Neurogenic lower urinary tract dysfunction is a frequent consequence of spinal cord lesions. This dysfunction is heterogeneous, with patients suffering from detrusor over or underactivity, and often a combination of both. Clean intermittent catheterization (CIC) is a commonly used tool to facilitate voiding and improve quality of life. However, patients with mobility disabilities frequently describe difficulties in transferring themselves to the bed in order to perform CIC, often requiring the help of a caretaker. Continent diversions such as the Mitrofanoff procedure may overcome this problem, allowing for the voiding to take place while sitting in a wheelchair, for example.

We describe the case of a 67 years old female patient, paraplegic after a spinal cord trauma in 2010. She performed self-catheterization 6 times per day, but still complained of frequent urinary incontinence between catheterizations. Her Urodynamic study revealed a severe detrusor overactivity in the filling phase, with associated urinary incontinence and a functional bladder capacity of only 120 mL. She also reported an increasing difficulty in self-transferring to the bed, in order to perform CIC. Previously, the patient had been submitted 3 times to Botulinum toxin injections (200 units), with a fair, although short-lasting, remission of symptoms.
With the intention of increasing bladder capacity and providing a continent catheterizable urinary diversion, we proposed a laparoscopic augmentation ileocistoplasty and Mitrofanoff procedure, which the patient accepted.
The procedure consisted of the following: 1) identification, ligation and mobilization of the appendix; 2) incision of the tip of the appendix and its catheterization; 3) resection of the superior part of the bladder; 4) incision in the posterior wall of the bladder and anastomosis between appendix and bladder; 5) extracorporeal (through midline incision) selection of ileum segment, division and ileoileostomy; 6) longitudinal incision and W plasty of the ileum patch; 7) ileum patch suture to the bladder; 8) cutaneous appendicovesicostomy. The surgery had a duration of 4 hours, with blood loss of around 200 mL.

The urethral bladder catheter was removed at D2 post-op and the patient discharged at D7. 2 weeks after the surgery, the appendicovesicostomy catheter was removed and the patient started to perform CIC through it, with no difficulty. 
In a post-op evaluation at 3 months post-op, the patient was performing CIC 5-6 times/day and reported no incontinence. No complications were observed in this follow-up period.

In paraplegic patients with neurogenic overactive bladders, there is often a reduction in bladder capacity, which can be managed with an augmentation cystoplasty. However, a high number of these patients will require intermittent catheterizations, which often require a transfer to a bed, especially in women, potentially reducing their autonomy and quality of life. Therefore, combining augmentation cystoplasty with the construction of a catheterizable conduit, such as the Mitrofanoff procedure, offers the opportunity of an easily-catheterizable low-pressure high-capacity reservoir.

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. French. PMID: 7408090
Fan YH, Shen YC, Hsu CC, Chow PM, Chang PC, Lin YH, Chang SJ, Jiang YH, Liao CH, Wang CC, Wu CT, Kuo HC. Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury. J Clin Med. 2023 Feb 10;12(4):1400. doi: 10.3390/jcm12041400. PMID: 36835937; PMCID: PMC9963408
Mostafa MM, Khallaf A, Kamel M, Patil N, Mahdy A. Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction. Arch Ital Urol Androl. 2022 Dec 27;94(4):384-389. doi: 10.4081/aiua.2022.4.384. PMID: 36576458

Continence 12S (2024) 101399
DOI: 10.1016/j.cont.2024.101399