title: Using Mitrofanoff's principle and Monti's technique as a surgical option for bladder augmentation with a continent stoma: a case report.
abstract: BACKGROUND
  Hydronephrosis, reflux and renal failure are serious complications that occur in patients with neurogenic bladder associated with myelomeningocele. When the bladder compliance is lost, it is imperative to carry out surgery aimed at reducing bladder storage pressure. An ileocystoplasty, and for patients not suitable for intermittent catheterization, using the Mitrofanoff principle to form a continent stoma and the subsequent closure of the bladder neck, can be used. We report here, for the first time to the best of our knowledge, an association between two previously described techniques (the Mitrofanoff principle and the technique of Monti), that can solve the problem of a short appendix in obese patients.
  
  
  METHODS
  A 33-year-old male Caucasian patient with myelomeningocele and neurogenic bladder developed low bladder compliance (4.0 mL/cm H2O) while still maintaining normal renal function. A bladder augmentation (ileocystoplasty) with continent derivation principle (Mitrofanoff) was performed. During surgery, we found that the patient's appendix was too short and was insufficient to reach the skin. We decided to make an association between the Mitrofanoff conduit and the ileal technique of Monti, through which we performed an anastomosis of the distal stump of the appendix to the bladder (with an antireflux valve). Later, the proximal stump of the appendix was anastomosed to an ileal segment of 2.0 cm that was open longitudinally and reconfigured transversally (Monti technique), modeled by a 12-Fr urethral catheter, and finally, the distal stump was sutured at the patient's navel.After the procedure, a suprapubic cystostomy (22 Fr) and a Foley catheter (10 Fr) through the continent conduit were left in place. The patient had recovered well and was discharged on the tenth day after surgery. He remained with the Foley catheter (through the conduit) for 21 days and cystostomy for 30 days. Six months after surgery he was continent with good bladder compliance without reflux and fully adapted to catheterization through the navel.
  
  
  CONCLUSIONS
  The unpublished association between the Mitrofanoff and Monti techniques is feasible and a very useful alternative in urologic cases of derivation continent in which the ileocecal appendix is too short to reach the skin (i.e., in obese patients).
authors.affiliation: Department of Surgery and Anatomy, Division of Urology, Ribeirao Preto Medical School, Sao Paulo University, Sao Paulo, Brazil. marcelo.cassini@globo.com.
authors.forename: Marcelo F
authors.initials: MF
authors.lastname: Cassini
authors.forename: Antonio A
authors.initials: AA
authors.lastname: Rodrigues
authors.forename: Silvio
authors.initials: S
authors.lastname: Tucci
authors.forename: Adauto J
authors.initials: AJ
authors.lastname: Cologna
authors.forename: Rodolfo B
authors.initials: RB
authors.lastname: Reis
authors.forename: Antonio Cp
authors.initials: AC
authors.lastname: Martins
authors.forename: Haylton J
authors.initials: HJ
authors.lastname: Suaid