|LETTER TO EDITOR
|Year : 2009 | Volume
| Issue : 2 | Page : 69
Resorption of distal appendix: A rare complication after Mitrofanoff's appendicovesicostomy
Dinesh Sarda, Gursev Sandlas, Parag Karkera, Paras Kothari
Department of Pediatric Surgery, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai - 400 022, India
|Date of Web Publication||26-Sep-2009|
Department of Pediatric Surgery, L.T.M. Medical College and General Hospital, Sion, Mumbai - 400 022
|How to cite this article:|
Sarda D, Sandlas G, Karkera P, Kothari P. Resorption of distal appendix: A rare complication after Mitrofanoff's appendicovesicostomy. Urol Ann 2009;1:69
|How to cite this URL:|
Sarda D, Sandlas G, Karkera P, Kothari P. Resorption of distal appendix: A rare complication after Mitrofanoff's appendicovesicostomy. Urol Ann [serial online] 2009 [cited 2019 Oct 21];1:69. Available from: http://www.urologyannals.com/text.asp?2009/1/2/69/56039
Mitrofanoff appendicovesicostomy as a conduit for clean intermittent catheterization (CIC) is a well-approved procedure in practice for the wide array of clinical situations. The vermiform appendix, if available, is found to be the best choice to construct the conduit. It has a good vascular pedicle. Its wall is compliant and thin enough to allow easy submucosal implantation.  Most common complications after Mitrofanoff procedure are non-catheterization and stomal stenosis. Appendix is well tolerated than other non-appendiceal conduits. Non-catheterization and stomal stenosis is relatively less common with appendix than others.  We report a unique complication that we encountered after the Mitrofanoff procedure.
A 12-year-old female child presented with continuous dribbling of urine since birth. She was operated for meningomyelocele in neonatal age, details of which were not available. On examination, she was having neuropathic ulcers over the feet. Bladder was not palpable. On micturating cystourethrogram (MCU), bladder capacity was small with wide bladder neck. Urodynamic study revealed small capacity bladder with decreased bladder pressure. Leakage could be observed after instillation of 30 cc of saline. Bladder neck plication with ileocystoplasty with Mitrofanoff procedure was done. Postoperative course was uneventful and she was discharged with advice about CIC. Mitrofanoff conduit was functioning well. However, the child presented again after 2 months with difficulty in catheterization. Patient was examined under anesthesia. There was stomal stenosis, which could be dilated using feeding tubes under anesthesia. Patient was discharged with advice of CIC as now stoma was catheterizable. After that, patient was lost to follow-up. Patient presented after 2 years with continuous dribbling of urine. In the intervening period, she did not do CIC. Micturating cystourethrogram was suggestive of good capacity bladder with wide bladder neck. The child was examined under anesthesia. Cutaneous stoma was negotiable. However, catheter could not be passed for more than 4 cm and was not draining the bladder. Bladder neck reconstruction with refashioning of Mitrofanoff stoma was planned. On exploration, to our surprise, appendix was lying free in peritoneal cavity with total disconnection from the bladder. Tip of the appendix was smooth. No stoma of appendicovesicostomy was found inside the bladder. Bladder neck closure with submucosal reinsertion of appendix was done.
Complete resorption in the distal part of appendix is not the documented complication after the Mitrofanoff procedure. Complications pertain primarily at the skin level, but may also occur in the channel itself.  Distal stomal stenosis can occur if the appendicular tip is not cut adequately at the time of anastomosis between the appendicular and bladder mucosa. No comment about such complication has been there in the literature. We postulate that such complication can occur if the submucosal tunnel length is very short and if tension exists on appendicular stump. Appendicular stump might have got retracted from bladder mucosa. Acute appendicitis complicating Mitrofanoff procedure has been well documented in literature.  Appendicular artery being an end artery, tip of appendix is vulnerable to ischemia. Subclinical episode of appendicitis might have caused ischemia or gangrene of the terminal part of appendix. Ischemic part of appendix might have been sloughed out or resorbed with subsequent retraction of appendix. To the best of our knowledge, this has been the first report of such complication documented in the literature.
| References|| |
|1.||Shah TP, Vishana K, Ranka P, Shah H, Choudhary R. Mitrofanoff procedure: A versatile method of continent catheterisable urinary diversion. Indian J Urol 2002;19:4-8. |
|2.||Sozer O, Vates TS, Freedman AL. Results of the Mitrofanoff procedure in urinary tract reconstruction in children. Br J Urol 1997;79:279-82. |
|3.||Yerkes E, Matcalfe P, Rink R. Incontinent and continent urinary diversion. Pediatric surgery. 6 th ed. Elsevier Publication; p. 1791-804. |
|4.||Sarin Y, Sinha A. Acute appendicitis complicating Mitrofanoff procedure. J Pediatr Surg 2004;39:1294-5. |