To evaluate the success and complications associated with using the appendix as stoma in mitrofanoff procedure in a pediatric age group.The management of bladder dysfunction is complex phenomena with patients suffering from it may face many challenges and complications for preservation of continence.

The study was conducted after approval of the institutional review board and informed consent was taken from every patient before participation in the study.
This was a prospective study that was conducted between January 2020 to January 2022 at Menoufia university hospital and Alexandria university hospital.  The study included 30 patients (18 male and 12 female) who underwent appendico-vesicostmoy using the appendix as a stoma attached to the urinary reservoir with non-refluxing mechanism in the posterior wall of the bladder. 
All children were reviewed post operatively at 2 weeks then every 3 months. Each visit included regular imaging of the upper urinary tract by ultrasound, VCUG was done if recurrent febrile UTI. Serum biochemical measurements including creatinine, urea, Na and K level were made at each clinic visit together with the assessment of symptoms.   
Operative procedure, Abdominal exploration and preparation of the bladder were done for augmentation if necessary. The appendix was divided from cecum with preserving its blood supply then mobilized and attached at one end with the posterior wall of the bladder with antireflux submucosal mechanism. The appendix was stretched to prevent angulation then attached by the other end to the umbilicus in 20 cases (66.7%) or to the lower abdominal wall in 10 cases (33.3%). Catheterization of the stoma was done after closure of the urinary reservoir to check the patency and the ease of CIC. The catheter was left for 2 weeks in the stoma.

The study included 30 patients. 18 (60%) of them were male and 12(40%) were female. Twelve patients (40%) were less than 10 years and 18 patients (60%) with age ranged from 10-15 years. The reason for bladder augmentation was neurogenic bladder in 22 patients (73%) (posterior urethral valve in 12 patients (40%) and spina bifida in 10 patients (33%), bladder exstrophy complex in 2 patients (7%) and complex urethral stricture in 6 patients (20%).
There were no complications in 22 cases (73.3%). There was one case (3.3%) with stomal stenosis. Urinary tract infection (UTI) was reported in 3 cases (10%). Incontinence was reported in one case (3.3%) and the patient refused any intervention. Prolapse of the stoma in one case (3.3%) requires revision of stoma.  Difficult stomal catheterization was reported in 2 cases (6.8%).

In our study, there were 20 cases (66.7%) with umbilical fashioned stoma and 10 cases (33.3%) with the stoma fashioned at the  lateral abdominal wall below umbilicus which was similar to Süzer et al. who reported  no significant differences  between the two sites. [9]
In our study, there was one  case (3.3 %) of post-operative stoma stenosis that underwent endoscopic dilatation which was similar to stomal stenosis rate  published in the literature that  vary from 3% to 61%.[10, 11]
Liard et al. have the longest follow-up of 20 years and had stomal stenosis rates of up to 61%, compared with Horowitz et al. who only had a 3% stomal stenosis rate. This may be due to short follow-up. [12, 13]
In our study there were 3 cases (10%) that developed post-operative UTI. The incidence of UTIs has not been widely reported in many other studies. Apart from the risk factors such as the use of clean intermittent self-catheterization and intestinal augmentation, compliance has been reported to be one of the pre-disposing factors for UTI. Patients who do not empty their bladder regularly seem to have a higher incidence of UTI.[14, 15]
In our study, Continent rate was 96.7 % with only one case with incontinence that refused any other intervention for repair .This was similar to that reported by the literature (79% and 100%).[13, 16]
In our study There was one case of prolapse( 3.3%) managed with refashioning of the stoma, while in other studies, The incidence of stomal prolapse requiring revision appears to be between 2–5% .[8, 9]
In our study the main concern was to create a continent catheterizable conduit that is easily accessible to the patient’s dominant hand. There was two cases with post repair difficult catheterization (6.8%) which was managed with endoscopic catheterization for two week then the patient could do (CISC). According to the literature, difficult catheterization occurs in up to 30% of patients with CCC and over 50% will ultimately require surgical revision.[17] The significant differences in our study was due to  the short term (9 months) follow up in our study as the incidence may increase with time due to severe scarring and stenosis of stoma.

The principles set out by Mitrofanoff have enabled the development of a continent, catheterizable abdominal conduit. Such conduits have provided new options for lower urinary tract management in patients for whom urethral self-catheterization is either impossible or unacceptable.

Süzer O, Vates T, Freedman A, Smith C, Gonzalez R. Results of the Mitrofanoff procedure in urinary tract reconstruction in children. British journal of urology. 1997;79(2):279-82.
Thomas JC, Dietrich MS, Trusler L, DeMarco RT, Pope JCt, Brock JW, 3rd, et al. Continent catheterizable channels and the timing of their complications. The Journal of urology. 2006;176(4S):1816-20.
Harris CF, Cooper CS, Hutcheson JC, Snyder HM. Appendicovesicostomy: the Mitrofanoff procedure—a 15-year perspective. The Journal of urology. 2000;163(6):1922-6.