What is a Mitrofanoff?
A Mitrofanoff is a small tunnel from the bladder to the outside of the body. This tunnel is used to empty the bladder with a catheter. A catheter is a small but flexible tube that is put into the bladder through the Mitrofanoff. .
There are many reasons a child may need a Mitrofanoff, such as:
- congenital malformations (abnormalities present from birth)
- injury
- cancer
- trouble or pain with using a catheter through the urethra (the tube that normally carries urine (pee) out of the bladder)
A Mitrofanoff is created with surgery. To make the tunnel, the surgeon will use your child’s appendix. The appendix is an unused part of the bowel. The surgeon will take it and re-attach it between your child’s bladder and the skin of the belly. This whole procedure is sometimes called a Mitrofanoff procedure or catheterization using a Mitrofanoff.
More information about preparing for surgery can be found in Coming for Surgery.
Preparing for the operation
Your child may be asked to drink clear fluids, oral laxatives (e.g., PEG) and have rectal therapy (e.g., suppository, enema) completed before the procedure.
An enema is a liquid that is placed in your child’s anus to clear out the rectum. After an enema is given, your child will sit on the toilet to push out the water and feces (poo) from the bowel. Enemas may be uncomfortable, but they do not hurt.
If your child has severe constipation or other concerns before the surgery, the health-care team may ask for them to be admitted to the hospital one or two days before the day of the surgery.
You will be told what time your child should stop eating/drinking before surgery.
The day of the operation
Your child will be given a general anesthetic during the operation to put them into a deep sleep. This means that your child will not feel any pain during the procedure.
Mitrofanoff surgery usually takes about four hours. The surgery may take longer if it is paired with another procedure, such as a cecostomy or a bladder augmentation.
After the operation
When your child goes to the Post-Anesthetic Care Unit from the operating room, they will have an intravenous line (IV). An IV is a tiny plastic tube that is placed in a vein in the hand or arm. For the first few days after the operation, your child will get the liquids and medicines they need through the IV.
Your child will also have some of the following:
Incision, stitches and gauze
Your child’s incision will be closed with stitches and surgical glue (Dermabond). The incision is the place where the surgeon cuts through the skin to operate. The stitches and surgical glue will start to dissolve about 10 to 14 days after the surgery. It is important not to remove the surgical glue; let it peel off on its own.
The incision and the stitches may be covered with a dressing. This will be changed by your child’s nurse while your child is in the hospital.
Urinary catheter in the Mitrofanoff
Your child will have a urinary catheter inside the Mitrofanoff channel. It may or may not be attached to a urine collection bag. Flushes may be completed on a schedule or as needed through this catheter to ensure the Mitrofanoff channel stays open.
Urinary catheter in the urethra
Your child will likely also have a urinary catheter in their urethra that may be used until the Mitrofanoff channel heals. The catheter is connected to a urinary drainage bag. This catheter will remain in place for at least a few days and is usually removed before your child leaves the hospital. Anesthesia and sedation are not required to remove the catheter. Flushes may be completed on a schedule or only as needed through the catheter.
Suprapubic catheter
If your child cannot have a urethral catheter placed, then they will have a suprapubic catheter after the operation. A suprapubic catheter is a small tube that goes through the skin of the belly into the bladder. This catheter will likely be in place for a few weeks. Flushes may be completed on a schedule or only as needed through the suprapubic catheter while it is in place.
Nasogastric tube
Some children may require a nasogastric tube, or a thin tube that goes from the nose to the stomach; to help decompress the stomach. This allows the stomach to stay empty and rest after the operation. The tube may be used for a few days or longer. The NG tube will be removed when your child is ready to feed by mouth.
Jackson Pratt (JP) drain
A JP drain may be placed in your child's belly, close to the incision. The drain removes extra fluids that may collect in the abdomen during the operation. The JP drain looks like a thick elastic band attached to a bulb. It is stitched in place and covered with a piece of gauze. In most cases, the drain will be removed before your child leaves the hospital.
Managing your child's pain
There are several ways to control pain that work well. The way your child receives pain medication will depend on their age and needs.
- Your child may get medicine for pain through the IV.
- Your child may have an epidural catheter. An epidural catheter is a small plastic tube that an anesthesiologist puts into a space in the spine. The anesthesiologist is the doctor who gives general anesthetic, sedatives and other pain relievers so that your child will sleep and not feel any pain during surgery. The epidural catheter is placed while your child is asleep in in the operating room. This catheter lets your child have medicine for pain all the time. The epidural catheter works well because it numbs the body below the incision. The medical team will decide when it is appropriate for your child to have this epidural catheter removed, and transition to intravenous or oral pain medications.
The cause and treatment of bladder spasms
Catheters and stents may bother the bladder and cause cramps, called bladder spasms. Sometimes bladder spasms can hurt a lot. If your child has painful bladder spasms, they will be given a medicine called a B&O suppository. This medicine relaxes the bladder and reduces the pain.
Symptoms of bladder spasms
Signs that your child is having bladder spasms may include:
- pain that comes on quickly and then stops
- an itchy bottom
- the need to urinate or have a bowel movement (poo) often
- holding or rubbing their genitals (private parts) more than usual
- urine leaking around the catheter
- drawing the knees up to the chest, especially in babies and toddlers
The nurse will check your child's pain control regularly. But you know your child best. The nurse will want to know if you think your child's pain is being controlled well. If you feel your child is in pain, tell the nurse.
Eating and drinking after the operation
Your child's bowel needs to rest after the operation and they will have a period of time where they need to remain NPO. This means they would not be able to eat or drink any fluids by mouth. Eventually your child’s health-care team will decide to trial clear liquids only, then normal food. It is important for your child to be well hydrated. The health-care team will give your child a goal of how much fluid they should drink per day when they go home.
Complications of the Mitrofanoff surgery
- Bleeding
- Infection (e.g., urinary tract infection, surgical site infection)
- Damage to surrounding structures (e.g., bladder or bowel perforation)
- Ileus (bowels slowed down too much)
- Surgical dehiscence (opening of wound)
- Stricture (narrowing) of Mitrofanoff channel, which requires a second surgery
Learning to use the catheter and Mitrofanoff
When your child’s doctor feels that everything has healed, your child will be discharged home with the catheter still in place through the Mitrofanoff channel. This catheter is usually kept in place for four weeks after the surgery.
Catheter care
- The catheter will be kept open to always drain into the urinary bag.
- This is usually a smaller leg bag during the daytime and a larger urometer at nighttime.
- It is important to always keep the bag below the level of the bladder for proper drainage and to avoid leaks.
- Empty the bag when it is ½ to ⅔ full and examine the bag every one to two hours to ensure there are no kinks or breaks that would prevent urine from draining well.
- You will be given instructions on how to flush or irrigate the catheter and how often. For more information please see Bladder irrigation using normal saline and Indwelling catheter care.
- You can complete extra flushes of the catheter if there is a suspected blockage of the tubing (e.g., low output for up to three to four hours) or if you notice a lot of debris or mucous in the tubing. Do not force a flush.
- If the extra flush does not resolve the blockage, please go to the nearest Emergency Department immediately.
Wound care
- Do not submerge the Mitrofanoff site underwater.
- You can use a washcloth or personal wipe to clean around the area.
- The Mitrofanoff site should be cleansed with normal saline twice daily. You can keep the site open to air or apply a small gauze. Change the gauze as needed or if it becomes dirty or soaked.
- It is normal to have some oozing or mucous at the Mitrofanoff insertion site. If you notice blood or green pus, please contact your child’s health-care team.
Activity/restrictions
- Your child should not go swimming until their health-care team confirms that it is OK to do so.
- Your child will be instructed to restrict activities that could result in accidental removal of the catheter.
- If the indwelling catheter is accidentally removed, please bring your child to the nearest Emergency Department immediately to have a new catheter placed as this may be difficult to complete by yourself at home.
- Your child’s health-care team will decide when you should learn how to put a catheter into the Mitrofanoff to drain the urine. This is called catheterization.
Home care
- Your in-patient team will arrange for a home care nurse to visit you at home and help you manage this catheter.
- The health-care team can also send a request for your child’s school nurse to help your child during school hours.
- Most young children who go to school can catheterize their Mitrofanoff on their own.
- Many children can help care for their own Mitrofanoff, even children who are not going to school yet.
Telling your child’s other health-care providers about the Mitrofanoff
Inform all of your child's health-care providers, including their primary care provider, that your child has a Mitrofanoff. Some providers may not have heard of this before. You may have to explain it to them.
You should also tell the school nurse that your child has a Mitrofanoff.
Your child needs to wear a Medic Alert bracelet. Before your child leaves the hospital, the nurse will give you the forms to fill out to get this bracelet.
Follow-up care
You and your child will be booked for an appointment with a clinic nurse approximately four weeks after the surgery. This appointment is to remove the indwelling catheter from the Mitrofanoff and learn to catheterize the Mitrofanoff.
- Care providers that will complete catheterization should attend this appointment. We recommended one to two caregivers attend.
- You can discuss where to purchase supplies and funding with the nursing team at this appointment.
Your child will be booked for an appointment with the health-care team approximately six weeks after the surgery with a routine kidney and bladder ultrasound. This appointment is to review your child’s care and if the Mitrofanoff is working well.
When to seek medical attention
Take your child to an emergency department if:
- Your child has a fever greater than 38˚C or 100.4˚F.
- There has not been any urine from the Mitrofanoff catheter for more than four to six hours and your child is unable to flush the catheter to relieve the blockage.
- There is blood in the urine, especially if you see fresh blood or blood clots.
- The catheter was accidentally or traumatically removed from the Mitrofanoff channel.
- The surgical wound site(s) appear to be opening up (dehiscence).
- There is non-clear drainage from the wound (e.g., yellow/green pus, blood).
- Your child has severe abdominal or flank pain unmanaged by prescribed medications.
- Your child has repeated vomiting or diarrhea.
- Your child is not tolerating oral intake.
- Your child is irritable, lethargic, pallor or generally feeling unwell.
Contact your child’s health-care team for support if:
- You require support with Mitrofanoff stoma care.
- You were directed to irrigate your child’s bladder but are unsure of how to proceed.
- Irrigation is consistently painful for your child.
- Your child is not tolerating the oral medications that were prescribed at discharge from the hospital.
- You suspect your child has an infection, but they appear well and do not have a fever.
At SickKids
If you have questions about your child’s catheterization, please contact the Urology Clinic via phone or email.
- 6D Urology Clinic Phone: 416-813-6661
- E-mail: urology.nurses@sickkids.ca
For URGENT concerns after hours or on weekends, please consult your child’s primary care provider or go to an Emergency Department.
A Child Life Specialist can also help to prepare and support your child if they are anxious about CIC. Ask a urology team member if you would like the child life team to be involved in care.