´óÏóÊÓƵ

RCH logo

Nursing guidelines

Mitrofanoff stoma



  • ±õ²Ô³Ù°ù´Ç»å³Ü³¦³Ù¾±´Ç²ÔÌý

    A mitrofanoff is a surgical procedure that usually uses the child’s appendix, or if not available a short segment of small bowel to create a conduit between the bladder and the skin surface to create an opening called stoma.Ìý

    The stoma opening is generally made on the lower abdomen or in the umbilicus. A catheter is inserted several times a day into the mitrofanoff stoma conduit to empty the bladder.Ìý

    A child may need a mitrofanoff procedure due to poor bladder emptying for many reasons, including congenital renal or urological abnormalities, neurogenic bladder and continence problems. This includes children with:Ìý

    • Spina bifida
    • Bladder extrophy Ìý
    • Bladder obstructionÌý
    • Problems voidingÌý

    Some children may be able to perform urethral catheterisation, but if this is not possible or painful, a mitrofanoff procedure might be helpful in allowing improved continence by using intermittent bladder catheterisationÌý

    The mitrofanoff procedure may also encourage children’s independence by allowing them to self-catheterise. ÌýÌý

    ´¡¾±³¾Ìý

    To guide nurses’ practice in caring for patients admitted with a newly formed or established mitrofanoff. Ìý

    To provide nurses’ with knowledge and skills about care and complications of mitrofanoff allowing them to educate and support children/family/carer understanding of the procedure and outcome.Ìý

    Definition of TermsÌýÌý

    • Bladder augmentation: A surgical procedure which makes the bladder larger by using a small piece of bowel.Ìý
    • Bladder extrophy: A congenital abnormality where the abdominal wall does not fully form, leaving the bladder exposed outside the skin.Ìý
    • Clean Intermittent Catheterisation (CIC) of mitrofanoff: Refers to the act of draining urine by passing a catheter through the mitrofanoff stoma into the bladder. The catheter is removed after the urine has been drained. This process is performed using a clean technique. A new sterile catheter is used for each episode.Ìý
    • Clean Intermittent Self Catheterisation (CISC): Performing CIC for oneself.Ìý
    • Conduit: An artificial channel which fluid can go through.Ìý
    • Cystoscopy: A procedure to see inside the bladder using a hollow tube equipped with a lensÌý
    • KUB Xray: Provides basic information regarding the size, shape and position of the kidney, ureters and bladder.Ìý
    • Mitrofanoff: A surgical procedure in which the appendix or piece of bowel are used to create a connection between the bladder and the abdominal skin surface to allow for urinary catheterisation through a stoma.Ìý
    • Spina bifida: A neural tube defect in which the bones of the spine do not completely form resulting in a defect in the spinal canal. This can cause lack of sensation and/or movement in the lower limbs and bladder and bowel dysfunction.Ìý
    • Neurogenic Bladder: A dysfunction of the bladder due to a neurological condition. Ìý
    • Urodynamic testing: Shows how well the bladder, sphincters and urethra hold and release urine by measuring the pressure of the bladder.Ìý

    Urinary SystemÌý

    Ìý

    RCH Image, courtesy of RCH staff

    Preparation for Surgery Ìý

    • Education and counselling by urology and CNC Stomal therapy for familiesÌý
    • Use of diagram, videos and models can be helpful.Ìý
    • Allowing children to handle equipment and practice on the model if they wish to do so.Ìý
    • Colouring books can help younger children to understand the procedure.Ìý
    • Child life therapy can be a great help in preparing some children.Ìý
    • Pre-operative InvestigationsÌý

    Prior to surgery the urologist might prescribe tests to check suitability for the mitrofanoff procedure and the need for bladder augmentation. This might include:Ìý

    • CystoscopyÌý
    • Renal Ultrasound (pre and post void)Ìý
    • Xray of kidney, ureters, bladder (KUB)Ìý
    • Blood testsÌý
    • Urodynamic testingÌý

    SurgeryÌýÌý

    The surgeon separates the appendix from the large intestine and creates an opening at its other end. One end of the appendix is connected to the bladder and the other end tunnelled is connected to the abdominal wall skin to form the stoma, usually in the umbilicus. The most important part of this surgery is the creation of a continence valve in the bladder by tunnelling the appendix 4-5 cm through the bladder wall. As the bladder fills with urine the pressure squeezes the tunnelled appendix shut to prevent urinary leakage between catheterisations. Mitrofanoff surgery can be done laparoscopically or open as per surgeon preference and medical need.Ìý

    Ìý Ìý

    RCH Photo, courtesy of RCH staff

    Post operative assessment and management of a patient with a newly formed mitrofanoffÌý

    • Children will usually be admitted for 3 to 7 days post formation of a mitrofanoff.Ìý
    • Routine post anaesthetic observations as per RCH Nursing Guideline:ÌýRoutine Post Anasethtic Observation guideline. Ìý
    • Monitor newly formed mitrofanoff dressing for ooze, at least once a shift.Ìý
    • Ensure patients remain comfortable with adequate pain relief.
      • IV Analgesia may be needed initially, transition to Oxybutin and simple oral analgesia as tolerated.Ìý
      • +/- Epidural, see RCH Nursing Guideline:ÌýEpiduralÌýfor more information.Ìý
    • Patients will have mitrofanoff, urethral +/- suprapubic catheters insitu post operatively. Monitor all catheter sites.Ìý
    • A strict fluid balance should be maintained and documented.
      • The urology team will outline expected urine output for individual patients, typically 0.5-1ml/kg/hr of urine output combined across all catheters.ÌýÌý
      • If urine output decreases or exceeds this notify the Urology registrar.ÌýÌý
      • Catheters should be checked hourly for first 24 hours, then 2 hourly for 48 hours.Ìý
    • If catheter stops draining or is blocked escalate immediately to Urology team. Do not flush the catheters without Urology team approval.ÌýÌý
    • Urethral +/- suprapubic catheters are usually removed prior to discharge as per Urology instructions (please note some patients may be discharged with Suprapubic catheter insitu).
      Ensure adequate procedural pain management prior to catheter removal, please see the RCH Nursing Guideline: procedure management for more information.ÌýÌý
    • Encourage child to sit out of bed as soon as possibleÌý
    • Leg bags can be used when child is up and walkingÌý
    • Advised to have sponge bath while inpatient to avoid getting dressing wetÌý
    • Weight and blood as required by urology teamÌý

    Discharge and follow up post newly formed MitrofanoffÌýÌý

    • Discharge home with the mitrofanoff catheter on free drainage: the catheter may be with or without a balloon as per surgeon preference. The catheter size is determined by the size of the conduit. Children are discharged with leg bags.ÌýÌý
    • Discharge supplies for 3-4 weeks are to be provided by the ward as required including: leg bags x1/week, leg straps, catheter tip syringes, tape, alcohol swabs, saline bottle etc.Ìý
    • Children can shower at home if wound and tape can be protected.Ìý
    • Families do not need to measure output, however they need to ensure that catheter is draining and not blocked. They may need to flush with saline (as required) as shown prior to discharge.Ìý
    • As per urology preference, the mitrofanoff catheter might need to remain on free drainage for 2 weeks followed by use of a catheter valve to train the bladder for 2 weeks prior to catheter removal.Ìý
    • Slow, light activities are recommended until catheter removed.Ìý

    Patients will be booked to return to the hospital 2-4 weeks post discharge, for an overnight stay. During this admission:Ìý

    • The catheter is removed from the stoma and commencement of clean intermittent catheterisation (CIC) education with stomal therapy CNC. Patient may need sedation and support of child life therapy for catheter and tape removal. Please see the RCH Nursing Guideline: procedure management for more information on support during procedures.Ìý
    • Frequency of CIC varies between two to five times a day and some children might require the catheter to stay on free drainage overnight.Ìý
    • Families should be advised to present to emergency if difficulties catheterising occur at home.Ìý
    • The child can go back to regular activities and sport, protective belts are advised to be worn for contact sport to avoid injury.Ìý
    • School education and support can be provided by stomal therapy CNC.Ìý
    • Follow-up appointments for review in Urology and Stomal therapy clinics.Ìý
    • Stoma appliance scheme application and supplies organised by stomal therapy CNC.Ìý

    Ongoing assessment and management of patients admitted with a MitrofanoffÌý

    • Assess mitrofanoff site as clinically indicated.Ìý
    • Patients and families should be supported to continue their normal CIC routine in hospital.Ìý
    • Nursing staff to support with CIC’s as needed see information below.Ìý
    • Refer to Urology and/or Stomal therapy if concerns regarding mitrofanoff arise. Ìý

    Catheterising a MitrofanoffÌý

    Equipment needed:Ìý

    • Nelaton Catheter of appropriate sizeÌý
    • Scent free wipes (in hospital use patients own or use baby wipes)Ìý
    • Water soluble lubricated gel Ìý
    • Container into which to drain urine (unless draining into toilet)Ìý
    • Alcohol based hand rub, if there is no facility to wash hands adequately with soap and water (for child/family). Clinical staff should perform Hand Hygiene as per
    • Nonsterile latex-free gloves (child and parents performing CIC may choose not to wear gloves) or sterile gloves (for nursing staff in hospital)

    Directions for catheterising (for nursing staff and/or parent/carer):Ìý

    Please note nursing staff performing catheterisation of a mitrofanoff in hospital should complete the procedure in a sterile manner, following the . Families and children performing CIC can continue to complete the procedure in a clean manner in hospital as they do at home.ÌýÌý

    1. Inform and gain verbal consent from patient/carer.Ìý
    2. Ensure the child is comfortably positioned (bed/chair/toilet).Ìý
    3. Perform hand hygiene.Ìý
    4. Onto a clean surface, prepare equipment: open wipe, open catheter package halfway, being careful not to touch catheter tip. Place lubricant gel on the inside of open packet. Ìý
    5. Perform hand hygiene and clinical staff apply nonsterile gloves where appropriate, nursing staff may use sterile gloves when completing this procedure in hospital.Ìý
    6. Clean the stoma starting at stoma opening and work outwards in a circular motion with scent free wipe.Ìý
    7. Lubricate the tip of the catheter inside the package with the water -soluble lubricating gel.Ìý
    8. With a non-touch technique to protect key part catheter tip, slide the catheter slowly into the opening of the stoma until urine starts to flow. If resistance is felt, stop for a few seconds then continue. Direct catheter end into container or toilet.Ìý
    9. When urine flow stops, ask the child to cough or wiggle and press gently on their bladder. This ensures complete bladder emptying.Ìý
    10. Withdraw the catheter slowly. It may start to drain again. Wait until this ceases, then remove the catheter. Ìý
    11. The catheter should be discarded into the waste bin, container should be cleaned or discarded.Ìý
    12. Remove gloves if worn and perform hand hygiene. Dispose of waste.Ìý
    13. Document procedure. Ìý

    RCH Photo, courtesy of RCH staff Ìý

    Complications/troubleshooting Ìý

    ComplicationsÌý

    TroubleshootingÌý

    Stomal/conduit stenosis - Difficult to catheteriseÌý

    • Trial smaller size catheterÌý

    • Use a stopperÌý

    • Notify Urology/Stomal therapy CNCÌý

    • Families should be advised to present to emergency if difficulties catheterising occur at homeÌý

    Stomal widening-leakingÌý

    • Protect the skin by using a barrier creamÌý

    • Notify urologyÌý

    • Injection of bulking agent might be consideredÌý

    • Revision of stoma might be neededÌý

    Stone formation- build-up of mucusÌý

    • Regular bladder washout, as per plan from Urology +/- Stomal therapy supportÌý

    • Monitor fluid intake, encourage clear fluids, consider increasing fluid intake where appropriate Ìý

    Urine infectionÌý

    • Monitor urine for appearance changes, offensive odour, presence of blood, increased pain, fever etc.Ìý

    • Only treated if child symptomaticÌý

    Ìý

    Pain with catheterisingÌý

    • Catheter might be in too far, pull out slightlyÌý

    Companion DocumentsÌýÌý

    Videos

    LinksÌý

    • Young ostomates united (YOU):ÌýÌý
    • Stoma appliance scheme:ÌýÌý
    • Australian association of stomal therapy nurses (AASTN):ÌýÌý
    • Victorian Children’s Ostomy Association:ÌýEdc@rch.org.auÌý


    ÌýPlease remember to .

    The development of this nursing guideline was coordinated by Carmen Akaoui, Nurse Consultant, Neurodevelopment and Disability, and approved by the Nursing Clinical Effectiveness Committee. Published September 2024.ÌýÌý

    Ìý

    Evidence TableÌý

    Reference

    Source of Evidence

    		 Key findings and considerationsÌý
    Abdelhalim, A. Omar, H. Edwan, M. Helmy, T.E. El-hefnawy, A.S. Hafez, A.T. Dawaba, M.E 2021, ‘Reoperation for channel complications in children with continent cutaneous catheterizable channels: the test of time’, Urology (159), pp.196-202ÌýÌý Retrospective studyÌý
    • Between 1993-2012, total 120 patients underwent continent cutaneous catheterizable channels (CCCC)Ìý
    • Channels created by using appendix (74) , Monti (33), and tapered ileal segments (13)Ìý
    • 42 additional surgeries were required to treat channel complications in 26 patients; Channel stenosis was the most frequent complicationÌý
    • High re-operation expected in CCCC but the appendicovesicostomy had lower complications than the ileal channelÌý
    • Commitment to lifelong follow-up at centres of expertise is mandatoryÌý
    Blanc, T Muller, C Pons, M Pashootan, P Paye-Jaouen, A & El Ghoneimi, A 2015, ‘ Laparoscopic Mitrofanoff procedure in children: Critical analysis of difficulties and benefits’, Journal of Pediatric Urology, vol.11, no.28, pp.21-28Ìý Retrospective study
    • This study describes a series of patients undergoing laparoscopic Mitrofanoff appendivesicostomy procedure during 10 years periodÌý
    • 15 children with a median of 9 years old were included
    • Urodynamics performed prior to surgery, demonstrated significant bladder dysfunction
    • Laparoscopic surgery was successful in 12 children, 3 needed to be converted to openÌý
    • laparoscopic approach does not need bladder mobilization and leaves the anterior bladder wall free for any future bladder surgeryÌý
    • Provide minimal invasive procedure that may avoid bladder augmentation in childrenÌý
    Burgess-Stocks, J Gleba, J Lawrence, K & Mueller, S 2022, ‘Ostomy and continent diversion patient bill of rights: research validation of standards of care’, journal of Wound ,Ostomy& Continence Nursing,49(3), pp.251-260Ìý
    		 Guideline for high quality standards of ostomy careÌý
    • Patients are guaranteed high quality of care in hospital during ostomy surgical experience and for continuum of careÌý
    • Education provided on living with continent diversion and self-care post dischargeÌý
    • Counselling, care and education should be delivered at a level of understanding suitable to the patientÌý
    • ongoing emotional/social supportÌý
    • Right supplies for right patientÌý
    • Providing information about organizations that support and advocate for patients living an ostomy.
      Iqbal, N. Syed, O.Z. Bukhari, A.H. Sheikh, A.A.E. Mahmud, U.S. Khan, F. Hussein, I. Akhter, S 2019, ‘Utility of mitrofanoff as bladde4r draining tool: a single centre experience in pediatric patients’, Turkish journal of urology, 45(1), pp. 42-47Ìý Retrospective study
      • 29 children underwent continent catheterizable conduit (CCC)Ìý
      • charts reviewed for age, gender, presenting complaints, need for augmentation,mitrofanoff channel source, duration of surgery, hospital stay, pre and post-operative complicationsÌý
      • complications noted ; stomal stenosis, stuck catheter, stomal reviosion, UTI, persistent leakage and bladder stonesÌý
      • Children and parents should be educated about the importance of regular follow up and possible complicationsÌý
      • review outcome in 81 patientsÌý
      • Mean follow up was 80.1 monthsÌý
      • difficult catheterisation most commonÌý
      • complications clustered in the first 2 years, then significantly declineÌý
      ÌýJacobson, D.L. Thomas, J.C. Pope, J. Tanaka, S.T. Clayton, D.B. Brock, J.W. Adams, M.C. 2017, ‘Update on continent catheterizable channels and the timing of their complications’, The journal of urology, vol.197, pp.871-876ÌýÌý ÌýRetrospective studyÌý
      • review outcome in 81 patientsÌý
      • Mean follow up was 80.1 monthsÌý
      • difficult catheterisation most commonÌý
      • complications clustered in the first 2 years, then significantly decline ÌýÌý
        Kari, J Al-Deek , B Elkhatib, L Salahudeen, S Mukhtar, N Al Ahmad, R Eldesoky, S& Raboei, E 2013, ‘Is Mitrofanoff a more socially accepted clean intermittent catheterization (CIC) route for children and their families?’,Ìý European Journal of Pediatric Surgery, vol.23, no.5, pp. 405-410Ìý
        		 ÌýQualitative studyÌý
        • Questionnaire of 29 questions
        • administered to 50 children about the social impact of CIC on the children and their familiesÌýÌý
        • Interviews with fathers for 22children and 26 with mothers
        • 17 children using Mitrofanoff CIC and 33 urethral catheterizationÌý
        • Mitrofanoff was associated with fewer episodes of UTI, greater adherence and lower social impact in terms of school performance

          ÌýKurzrock, E.A. 2020, ‘A new appendicostomy technique to prevent tstomal stenosis’, The journal of urology, vol.203,pp.1200-1206Ìý Retrospective study
          • stomal stenosis reported in 12% to 45% of patients in standard stoma technique that entails excision of the distal appendixÌý
          • A new technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would decrease
          • 75% stenosis with standard technique occurred within 1 year of surgery.
          • Stenosis did not occur after new technique after 3 yearsÌý
          Nerli, R.B Patil, S.M Hiremath, M.B & Reddy, M 2013, ‘Yang-Monti Catheterizable Stoma in children’, Nephro-urology monthly, vol.5, no.3, pp.801-805Ìý Research studyÌý
          • report experience on monti procedureÌý
          • children <18years with congenital conditions or neurogenic bladder undergone urinary diversion with a yang-monti procedureÌý
          • these children all taught CIC with Fg 14 and 16 catheters doing 3/24 CICÌý
          • Children followed up for any complications with catheterization or incontinence at 3, 6, 12, 18 and 24 monthsÌý
          • long term complications with yang- monti minimal
          ÌýO’connor, E.M Foley, C. Taylor, C. Malde, S. Raja, L. Wood, D.N. Hamid, R. Ockrim, J.L. Greenwell,T.J. 2019, ‘Appendix or ileum – which is the best material for mitrofanoff channel formation in adults? ‘, The journal of urology, vol.202, pp.757-762Ìý
          		 Retrospective reviewÌý
          • 176 adult patient had mitrofanoff created, 114 women and 59 menÌý
            the rate of revision was higher in the ileal groupÌý
          • 90.2% were continentÌý
          • Tissue selection depends on availability and individual patient factor.

            Raup, V.T, Eswara, J.R, Marshall, S.D, Brandes, S.B 2016 ‘Botulinium toxin type A injections for the treatment of continent catheterizable ileal-colic urinary diversion muscularis overactivity’, Urology 88(1), pp,213-217Ìý Case presentationÌý
            • Continent catheterizable diversions can exhibit long term complications such as high pressure and involuntary contractionsÌý
            • Botox injections may be an option for contracted continent catheterizable diversion or temporary measure before augmentationÌý
            • Further studies neededÌý
            Reddy, M.N Nerli, R.B Patil, R.A & Jali,S.M 2015, ‘Laparoscopic Mitrofanoff continent catheterisable stoma in children with spina bifida’, African journal of Pediatric Surgery, vol.12, no.2, pp. 126-130Ìý ÌýRetrospective studyÌý
            • 11 children with SB underwent mitrofanoff, all laparoscopicÌý
            • Mean age was 11 years;6 female and 5 maleÌý
            • Appendix was used, no immediate post op complicationsÌý
            • Only 4 of the 11 able to self-catheterise pre op, post op all 11 able to self-catheteriseÌý
              Improves patient self-reliance, mobility and body imageÌý
            Schaefffer, A.J &Diamond,D.A 2014, ‘ Pediatric urinary incontinence: Classification, evaluation, and management’, African Journal of Urology, vol.20, pp. 1-13ÌýÌý Literature and peer reviewÌý
            • Paediatric urinary incontinence is a common conditionÌý
            • A thorough history and physical exam will guide tests needed if any and treatmentÌý
              treating constipation is important prior to beginning incontinence therapyÌý
            • Surgery is for those children with a well-defined anatomic etiologyÌý

            ÌýWhat is the Mitrofanoff procedureÌýhttps://www.nationwidechildrens.org/specialties/urology/procedures/mitrofanoffÌý

            Ìý

            		 ÌýInformation sheetÌý
            • What is Mitrofanoff procedureÌý
            • Why is the Mitrofanoff doneÌý
            • What to expect at the hospitalÌý
            • Follow-up care after a Mitrofanoff procedureÌý
            • Benefits of the Mitrofanoff procedureÌý
            • Risks of the Mitrofanoff procedureÌý
            • Questions to ask your child’s doctor about the Mitrofanoff procedureÌý