Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
J Pediatr Urol. 2018 Oct;14(5):433.e1-433.e4. doi: 10.1016/j.jpurol.2018.02.024. Epub 2018 Apr 4.
Bladder calculi are a known complication of bladder augmentation. Open cystolithotomy remains the preferred option for treating large or multiple stones. Increasingly, however, minimal access techniques have been used. Reports of Mitrofanoff cystolitholapaxy are rare and have been limited to adults. This study presented a two centre series of children treated by cystolitholapaxy via the Mitrofanoff/Monti channel.
With institutional approval the current study retrospectively reviewed and identified 14 patients, on a prospective database, who underwent Mitrofanoff cystolitholapaxy to treat bladder calculi at two independent institutions in the UK and Chile between 2004 and 2016. It looked at patient demographics, surgical technique, stone clearance and recurrence, as well as leak or catheterisation difficulties of the Mitrofanoff/Monti channel post-procedure.
Fourteen patients underwent Mitrofanoff cystolitholapaxy during the period 2004-2016. One patient was excluded due to lack of follow-up. The remaining 13 patients were aged 5-22 (median 14) years at the time of the procedure. Their underlying diagnoses were four neuropathic bladders, four bladder exstrophy, four cloacal exstrophy and one posterior urethral valve. Patients underwent augmentation cystoplasty at a median age of 5 (range 1-15) years, using ileum in 10 and sigmoid colon in three. The channel for clean intermittent catheterisation was an appendix Mitrofanoff in nine and a Monti channel in four. An Amplatz sheath was placed through the Mitrofanoff to allow safe access to the bladder for treating the stones (see Summary Table). Recurrent stones were treated using the same technique. Stone and channel outcomes were analysed for each procedure. There were 22 procedures in 13 patients; five (38%) patients had recurrent stones. Median time to recurrence was 6 months. There were no immediate complications. Stone clearance was confirmed by ultrasound and abdominal x-ray at 3-6 months after the procedure. Median follow-up was 15 (range 3-53) months. There were no leaks or difficulties catheterising the channel on follow-up.
This was the first series of Mitrofanoff/Monti cystolitholapaxy for the treatment of calculi in augmented bladders of paediatric patients. Previous concerns about damaging the continence mechanism of the conduit appeared to be unwarranted. The use of an Amplatz sheath protected the continence system from repeated instrumentation, and permitted free backflow of irrigation and rapid clearance of stone fragments. Recurrence of stones occurred in 38%, which was in keeping with rates reported in the wider literature.
Mitrofanoff cystolitholapaxy was safe, and with appropriate care did not result in leakage or difficulty catheterising.
膀胱结石是膀胱增大的已知并发症。开放式膀胱结石切开术仍然是治疗大结石或多发性结石的首选方法。然而，越来越多的微创技术已被应用。关于米托法诺夫膀胱结石碎石术的报告很少，且仅限于成人。本研究介绍了两家中心通过米托法诺夫/蒙蒂通道治疗儿童膀胱结石的系列病例。
经机构批准，本研究回顾性地从英国和智利的两个独立机构的前瞻性数据库中检索并确定了 2004 年至 2016 年间接受米托法诺夫膀胱结石碎石术治疗膀胱结石的 14 名患者。研究观察了患者的人口统计学特征、手术技术、结石清除率和复发情况，以及术后米托法诺夫/蒙蒂通道的漏尿或置管困难情况。
2004 年至 2016 年间，14 名患者接受了米托法诺夫膀胱结石碎石术。由于缺乏随访，1 名患者被排除。其余 13 名患者在手术时的年龄为 5-22 岁（中位数 14 岁）。他们的基础诊断分别为：4 例神经源性膀胱、4 例膀胱外翻、4 例泄殖腔外翻和 1 例后尿道瓣膜。患者在 5 岁（1-15 岁）时接受了中位年龄的膀胱增大术，其中 10 例使用回肠，3 例使用乙状结肠。用于清洁间歇性导尿的通道是 9 例阑尾米托法诺夫，4 例蒙蒂通道。通过米托法诺夫放置阿姆斯壮护套，以便安全进入膀胱治疗结石（见总结表）。使用相同的技术治疗复发性结石。对每个手术的结石和通道结果进行了分析。13 名患者中有 22 例手术；5 名（38%）患者有复发性结石。中位复发时间为 6 个月。无即刻并发症。术后 3-6 个月行超声和腹部 X 线检查确认结石清除。中位随访时间为 15 个月（3-53 个月）。随访期间，通道无漏尿或置管困难。
这是米托法诺夫/蒙蒂膀胱结石碎石术治疗小儿增大膀胱结石的首个系列。之前人们担心会损害导管的控尿机制，但这种担忧似乎是没有根据的。阿姆斯壮护套的使用保护了控尿系统免受反复操作的影响，并允许冲洗液自由回流和快速清除结石碎片。复发性结石的发生率为 38%，与更广泛文献报道的发生率一致。
米托法诺夫膀胱结石碎石术是安全的，适当的护理不会导致漏尿或置管困难。
