pressure bladder emptying.

Surgery Monti Ileovesicostomy Surgery:

Preoperative Preparation

• Full bladder test (urodynamics, ultrasound, MCU)
• Renal function tests
• Surgeon-preferred bowel prep.
• Stoma counselling and CIC.

Anaesthesia

• General anaesthesia was used.
• Foley catheter inserted into the bladder. 

Procedure

Step 1: Preparation of Ileal Segment.

• A 2-3 cm piece of ileum is chosen.
• To avoid the loss of blood, mesentery is spared.
• Segment separated and intestinal continuity.

Step 2: Creating the Monti Tube

• The ileal part is incised at the antimesenteric margin.
• The flat ileal patch is then re-tubularized in a thin tube (6-8 mm diameter).
• Longitudinal suture of tube is used to create a catheterizable conduit.
• Stoma positioning is long enough without tension.

Step 3: Bladder implantation.

• Within the wall of the bladder, a submucosal tunnel is developed (as in an antireflux implantation).
• A portion of the Monti tube and its one end is placed into the bladder.
• It is firmly fastened to ensure continence (this is the prevention of leakage).

Step 4: Creating the Stoma

• The other end of Monti tube is extended to the skin surface.

Usually placed in:

• Umbilicus (cosmetic), or
• Right lower abdomen
• The tube is prepared and made a stoma so that the catheters can be inserted.

Step 5: Catheters and Closure

• The catheter goes via the Monti channel to the bladder.
• Abdominal incision is sewed up.
• The Foley catheter of the bladder is maintained.

Duration of Surgery

• Typically 2–4 hours
• Longer with augmentation cystoplasty or bladder reconstruction.

Ileovesicostomy surgery

Ileovesicostomy is a urinary diversion surgery, which involves connecting a piece of the ileum (small intestine) to the bladder and exerted to the abdominal wall as a stoma.

Ileovesicostomy, not a continent diversion as is the case with Mitrofanoff and Monti channels, urine freely and continuously comes out of the stoma and through a drainage bag.

It is primarily applied to patients who lack the ability to catheterize their urinary tract, are chronically urinary retented and have high-pressure neurogenic bladder.

Indications

Ileovesicostomy is normally done in case of:

• Neurogenic bladder 
• Severe bladder outlet blockage. 
• Incontinence (refractory urinary).
• Urethral destruction or complicated urethral strictures.
• Failure to do clean intermittent catheterization (CIC).
• Children (or adults) who are not fit in Mitrofanoff/Monti channels.
• To shield kidneys against high bladder pressures.

Types of Ileovesicostomy

Non-continent Ileovesicostomy

• Urine drains continuously
• Needs stoma and external bag.
• Most commonly performed

Abdominal Ileovesicostomy

• Stoma located at lower abdomen.
• Simple no-problem bag-hanging.

Monti channel complications

The monti channel is a catheterizable tube that is made out of a short division of ileum. Although very effective, it can acquire some complications in the long run. The severity of these complications can be treated by medical management, dilation or revision surgery.

Early Complications (Immediate–6 weeks)

• Stomal Infection
• Urinary Leakage
• Channel Edema
• Urinary Extravasation
• Wound Infection or Hematoma

Late Complications (Weeks–Years)

• Stomal Stenosis (Most Common)
• Channel Stricture
• Catheterization Difficulty
• Mucus Production
• False Passage Formation
• Urinary Tract Infections
• Channel Incontinence
• Bladder Stones
• Stomal Prolapse (Rare)
• Channel Kinking or Redundancy
• Skin Complications Around the Stoma

Ileovesicostomy Monti recovery

Monti ileovesicostomy recovery includes wound healing, stoma maturation, bladder rest and learning clean intermittent catheterization (CIC). It requires several weeks to heal and long-term care is necessary to ensure that the channels are kept patency.

Hospital Recovery (0–7 Days)

Monitoring

• Vital signs and urine output
• Stoma color, swelling and drainage.
• Bowel activity (peristalsis is usually returned by 2-3 days)

Pain Management

• IV and oral analgesics
• Catheter at times used in children in epidural form.

Bladder and Channel Catheters

• Monti channel catheter retained 2-3 weeks.
• Insert Foley catheter in bladder 10-14 days.
• Maintains adequate healing of the bladder- channel connection.

I.V. Fluids and Antibiotics

• Given for the first 24–48 hours
• Switch to oral antibiotics where necessary.

Early Home Recovery (1–4 Weeks)

Stoma Care

• Clean daily with warm water
• Do not keep wet to avoid being infected.
• Note the presence of redness, discharge or crusting.
• The guidance of stoma nurses is quite useful.

Catheter Management

• Channel catheter is still in place.
• Pulling or dislodging is of great importance to be avoided.
• Bladder Foley was taken out at 10-14 days when the cystogram was confirmed.
• Monti tube Catheterization (first) is supervised (after 2-3 weeks).

Diet

• Light diet first, back to normal after 1 week.
• Keep hydrated to decrease the mucus.

Activity

• No heavy weight lifting
• Do not play strenuously (in children).
• Ambulation recommended after 1-2 days.
• Resume full activity in 6 weeks.

Intermediate Period of Recovery (4-12 Weeks) 

Clean Intermittent Catheterization

• Confirmation of taught after channel healing.
• Catheter passed every 3–4 hours
• Catheter 1014 Fr based on patient size.
• Report pain/ difficulty during CIC.

Mucus Management

• Normal due to the fact that ileum secretes mucus.

Management:

• Regular catheterization
• Saline irrigation, which happens infrequently.

Stoma Maturation

• Size stabilizes over 2–3 months
• Protective barrier may be required in case of irritation of the skin.

Follow-up

• Kidney and Bladder ultrasound to examine.
• Stoma examination
• Urine culture in case of symptoms.

Long-term Recovery (3 months-life)

Continence

• The channel between catheterizations between Monti channel should be continuous.
• Channel or tunnel problem is indicated by leakage.

Routine Follow-Up

• Every 6 months initially
• Later annually
• Incorporates urine bladder ultrasound, stoma.

Stimulus Fiscal Policy (Children)

• The Monti tube may stretch or be obstructed as the child grows.
• May needs to be changed during adolescence.

Best hospital for ileovesicostomy Monti India

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

Conclusion

Monti ileovesicostomy is a well-established, continent urinary diversion for patients unable to catheterize through the urethra and who do not possess an appendix for a Mitrofanoff. By way of a catheterizable channel formed from short ileal segment, an intermittent catheterization allows the patient to empty regularly and safely his bladder, protecting the kidneys from distension, and improves continence and life quality. While the operation has a lengthier convalescence and necessitates lifelong stoma care and catheterization, the latter with excellent inform I can attest that most patients achieve superior long-term outcomes. Timely recognition and treatment of common problems such as stenosis, mucus plugging and infection can allow the Monti channel to function well for many years.

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FAQ

1. Is the Monti channel continent? 

• Yes. The bladder end is implanted with an antireflux mechanism; there is no leakage of urine between catheterizations.

2. Is daily stoma care needed? 

• Yes. The stoma should be kept clean and dry as moisture can cause infection, stenosis, or skin irritation. 

3. Does the Monti channel secrete mucus? 

• Yes. The ileum produces mucus, which on rare occasions can clog the catheter. Regular irrigation and adequate hydration have been shown to decrease the production of mucus.

4. Can the channel close or narrow? 

• Yes. Stenosis of the stoma or stricture of the channel is also among the most common complications. Early detection is critical to prevent complete obstruction.

5. Will I be able to catheterize by myself? 

• It seems like most people, children and adults with neurogenic bladder, do just fine with catheterizing on their own after training.

6. Is the Monti channel permanent? 

• Yes, but it can be revised if (in children) if it is needed or if complications arise.

7. Is it kidney protective?

• Yes, the Monti channel facilitates low-pressure emptying of the bladder preventing upper tract deterioration resulting from high bladder pressure.

8. Can the Monti ileovesicostomy be revised or converted at a later time?

• Yes. It can be revised, lengthened or exchanged for a different continent diversion if the need arises.

9. Is it safe to do this procedure on children?

• Yes. It is a commonly used procedure in children with neurogenic bladder, posterior urethral valves, or urethral anomalies.