Continent catheterisable channel formation using the Mitrofanoff principle – Long-term outcomes in a large adult cohort

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

Research Type

Clinical

Abstract Category

Neurourology

Abstract 75
E-Poster 1
Scientific Open Discussion ePoster Session 7
Wednesday 4th September 2019
13:15 - 13:20 (ePoster Station 1)
Exhibition Hall
Anatomy Incontinence Infection, Urinary Tract Surgery Retrospective Study
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
Indications for creation of a continent catheterisable channel using the Mitrofanoff principle in adults are varied and long term data in this challenging patient cohort are lacking. We present one of the largest reported series of patients undergoing urinary diversion in this form and assess whether the underlying aetiology of urological dysfunction impacts their outcomes.
Study design, materials and methods
We performed a retrospective review of consecutive patients over the age of eighteen having creation of a continent catheterisable channel using the Mitrofanoff principle at our institution between 1985-2013 This was a single centre multi surgeon series, with nine consultant surgeons with a sub-specialist interest in reconstructive urology undertaking Mitrofanoff channel formation during this study period (sequentially and in parallel). Demographic information was collected, including: age at surgery, gender and length of follow up. 

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. Neurological aetiology comprised those with a neurogenic bladder due to conditions such as multiple sclerosis or spinal dysraphism. End stage urinary incontinence typically was composed of patients who had undergone numerous previous unsuccessful surgeries for incontinence, of a non-neurogenic aetiology. The congenital group predominantly comprised patients with exstrophy, epispadias and prune belly syndrome. Patients in the malignancy group had undergone oncological surgery, typically for bladder or urethral cancers. The bladder pain syndrome group comprised patients with interstitial cystitis and other painful inflammatory bladder conditions such as those caused by ketamine use. 

Patients with less than 12 months follow up data available were considered lost to follow up. Patients were generally discharged 5-10 days post their surgery with a 12Ch - 16Ch catheter in their channel, often in addition to a urethral or suprapubic catheter, for 6 weeks until the anastomosis had healed. They were then brought back for ‘activation’ of their channel with instigation of clean intermittent self catheterisation via their continent channel. Patients were typically reviewed at 6 months thereafter with renal ultrasound and bloods including urea & electrolytes, folate, sodium bicarbonate and vitamin B12. Notwithstanding any issues, patients were generally reviewed annually thereafter with blood results and an alternating regimen of renal ultrasound and MAG3 renogram imaging.
Results
The 176 patients had a median of 60 months (range 2-365) follow-up (FU) available. Outcomes at last follow up are listed in Table 1. Patients with a neurogenic bladder represented the largest patient cohort (n=59, 33.5%) with the most common underlying neurological conditions being spinal dysraphism, spinal cord injury and multiple sclerosis. Other underlying aetiological conditions included congenital anomalies (v.v. bladder extrophy and epispadias) in 37 (21.0%), end stage urinary incontinence (patients who had undergone multiple previous unsuccessful anti-incontinence surgeries) in 39 (22.2%), cancer in 22 (12.5%) and inflammatory conditions of the bladder (v.v. interstitial cystitis and recreational ketamine use) in 19 (10.8%). 53 (30.6%) of patients had their index surgery within the last ten years (i.e. 2008 or after). Overall, 7.5% (n=13) of patients were lost to follow up
Interpretation of results
Mitrofanoff formation was successful (in use by patient) in 75.8% of adult patients at the expense of stone development in 19.9%, a 42.2% endoscopic and a 39.8% open revision rate. Stone development rate was highest in patients with congenital aetiology whilst revision rates were highest in patients with complex incontinence aetiology. Persistent usage was lowest in patients with neuropathic aetiology.
Concluding message
The formation of a continent catheterisable channel using the Mitrofanoff principle represents a durable technique across a wide array of patient cohorts. Patient education and counselling is paramount to ensure that patient expectations are managed prior to undertaking such major surgery. We feel this study represents  provides a pragmatic overview of the outcome of these challenging patients.
Figure 1
Disclosures
Funding I have no funding or grant source to declare Clinical Trial No Subjects None