Introduction 

A mitrofanoff is a surgical procedure that usually uses the child’s appendix, or if not available a short segment of small bowel to create a conduit between the bladder and the skin surface to create an opening called stoma. 

The stoma opening is generally made on the lower abdomen or in the umbilicus. A catheter is inserted several times a day into the mitrofanoff stoma conduit to empty the bladder. 

A child may need a mitrofanoff procedure due to poor bladder emptying for many reasons, including congenital renal or urological abnormalities, neurogenic bladder and continence problems. This includes children with: 

• Spina bifida
• Bladder extrophy  
• Bladder obstruction 
• Problems voiding 

Some children may be able to perform urethral catheterisation, but if this is not possible or painful, a mitrofanoff procedure might be helpful in allowing improved continence by using intermittent bladder catheterisation 

The mitrofanoff procedure may also encourage children’s independence by allowing them to self-catheterise.   

Aim 

To guide nurses’ practice in caring for patients admitted with a newly formed or established mitrofanoff.  

To provide nurses’ with knowledge and skills about care and complications of mitrofanoff allowing them to educate and support children/family/carer understanding of the procedure and outcome. 

Definition of Terms  

• Bladder augmentation: A surgical procedure which makes the bladder larger by using a small piece of bowel. 
• Bladder extrophy: A congenital abnormality where the abdominal wall does not fully form, leaving the bladder exposed outside the skin. 
• Clean Intermittent Catheterisation (CIC) of mitrofanoff: Refers to the act of draining urine by passing a catheter through the mitrofanoff stoma into the bladder. The catheter is removed after the urine has been drained. This process is performed using a clean technique. A new sterile catheter is used for each episode. 
• Clean Intermittent Self Catheterisation (CISC): Performing CIC for oneself. 
• Conduit: An artificial channel which fluid can go through. 
• Cystoscopy: A procedure to see inside the bladder using a hollow tube equipped with a lens 
• KUB Xray: Provides basic information regarding the size, shape and position of the kidney, ureters and bladder. 
• Mitrofanoff: A surgical procedure in which the appendix or piece of bowel are used to create a connection between the bladder and the abdominal skin surface to allow for urinary catheterisation through a stoma. 
• Spina bifida: A neural tube defect in which the bones of the spine do not completely form resulting in a defect in the spinal canal. This can cause lack of sensation and/or movement in the lower limbs and bladder and bowel dysfunction. 
• Neurogenic Bladder: A dysfunction of the bladder due to a neurological condition.  
• Urodynamic testing: Shows how well the bladder, sphincters and urethra hold and release urine by measuring the pressure of the bladder. 

Urinary System 

RCH Image, courtesy of RCH staff

Preparation for Surgery  

• Education and counselling by urology and CNC Stomal therapy for families 
• Use of diagram, videos and models can be helpful. 
• Allowing children to handle equipment and practice on the model if they wish to do so. 
• Colouring books can help younger children to understand the procedure. 
• Child life therapy can be a great help in preparing some children. 
• Pre-operative Investigations 

Prior to surgery the urologist might prescribe tests to check suitability for the mitrofanoff procedure and the need for bladder augmentation. This might include: 

• Cystoscopy 
• Renal Ultrasound (pre and post void) 
• Xray of kidney, ureters, bladder (KUB) 
• Blood tests 
• Urodynamic testing 

Surgery  

The surgeon separates the appendix from the large intestine and creates an opening at its other end. One end of the appendix is connected to the bladder and the other end tunnelled is connected to the abdominal wall skin to form the stoma, usually in the umbilicus. The most important part of this surgery is the creation of a continence valve in the bladder by tunnelling the appendix 4-5 cm through the bladder wall. As the bladder fills with urine the pressure squeezes the tunnelled appendix shut to prevent urinary leakage between catheterisations. Mitrofanoff surgery can be done laparoscopically or open as per surgeon preference and medical need. 

RCH Photo, courtesy of RCH staff

Post operative assessment and management of a patient with a newly formed mitrofanoff 

• Children will usually be admitted for 3 to 7 days post formation of a mitrofanoff. 
• Routine post anaesthetic observations as per RCH Nursing Guideline: Routine Post Anasethtic Observation guideline.  
• Monitor newly formed mitrofanoff dressing for ooze, at least once a shift. 
• Ensure patients remain comfortable with adequate pain relief.
  • IV Analgesia may be needed initially, transition to Oxybutin and simple oral analgesia as tolerated. 
  • +/- Epidural, see RCH Nursing Guideline: Epidural for more information. 
• Patients will have mitrofanoff, urethral +/- suprapubic catheters insitu post operatively. Monitor all catheter sites. 
• A strict fluid balance should be maintained and documented.
  • The urology team will outline expected urine output for individual patients, typically 0.5-1ml/kg/hr of urine output combined across all catheters.  
  • If urine output decreases or exceeds this notify the Urology registrar.  
  • Catheters should be checked hourly for first 24 hours, then 2 hourly for 48 hours. 
• If catheter stops draining or is blocked escalate immediately to Urology team. Do not flush the catheters without Urology team approval.  
• Urethral +/- suprapubic catheters are usually removed prior to discharge as per Urology instructions (please note some patients may be discharged with Suprapubic catheter insitu).
  Ensure adequate procedural pain management prior to catheter removal, please see the RCH Nursing Guideline: procedure management for more information.  
• Encourage child to sit out of bed as soon as possible 
• Leg bags can be used when child is up and walking 
• Advised to have sponge bath while inpatient to avoid getting dressing wet 
• Weight and blood as required by urology team 
  

Discharge and follow up post newly formed Mitrofanoff  

• Discharge home with the mitrofanoff catheter on free drainage: the catheter may be with or without a balloon as per surgeon preference. The catheter size is determined by the size of the conduit. Children are discharged with leg bags.  
• Discharge supplies for 3-4 weeks are to be provided by the ward as required including: leg bags x1/week, leg straps, catheter tip syringes, tape, alcohol swabs, saline bottle etc. 
• Children can shower at home if wound and tape can be protected. 
• Families do not need to measure output, however they need to ensure that catheter is draining and not blocked. They may need to flush with saline (as required) as shown prior to discharge. 
• As per urology preference, the mitrofanoff catheter might need to remain on free drainage for 2 weeks followed by use of a catheter valve to train the bladder for 2 weeks prior to catheter removal. 
• Slow, light activities are recommended until catheter removed. 

Patients will be booked to return to the hospital 2-4 weeks post discharge, for an overnight stay. During this admission: 

• The catheter is removed from the stoma and commencement of clean intermittent catheterisation (CIC) education with stomal therapy CNC. Patient may need sedation and support of child life therapy for catheter and tape removal. Please see the RCH Nursing Guideline: procedure management for more information on support during procedures. 
• Frequency of CIC varies between two to five times a day and some children might require the catheter to stay on free drainage overnight. 
• Families should be advised to present to emergency if difficulties catheterising occur at home. 
• The child can go back to regular activities and sport, protective belts are advised to be worn for contact sport to avoid injury. 
• School education and support can be provided by stomal therapy CNC. 
• Follow-up appointments for review in Urology and Stomal therapy clinics. 
• Stoma appliance scheme application and supplies organised by stomal therapy CNC. 

Ongoing assessment and management of patients admitted with a Mitrofanoff 

• Assess mitrofanoff site as clinically indicated. 
• Patients and families should be supported to continue their normal CIC routine in hospital. 
• Nursing staff to support with CIC’s as needed see information below. 
• Refer to Urology and/or Stomal therapy if concerns regarding mitrofanoff arise.  

Catheterising a Mitrofanoff 

Equipment needed: 

• Nelaton Catheter of appropriate size 
• Scent free wipes (in hospital use patients own or use baby wipes) 
• Water soluble lubricated gel  
• Container into which to drain urine (unless draining into toilet) 
• Alcohol based hand rub, if there is no facility to wash hands adequately with soap and water (for child/family). Clinical staff should perform Hand Hygiene as per RCH Policy and Procedure: Hand Hygiene
• Nonsterile latex-free gloves (child and parents performing CIC may choose not to wear gloves) or sterile gloves (for nursing staff in hospital)

Directions for catheterising (for nursing staff and/or parent/carer): 

Please note nursing staff performing catheterisation of a mitrofanoff in hospital should complete the procedure in a sterile manner, following the RCH Policy and Procedure: Aseptic Technique. Families and children performing CIC can continue to complete the procedure in a clean manner in hospital as they do at home.  

1. Inform and gain verbal consent from patient/carer. 
2. Ensure the child is comfortably positioned (bed/chair/toilet). 
3. Perform hand hygiene. 
4. Onto a clean surface, prepare equipment: open wipe, open catheter package halfway, being careful not to touch catheter tip. Place lubricant gel on the inside of open packet.  
5. Perform hand hygiene and clinical staff apply nonsterile gloves where appropriate, nursing staff may use sterile gloves when completing this procedure in hospital. 
6. Clean the stoma starting at stoma opening and work outwards in a circular motion with scent free wipe. 
7. Lubricate the tip of the catheter inside the package with the water -soluble lubricating gel. 
8. With a non-touch technique to protect key part catheter tip, slide the catheter slowly into the opening of the stoma until urine starts to flow. If resistance is felt, stop for a few seconds then continue. Direct catheter end into container or toilet. 
9. When urine flow stops, ask the child to cough or wiggle and press gently on their bladder. This ensures complete bladder emptying. 
10. Withdraw the catheter slowly. It may start to drain again. Wait until this ceases, then remove the catheter.  
11. The catheter should be discarded into the waste bin, container should be cleaned or discarded. 
12. Remove gloves if worn and perform hand hygiene. Dispose of waste. 
13. Document procedure.  

RCH Photo, courtesy of RCH staff  

Complications/troubleshooting  

Companion Documents  

Videos

• Mitrofanoff stoma Hannah
• Mitrofanoff stoma Maddy
• Mitrofanoff stoma Christopher

Links 

• Young ostomates united (YOU): https://youinc.org.au/ 
• Stoma appliance scheme: https://www.health.gov.au/our-work/stoma-appliance-scheme 
• Australian association of stomal therapy nurses (AASTN): https://stomaltherapy.au/ 
• Victorian Children’s Ostomy Association: Edc@rch.org.au 

 Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Carmen Akaoui, Nurse Consultant, Neurodevelopment and Disability, and approved by the Nursing Clinical Effectiveness Committee. Published September 2024.