his development of alternative continent bladder access through a continent stoma has relieved the necessity for the patient to either void efficiently or to catheterize through the urethra .
there have been other alternatives to mitrofanoff 's original use of appendix for extra - anatomic access to the bladder .
other options for continent bladder access include ureter , fallopian tube , bladder tubes , and tubularized bowel.[13 ] many surgeons believe that catheterizable abdominal stomas promote continence by avoiding manipulation of the urethra or in some cases a reconstructed bladder neck .
in some cases they encourage patient compliance with intermittent catheterization because catheterizing through an abdominal stoma is easier and less time consuming than urethral catheterization for many patients .
regular catheterization keeps bladder pressures low and minimizes stress on the urethra or reconstruction done at the bladder neck .
stomas allow the surgeon to be more aggressive in creating resistance at the bladder outlet because the urethra will not be needed as the primary access for catheterization .
the combination of continent stomas and augmentation has allowed patients who have suffered multiple failed continence surgeries to be salvaged with good results . the mitrofanoff procedure has traditionally been performed using an open surgical technique using either a lower midline or pfannenstiel incision .
there have been a few reports in the literature where laparoscopic techniques have been applied to this procedure in an attempt to minimize morbidity and improve cosmesis .
jordan and winslow , and van savage and slaughenhoupt described a laparoscopic assisted appendicovesicostomy where the appendix and right hemicolon were mobilized laparoscopically and the appendicovesical anastomosis was completed through a pfannenstiel incision .
intracorporeal suturing is a technically demanding task that requires a significant amount of experience and surgical skill .
we report our experience with a complete laparoscopic mitrofanoff appendicovesicostomy to promote a catheterizable abdominal stoma .
a 10 mm laparoscopic camera port was placed through the umbilicus and 2 , 5 mm laparoscopic ports were placed in the left lower quadrant and right midaxillary line at the level of the umbilicus .
a fourth port was placed in the left midaxillary line , also at the level of the umbilicus .
the appendix was ligated and divided at its base and the stump was buried into the caecum using a 3-zero silk purse - string suture .
the appendix was assessed to determine whether the length was adequate to reach the anterior abdominal wall ( approximately 5 to 6 cm ) and whether the diameter was of sufficient caliber to accommodate at least a 12 fr catheter .
this maneuver was done without desufflating the abdomen to allow more room for error in appropriating an adequate distance .
ligation of the base of the appendix appendix mobilized on an adequate length of mesoappendix the bladder was filled with saline and a 5 cm vertical seromuscular incision was made in the right posterior wall of the bladder down to the mucosa [ figure 3 ] .
after incision of the mucosa the appendix was anastomosed to the bladder using 4 zero polyglactin interrupted sutures .
the seromuscular layer of the bladder was closed using interrupted 3 zero polyglactin sutures , [ figure 4 ] creating a tunnel for the appendix .
the appendix was then brought up to the umbilicus and a catheterizable stoma was created [ figure 5 ] .
smooth catheterization through the appendix with full pneumoperitoneum and with the pneumoperitoneum released was performed .
a 16 fr suprapubic catheter was inserted into the bladder and a 10 fr stenting catheter was left through the appendix .
pouting bladder mucosa after dissection of detrusor completed appendico - vesical anastomosis and detrussoraphy distal end of the appendix being brought out to the skin via a 10 mm port the child was started on oral liquid feeds within 6 - -8 hours .
the catheter was left indwelling for 3 weeks and was removed after ensuring that the patient or family could catheterize without difficulty .
during the period january 2004 and december 2009 , six children with a mean age of 12.8 years ( range 9 - -16 years ) underwent laparoscopic mitrofanoff appendicovesicostomy .
three of these children had neurogenic bladder secondary to spina bifida , two had non - neurogenic neurogenic ( hinman ) bladder , and one child was a case of urethral stricture following posterior urethral injury and had undergone multiple surgeries for the same .
the reasons for failed urethral cic in these children included urethral strictures in three , down 's syndrome in two and painful cic in the remaining child .
overall the mean operative time was 139.6 min ( range 125 - -175 min ) .
all children had liquid diet in the evening of surgery or on the postoperative day 1 .
two children developed urinary incontinence via the mitrofanoff ; however both responded well to anticholinergic therapy .
one of these children has been off anticholinergic therapy , while the other child still needs low dose anticholinergic therapy .
one child had a severe episode of urinary infection in the follow - up period , but responded well to antibiotics .
the mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder .
it creates a conduit to the bladder through which patients with a sensitive , absent , or traumatized urethra can perform clean intermittent catheterization ( cic ) easily . fashioning this continent , catheterizable channel using the appendix
the use of laparoscopic and robot - assisted approaches to reconstruct the lower urinary tract has been slowly introduced in the past several years .
individual cases of laparoscopic and robot - assisted mitrofanoff appendicovesicostomy have appeared in the literature .
the adoption of a purely laparoscopic or robot - assisted approach to lower urinary tract surgery in pediatric patients has been slow , given the steep learning curve and relative paucity of cases .
congruent with the limited published experience , the surgical outcomes have compared favorably with those of an open approach in these selected patients .
parents of children undergoing this minimally invasive procedure were satisfied with the short - term outcomes and postoperative recovery , particularly early resumption of physical activity and the avoidance of a prolonged absence from school . in children approaching adolescence and adulthood , the perceived benefits of a minimally invasive approach such as lower analgesic requirements , improved recovery time and improved cosmesis might be more apparent than in younger children .
some surgeons have reported that prolonged operative time was a potential disadvantage associated with laparoscopic approach .
the operative time should improve significantly in subsequent cases with better handling of technical issues .
our reduced operative time has been due to our experience in performing laparoscopic pyeloplasty in children . in our experience
the use of the da vinci robotic technology has added advantages for the pediatric population .
it has allowed for the more complex laparoscopic procedures to be performed with greater dexterity .
pedraza et al found that by incorporating the da vinci robotic system they were able to create efficiently a circumferential watertight appendicovesical anastomosis and decrease the overall operative time of the procedure .
nguyen et al reported on 10 patients who underwent the robot - assisted laparoscopic mitrofanoff procedure using the da vinci surgical system .
they similarly believe that the robot - assisted laparoscopic mitrofanoff procedure is feasible to perform , is associated with satisfactory outcomes and minimal complications , and has the benefits of a minimally invasive approach .
pure laparoscopic mitrofanoff appendicovesicostomy is feasible and is associated with reasonable outcome with early recovery , resumption of normal activities , and excellent cosmesis .
 introduction : the mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder . 
 it creates a conduit to the bladder through which patients with a sensitive , absent , or traumatized urethra can perform clean intermittent catheterization ( cic ) easily . 
 we report our experience with complete laparoscopic mitrofanoff appendicovesicostomy to promote a catheterizable abdominal stoma.materials and methods : a 4-port transperitoneal approach was used to create a complete laparoscopic mitrofanoff appendicovesicostomy.results:six children with a mean age of 12.8 years ( range 9 - 16 years ) underwent laparoscopic mitrofanoff appendicovesicostomy . 
 mean operative time was 139.6 min and mean estimated blood loss was 46 cc . 
 no cases of urinary leaks were noted . 
 there have been no cases of either stomal stenosis or appendicovesical stenosis noted.conclusions:pure laparoscopic mitrofanoff appendicovesicostomy is feasible and is associated with reasonable outcome with early recovery , resumption of normal activities and excellent cosmesis . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS