Q. I read your answer to the woman who is a C5-6 quad that was experiencing serious problems with her indwelling Foley catheter and was considering a suprapubic procedure (“Suprapubic Revisited,” June 2010 Bladder Matters).
I am also a C5-6 female with an indwelling Foley. Although I’m not having any trouble the Foley, I would love to be able to ditch the tubing and leg bag. The suprapubic sounds better but also sounds like more tubing and a collection bag in another place.
I heard about a procedure called a Mitrofanoff in which you have a hole near your belly button like a suprapubic, but instead of an indwelling Foley and a bag, you do intermittent catheterization through the hole. It sounds good, but all the research I’ve turned up on the procedure applies only to kids.
How come there isn’t any info on this procedure for adults with SCI? Is it done in adults with SCI?
A. Janice, let’s start by explaining the surgery. A Mitrofanoff (pronounced me-TROFF-an-off) is a procedure in which a surgeon cuts a piece of tubular tissue — usually the appendix — and creates a conduit from a stoma (hole at or near the belly button) to the bladder. A person with a Mitrofanoff empties the bladder by passing an intermittent catheter through the stoma into the bladder — cathing with the same frequency as urethral intermittent catheterization.
In the right circumstances, a Mitrofanoff has advantages over a suprapubic because there is no indwelling Foley tube or no collection bag, and the stoma is visible and accessible, making it easier than trying to insert a catheter into the urethra. This enables a person with limited hand dexterity who can’t catheterize through the urethera to manage the bladder independently. Another advantage is, because the stoma is so easy to see and reach, cathing can be accomplished from the chair.
Charleene Frazier, RN, MS, an information specialist with Spinal Cord Central, says she has worked with several people who are happy with the Mitrofanoff. One of the success stories involves a C6 quad who had completed her master’s degree and built a career that required travel. After a successful Mitrofanoff, she was able to manage her bladder, travel and continue on her career path.
Frazier reports another person, a C4-5 quad, who had a successful Mitrofanoff and was able to catheterize with minimal assistance from her attendant, making her daily living easier and more convenient. It is important to note that in this person’s case, having an attendant who can assist with cathing on a regular basis is paramount.
As you have already discovered, most of the literature on Mitrofanoffs is associated with pediatric bladder management. Paula Wagner, a urology nurse practitioner at U.C. Davis Medical Center in Sacramento, Calif., says when children are born with neurogenic bladders from conditions like spina bifida or cerebral palsy, it is important to manage the bladder early on to prevent urinary problems later. In this circumstance, a Mitrofanoff provides an easy way for parents to do intermittent catheterization on the child, especially an infant, which helps keep the bladder and kidneys healthy and hopefully avoids urinary problems later on in life. Wagner says the procedure is also used for conditions where a child needs to be catheterized but has sensation and can’t tolerate a catheter in their urethra because it hurts too much.
When it comes to adults and Mitrofanoffs, Frazier says there are good first-hand accounts of the procedure and how it has worked for people at the SCI Community Forums site.
Dr. Rodney Anderson, a professor of urology at Stanford University School of Medicine, explains more about this major surgical procedure, noting that a person has to be a perfect candidate to warrant the surgery. Anderson says for the procedure to be successful, a person must have a bladder that is in good condition with no scarring, or thickening of the bladder wall. The bladder must also have a normal capacity and must not have any spasticty.
Wagner lists the same criteria and adds that if there is any spasticity in the bladder, it will cause urine to squirt out of the stoma or, worse, cause reflux — urine backing up into the kidneys, which can cause serious damage.
Before considering a Mitrofanoff, a urologist would to run tests to see if the candidate meets these criteria. The tests would make sure the kidneys and ureters (the ducts that carry the urine from the kidneys to the bladder) are in good shape and free from obstruction; assess the contour of the bladder; identify any ureteral reflux (back up of urine to the kidneys); and measure pressure and volume the bladder holds before it leaks — to make sure there is no spasticity.
A PubMed search on “SCI and outcomes with Mitrofanoff” procedures revealed four studies between 2002 and 2007. The participants in the studies ranged from 6 to 27 years old. Each of the four studies revealed a high satisfaction rate. Two of the studies emphasized Anderson and Wagner’s statements that in order for the procedure to be successful the candidate must have a healthy and quiet bladder.
If you are going ask your urologist if a Mitrofanoff is an option that may work for you, be sure to ask about possible complications. Both Anderson and Wagner caution that Mitrofanoffs can leak at the stoma, and the conduit can develop stenosis (meaning the passage starts to close or closes).
Anderson also stresses that there is no standard, sure-fire surgical way to provide continent access to the bladder. All surgery can create new complications, and the Mitrofanoff is a surgical treatment option that is still in developmental progress.
Mitrofanoff surgery itself generally takes between 45 minutes and three hours depending on the type of tissue used for the surgery. According to Wagner, the preferred method uses the patient’s appendix for the conduit between the abdomen and bladder, called a Mitrofanoff appendicovesicostomy. This type of procedure has recently been refined and can now be done laparoscopically (through small incisions in the abdomen). Wagner says laparoscopic Mitrofanoff surgery takes about 45 minutes.
If a person no longer has an appendix, the surgeon will need to use a small piece of intestine, making the surgery much more complicated. The patient will have to come in to the hospital two to three days before the surgery for a complete bowel prep. The surgery itself takes two to three hours. During the procedure, the surgeon makes an incision in the abdomen and removes a piece of the small bowel, cleans it and uses it to create the bladder to navel conduit.
Frazier says that when intestine is used for the conduit, there are additional considerations. Any time the intestines are cut, bowel function is interrupted. A nasogastric feeding tube will be kept in place until the bowel returns to normal (usually about two to three days).
In either type of surgery, once finished, an indwelling Foley catheter is placed in the newly created conduit, and another indwelling Foley catheter is placed in the urethra. These stay in place until the Mitrofanoff is fully healed. Usual length of hospital stay after surgery is five to 10 days.
Urological sites explaining the procedure say a Mitrofanoff generally heals in about two weeks. At that time a doctor will remove both catheters and the Mitrofanoff is ready for use.
If the convenience of being able to catheterize through a stoma is appealing, but your bladder doesn’t meet the narrow criteria for a Mitrofanoff, there is another option called bladder augmentation, also known as continent urostomy. This procedure significantly enlarges the bladder and provides a Mitrofanoff-type conduit. The result is an easier and more convenient way to do intermittent catheterization, and the larger bladder volume enables people to safely extend the time between cathing for six or more hours.
A bladder augmentation is a serious, major surgery requiring weeks in the hospital and months to recover. Bladder augmentation increases the size of the bladder by sewing part of the bowel into the bladder, in addition to creating a conduit between the bladder and the abdomen. For more on this procedure please see the December 2008 Bladder Matters column.
As always, knowing your options and discussing them with a urologist well-versed in neurogenic bladders are keys to good bladder management.