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Split appendix technique is safe and effective for creation of simultaneous Mitrofanoff and MACE conduits
Christopher Bean, MD, Brian VanderBrink, MD, Eugene Minevich, MD, Shumyle Alam, MD, Paul Noh, MD, William Defoor, MD, Pramod Reddy, MD.
Cincinnati Children's, Cincinnati, OH, USA.

BACKGROUND: Patients undergoing creation of a Mitrofanoff (MF) during continent urinary reconstruction frequently require a Malone antegrade continence enema (MACE) for management of neurogenic bowel. The appendix is commonly used to construct one or both of these channels. Previously we reported a split-appendix technique for simultaneous creation of continent catheterizable channels (CCC). We examined the outcomes of patients in which the appendix was used for both MF and MACE creation during continent urinary reconstruction.

METHODS: A retrospective chart review was conducted on patients that underwent lower urinary tract reconstruction during the past 10 years. Data analyzed included patient age, sex, indication for reconstruction, length of follow up, segment of bowel used for the CCC, and complications.

RESULTS: A total of 62 patients, 35 males and 27 females, were identified in which the split-appendix was used for the simultaneous creation of a MF and MACE. Mean patient age was 8.3 years (2-16yrs). Average length of follow up was 36.4 months. The indication for reconstruction was neurogenic bladder secondary to multiple etiologies including myelomeningocele in 51%, anorectal malformation in 25%, spinal cord injury in 8%, and other etiologies in 16%. Nine patients required MF revisions: 5 for stomal stenosis (SS), and 1 each for mucosal prolapse (MP), false passage, incontinence, and stomal retraction. One patient required a second revision for SS due to keloid formation. Four patients had urinary incontinence from the MF: 3 due to poor bladder compliance and one patient with inadequate submucosal tunnel. MF incontinence improved with bladder augmentation in 3, and 1 patient ultimately requested an ileal conduit for continued urinary incontinence. MACE revisions were performed in 17 patients: 13 for SS, 2 each for fecal incontinence and false passage, and 1 for mucosal prolapse. One patient with a false passage no longer uses the MACE. All 9 patients that required MF revisions also required MACE revision during follow up.

CONCLUSIONS: The appendix is a suitable and preferable structure for CCC. When possible the appendix should be split to create both MF and MACE. Complications were usually minor and mostly due to skin level SS.

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