combined Monti-Ghonaim technique as urinary stoma


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a new technique combining Monti-Ghonaim technique to achieve wide continent stoma fit for bigger cic and irrigation in augmented bladder.

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combined Monti-Ghonaim technique as urinary stoma

  1. 1. Augmentation cystoplasty Dr. Mohammed Sammour Consultant Urologist King Abdulaziz National Guard Hospital Alhofuf
  2. 2. <ul><li>A 12 years old smart girl and known case of neuropathic bladder due to myelomeningocele. </li></ul><ul><li>As neonate, she had undergone repair of myelomeningocele and started on clean intermittent catheterization with prophylactic antibiotic. </li></ul><ul><li>At age of 5, she started to have recurrent febrile urinary tract infections 2-3 times per year, which required hospitalization many times every year </li></ul><ul><li>she was incontinent In spite of intermittent catheterization performed by her mother every 4 hour and oral anticholinergic medication </li></ul>
  3. 3. <ul><li>On Exam.: </li></ul><ul><li>Looked smaller for her age. </li></ul><ul><li>Smart girl. </li></ul><ul><li>On wheel chair. </li></ul><ul><li>Spastic paraplegia . </li></ul><ul><li>Moving her upper limbs freely. </li></ul>
  4. 4. <ul><li>CBC, chemistry within normal values. </li></ul><ul><li>Urinalysis and culture showed recurrent growth of E. Coli bacteria. </li></ul><ul><li>Ultrasound showed bilateral severe hydronephrosis with scarred kidneys, dilated ureters and thick, trabeculated bladder wall. </li></ul>
  5. 5. <ul><li>M.C.U.G </li></ul>
  6. 6. D.M.S.A
  7. 7. Urodynamic study <ul><li>Showed low compliance with bladder capacity 70 ml and detrusal leak point pressure was 60 cm water . </li></ul>
  8. 8. <ul><li>The goal of management </li></ul><ul><li>To protect upper urinary tract </li></ul><ul><li>To keep the patient dry </li></ul><ul><li>To be independent of her mother . </li></ul>
  9. 9. <ul><li>Initially the patient underwent left to right transureterureterostomy with ureterocystoplasty and Mitrofanoff appendicovesicotomy </li></ul>
  10. 18. <ul><li>Post operatively, the upper urinary tract function preserved </li></ul>
  11. 19. <ul><li>The patient exhibited difficulty in carrying out self-catheterization causing cellulitis around the stoma </li></ul><ul><li>She had a leak through the umbilical stoma with a bladder capacity of 150 ml that made her to wear diaper. </li></ul>
  12. 21. <ul><li>What is next: </li></ul><ul><li>What is our goal </li></ul>
  13. 22. <ul><li>To revise the augmentation to make the bladder bigger. </li></ul><ul><li>To use the ileum for that purpose. </li></ul><ul><li>Revise the Mitrofanoff to have wider conduit that can be utilized for easy intermittent catheterization and washing out the bowel segment mucous. </li></ul><ul><li>To achieve continence through the umbilical stoma. </li></ul>
  14. 23. <ul><li>What type of augmentation ? </li></ul><ul><li>What type of conduit ? </li></ul><ul><li>What type of continent mechanism ? </li></ul>
  15. 24. <ul><ul><li>Ileocystoplasty </li></ul></ul><ul><ul><li>MONTI conduit to the umbilicus </li></ul></ul><ul><ul><li>Serosal lined trough for continence. </li></ul></ul>
  16. 25. Ileocystoplasty
  17. 32. Serosal lined trough for continence.
  18. 35. Result <ul><li>Dry and off of diaper </li></ul><ul><li>On CIC every 6 hours </li></ul><ul><li>Independent </li></ul><ul><li>Capacity 300ccs </li></ul>