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British Journal of Urology (1998), 81, 253256

Transversely tubularized ileal segments for the MitrofanoV


or Malone antegrade colonic enema procedures:
the Monti principle
I.D . SUGARMAN, P .S. MALONE, T .R. T ERRY* and M. A. KOYLE
Department of Paediatric Urology, Wessex Department of Paediatric Surgery, Southampton General Hospital, *Department of
Urology, Leicester General Hospital, UK and Department of Pediatric Urology, The Childrens Hospital, Denver, Colorado, USA

Objective To assess the use of a transverse tubularized


segment(s) of ileum in the MitrofanoC or Malone
antegrade colonic enema (MACE) procedures.
Patients and methods Eleven patients in three centres
underwent the formation of a continent conduit to
bowel (MACE, eight patients) and/or bladder
(MitrofanoC, four) using either a single segment of
transverse tubularized ileum (10 patients) or two
segments of ileum anastomosed and tubularized into
a single conduit (two).

Introduction
The treatment of urinary and faecal incontinence has
improved dramatically over the last two decades, after
the introduction of the MitrofanoC principle and the
Malone antegrade colonic enema (MACE) procedure,
respectively [1,2]. For both of these procedures, the
appendix is the favoured catheterizable conduit but
problems arise when the appendix is absent or both
procedures are performed simultaneously [3]. Therefore,
diCerent conduits have been devised using tapered ileum,
caecal flaps, tubularized colon, gastric tubes, ureter,
fallopian tube, detrusor muscle, prepuce and button
devices [411].
Recently, Monti et al. described an experimental technique of transversely tubularizing a short segment of
ileum, converting a 2 cm segment into a 7 cm tube
which could then be reimplanted following the
MitrofanoC principle [12]. It was also shown that two
segments could be anastomosed to create a 14 cm tube.
We have adapted this technique to clinical practice and
present the preliminary results.

Patients and methods


Eleven patients (450 years old) in three centres underwent the formation of a transverse ileal tube conduit.
Accepted for publication 15 October 1997
1998 British Journal of Urology

Results Within a follow-up of 8 weeks to 6 months, all


conduits were continent and catheterized easily. One
stomal stenosis required a revision procedure.
Conclusion This method for forming a continent catheterizing conduit, based on the MitrofanoC principle,
appears to be eCective and is recommended in cases
where the appendix cannot be used or where a second
conduit is required.
Keywords Incontinence, conduit, MitrofanoC principle

Nine had spina bifida and two had high anorectal


malformations. The conduit was used for the MACE
procedure in eight and MitrofanoC in four (patient no. 10
had a Monti conduit for both bowel and bladder). Seven
patients had a combined MACE and bladder reconstruction with a MitrofanoC, three had an isolated MACE and
one an isolated MitrofanoC. In nine patients a singlesegment tube was constructed and in two a composite
tube, using two segments of ileum; their details are
shown in Table 1.
Technique
One or two ileal segments 2 cm long are isolated (Fig. 1).
The ileum is divided longitudinally either on the antimesenteric border or eccentric to it, to produce a 7 cm ileal
flap from each segment, with the valvulae conniventes
now running in the longitudinal axis (Fig. 2). The bowel
is then tubularized over a 12 F catheter producing ends
free of mesentery to facilitate the creation of an antireflux
tunnel, and an exit through the abdominal wall (Fig. 3).
When two segments are used they are anastomosed at
their mesenteric ends to produce a 14 cm conduit
(Fig. 4). For those patients undergoing a MACE procedure, the conduit is implanted into a 45 cm submucosal tunnel along a taenia. For the MitrofanoC, a standard
submucosal tunnel into the bladder was used. All conduits were brought out onto the abdominal wall, incorporating either a V skin flap or multiple flaps (VZQ) [13].
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14

SB

SB

SB

SB

HAR

SB

SB

SB

HAR

SB

SB

Diagnosis

6 months

5 months

4 months

8 weeks

6 months

6 months

6 months

6 months

6 months

6 months

8 weeks

Follow-up

S
S

MACE caecum
MitrofanoC
bladder

Single/double
ileal segment

MitrofanoC
bladder +

MitrofanoC
bladder
MACE
caecum
MitrofanoC
bladder

MACE
A colon
MACE
A colon
MACE
A colon

MACE
T colon
MACE
A colon

MACE
T colon

Conduit

Appendix MACE
Ileocystoplasty
Pippe-Salle UL

Appendix MACE
Ileocystoplasty
Pippe-Salle UL
Ileocystoplasty

None

Appendix MitrofanoC
Pippe-Salle UL
Appendix MitrofanoC
Ileocystoplasty
Pippe-Salle UL
None

Bladder neck closure


Ileocystoplasty
Appendix MitrofanoC
None

Bladder neck closure


Colocystoplasty
Appendix MitrofanoC
None

Other procedure
at same operation

Umbilical
MitrofanoC stoma
revised
MACE stoma Easy
Easy

Easy

Easy

Easy

Easy

Easy

Easy

Minimal ACE
stomal stenosis
Minimal ACE
stomal stenosis

Easy

Catheterization

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Continent

SB, spina bifida. HAR, high anorectal malformation. T, transverse. A, ascending. D, double. S, single. UL, urethral lengthening. F-C, faecally clean. U-D, urinary-dry.

50

11

11

11

17

10

15

Age
(years)

Patient

Table 1 Patients details, procedure, complications, follow-up and outcome

UD

FC
FC

UD
UD

FC

FC

UD
UD

FC
UD
FC

UD
FC

FC

UD
FC

FC

Outcome

254
I. D. SU GAR MAN et al.

1998 British Journal of Urology 81, 253256

C ONTINENT C AT HETER IZI NG CONDUI T B ASED ON T HE M ITR OFANOF F PRINC IPLE

1a

255

1b

Fig. 1. a. A single 2 cm ileal segment and b, two 2 cm ileal segments.

Fig. 2. Detubularized ileal segment 7 cm long; note the longitudinal


axis of the valvulae conniventes.

Fig. 4. A double-segment 14 cm conduit.

did so easily; the remaining two had slight diBculty in


catheterizing their ACEs, but neither catheterized the
stoma on the other days, as advised. They have since
done so and their diBculty resolved. Of the four patients
with a MitrofanoC, all are dry and have normal upper
tracts on ultrasonography. Three catheterized easily and
one patient underwent a revision procedure for an
umbilical stomal stenosis.

Discussion

Fig. 3. Seven centimetre tubularized conduit; note the free ends.

Results
The follow-up ranged from 8 weeks to 6 months
(Table 1). Six of the eight patients with the MACE
catheterized daily and two on alternate days; all the
conduits were continent. The six who catheterized daily
1998 British Journal of Urology 81, 253256

The MitrofanoC and MACE procedures have proved to


be useful for patients with urinary and faecal incontinence to become both dry and clean. If the appendix is
not available or, as is often the case, more than one
catheterizable stoma is necessary, another conduit is
required. In a few patients it is possible to split the
appendix to form the two conduits and results with this
are encouraging. Koyle et al. reported 14 patients in
whom this procedure was performed, with complete
success and minimal problems [14].
Longitudinal tubularized ileal conduits have been

256

I. D. SU GAR MAN et al.

described but revision rates of up to 30% have been


reported [4,7]. Most problems relate to catheterizing the
channel, as it will be at right-angles to the valvulae
conniventes. Tubularized caecal or colonic flaps fare little
better [10]. Gastric tube conduits are well described but
the problems of skin excoriation, with the possible
requirement for long-term H2-antagonist medication,
make this procedure less attractive [8,15].
Non-gastro-intestinal conduits are also fully described;
Woodhouse and MacNeily reviewed their experience
with ureter, fallopian tube and detrusor flaps [5].
Although the continence rate was 83% in these patients,
the revision rate was >40%, compared with 24% when
the appendix was used. For the ureter to be used
transuretero-ureterostomy is necessary, with its possible
complications [16]. Duckett and Lofti found that ureteric
conduits caused more discomfort than other conduits
and recommended that they were not used [6]. For a
detrusor tube, the bladder needs to have a high capacity
and be thin-walled, and the fallopian tube conduit
required revision in all three cases described by
Woodhouse and MacNeily [5]. The use of the prepuce
for continent vesicostomy was described by Krstic [9]
and in a subsequent study of eight patients, complete
success was reported [17]. However, if the patient is
female or a circumcised male, this conduit is unavailable.
Another restriction with this technique is that the position of the stoma is restricted to the lower abdomen.
Because of these problems, there is an obvious need
for a better conduit to replace the appendix when it is
absent or used for another channel. Although the followup of the present patients is short, the Monti principle
may well prove to be the ideal alternative to the appendix. It is created easily using a short segment of an
abundant tissue, producing a good calibre tube with
minimal loss of bowel length, and it configures the
valvulae conniventes in the longitudinal axis of the
conduit, facilitating easier catheterization. It can be
extended to 14 cm long, rendering the technique possible
even in very obese patients. The ends of the conduit are
free of mesentery, facilitating the creation of an antireflux
tunnel and the exit through the abdominal wall. As the
conduit is on a mobile mesentery, there is no restriction
on siting the abdominal wall stoma.

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Authors
References
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I.D. Sugarman, FRCS(Ed), Specialist Registrar in Paediatric


Surgery.
P.S. Malone, MCh, FRCS(I), Consultant Paediatric Urologist.
T.R. Terry, MS, FRCS, Consultant Urologist.
M.A. Koyle MD, FAAP, FACS, Consultant Paediatric Urologist.
Correspondence: Mr P.S. Malone, Department of Paediatric
Urology, Wessex Department of Paediatric Surgery,
Southampton General Hospital, Tremona Road, Southampton
SO16 6YD, UK.
1998 British Journal of Urology 81, 253256