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THE MITROFANOFF PRINCIPLE IN CONTINENT URINARY RECONSTRUCTION - 11/09/11

Doi : 10.1016/S0094-0143(05)70421-3 
Martin Kaefer, MD *, Alan B. Retik, MD *

Résumé

Continent urinary diversion (CUD) has dramatically changed the quality of life of many children who would otherwise be incontinent or be faced with wearing a bag to collect urine.29, 31 The most common etiologies requiring the construction of a CUD include the exstrophy and epispadias complex, neuropathic bladder dysfunction, and pelvic malignancies. The definition of a CUD includes any reservoir subserved by a catheterizable efferent mechanism other than the native urethra and bladder neck. Furthermore, the upper urinary tract must insert into the reservoir in a nonrefluxing fashion so as to reduce the chance of pyelonephritis and preserve renal function. Many operations have been developed to achieve these goals, each with their individual proponents.

Often, the most challenging aspect in constructing a CUD is the creation of a reliably continent efferent limb for catheterization. Gilchrist et al20 were the first to suggest a continence mechanism using an ileocecal segment. They reasoned that continence could be achieved through a combination of sphincteric compression by the ileocecal valve and reversed peristalsis of the terminal ileum. It was later shown, however, that only a quarter of all normal individuals have adequate sphincteric function at the terminal ileum.50 In addition, peristaltic activity was shown experimentally to be effective only against pressures less than 7 cm H2O.27 Improved continence using the ileocecal segment was later achieved by decreasing the diameter of the ileum through either imbrication or tapering.55 Intussusception, as utilized in the Kock pouch, the Benchekroun ileal nipple, and the reversed ileal nipple also serves to provide continence.6, 23, 34, 36 Pressure in the reservoir is transmitted to the nipple lumen and thereby prevents leakage.26 The success of each of these procedures is greatly dependent on the experience of the surgeon. Although initial continence results have been excellent, problems with either catheterization, fistula formation, nipple slippage, or stomal stenosis can be excessive, especially when these procedures are performed by surgeons who are not versed in the nuances of their construction.13, 40, 49, 56 Finally, all of these techniques require the use of small bowel with a resultant bowel anastomosis. In contrast, the flap valve principle is a versatile technique that is simple to perform, provides a reliable continence mechanism, and requires minimal or no use of functional bowel.

The creation of a continence mechanism that utilizes the flap valve principle to prevent the egress of urine from a low-pressure storage reservoir was first introduced by Dr. P. Mitrofanoff46 in 1980. In the 16 years since his initial report, the principle that bears his name has been adapted to almost every form of continent urinary reconstruction now performed. In addition, this physical principle has been utilized successfully to provide improved fecal continence in patients with neurogenic bowel dysfunction. This article reviews the many ways in which orthotopic and heterotopic structures can be utilized to achieve reliable continence while minimizing the risk of postoperative complication and the need for postoperative revision.

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 Address reprint requests to Alan B. Retik, MD, The Children's Hospital, 300 Longwood Avenue, Boston, MA 02115


© 1997  W. B. Saunders Company. Publié par Elsevier Masson SAS. Tous droits réservés.
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Vol 24 - N° 4

P. 795-811 - novembre 1997 Retour au numéro
Article précédent Article précédent
  • ILEAL ORTHOTOPIC BLADDER SUBSTITUTES : What We Have Learned From 12 Years' Experience With 200 Patients
  • Urs E. Studer, Ernst J. Zingg
| Article suivant Article suivant
  • ILEAL URETER
  • Rogério M. Mattos, John J. Smith

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