Appendix, Ileum or Ureter – Which is the Best Material for Mitrofanoff Channel Formation in Adults?

O'Connor E1, Malde S2, Foley C3, Taylor C2, Wood D1, Hamid R1, Ockrim J1, Greenwell T1

Research Type

Clinical

Abstract Category

Neurourology

Abstract 72
E-Poster 1
Scientific Open Discussion ePoster Session 7
Wednesday 4th September 2019
13:00 - 13:05 (ePoster Station 1)
Exhibition Hall
Retrospective Study Mixed Urinary Incontinence Detrusor Hypocontractility Urgency Urinary Incontinence Anatomy
1.University College Hospital at Westmoreland Street, 16-18 Westmoreland Street, Marylebone, London, UK, 2.Guy’s and St Thomas’s Hospital Trust, London, UK, 3.Lister Hospital, Stevenage, UK
Presenter
R

Rizwan Hamid

Links

Poster

Abstract

Hypothesis / aims of study
First described in paediatrics, the formation of a catheterisable channel utilising the Mitrofanoff principle has been used for the past few decades in adult populations. The use of appendiceal and ileal segments has been well documented in paediatric populations with several studies reporting long term follow up. In this study, we examine a large adult cohort undergoing formation of a continent catheterisable stoma for a variety of indications. We aim to elucidate the optimal tissue for channel formation and quantify the risk of stenosis and incontinence. We hope that this will facilitate adequate patient counselling in those who choose to undergo this challenging procedure and advise future surgical practise.
Study design, materials and methods
We performed a retrospective case note review of 176 consecutive adult patients (median age 42 years) having creation of a continent catheterisable channel using the Mitrofanoff principle for a broad range of indications a median of 142 months (range 54-386) ago. Patients were categorised by aetiology of their underlying incontinence into five distinct sub-groups; neurological, end stage urinary incontinence, congenital, malignancy and bladder pain syndrome.  We evaluated outcomes in terms of continued use and continence for each type of material used for channel formation. Ileal channels were evaluated both as one type of channel material and separately as single and double ileal channels and those created from a retubularized portion of a pre-existing ileal conduit (tapered ileum).
Results
At the time of this review, 165 (95.4%) out of 173 patients included in this study were alive.  The study group included 114 (65.9%) women and 59  (34.1%) men who underwent surgery at a median age of 42 years (range 18-73) with a mean (median, range) follow up of 78.6 months (60, 2-365). The majority of patients (137, 77.5%) also had an augmentation cystoplasty or neobladder, formed either prior to or at the time of their Mitrofanoff channel creation. Of note, almost all patients (15/16) who had their channel created out of tapered ileum or ureter had an augmented bladder. The presence of a patient’s native bladder was highest in the group who had an appendiceal channel but this was not statistically significant (25.3% appendix v 20.0% ileal, p=0.42). Revision rates for all causes were higher in the ileal group compared to those with appendiceal channels (17.2% appendix v 22.7% ileal, p = 0.39 for channel stenosis and 19.5% appendix v 36.0% ileal, p = 0.03 for incontinence). Despite 38.7% of patients undergoing major surgical revision of their channel at some point, 75.9% of channels continue to be used and of these 90.2% are continent.
Interpretation of results
The Mitrofanoff principle has been expanded in the past few decades for use in a large array of urological situations. It may be utilised in situations where either the urethra is not available (e.g. following urethral closure for intractable stress urinary incontinence or in continent urinary diversion following cystourethrectomy) or where the urethra is patent and continent but the patient is unable or unwilling to perform urethral self-catheterisation (e.g. spinal cord injury in females or Fowler’s syndrome). We present a large series of continent catheterisable channels formed in adults using the Mitrofanoff principle with a mean follow up 78.6 months focusing on channel related complications and revision rates. Our data provide insights into a challenging patient cohort spanning three decades of urological reconstruction. Despite a high revision rate, 75.9% of those patients alive at last assessment are using their catheterisable channel and of these 90.2% are continent.
Concluding message
This study provides a pragmatic overview of the outcome of these challenging patients. Mitrofanoff channel formation represents a durable technique. We recommend the use of appendix over ileum where possible due to the better continence and catheterisation outcomes of appendiceal channels. Appropriate patient counselling is paramount to ensure realistic expectations regarding outcomes and revision rates are met. There is a need to maintain prospective databases on these patients and promote collaboration between regional centres, as large case series with long-term follow up remain few.
Figure 1
Disclosures
Funding I have no specific conflicts of interest to disclose Clinical Trial No Subjects None