Clean intermittent catheterization (CIC) is one of the main tools for neurogenic lower urinary tract dysfunction management, as it provides adequate bladder emptying and protects the upper urinary tract from high pressures, hence preventing progressive renal damage. It also lowers the risk of urinary tract infections. Despite its important role, CIC is difficult to perform in various situations: lack of manual dexterity, female wheelchair patients, body habitus, anatomical morbidity due to extensive surgery or psychological problems. For such patients, continent urinary diversion (CUD) is a viable option for bladder emptying optimization. The cutaneous appendicovesicostomy, initially described by Mitrofanoff, remains one the most commonly performed CUD, especially in the pediatric population. This work aims to describe the technique of laparoscopic appendicovesicostomy using the Mitrofanoff principle in an adult neurogenic female patient.

We present a case of a 72 years-old female with multiple sclerosis diagnosed 22 years ago. Disease progression caused mobility restriction with paraparesis and underactive bladder. She initiated CIC 7 to 8 times per day. Cystometry showed a compliant bladder, with adequate capacity and minor leakage secondary to low amplitude detrusor overactivity. Pressure-flow study revealed detrusor underactivity with a high post-void residual volume. Increasing difficulty in CIC caused by wheelchair confinement and motor restraints prompted the proposal for CUD through a minimally invasive technique.

The patient is positioned in lithotomy with slight Trendelenburg. Six ports are placed: one 11mm supraumbilical; another 11mm in the right pararectal line laterally to the umbilicus; and further 4 ports of 5mm, one half-way between the umbilicus and the pubic symphysis, one on the right pararectal line and two medial to the left and right anterior superior iliac spines. The procedure begins with the identification of the appendix and its length and caliber assessment. The appendix should have at least 5cm and be capable to accommodate a minimum 10–12 Ch catheter. The right colon is mobilized, and the appendix is sectioned at its base after placing an absorbable ligation. A silicone 14Ch catheter is introduced in the appendix and the mesoappendix is dissected to achieve adequate mobilization without compromising the vascularity. The bladder is then dissected from the abdominal wall. Three straight needle stay sutures are placed at the dome of the bladder for retraction and exposition of the posterior wall. After bladder suspension, a vertical detrusor incision of 5cm is performed in the posterior midline until the mucosa of the bladder is visualized. The bladder mucosa is then opened approximately 1 cm in length. The apenddicovesical anastomosis is performed using a 3/0 absorbable barbed suture, followed by 3 interrupted absorbable monofilament stiches to create a Lich Gregoir anti-reflux subserous tunnel. Finally, the other end of the appendiceal conduit is brought to skin surface through an umbilical port where a catheterizable stoma is created. Operative time was 135 minutes and minimal blood loss was recorded. The patient was discharged at day 4 post-operative without complications. The stoma catheter was removed two weeks after the surgery ensuring that the patient could catheterize the stoma easily. Currently, the patient has gained significant autonomy and increased quality of life. Occasional detrusor overactivity is managed with anticholinergics.

Despite being challenging, laparoscopic Mitrofanoff appendicovesicostomy is a feasible and safe procedure when performed by experienced surgeons. This technique offers a significant increment in autonomy and better quality of life, while minimizing the risk of upper urinary tract deterioration. The minimally invasive technique allows for a better post-operative recovery with less pain, shorter hospital stay and better aesthetic results.

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Mitrofanoff P. Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques [Trans-appendicular continent cystostomy in the management of the neurogenic bladder]. Chir Pediatr. 1980;21(4):297-305
Rey D, Helou E, Oderda M, Robbiani J, Lopez L, Piechaud P-T. Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique. BJU Int. 2013;112: 953–958

Continence 7S1 (2023) 100798
DOI: 10.1016/j.cont.2023.100798