Laparoscopic Mitrofanoff procedure in children: Feasibility and outcome analysis over 18 years in a single centre

Abstract

BACKGROUND: Since the first description procedure in 1980, the Mitrofanoff procedure involving appendicovesicostomy has become a widely adopted method for continent urinary diversion in children and adults. OBJECTIVE: This study aims to evaluate the feasibility and outcomes of employing a technically challenging minimally-invasive (MIS) approach in pediatric patients. STUDY DESIGN: A retrospective analysis of the prospective institutional database was conducted (2003-2020). Patients were categorized into two cohorts: (i) those who underwent surgery before 2013 (Group 1) and (ii) those who underwent surgery after 2013 (Group 2). Prior to surgery, urodynamic studies were performed to assess bladder compliance, capacity, and detrusor activity. Outcome measures included complications, revisions, stenosis, and stomal incontinence, with the latter classified according to the Schulte-Baukloh score. RESULTS: A total of 29 children (Group 1, n = 15; Group 2, n = 14) with a median (IQR) age of 8 years (6-13) underwent a MIS Mitrofanoff procedure. Median (IQR) follow-up was 60 months (17-88). The procedure was completed by laparoscopy in 26 cases. Three laparoscopic surgeries were converted to an open procedure due to tearing of the bladder mucosa (n = 2) or appendix ischemia (n = 1). All conversions occurred before 2013 (p = 0.23). Median (IQR) operative time was 310 min (250-360) (295 (245-330) vs. 324 (273-351) min for Group 1 vs. Group 2, respectively; p = 0.44). Social continence was achieved in 21 patients (72 %) (n = 10/15 (67 %) vs. 11/14 (79 %), respectively; p = 0.68). Stomal urinary leakage was reported by nine (31 %) patients (6 (40 %) vs. 3 (21 %), respectively; p 0.68, no cases in robotic subgroup) of whom five (63 %) were managed successfully by hyaluronic acid/dextranomer injection and four required an open revision of the appendicovesical anastomosis (Group 1: n = 3; Group 2: n = 1). No patient developed stenosis of the catheterizable channel. One patient subsequently had a bladder augmentation. There was an improvement in outcomes with regards to continence and complications as the surgical team gained in experience: revision surgeries: Group 1 (n = 3; 20 %) vs. Group 2 (n = 1; 7 %) p = 0.61; conversions: Group 1 (n = 3; 20 %) vs. Group 2 (n = 0) (p = 0.23). The last three cases were performed robotically without any complications or conversion, and with stomal continence, in a shorter median operative time (300 min (293-330) vs. 338 min (245-344) laparoscopically, p = 0.70). CONCLUSION: The laparoscopic Mitrofanoff procedure is a safe and feasible option in children. A trend toward improved continence and fewer revisions was observed in the later cohort, although these differences did not reach statistical significance. None of the patients developed channel stenosis. Previous pediatric literature suggests that minimally invasive approaches may offer additional benefits such as reduced postoperative pain and improved cosmetic outcomes, although these were not assessed in our series. The robotic approach was feasible in our limited experience, with no conversions and short-term continence achieved, but longer follow-up is required to draw firm conclusions.