Dr. Sean Elliott, MD
Reconstructive Urologist
Mitrofanoff or Monti catheterizable channel
What is a Mitrofanoff or Monti catheterizable channel?
Like it sounds, a catheterizable channel is a tube through which you can pass a bladder catheter. The tube is constructed from intestine and is the same diameter as your catheter, so that the catheter glides through in a straight line to the bladder. A Mitrofanoff is a tube made out of your appendix with one end connected to the bladder and the other end connected to your abdominal wall, usually at the umbilicus. A Monti is the same thing but made with small intestine instead of appendix. They are both named for the person that invented them. There are other types of catheterizable channels that use different parts of the intestine too; often, people refer to all of these as Mitrofanoff, whether made from the appendix or not.
Is this the same thing as a stoma?
A stoma is really any opening on your body that was created surgically. So, yes, a Mitrofanoff or Monti catheterizable channel does have an opening on the abdominal wall and that opening is called a stoma. Other types of stomas include a colostomy or urostomy.
Why do some people need a Mitrofanoff or Monti?
Some people who perform intermittent catheterization to drain the bladder are unable to do so through their urethra and so we create an alternative route for catheterization on the abdominal wall. Reasons for this include: (1) the urethra is blocked by scar tissue; (2) the urethra (or bladder neck) has been surgically closed to prevent urinary leakage; (3) pain with urethral catheterization; (4) the urethra is difficult to access. The last reason (problems accessing the urethra) is the most common reason we create a Mitrofanoff or Monti. The most common reason people have difficulty accessing their urethra is that spinal cord injury, spina bifida, cerebral palsy or some other neurologic condition causes them to use a wheelchair for mobility and it is difficult to access the urethra in the wheelchair. Being able to catheterize while in your wheelchair give people a lot of independence – they don’t have to depend on others to transfer them out of their chair or catheterize them. Even people with partial quadriplegia and limited hand dexterity can often catheterize through a Mitrofanoff or Monti channel.
Does it hurt to catheterize a stoma?
No, the intestines don’t feel pain in that way.
Will people see my Mitrofanoff or Monti stoma?
The stoma is usually in the belly button and not visible to most people. It is about the size of a pencil eraser.
Will I leak urine out the Mitrofanoff or Monti?
No, you should not leak urine. You might have a few drops of mucous come out the stomal opening per day but you should not leak urine. We surgically create a one-way valve at the bladder end of the Mitrofanoff or Monti. When the catheter passes through, it opens this valve and drains the bladder. When the catheter is removed, the valve closes.
Description of surgery
The surgery is done through a vertical (a.k.a. midline) or horizontal (a.k.a., Pfannenstiel) abdominal incision. We start by examining your appendix to see if it is usable as a Mitrofanoff. The appendix is nice to use because in many people it is just the right diameter for a catheter and it is long enough to reach from the bladder to the belly button (we need about 8-10 cm in adults). Of course, some people have had their appendix removed already for appendicitis; but, even if you still have yours, we might find that it is too small or that it is rotated in the wrong direction to meet the bladder. These subtle things are hard to tell ahead of time on x-rays so we have to figure it out during surgery. But don’t worry, we can still do your surgery. If your appendix is usable then we proceed with a Mitrofanoff tube. We divide the appendix from its connection to the colon. We keep its blood supply intact. We open both ends of the appendix and ensure that a catheter passes through nicely. We then create a tunnel in the wall of the bladder for the appendix to go through. This tunnel is in between the outer muscle of the bladder and the inner mucosa. When the bladder is full, the mucosa gets pushed out against the muscle and it acts as a valve, closing the Mitrofanoff. We then stitch one open end of the appendix to the bladder mucosa and the other end to your belly button (a.k.a., umbilicus). If it won’t reach your belly button then we can connect it to the skin of your abdominal wall elsewhere, lower down. If your appendix is not usable then we make a Monti tube. We remove about 2-3 cm, (1 inch) of small intestine and reconfigure this so that it is shaped exactly like an appendix. The small intestine is naturally wider than the appendix so we take this short 1 inch piece of really wide intestine and make it into something that is much longer (6-12cm) and just the right diameter for a catheter. The rest of the surgery is the same as for a Mitrofanoff (see above). It is very common for people to get a bladder augment at the same time as a Mitrofanoff/Monti (see separate instructions). This surgery enlarges the bladder and will usually be done with small intestine. If we are doing a Monti then we take the Monti and the augment sections of small intestine from adjacent parts of the small bowel so that we only have to reconnect the small bowel once. One special situation is a CCIC. It stands for a catheterizable channel and bladder augment created using a segment of ileum and cecum. The cecum is the first part of the large intestine (a.k.a., colon). There is a valve between the cecum and the last part of the small intestine. This last part of the small intestine is called the ileum. So, the valve between the two is called the ileocecal valve (ICV). The cecum is used as the bladder augment and the last part of the ileum is used as a catheterizable channel. What makes this surgery unique is that we don’t create a tunnel in the wall of the bladder to make a valve to keep your stoma dry. Instead, the ICV acts as that valve. We prefer to do the previous procedures (Mitrofanoff or Monti and separate bladder augment) when we can because your stools can become looser and more frequent when we remove the ICV from your intestine. However, in some people it is impossible to tunnel the Mitrofanoff or Monti into the bladder to create a valve so we have to do the CCIC so we can use the ICV as our bladder valve. In fact, many people who need this surgery also suffer from constipation; so, losing this valve actually can help them have more regular bowel movements. At the end of the surgery 2 catheters are inserted to help keep the bladder empty during the healing process so that urine does not leak between the stitches. One catheter comes out the Mitrofanoff or Monti. The second catheter can come out the urethra and or through a temporary hole on your abdominal wall (we call this a suprapubic tube). Most people opt for the urethral catheter as the second catheter; but some people can’t have urethral catheters or really don’t like them. Both catheters are removed one month after surgery and the person is taught to catheterize their bladder through the new Mitrofanoff or Monti to empty it. The skin is closed at the end of the surgery with either dissolvable stitches or non-dissolvable staples. When staples are used, these are removed about 2 weeks after surgery.
Hospital stay
After surgery people usually remain in the hospital for 3-9 days. If you just had a Mitrofanoff then the recovery is usually shorter than the other techniques because there is no bowel reconnection that we have to make; so, your intestines wake up faster. We know you are ready to go home when you have good pain control with pills, are able to eat and are back to your baseline level of mobility.
Care team
There will be several people seeing you every day in the hospital. These may include: nurses, nursing assistants, dieticians, physical therapists, occupational therapists, social workers, surgeons, medical doctors, nurse practitioners, physician assistants, residents and medical students. At a teaching hospital like this one, the residents and medical students are central members of the care team. Your surgeon may not be able to see you every day in the hospital because they work in several different hospitals and clinics each day; so they have to rely on their team of doctors to help manage you after surgery. Rest assured that this team is communicating with your surgeon multiple times a day and that as the captain of the team your surgeon is making the decisions about your care.
Diet
When we operate on the intestines they tend to go to sleep for a few days. If you try to eat right away you are likely to vomit. So, we typically allow you to have just sips of water and ice chips for the first two days. Once you feel hungry and not bloated with gas we know that your intestines are waking up. Then we try a diet of clear liquids (juice, soda, Jello and soup broth). If this goes well then, we try a regular diet.
Bowel movements
When we operate on the intestines they tend to go to sleep for a few days. This, plus the fact that you may not have eaten normally right before and after surgery means that you might not have a bowel movement for a few days. If you normally need help from things like enemas in order to have a bowel movement, then please explain this to the doctors or nurses in the hospital. We can make sure you are on the medicines you need in order to have a bowel movement. When you do have a bowel movement the first few may be loose because of the recent intestinal surgery plus the alterations in your diet.
Pain control
Some people opt for an epidural or a nerve block before surgery. This can help with pain control in your abdominal incision for the first few days. You may have a pain pump or pain button, also called Patient Controlled Analgesia (PCA). This is a button that you push that automatically delivers a narcotic pain medicine through your IV. If you cannot push the pain button or prefer not to have one, then an alternative is that a nurse can deliver pain medicines through the IV as needed. You may also get an IV form of non-narcotic pain medicines to allow you to take fewer narcotics. Once your intestines start working we will have you try taking pain pills by mouth (a.k.a., orally). Oral pain medicines work longer than IV forms and are, of course, the type that need to be working for you in order to go home.
Catheters
At the end of the surgery, 2 catheters are inserted to help keep the bladder empty during the healing process so that urine does not leak between the stitches. One catheter comes out the Mitrofanoff or Monti. The second catheter can come out the urethra and or through a temporary hole on your abdominal wall (we call this a suprapubic tube). Both are removed one month after surgery and you and/or your caregivers are taught to catheterize your bladder to empty it. Both catheters will be attached to their own bag after surgery. By the time you go home we may cap or plug one of the catheters and keep the other attached to one bag. Whether the catheter is plugged or attached to a bag, it is important to flush (a.k.a., irrigate) both catheters twice a day to remove mucous and prevent clogging of the catheter. The flushing can be done with sterile saline. You will be taught by the nurses and/or doctors how to flush the catheters.
Incision
There will be a dressing over your incision after surgery. This will be removed 2 days after surgery and the incision can be left open to air. If there are staples then these will be removed about 2 weeks after surgery. If you go home with them then you can arrange to have us or your local doctor remove them.
JP drain
At the end of surgery, a tube is placed that is on the outside of the bladder and comes through the abdominal wall through a small puncture hole. This tube is called a JP drain and it attaches to a suction canister. The JP drain suctions out any urine or blood that may accumulate outside the bladder; it is removed before the patient leaves the hospital. After removing the drain, a bandage will be placed over the hole and it can be removed in 2 days. The hole in the skin closes on its own in 1-2 days.
Mobility
At first, it can be hard to move around or transfer out of bed after surgery due to the pain of the incision. But, it is important to try to get back to your baseline level of activity after surgery. By moving around, you help prevent bed sores and pneumonia, and you help wake up the intestines. Physical therapists may see you in the hospital to help you regain mobility. Some people will need to go to a rehabilitation center after the hospital in order to get further help with mobility; the physical therapists will help determine your level of need and their documentation will help ensure that your insurance company will pay for any rehabilitation care you need.