The Mitrofanoff procedure: 20 years later

Purpose: We review our initial cases of continent cystostomy to assess long -term functional results and complications after a minimum of 15 years of f ollowup. Materials and Methods: Between 1916 and 1984, 23 continent cystostomies wer e performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup w as 20 years (range 15 to 23). The neurological lesions were due to 21 myelo meningocele (2 associated with an imperforated anus in 21 cases), spinal ne uroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cas es (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases , I ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patie nts presented with unilateral or bilateral secondary vesicoureteral reflux. Results: One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection . The remaining 22 patients were followed every 6 to 12 months. No metaboli c disorder, secondary malignancy or spontaneous bladder perforation was not ed. Bilateral upper tract deterioration was found in 10 cases leading to se condary bladder augmentation by enterocystoplasty in 6 and creation of nonc ontinent diversion in 4. Leakage occurred after bladder neck closure in 5 p atients. Bladder stones were found in 5 patients (2 had prior bladder augme ntation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or rep eated dilations and 1 noncontinent diversion after revision failure. Five p atients presented with intestinal occlusion due to volvulus in 3 and adhesi on in 2. We noted that after 10 years of followup complications were rare a nd concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion. Conclusions: The rate of complications has a tendency to decrease with time . The results obtained in this series may appear less satisfactory than tho se of more recent series, which may be due to the fact that these oldest co ntinent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was no t yet established and bladder augmentations were not routinely performed. S ince 1984 no continent cystostomy performed at our institution was converte d into a noncontinent diversion. This series with long followup demonstrate s that continent cystostomy is a procedure with lasting efficiency.