The Mitrofanoff Procedure Explained
Mr Jeremy Ockrim, MD BSc (Hons) FRCS (Urol)
Honorary Lecturer University College London (UCL), Consultant Female and Reconstructive Urological Surgeon, Institute of Urology, University College London Hospital (UCLH)
When urethral access to the bladder is lost an alternative route to empty the bladder is required. Paul Mitrofanoff first described the trans-abdominal continent channel in 1980. Mitrofanoff described the use of the appendix as a conduit between the bladder and the skin of the abdominal wall. A catheter is used (usually 4-7 times a day) to empty the bladder. This avoids the need for a long-term stoma bag, which is the more commonly used alternative (see Figure 4 below).
The most important principal of this procedure is the creation of a continent valve in the bladder to prevent urinary leakage between catheterization. This is created by tunnelling the Appendix through the wall of the bladder for a distance of 4-5cm. As the bladder fills the bladder wall is compressed closing the Mitrofanoff tube and preventing leakage.
Figure 1. shows how the appendix is separated from the bowel leaving the blood supply intact.
The preferred tube for the Mitrofanoff is the appendix. However the appendix may be absent or of insufficient length or diameter to be of use. If this is the case a similar tube can be fashioned from a short segment (2.5cm) of small bowel, which is opened out flat and then rolled to give a longer and narrower tube (5cm length). These Monti-Yang tubes can be joined together to create a sufficient length to bridge the gap between the bladder and the skin.
For many patients the preferred position of the skin into the tube is at the umbilicus. Catheters are then passed through the umbilicus which is hidden from everyday view.
Figure 2. Mitrofanoff opening hidden in the umbilicus
In some cases this is technically not possible and the skin entering the tube is brought out in the lower part of the abdomen below the belt or skirt line.
Figure 3. Mitrofanoff opening on the right side of abdomen on a young bladder exstrophy patient.
The mitrofanoff stoma can be seen as a small dimple to the left of the image. The stoma is normally hidden under the bikini line, the waist of the jeans are pulled down in this image to show the stoma. The imprint of where the jeans usually sit can be seen in the patterning on the skin located above the mitrofanoff. The scar from mitrofanoff surgery is the thin long line located horizontally across the belly below the mitrofanoff stoma. The midline scarring is from closure of the bladder and urethra at birth. The photo was taken 2 years post surgery.
Figure 4. Urostomy Stoma