A 28 y.o. woman with spina bifida comes to the ED with a chief complaint that " my tube is leaking". On exam, she has a foley draining clear urine and an appliance in the RLQ as well as a tube which appears to be coming from the umbilicus. What surgery has she had?
This woman with spina bifida has had both Mitrofanoff and a MACE procedures.
A Mitrofanoff procedure is an appendicovesicostomy. The appendix is taken with its blood supply and it is attached to the bladder near the umbilicuscreating a conduit for a person with urinary incontinence to catheterize themselves. The appendix is tacked down in several places creating a continence mechanism. A catheter is left in the new tract for one month, allowing it to heal. Our patient presented with this tube near the umbilicus. It has a direct connection to the bladder and is to be irrigated every day. This allows a patient who is wheelchair bound to catheterize themselves easily.
A MACE is a Mahoney antegrade continence enema procedure. A connection is made near the ascending colon between the skin and large bowel often using a tube of jejunum( or appendix if available) . An appliance is placed in the bowel that allows the patient to irrigate the colon. If the colon is irrigated daily, the patient will have regular bowel movements and not be incontinent of feces. This allows the patient to care for themselves.
Teaching point: This would not be someone a catheter could be easily replaced in. The track would need to mature first.
This patient had been cared for by her mother for years but unfortunately her mother had a stroke and could no longer provide her twice daily urinary catheterizations or enemas. A decision was made to place the Mitrofanoff conduit so she could catheterize herself. Similar reasoning applied to the MACE procedure so that she could irrigate herself daily and produce a bowel movement.
On CT she had a staghorn calculus in the L kidney and a large bladder stone secondary to her chronic UTIs and stasis. The bladder stone was removed at the time of the surgery as well as two ovarian cysts. A stent was placed in the L kidney in preparation for removal of the L staghorn at a later date. She presented to the ED with “leaking” around the bladder tube. She underwent cystoraphy through the indwelling foley and no evidence of a leak was found withdye refluxingappropriately into the L renal stent. She was discharged with instructions to follow up with urology
Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet. 1990;336:1217-18.
Bruce R, el-Galley RE, Wells J, et al. Antegrade continence enema for the treatment of fecal incontinence in adults: use of gastric tube for catheterizable access to the descending colon. J Urol 1999;161(6): 1813-16.
Breen, M, Phelps A, Estrada C, Chow J. he role of imaging in pediatric bladder augmentation Pediatri Radiology 2015 45(10)1440-1447.
Merenda LA, Duffy T, Betz R et al. Outcomes of urinary diversion in children with spinal cord injuries
J Spinal Cord Med 1994 30 Suppl 1: S41-7.