Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study

Summary

Introduction and objective

For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children.

Materials and methods

A research ethics board–approved retrospective review was performed to assess peri-operative outcomes among pediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann–Whitney U test were used to determine statistical significance.

Results

Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8–14.0) and 9.9 years (4.2–14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n = 3, 20.0%; n = 9, 47.4%). The median follow-up period was 25.9 (IQR 7.7–47.2) months and 28.0 (IQR 13.0–53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes.

Discussion

Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS.

Conclusion

Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.

Summary Table. Comparison of peri-operative outcomes.

Laparoscopic Mitrofanoff procedure patients (n = 34)	No previous abdominal surgery (n = 15)	Previous abdominal surgery (n = 19)	P-value
	N (%), median (IQR)	N (%), median (IQR)
Operative time (min)	267 (255–340)	255 (196–292)	0.256
Estimated blood loss (mL)	25 (25–50)	50 (25–100)	0.089
Conversion to open surgery	0 (0.0)	0 (0.0)	–
Length of stay (days)	4 (4.0–5.0)	4.0 (3.0–6.0)	0.302
Follow-up (months)	25.9 (7.7–47.2)	28.0 (13.0–53.0)	0.477
Stoma continence	13 (81.3)	17 (89.5)	0.634
Patients with stoma stenosis	2 (13.3)	4 (21.1)	0.672
Patients with complications requiring intervention (Clavien-Dindo classification ≥3 complication)	3 (20.0)	9 (47.4)	0.152

IQR, interquartile range.

Introduction

Laparoscopic procedures have become increasingly prevalent in the pediatric urology because of its excellent short-term clinical advantages in children with outcomes comparable to the traditional open procedures. Traditionally, previous abdominal surgery (PAS) has been identified as a risk factor that may complicate and increase the difficulty of laparoscopic procedures [1], [2]. In the pediatric population, there are limited data on the impact of PAS on complexity and outcomes of subsequent laparoscopic surgery [3], [4], [5].

Creation of an appendicovesicostomy, or Mitrofanoff, is a common technique used for continent urinary diversion in children or adolescents wanting independence for self-intermittent catheterization [6]. Patients with an indication for the Mitrofanoff procedure are often those with neurogenic bladders arising from spina bifida, urethral strictures, or congenital abnormalities, who often also have had other intra-abdominal surgeries [7]. However, although the laparoscopic Mitrofanoff procedure is feasible in patients with PAS, it may have an increased likelihood of being converted to an open operation [8]. Despite the benefits the laparoscopic Mitrofanoff procedure offers to pediatric population, including improved cosmesis and decreased hospital stay compared with the open approach [9], [10], [11], owing to a paucity of data in the pediatric patients with PAS and negative consequences of extended operative procedures on children, surgeons may be less inclined to offer it as an option [3], [12], [13]. Therefore, this study aims to determine whether PAS has an impact on the peri-operative outcome for laparoscopic Mitrofanoff procedure in children.