Introduction
The reconstruction of the urinary tract is a necessary procedure for many of the congenital anomalies of the urinary tract and some other diseases related to children. The main aim of the reconstruction is to give the bladder sufficient capacity, good function of the sphincter, and keep the bladder empty. In some cases, the patients urinate normally. In most cases, the children require a procedure of clean cross-section catheterization that is done through the urethra or the abdominal cavity. Various types of surgical procedures are there for this. One of the procedures includes Mitrofanoff’s law.
What Is Urinary Tract Reconstruction Done in Children?
Abdominal stoma using the Mitrofanoff method is a reliable procedure and has success in children. When clean cross-section catheterization is performed, this procedure for treating children with primary retention should be considered. The appendix is quite suitable for this procedure, but using a ureter is usually satisfactory. When neither is available, an alternative method to construct a catheterizable channel should be considered.
Among all the methods for reconstructing the urinary tract, the Mitrofanoff procedure is simple to perform in children with intermittently dependent catheterization. A vermiform appendix has been proven to be the most effective and best source for constructing conduits.
Surgical revision is necessary to treat the urinary tract in case of care failure. Along with the reconstruction of the urinary tract, a kidney transplant is also required and is a safe treatment for better results in children with few complications. Treatment is done before any chemotherapy, and quality of life is improved.
How Is Urinary Tract Reconstruction Done in Children?
In most cases, an appendix is used for reconstruction.
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It is moved on its vascular pedicle carefully, including the caecal extension in some cases to provide extra length.
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This appendix is then drawn in the bladder at a point, and a submucosal tunnel of 3cm is constructed with dissection scissors. Amputating its tip, the appendix is anastomosed using Vicryl suture with the bladder.
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The proximal end is brought out from the right side of the abdomen. It acts as a stoma. Without any skin flaps, simple skin anastomoses are done. In some cases, the appendix is inverted, and the antireflux tunnel is constructed extravesically in a few patients. The distal part of the ureter is used as the Mitrofanoff channel.
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After mobilizing and dissecting, the ureter is implanted in the bladder in the submucosal channel and runs straight to the abdominal stoma. By nephrectomy, the distal part of the ureter is available for the Mitrofanoffs procedure.
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In the case of a tortuous ureter, it can be divided for the procedure.
Intestinal grafting
The abnormalities in the urinary tract can cause kidney failure also. Over the years, various procedures for reconstruction have developed. This has also resulted in successful kidney transplants. Recently the success of intestinal grafts in children's suffering from urinary tract dysfunction has proved better than a bladder transplant. In some cases, grafts may get rejected, as in pyelonephritis. Severe urinary tract infection is seen in some children with transplanted bladder, leading to graft loss in some and may also cause death. Antibiotics are not generally given to those patients. In some female patients, the appendix has been removed, and no suitable ureter or Fallopian tubes are available. A 10 cm colon is taken and added on in such cases with bladder exstrophy. Half of this colon is used in the construction of catheterizable tube mucosa. The detrusor tube can also be made of about 7 cm and is bought out from the abdomen as a stoma.
A French polyvinyl catheter is stented in patients undergoing Mitrofanoff procedure after the surgery. Two weeks later, this catheter is removed after the commencement of clean cross-section catheterization. After the procedure, the patient and the patient are educated about the routine clinical follow-up, renal profile, and performing urine culture. Investigations such as ultrasonography, renal nuclide scan, pyelogram, and cystogram are performed.
What Are the Complications Associated With Urinary Tract Reconstruction in Children?
The major complication associated with urinary tract reconstruction is the difficulty of catheterizing the conduit. In cases, where the conduit is made with the help of an appendix, the problem is less than when the appendix was not used.
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Conservative treatment with dilation can fail, and a surgical procedure needs to be conducted.
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There can be the appearance of strictures in the conduit made from the appendix, and the reason for the same remains unknown. Some of the suggestive causes can be ischemia, body habitus, recurrent trauma, or there can be differences in the rate of growth between the Mitrofanoff conduit and the growth of the abdominal wall.
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Increases in fibrosis of the appendix, decrease in lymphoid tissue, and reduced appendix lumen diameter with patients of increasing age can be seen.
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Excessive conduit angulation can be a cause of difficulty in catheterization.
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Technical issues can occur because of the extra vesicle length of the conduit.
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Urolithiasis is a complication associated with urinary tract reconstruction. Daily irrigating the bladder and avoiding mucus accumulation in forming stones is helpful.
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Graft rejection can also be seen in some patients, causing loss of graft in some, and death in children is also reported.
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Metabolic alteration is seen in some patients having urinary diversion. Patients also report metabolic acidosis and require medical treatment for the same. This acidosis is not dependent on urinary diversion or reconstruction.
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In some patients, vitamin B12 deficiency and pernicious anemia are reported in patients along with malabsorption syndrome.
Conclusion
Urinary tract reconstruction therapy for patients suffering from congenital malformation and certain infections in children is common. The symptoms include tenderness, inaccessibility, and narrowing of the urinary tract. Pediatric urologists now usually prefer the Mitrofanoff principle for reconstruction. Using an appendix for reconstruction has proven to be more successful than other grafts. It has a stable, fair, and reliable blood chamber, and the lumen of the appendix is soft and narrow and maintains tension. Mitronoff procedure has a better success rate and a procedure with fewer complications.
