Continent cutaneous derivation (CCUD) is a useful treatment strategy for neurogenic lower urinary tract dysfunction (NLUTD) patients who are unable to perform clean intermittent catheterization (CIC). This can happen due to loss of upper-limp dexterity, difficult urethral access, or anatomical destruction of the urethra. Mitrofanoff appendicovesicostomy or Yang-Monti ileovesicostomy are surgical techniques which allow the use of the appendix or a transverse ileal tube, respectively, as alternate conduits to bypass the native urethra for CIC. While the former is the most frequently performed CCUD, the latter is an alternate procedure when the appendix is unavailable or unsuitable. These techniques aim to restore an adequate bladder emptying with long-term continence and, therefore, prevent future renal function deterioration, decrease urinary tract infections, and improve quality of life. The advantages of the minimally invasive approaches include reduced intraoperative bleeding and postoperative pain, quicker recovery with shorter hospitalization length and better cosmetic results. Despite the more and more common use of robotic techniques, laparoscopy might still be an optional minimally invasive approach, due to its decreased costs and higher availability. Long-term efficacy and safety data regarding these procedures is still scarce. The objective of this study is to report our experience with laparoscopic appendico and ileovesicotomies in adult patients with NLUTD.

We retrospectively review all patients submitted to CCUD, either Mitrofanoff or Yang-Monti procedure, in a single institution from January 2014 to March 2023. All surgeries were performed laparoscopically by one experienced surgeon. Data collected included demographics and baseline characteristics; surgical procedure details; early post-operative results and complications and long-term outcomes in terms of urinary continence, ability to catheterize the stoma, renal function, late complications and global satisfaction rate.

A total of 12 patients underwent CCUD over a 9 years period. A Mitrofanoff appendicovesicostomy was perfomed in 8 patients, while Yang-Monti ileovesicostomy was completed in 4 patients. Augmentation enterocystoplasty was required in 3 patients due to low bladder compliance.  Mean age at the time of surgery was 49.92±0.64 years-old, female to male ratio was 2:1 (8 females and 4 males). Concerning the aetiology of NLUTD, 8 were due to traumatic spinal cord injury, 2 multiple sclerosis, 1 myelomeningocele and 1 medullary ischemia. Six patients were tetraplegic (50%). Seven patients (58%) performed self-CIC while 5 (42%) needed help from a caregiver for CIC. Mean operative time was 156.67±0.67 minutes, with a slightly higher value in the Yang-Monti procedure, and intraoperative blood loss was minimal. In 91.7% the umbilicus was the local of choice for the cutaneous stoma (n=11). No need for laparotomy conversion was reported. The median length of hospitalization was 6 days (IQR 5.00-6.75), similar for both types of surgery. 
Median time of follow-up was 82 months (IQR 7-85). The global complication rate was 83%. Stoma stenosis was the most common complication (50%) and the only reported early (<3 months) complication. Half of these patients were treated conservatively while the other 50% required surgical revision. Four patients showed stress urinary incontinence (SUI) through the native urethra (33%), 3 of which were treated surgically with midurethral sling . Two patients had urinary tract infections (UTI), one managed with oral antibiotics and other complicated in fatal urosepsis. One patient developed bladder lithiasis and was treated endoscopically with LASER lithotripsy. One patient developed BCG-refractory urothelial bladder tumour and was proposed for pelvic exenteration and Bricker ureteroileostomy. One patient had idiopathic sporadic episodes of haematuria which were conservatively managed, and another one had a urinary infection treated with oral antibiotics. At the time of the last assessment, mean creatinine was 0.51±0.64mg/dl and mean Glomerular filtration rate (CKD-EPI) was 115.96±0.66 mL/min/1,73m2. Regular urological ultrasound showed non-significant post void residual and no upper urinary tract dilation. Currently, 75% have a catheterizable continent stoma (2 patients died from UTI and respiratory infection and 1 had conversion to non-continent urinary diversion) with a mean 6.5±0.75 CIC per day. The global satisfaction rates were positive, with all the patients reporting a moderate-to-significant increase in quality of life.

CCUD is a challenging technique with non negligible complication rates. However, nearly half of the complications were managed conservatively and the patients who required intervention underwent uncomplicated procedures, such as stoma revision, midurethral sling implantation or endoscopic stone treatment. Decision not to close the bladder neck, despite the higher risk of SUI, was made considering the potential need of endoscopic access in case of conduit or anastomosis complications and to prevent high intravesical pressures with the risk of ureteral reflux or bladder perforation. The laparoscopic approach did neither increase the operative time compared to other series, nor the intraoperative complications compared to open or robotic approach. Our series showed a reasonable continence rate, with a good stoma catheterization rate, allowing for a significant increase in autonomy and quality of life. At a mean follow-up of nearly 7 years, the postoperative creatinine and glomerular filtration rate maintain stable values which, considering the absence of upper tract dilation on ultrasound, show the effective role of these procedures in preventing renal function damage.

CCUD are feasible and safe in adults with NLUTD. However, considering their significant complication rate, adequate patient selection, multidisciplinary evaluation and careful expectation management are of utmost importance for optimal results. The laparoscopic technique allows a less invasive approach with better recovery. These patients should be followed in referral and high volume centres as further studies with larger samples are still deemed necessary.

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