**4. Surgical complications and treatment options**

Overall complication rates are reported to be high and depend on the follow up time but may be estimated between 23 to 36% for appendicostomies [37,38].

The complications related to stoma represent the vast majority of those found in urinary diversion procedures involving a conduit. Many of these are consequences of preventable technical errors during surgery [39]. Retraction, stomal prolapse, parastomal hernia, and stenosis are the most frequent. Stenosis occurs in up to 33% of patients and is considered one of the major complications [39-43]. Stomal stenosis can result from a combination of factors, including ischemia, fascial contraction, retraction, local skin alterations, and stoma placement [37, 39]. Long term stenosis at the skin level has been shown to be preventable with the aid of a silicon device (ACE stopper, Medicina, Adlington, UK) by Lopez et al. [44]. In a retrospective study comparing VQZ technique, TSF technique and the umbilicus for stoma confection Landau et al. found VQZ plasty the most effective (patency rates 100%, 55% and 74%, p<0.001) hypothesizing this might be a consequence of better blood supply which would come from 3 different sources [23].

Welk et al. reported higher complication rates with Monti technique than Mitrofanoff (60% versus 19%, respectively) [18] although McAndrew et al. found more problems with appendicovesicostomy [21]. In a very recent report, Leslie et al. found no difference in complication rate comparing the two channel types [45]. CIC execution seems also to be more difficult after a Yang-Monti ileovesicostomy technique compared to the appendix. Narayanaswamy et al. reviewed patients who underwent apendicovesicostomy with those who had a Monti conduit. He found a 27% vs. 60% rate of problems to catheterize, respectively. Among Monti cases, there was a detectable stenosis in half (13 out of 25 patients). The authors observed the formation of "pouch-like dilatations" along the ileal channel and hypothesized this to be secondary to the creation of a zone of weakness resulting from the rearrangement of muscle fibers following retubularization which would facilitate "stretching-out" and false passage during catheterization [46]. Other authors

Most reports comparing the two types of channel did not show differences in continence rates when comparing site of conduit implantation into the native bladder versus bowel [21,35].

Whenever there is an indication for occlusion or reinforcement of the bladder neck resistance different procedures may be considered including a "tight" sling, periurethral bulking agents injection, or bladder neck closure. In a retrospective study, De Troyer et al. [36] compared bladder neck closure with reconstructive procedures aiming to reinforce the bladder outlet resistance in a pediatric population showing a higher continence rate in the former, with no increase in morbidity (such as stone formation and stomal stenosis) or relationship with augmentation procedures. The authors highlight the need for concern when considering a bladder neck closure as access to the reservoir and to the upper urinary

In Yang's original study, two main areas of elevated pressure were identified: bladder submucosal tunnel and the segment crossing the abdominal wall. Under Valsalva maneuver simultaneous pressure onto the conduit and the reservoir occurs, but not in the area through the abdominal wall [25]. As such, continence is highly dependent on the

Overall complication rates are reported to be high and depend on the follow up time but

The complications related to stoma represent the vast majority of those found in urinary diversion procedures involving a conduit. Many of these are consequences of preventable technical errors during surgery [39]. Retraction, stomal prolapse, parastomal hernia, and stenosis are the most frequent. Stenosis occurs in up to 33% of patients and is considered one of the major complications [39-43]. Stomal stenosis can result from a combination of factors, including ischemia, fascial contraction, retraction, local skin alterations, and stoma placement [37, 39]. Long term stenosis at the skin level has been shown to be preventable with the aid of a silicon device (ACE stopper, Medicina, Adlington, UK) by Lopez et al. [44]. In a retrospective study comparing VQZ technique, TSF technique and the umbilicus for stoma confection Landau et al. found VQZ plasty the most effective (patency rates 100%, 55% and 74%, p<0.001) hypothesizing this might be a consequence of better blood supply

Welk et al. reported higher complication rates with Monti technique than Mitrofanoff (60% versus 19%, respectively) [18] although McAndrew et al. found more problems with appendicovesicostomy [21]. In a very recent report, Leslie et al. found no difference in complication rate comparing the two channel types [45]. CIC execution seems also to be more difficult after a Yang-Monti ileovesicostomy technique compared to the appendix. Narayanaswamy et al. reviewed patients who underwent apendicovesicostomy with those who had a Monti conduit. He found a 27% vs. 60% rate of problems to catheterize, respectively. Among Monti cases, there was a detectable stenosis in half (13 out of 25 patients). The authors observed the formation of "pouch-like dilatations" along the ileal channel and hypothesized this to be secondary to the creation of a zone of weakness resulting from the rearrangement of muscle fibers following retubularization which would facilitate "stretching-out" and false passage during catheterization [46]. Other authors

tract may become more difficult [36].

**4. Surgical complications and treatment options** 

which would come from 3 different sources [23].

may be estimated between 23 to 36% for appendicostomies [37,38].

submucosal tunnel.

reported rates of 11% [47] and 23% of problems related to catheterization of retubularized intestinal tubes [27]. Management may involve a simple Foley catheter placement for a few weeks or a surgical resection of the pouches [3].

Narayanaswamy et al. also found an incidence of conduit stenosis at the bladder implant of 6% for appendix and 8% for Monti tubes. Stomal stenosis occurred in 15% vs. 16% comparing appendix and Monti, respectively [46]. Landau et al. reported on a retrospective series comparing different techniques for stoma confection: umibilical flap, tubularized skin flap and TVZ flap. Stenosis rates were 25%, 45% and zero, respectively [23].

Problems suspected to be related to conduit patency should be evaluated using an endoscopic approach or performing a conduitogram. This will allow differentiation between stenosis, pouching or kinking. Definitive treatment may vary from calibration to conduit or stoma surgical revision [3,18,48]. D'Ancona and Miyaoka presented an innovative option for salvage treatment of stomal stenosis that fails more conservative approaches such as dilatations and corticosteroid injections and traditional surgical revisions. In patients in whose stoma was placed in the lower abdomen and had the umbilicus preserved they used an umbilical grafting to reestablish conduit superficial patency. Although follow up was short (up to 6 months) results were promising [48].

In cases where urine leakage happens the valvular mechanism may be defective, the reservoir pressure may be excessively high, or both. Urodynamic study is key to establish the diagnosis [36]. If a high pressure-reservoir is diagnosed bladder augmentation may be considered. On the other hand, if the valve mechanism is the issue a submucosal injection of a bulking agent or surgical revision making the tunnel longer may solve the problem [26]. Bulking agents have conflicting results with reported success rates up to 71% [49].

Most conduit complications will occur within 2 years from surgery, but even initially stable channels are susceptible to complications and must be reassessed throughout patients' lifetime [18].

Calculi formation and urinary tract infection have a fairly high incidence in continent reservoir patients and may vary from 26-32% and 19-63%, respectively [47,50]. They may be facilitated by mucus formation in patients who undergo bladder augmentation and by the position in which the tube is implanted into the bladder (anteriorly placed tubes drain with lower efficacy than those positioned posteriorly) [51]. Patient compliance with CIC execution may also influence these complication rates [18].

Table 1 compiles comparatively the complication rates between Mitrofanoff and Monti channels (Table 1).


Table 1. Surgical complications and incidence rates

Continent Urinary Diversions in Non Oncologic Situations: Alternatives and Complications 289

[13] Duckett JW, Snyder HM 3rd.Continent urinary diversion: variations on the Mitrofanoff

[14] Liard AS, Uier-Lipszyc ES, Mathiot A, Mitrofanoff P. The Mitrofanoff Procedure: 20

[15] Kaefer M, Retik AB. The Mitrofanoff Principle in continent urinary reconstruction. Urol

[16] Chabchoub K, Ketata H, Fakhfakh H, Bahloul A, Mhiri MN. Continent urinary

[17] Monti PR, Lara RC, Dutra MA, de Carvalho Jr. New echniques for construction of efferent conduits based on the Mitrofanoff principle. Urology 1997; 49: 112-15. [18] Welk BK, Afshar K, Rapoport D, MacNeily AE. Complications of the catheterizable

[19] McLaughlin KP, Keating MA. The appendix in reconstructive urology. Surg Ann 1995;

[20] Furness PD, Malone PSJ, Barqawi A, Koyle MA. The Mitrofanoff principle: innovative applications incontinent urinary diversion. Contemp Urol 2003; 15(1):30-45. [21] McAndrew HF, Malone PSJ. Continent catheterizable conduits: which stoma, which

[22] Murthi GV, Kelly JH. V-Vplasty: a new technique for providing a resilient skin- lined

[23] Landau EH, Gofrit ON, Cipele H, Hardak B, Duvdevani M, Pode D et al. Superiority of

[24] England RJ, Subramaniam R. Functional and cosmetic outcome of the VQ plasty for

[25] Yang WH. Yang needle tunnelling technique in creating antireflux and continent

[26] Monti PR, Carvalho JR, Arap S. The Monti Procedure: Applications and Complications.

[27] Castellan MA, Gosalbez R, Labbie Jr. A, Monti PR. Clinical Applications of the Monti procedure as a continent catheterizable stoma. Urology 1999; 54: 153-156. [28] Leslie JA, Dussinger AM , Meldrum KK. Creation of continence mechanisms

[29] Gerharz EW, Tassadaq T, Pickard RS, Shah PJ, Woodhouse CR, Ransley PG. Transverse

[30] Sahadevan K, Pickard RS, Neal DE, Hasan TS. Is continent diversion using the

[31] Harris CF, Cooper CS, Hutcheson JC, Snyder HM. Appendicovesicostomy: the Mitrofanoff procedure—a 15-Year perspective. J Urol 2000; 163: 1922–1926. [32] Keating MA, Rink RC, Adams MC. Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J. Urol 1993; 149: 1091-1094. [33] Van Savage JG, Khoury AE, McLorie GA, Churchill BM. Outcome analysis of

lower quadrant stomal sites. J Urol 1996; 158: 1794- 1797.

the VQZ over the tabularized skin flap and the umbilicus for continent abdominal

(Mitrofanoff) without appendix: the Monti and spiral Monti procedures. Urol

retubularized ileum: early clinical experience with a new second line Mitrofanoff

Mitrofanoff principle a viable long-term option for adults requiring bladder

Mitrofanoff principle applications using appendix and ureter to umbilical and

explanation of continence. Progrès en Urologie 2008; 18: 120-124.

diversion (Mitrofanoff principle). Physical mechanisms and urodynamic

channel following continent urinary diversion: Their nature and timing. J Urol

principle. J Urol 1986; 136: 58–62.

Clin N Am 1997; 24:795-811.

2008; 180: 1856-1860.

27: 215–231.

Years Later. J Urol 2001; 165: 2394–2398.

conduit and which reservoir? BJU Int 2002, 89:86.

stoma in children. J Urol 2008; 180: 1761-1765.

Mitrofanoff stomas. JUrol 2007; 178:2607-2610.

mechanisms. J Urol 1993; 150: 830-834.

Urology 2000; 55: 616–621.

Oncol 2007; 25: 148–153.

tube. J Urol 1998; 159: 525-528.

replacement? BJU Int 2008;102:236-240.

opening for the Mitrofanoff stoma. Urology 2006; 68:661-662.
