Cassini Marcelo F, Rodrigues Antonio A, Tucci Silvio, Cologna Adauto J, Reis Rodolfo B, Martins Antonio Cp, Suaid Haylton J
Department of Surgery and Anatomy, Division of Urology, Ribeirao Preto Medical School, Sao Paulo University, Sao Paulo, Brazil.
J Med Case Rep. 2011 Feb 3;5:49. doi: 10.1186/1752-1947-5-49.
Hydronephrosis, reflux and renal failure are serious complications that occur in patients with neurogenic bladder associated with myelomeningocele. When the bladder compliance is lost, it is imperative to carry out surgery aimed at reducing bladder storage pressure. An ileocystoplasty, and for patients not suitable for intermittent catheterization, using the Mitrofanoff principle to form a continent stoma and the subsequent closure of the bladder neck, can be used. We report here, for the first time to the best of our knowledge, an association between two previously described techniques (the Mitrofanoff principle and the technique of Monti), that can solve the problem of a short appendix in obese patients.
A 33-year-old male Caucasian patient with myelomeningocele and neurogenic bladder developed low bladder compliance (4.0 mL/cm H2O) while still maintaining normal renal function. A bladder augmentation (ileocystoplasty) with continent derivation principle (Mitrofanoff) was performed. During surgery, we found that the patient's appendix was too short and was insufficient to reach the skin. We decided to make an association between the Mitrofanoff conduit and the ileal technique of Monti, through which we performed an anastomosis of the distal stump of the appendix to the bladder (with an antireflux valve). Later, the proximal stump of the appendix was anastomosed to an ileal segment of 2.0 cm that was open longitudinally and reconfigured transversally (Monti technique), modeled by a 12-Fr urethral catheter, and finally, the distal stump was sutured at the patient's navel.After the procedure, a suprapubic cystostomy (22 Fr) and a Foley catheter (10 Fr) through the continent conduit were left in place. The patient had recovered well and was discharged on the tenth day after surgery. He remained with the Foley catheter (through the conduit) for 21 days and cystostomy for 30 days. Six months after surgery he was continent with good bladder compliance without reflux and fully adapted to catheterization through the navel.
The unpublished association between the Mitrofanoff and Monti techniques is feasible and a very useful alternative in urologic cases of derivation continent in which the ileocecal appendix is too short to reach the skin (i.e., in obese patients).
肾积水、反流和肾衰竭是脊髓脊膜膨出相关神经源性膀胱患者出现的严重并发症。当膀胱顺应性丧失时，必须进行旨在降低膀胱储尿压力的手术。可以采用回肠膀胱扩大术，对于不适合间歇性导尿的患者，可利用米氏原理形成可控造口并随后关闭膀胱颈。据我们所知，我们首次在此报告两种先前描述的技术（米氏原理和蒙蒂技术）之间的关联，该关联可解决肥胖患者阑尾过短的问题。
一名33岁患有脊髓脊膜膨出和神经源性膀胱的白人男性患者，膀胱顺应性降低（4.0 mL/cm H₂O），但仍保持正常肾功能。实施了采用可控尿流改道原理（米氏原理）的膀胱扩大术（回肠膀胱扩大术）。手术过程中，我们发现患者的阑尾过短，不足以到达皮肤表面。我们决定将米氏导管与蒙蒂回肠技术相结合，通过该方法将阑尾远端残端与膀胱进行吻合（带有抗反流瓣膜）。随后，将阑尾近端残端与一段纵向开口并横向重新塑形的2.0 cm回肠段进行吻合（蒙蒂技术），以12 Fr尿道导管为模型，最后将远端残端缝合在患者肚脐处。手术后，留置耻骨上膀胱造瘘管（22 Fr）和通过可控导管置入的Foley导尿管（10 Fr）。患者恢复良好，术后第十天出院。他保留Foley导尿管（通过导管）21天，膀胱造瘘30天。术后六个月，他实现了可控排尿，膀胱顺应性良好，无反流，并且完全适应了通过肚脐进行导尿。
米氏技术和蒙蒂技术之间未发表的这种关联是可行的，在回盲部阑尾过短无法到达皮肤表面的泌尿外科可控尿流改道病例中（如肥胖患者）是一种非常有用的替代方法。
