BJU International (2000), 85, 160±162
POINT OF TECHNIQUE
A continent catheterizable ileum-based reservoir
A . M A C E D O J R and M . S R O U G I
Division of Urology, Federal University of Sao Paulo, Sao Paulo, Brazil
Indications
The development of new techniques of bladder augmen-
tation and clean intermittent catheterization (CIC) have
changed the prognosis of end-stage bladder disease in
children. The principle of Mitrofanoff, used with the
appendix or efferent conduits, offers the possibility of easy
access for CIC of the bladder or reservoir [1]. When both
augmentation and a suprapubic continent stoma for CIC
are required, the ileo-caeal segment can be used, with the
appendix in situ for an efferent conduit, or an augmenta-
tion with stomach, ileum or colon and the appendix
mobilized, or a catheterizable conduit can be created from
a small segment of ileum to empty the bladder [2]. We
previously proposed a new approach as an alternative to
the procedures above [3,4]. We describe herein a new
ileal-based reservoir technique using a 30 cm ileal
segment with a continent catheterizable stoma made
with an isolated ¯ap of ileum from the same segment. The
indications for this procedure are clinical situations such
as valve and neurogenic bladders, bladder exstrophy or
whenever bladder augmentation and suprapubic CIC are
needed.
Methods
A lower midline incision is made with a small left-sided
circumferential skin ¯ap between the pubis and umbili-
cus for further pseudo-umbilical stoma creation. A 30 cm
segment of distal ileum is isolated and bowel continuity
restored by end-to-end two-layer ileo-ileal anastomosis
(Fig. 1a). The detubularization of the ileal segment
follows the antemesenteric border of the intestine up to
the middle of the segment. Here the incision line moves
transversally to the anterior surface of the ileum,
reaching the mesenteric border. A 3 cm horizontal
incision along the mesenteric side is continued before
returning to its usual orientation at the antemesenteric
border. The rest of the ileum is then opened long-
itudinally. The 3 cm ¯ap from the anterior surface of the
middle part of the ileum is mobilized cranially (Fig. 1b). A
12 F silicone Foley tube is placed on the mucosal surface
of the ¯ap to allow tubularization of the plate with
160
interrupted polyglycolic acid 3/0 transverse sutures,
creating an efferent tubular conduit. The detubularized
ileum is placed in an inverted U-shaped position and the
posterior wall of the reservoir closed by a one-layer
running polyglycolic acid 2/0 suture. The anterior wall of
the reservoir is closed in the same way (Fig. 1c). The
reservoir can then be totally or partially closed if a total
substitution or an augmentation cystoplasty is planned.
The continence valve mechanism is produced by
embedding the tube over a serous-lined extramural
tunnel created by interrupted polypropylene 3/0 sutures
(Fig. 1d). The distal end of the tube is anastomosed into a
V-shape to the skin ¯ap to avoid stomal stenosis (Fig. 1e).
The silicone Foley tube exits through the efferent tube
and a cystostomy is left in place for 3 weeks.
Advantages and disadvantages
Patients with poorly compliant bladders caused by a
neurogenic bladder (especially myelomeningocele), PUV
and congenital malformations like bladder exstrophy are
candidates for augmentation cystoplasty. The ideal
material for bladder augmentation should be easily
available, easily shaped, must not absorb urinary
constituents and not secrete mucus. As no such material
presently exists, the controversy about the best material
for constructing a urinary reservoir is justi®ed.
The use of CIC has broadened the applicability of
bladder reconstruction techniques. Some patients are
unable to empty their bladders through catheterization of
the urethra and therefore require a suprapubic access.
The Mitrofanoff principle is a well accepted alternative for
these patients and both the appendix and other natural
efferent conduits are effective. The present technique has
some advantages over other procedures when augmen-
tation and suprapubic catheterization are needed. The
ileum is probably the most commonly used intestinal
segment for constructing reservoirs and is easy to handle.
The morbidity of an ileo±ileal anastomosis to restore
bowel continuity is very low. The conformation of the
present reservoir includes a tubular continent outlet for
catheterization and therefore the time spent preparing
the appendix with its pedicle or making a Monti tube
# 2000 BJU International
 P O I N T OF TE C H N IQ U E 161
Fig. 1. a, A 30 cm segment of distal a
ileum is isolated and bowel continuity
restored by end-to-end two-layer ileo±
ileal anastomosis. b, The 3 cm ¯ap
from the anterior surface of the middle
part of the ileum is mobilized cranially.
c, A 12 F silicone Foley tube is placed
on the mucosal surface of the ¯ap to
allow tubularization of the plate,
creating an efferent tubular conduit.
The detubularized ileum is placed in an
inverted U-shape position and the
posterior wall of the reservoir closed.
The anterior wall of the reservoir is
closed in the same way. d, The
continence valve mechanism produced
b
by embedding the tube over a serous-
lined extramural tunnel. e, The distal
end of the tube is anastomosed to the
skin ¯ap; the silicone Foley tube exits
through the efferent tube.

4.5 cm {

# 2000 BJU International 85, 160±162

162 POINT OF TECHNIQUE
from a second isolated segment of ileum is saved [2].
More recently, children with a neurogenic bladder have
been treated successfully for co-existing faecal incon-
tinence using antegrade enemas through a continent
appendicostomy, according to the Malone principle [5]. If
such a procedure is required in association with bladder
augmentation and a suprapubic stoma for catheter-
ization, the proposed technique seems to be very
attractive.
Dif®culties and complications
The feasibility of the technique was tested successfully on
mongrel dogs before introducing it clinically at our
institution. The initial experience with nine patients (four
with valve bladder, two with meningomyelocele, one
with neurogenic bladder from spinal cord injury and two
with bladder exstrophy) has been favourable. Only one
patient is incontinent through the stoma; he was the
second patient and we were still gaining experience of
the procedure. The mean (range) follow-up is now 7 (2±
13) months. The present technique is promising because
of its simplicity and reduced operative duration. The
initial clinical experience has been encouraging but a
longer follow-up will be needed to con®rm the initial good
results.
References
1 Mitrofanoff P. Cistostomie continente trans-appendiculare
dans le traitement des vessies neurologiques. Chir Ped 1980;
21: 297±300
2 Monti PR, Lara RC, Dutra M. New techniques for construc-
tion of efferent conduits based on the Mitrofanoff principle.
Urology 1997; 49:112±5
3 Macedo A Jr, Hachul M, Liguori R, Bruschini H, Ortiz V,
Srougi M. A continent catheterizable ileum-based reservoir:
preliminary experimental and clinical experience. BJU Int
1999; 83 (Suppl 3): 110±111(Abs154)
4 Macedo A Jr, Hachul M, Liguori R, Bruschini H, Ortiz V,
Srougi M. A continent catheterizable ileum-based reservoir:
preliminary experimental and clinical experience. J Urol
1999; 161 (Suppl 4): 199(Abst759)
5 Malone PS, Ransley PG, Kiely EM. Preliminary report: the
antegrade continence enema. Lancet 1990; 336:1217±9
Authors
A. Macedo Jr, MD, Assistant Professor of Urology.
M. Srougi, MD, Professor and Chairman.
Correspondence: Dr A. Macedo, Rua Maestro Cardim, 560l 215
Sao Paulo, Brazil, 01323-000
# 2000 BJU International 85, 160±162