OUTCOME ANALYSIS OF MITROFANOFF PRINCIPLE APPLICATIONS 1797

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EDITORIAL COMMENT

This is a comforting review of a generous experience using the Mitrofanoff principle, a technique that we brought back from France a h r personally visiting Paul Mitrofanoff in 1981. We too have a successful experience and much prefer this method of creating the catheterizable port in bladder reconstruction.

The authors fail to mention the major complication that we have seen with this reconstruction: stone formation seems even more prevalent with the appendix in place. This observation may be re- flected by our long followup and the fact that we were not vigorous in having our patients irrigate the mucus from the bladder in the past. Nowadays the ritual of irrigation with 300 cc tap water is well established and it is my clinical impression that we have seen less of a stone problem. We tried urea instillation, as recommended by Bushman and Howards,' but it was not well accepted by the pa- tients. I t led to burning and irritability, and we have abandoned it. As in this report, we too have noted such good continence with the

Mitrofanoff technique that the stomas do not leak. Although this is comforting for the patient, it is anxiety producing for the surgeon. We prefer to have a pop-off mechanism that will allow these recon- structed bladders to leak should they become over distended. For this reason we try to maintain the bladder neck for our pop-off port. With a leak-proof closed system we too have seen difficult catheterization situations when the reservoir becomes over distended. Therefore, we have instructed patients to use an 18 gauge needle for puncturing the lower bladder up to the hilt of the needle as an immediate vent for urine at home. Partial venting of the system will usually permit catheterization and it may be life saving by preventing perforation. This technique seems a more timely relief of over distension than to depend on the patient reaching medical care for suprapubic cystot- omy, as indicated in this article.

A comment should be made on the discomfort that some patients express using the ureter. We treat a number of patients who report significant discomfort when they pass the catheter through a distal ureter, particularly when the ureter is not grossly dilated when the ureterovesicostomy is formed.

This report supports the message that the Mitrofanoff principle is among the most reliable and easily constructed catheterizable ports in urinary reconstruction. We need to continue to impress this fact on our pediatric surgical colleagues, since some still have the uncontrol- lable urge to perform incidental appendectomy.

John W. Duckett Department of Urology Children's Hospital of Philadelphia Philadelphia, Pennsylvania

1. Bushman, W. and Howards, S. S.: The use of urea for dissolution of urinary mucus in urinary tract reconstruction. J . Urol., 151: 1036,1994.