MONTI as continent catheterized stoma using serosal-lined trough "Ghoneim Abolenin" technique in ileocystoplasty.

It is a great challenge to select and perform continent mechanism in a stoma for urinary reservoir. A new technique by combining MONTI ileal conduit with the serosal lined trough in order to achieve continent catheterizable stoma to the umbilicus as a part of augmentation ileocystoplasty. We applied serosal-lined trough as a continent mechanism with MONTI ileal tube in 12 years smart girl underwent ileocystoplasty for neuropathic bladder due to meylomeningocele in whom continence failed to be achieved by using Mitrofanoff with submucosal tunnel of the bladder as continent mechanism before, also the previous operation included left to right transuretero-ureterostomy, ureterocystoplasty and reimplantation of the right ureter. The patient became completely continent; she was able to do self-catheterization easily through the umbilical stoma using 16-French catheter and was able to wash the mucous easily. The capacity of the augmented bladder was 300ccs. She became independent from her mother and stopped using diapers, anticholinergic and antibiotics. Combining MONTI conduit with serosal-lined extramural valve trough (The Ghoneim technique) is an effective continent technique and gives wider channel for catheterization and washing out the mucous.

INTRODUCTION

Continence mechanism of the urinary stoma is challenging, especially in redo and complicated cases. Choosing the proper conduit also remains a difficult task and individualized. Also, the decision to choose the appropriate augmentation type sometimes is not easy and the decision to augment itself is not simple thing nowadays in the presence of many anticholinergic drugs in the market and the era of BOTOX intravesical thical injection.

In cases of high pressure neuropathic bladder that have failure of the conservative management like recurrent breakthrough febrile urinary tract infections, persisted urinary incontinence, developing of new scars and also failed to be independent like our case, the surgical option for augmentation and saving continence is there.

CASE REPORT

A 12-year-old smart girl and known case of neuropathic bladder due to myelomeningocele. As neonate, she had undergone repair of myelomeningocele and started on clean intermittent catheterization with prophylactic antibiotic. At age of 5, she started to have recurrent febrile urinary tract infections 2-3 times per year, which required hospitalization many times every year. Furthermore, she was incontinent In spite of intermittent catheterization performed by her mother every 4 hour and oral anticholinergic medication. Follow-up DMSA scan showed appearance of new scars with deterioration of renal function the left kidney was more than the right.

The goal of management was to protect upper urinary tract and to keep the patient dry and to be independent of her mother. At physical examination; looked smaller for her age, smart, on wheel chair, spastic paraplegia and moving her upper limbs freely. CBC, chemistry within normal values, urinalysis and culture showed recurrent growth of E. coli bacteria. M.C.U.G showed small capacity, severely trabeculated bladder, grade IV left vesico-ureteric reflux and obstructed right ureter. Ultrasound showed bilateral severe hydronephrosis with scarred kidneys, dilated ureters and thick, trabeculated bladder wall. DMSA; multiple bilateral renal scars, split renal function Right 42.4 % Left 57.6 %. Urodynamic study showed low compliance with bladder capacity 70 ml and detrusal leak point pressure was 60 cm water.

Initially the patient underwent left to right transureterureterostomy with ureterocystoplasty and Mitrofanoff appendicovesicotomy. Post operatively, the upper urinary tract function preserved. But the patient exhibited difficulty in carrying out self-catheterization causing cellulitis around the stoma, which required multiple hospitalizations for intravenous antibiotics. Also, she had a leak through the umbilical stoma with a bladder capacity of 150 ml that made her to wear diaper.

In reviewing the case, 12 years talent girl on wheel chair can take care of herself had the upper urinary tract saved and became off of febrile urine infection, became wearing diaper and can not catheterize herself properly, and had recurrent umbilical stomal cellulites. The plan was

To revise the augmentation to make the bladder bigger.

To use the ileum for that purpose.

Revise the Mitrofanoff to have wider conduit that can be utilized for easy intermittent catheterization and washing out the bowel segment mucous.

To achieve continence through the umbilical stoma.

The decision was made to perform ileocystoplasty and MONTI conduit to the umbilicus with serosal lined trough for continence.

She was admitted and had undergone augmentation ileocystolasty using an ileal segment almost 30 cms away from the ileo-cecal junction. The segment was 25 cms in length and was folded as s-shape and opened on anti-mesenteric border. The mitrofanoff appendix was found patent bur severely fibrotic and was excised, MONTI segment was prepared from the proximal ileal end, 5 cms length and divided into two segments 2.5 cm each. Each one was opened close to the mesenteric border in opposite side. Each segment created almost 7 cms length segment each was sutured to make one segment 14 cms in length [Figure 1], and was tabularized over 20 French Foley's catheter [Figure 2]. The distal coil of the ileal segment was sutured together from the serosa to create a bed for the MONTI using serosal lined trough (Ghoneim-Abolenin) technique [1-3], which was brought to lie over its bed, and the distal opening was anastemosed to the ileal augment keeping the Foley's catheter balloon inside the bladder.

Figure 1

Both segments were anastemosed near the mesentry

Figure 2

The MONTI segments were tubalarized

Then, the edges of the ileal coil sutured together to cover the MONTI creating the trough [Figure 3]. The other end of the conduit was brought out through the umbilicus and stoma was created with simple V-Y plasty. The proximal and distal ends of the ileum were anastemosed and bowel continuity was ensured.

Figure 3

The MONTI conduit was brought to lie on the trough bed and the edges of the ileal segment closed over the MONTI

The ileal patch was sutured to the bladder in watertight manner. The continence of the MONTI stoma was tested intra-operatively and there was no leak. Also the patency of the conduit was checked and found patent, the augment was anchored to the sacral promontory, drains were inserted and mass-closure of the wound was done.

Immediate postoperative period was uneventful and all stents and drains were removed accordingly. The MONTI catheter was removed for three weeks in the clinic. On follow-up, cystogram through Foley's catheter showed capacity of 250ccs with complete continence and no leak through the stoma. Now, she is doing the self-catheterization through the MONTI stoma 16-French catheter independently and mucous wash every second day. Also, she was started on NaHCO3625 mg twice daily and no more antibiotics nor anticholinergic.

Comments

The utilization of the bowel for augmentation is still on, the type of diversion and the use of MONTI conduit with combination of serosal trough for continence is a good technique that leads to

Achieve continence.

A large caliber catheter can be used for bladder wash.

Easy catheterization.

Previous appendectomy cases.

Can be at any length needed up to 15 cm length.

We believe that this technique is promising and need to be studied more; also, longer follow-up is required.