What Is the Mitrofanoff Procedure (Appendicovesicostomy)?
The Mitrofanoff procedure creates a new tube on a child’s belly through which a child can urinate (pee) by using a catheter (putting a small tube into the new tube). The new tube is made from the appendix. It connects the bladder to a small hole created in the belly button or in an area in the lower belly. This way, children can empty their bladders by catheterizing through the new tube instead of using the urethra (the tube that pee normally goes through when it leaves the body).
During the surgery, the appendix is cut away from the intestine but not from its blood supply. The surgeon sews one end of the appendix to the back side of the bladder. The other end of the appendix is then pulled up and attached to the belly. A small hole is made on each end of the new tube (one on the belly or in the belly button, one in the bladder) so that children can put in a catheter through the opening on their belly or belly button to empty the bladder.
There are two possible ways the surgery may be done:
- Open surgery - A small cut (a couple of centimeters wide) is made in the lower belly. The skin is pulled aside so the surgeon can see and work directly on the child. This is the only surgical technique used in many hospitals. However, Nationwide Children’s Hospital reserves open surgery only for patients who are not good candidates for minimally invasive surgery.
- Robotic surgery – Several tiny cuts (several millimeters wide) are made in the belly. The surgeon uses a computer to control the robotic arms, which move small tools underneath the skin to do the operation.
The Mitrofanoff procedure is often done at the same time as other operations. When this is the case, surgeons at Nationwide Children’s will try to use the same cuts for all of the procedures. This may speed healing and keep pain and scarring to a minimum.
The Mitrofanoff procedure is done for children who can not urinate on their own. Many of these children use traditional catheters before surgery. These catheters are inserted through the urethra, the normal place pee exits the body. However, catheters through the urethra can cause pain in boys and may be difficult for girls to put in because of their anatomy. Girls who use wheelchairs are often not able to put in a catheter unless they sit on a toilet, which can make them less independent.
In some cases, children for whom it is difficult to catheterize through the urethra may stay in diapers. In others, the sphincter muscles do not work well and the child continues to leak into a diaper. Diapers can become socially uncomfortable for children as they age. The smell of urine and its impact on the skin and any wounds in the diaper area can lead to low quality of life.
After a Mitrofanoff procedure, children can empty their bladders without diapers, without needing to transfer to a toilet, and without catheterizing through the urethra. This makes it easier and more comfortable for many children to empty their bladders. They can stay dry between catheterizations. In the case of many wheelchair users, it allows more independence, since children can catheterize themselves through the opening on their belly or in their belly button.
Mitrofanoff procedures are often done for children with:
- Spina bifida and myelomeningocele
- Spinal cord injuries
- Neurogenic bladder or non-neurogenic neurogenic bladder (Hinman syndrome)
The Mitrofanoff procedure is not an emergency surgery. You will schedule the operation in advance. A nurse from Nationwide Children’s will call 1-3 days before the operation to give instructions. Mitrofanoff procedures require a stay of 4 to 7 days at the hospital.
If your child has constipation problems, or is undergoing robot-assisted surgery or multiple operations at the same time, he or she will need to arrive a day before the scheduled surgery to help clean out their bowels.
- Early admission and bowel prep are not required for every child. However, if your child needs to arrive a day early, your child will start a liquid diet at the hospital to help clean out the bowels in time for surgery. This bowel prep may include a feeding tube or enema. This gives more room for the surgeon to work inside the belly.
- No matter what surgery technique is being done, your child will have to stop eating and drinking by midnight the night before the surgery.
- Early the next morning, your child will be put to sleep for the operation using medicine (general anesthesia).
- Your child will be given at least one dose of antibiotics through an IV (a needle and tube going into the arm). This will help lower the chance of infection at the site of the cuts.
- The surgery will last between 3-6 hours. A surgery nurse will come out from time to time to let you know how your child is doing.
- In the recovery room, your child will be checked for complications and given pain medicine.
- There will be at least two catheters in place after the surgery: one in the new Mitrofanoff tube plus one in the urethra and/or one suprapubic catheter (through a cut in the belly). These will drain into a bag.The tubes will be temporary but you will go home with them for a few weeks.
- Your child may not be allowed to eat or drink for a period of time at the hospital. They will then start a clear liquid diet and eventually a regular diet.
Your child’s catheters must stay in place for 3-4 weeks after the surgery. This allows the swelling to go down and the cuts and new tube to heal. You will have to return to the hospital for a nurse to remove the catheters. You and your child will also receive training from a nurse to learn how and when to catheterize using the new tube through the belly button. The nurse will provide some initial supplies and connect you with resources for home shipping for supplies in the future.
About 1 month after the surgical catheters come out, your child will need a follow-up ultrasound to check for swelling in the kidneys. This will let the doctor know if the surgery worked to effectively drain your child’s urine. Your child will also need an ultrasound at least every year to keep checking kidney health.
You should also expect the following after the Mitrofanoff procedure:
- The cut skin is usually closed with internal, absorbable stitches and skin glue (except for the new hole on the belly where the but connects, which stays open). The stitches disappear on their own and do not require any special removal or care.
- Your child can wash by sponge bath for the 2 days following the surgery. After that, showers are acceptable. Once the catheters are removed, baths are also okay.
- The cuts and catheters may be sore for a few days or weeks.
- Gym class, strenuous activity and heavy lifting should be avoided until the catheter is removed.
- Wheelchair transfers can begin again about 2 weeks after the operation.
- Your child must rinse (irrigate) the bladder once a day. This will be part of your child’s new routine. The rinse helps clear out mucus made by the appendix tube. If your child does not rinse the bladder, he or she may get kidney stones or infections.
You should call the doctor or seek medical attention for your child after the Mitrofanoff procedure if your child:
- Has a fever of 101°F or higher before the first follow-up visit
- Cannot pass urine through the catheter
- Passes blood through the catheter
- Accidentally pulls the catheter out
- Complains of severe pain in the belly, side or back that isn’t helped by the pain medicine they are given at discharge
- Has symptoms of a urinary tract infection (UTI) or kidney infection
- Feels pain or a blockage when catheterizing (once the surgery catheter is removed).
Mitrofanoff procedures allow intermittent catheterization – once every few hours. This offers a lower risk of infection than a permanent (indwelling) catheter and allows one to not leak urine continually like an ileovesicostomies, which drain from a hole (stoma) in the belly into a bag.
After mitrofanoff, children do not have to wear diapers and can stay dry between catheterizations. They can often empty their bladders independently and without transfer to a toilet. The opening in the belly is very small; most are hard to see even when looking at the belly. All of these characteristics of the Mitrofanoff procedure may help it improve children’s quality of life.
In general, the risks of the Mitrofanoff procedure include those of any surgery, such as infection, redness, swelling, bleeding, reactions to the anesthesia or failure of the operation. During surgery on the bladder, urine can also leak into other areas and cause some irritation.
Mitrofanoff operations also carry several unique risks. Since the appendix is being partially detached and moved, there is a low risk of internal bleeding. It is possible that after a Mitrofanoff there may be problems catheterizing. Sometimes a different size catheter or more lubricant will solve the problem. The catheters put in place during surgery also make infections more likely than with other surgeries, but your child will receive a course of antibiotics during the recovery period to help avoid infections. The new hole in the belly may also leak. Finally, children who gain a lot of weight in the future may have problems catheterizing the opening.
The Mitrofanoff procedure has a high success rate. However, most children will eventually need another operation to adjust the appendix tube or fix problems, such as scarring that blocks the new opening to the belly. In many cases, these surgeries are minor and your child will not need an overnight stay at the hospital.
- Why do you recommend the Mitrofanoff procedure?
- What surgical techniques are available, and which do you recommend for my child?
- What are the alternatives to this surgery for managing my child’s incontinence?
- What are the pros and cons of this surgery versus the alternative options?
- Will my child need other operations at the same time?
- What will life be like with a catheter channel in the belly or at the belly button?
- How do you choose the location of the channel?
- What type of catheterization schedule will my child need to follow?
- What does my child need to do to be self-sufficient once the operation is done?
- Are there other patients or families who might be willing to speak about their experience with the Mitrofanoff procedure?
At Nationwide Children’s, our goal is to get your child the help they need with the shortest possible recovery time. That is why we offer minimally invasive surgery for the Mitrofanoff procedure. Although we do perform open surgery when needed, robot-assisted Mitrofanoff procedures can help decrease pain, shorten hospital stays, speed recovery, and leave your child with less noticeable scars.
If the Mitrofanoff procedure is the right option for managing your child’s continence needs, talk to our surgeons about minimally invasive surgery. We will evaluate your child’s health needs to find out if your child is a good candidate for our robot-assisted surgical technique.
