British Journal of Urology (1997), 79, 985–986

P OI N T OF T E C H NI QU E

The in situ appendix in the Malone antegrade continenceenema procedure for faecal incontinenceE. W. GERH ARZ, V. VIK , G . WEBB and C .R.J . WO OD HOU SEThe Institute of Urology, University College London Medical School, London, UK

merging into a Y-shape at the base of the appendix. ByIndicationscareful dissection of the seromuscular tissue, a broadsubmucosal bed was created for the appendix. TheSix years ago Malone et al. [1] published a preliminary

report on the combination of two well-established prin- appendicular mesentery was freed of its excessive fattytissue and windows were excised between the branchesciples [2,3] in the treatment of patients with faecal

incontinence; the Mitrofano� non-refluxing catheteriz- of the appendicular artery, avoiding compromising theblood supply (Fig. 1). After the appendix was folded backable channel modified as an appendicocaecostomy,

allowing antegrade colonic irrigation to produce com- and correctly positioned, the seromuscular layer wasclosed over the embedded in situ appendix with interrup-plete colonic emptying and hence prevent soiling. The

Malone antegrade continence enema (MACE) has since ted 4-0 polydioxanone sutures. To avoid the formationof a diverticular ‘catheter catch’ the complete appendixbeen applied in several pathological conditions when all

other attempts to control incontinence have failed and was buried except for a short, mobile portion at its distalend for the creation of the appendicocutaneous stoma.the only remaining option was a colostomy [4]. The

recently reported success rate of 71% is obviously related The caecum was fixed to the anterior abdominal wall toprevent kinking of the appendix. To reduce the risk ofto the indication with the most satisfying results in

neuropathic disease. In urology, the technique is used stomal stenosis and avoid problems with exposed intesti-nal mucosa, the appendiceal tip was buried using asimultaneously with reconstruction of the lower urinary

tract in patients with double incontinence caused byspina bifida. We describe the application of the submucos-ally embedded in situ appendix in the MACE procedureto avoid unphysiological resection of the appendix, amethod analogous to the appendiceal configuration ofthe MAINZ pouch [5] in continent cutaneous urinarydiversion.

Methods

The in situ appendix technique for MACE was applied ina 28-year-old patient with myelomeningocele, who hadbeen performing high bowel irrigation twice a week. Healso needed a Mitrofano� channel for complete evacu-ation of his previously augmented bladder, being inconti-nent since the removal of an infected artificial urinarysphincter in 1986. A continent bladder outlet wasconstructed using tapered ileum, as described elsewhere[6].

After inspection of the vermiform appendix and ampu-tation of the distal end, it was examined for patency.Analogous to the Lich-Gregoir procedure for VUR, the Fig. 1. Windows in the meso-appendix are excised between theseromuscular layer of the intact caecal pole was split branches of the appendicular artery without compromising the

blood supply.along the taenia down to the mucosa, with the incision

985© 1997 British Journal of Urology

986 E. W. GERH ARZ et al.

V-shaped skin flap instead of a circular anastomosis. A revision (star-shaped incision, removal of scarred tissue)and will remain of adequate calibre [7]. Increasingcatheter was left in place for 3 weeks. The irrigation

regimen described by Malone et al. [1,4] was started experience with the various surgical options and animproved selection of patients will reduce both the rate9 days after surgery. Currently, the in situ appendix

conduit provides perfect continence with easy catheteriz- of failure and of complications.ation. The antegrade colonic irrigation is repeated everysecond or third day, with no faecal soiling in between. Acknowledgement

Drawing provided by Dr U. Koehl.Advantages and disadvantages

The MACE procedure has been performed in combinationwith urological surgery in 12 patients at the Middlesex ReferencesHospital in London. In most, the appendix was resected,

1 Malone PS, Ransley PG, Kiely EM. Preliminary report: thereversed and reimplanted according to Mitrofano�’s orig-

antegrade continence enema. Lancet 1990; 336: 1217–8inal technique. If the appendix had been removed before- 2 Shandling B, Gilmour RF. The enema continence catheterhand, a tubularized transverse caecal flap was used in spina bifida: successful bowel management. J Pediatr Surginstead. If a Mitrofano� channel is also required for the 1987; 22: 271–3reconstruction of the urinary tract, with favourable 3 Mitrofano� P. Cystostomie continente trans-appendiculairevascular anatomy the appendix may even be divided to dans le traitement des vessies neurologiques. Chir Ped 1980;

21: 297–305use one half in each procedure [4]. In comparison to4 Gri�ths DM, Malone PS. The Malone antegrade continenceMitrofano�’s original technique, the submucosal embed-

enema. J Ped Surg 1995; 30: 68–71ding of the in situ appendix avoids excision, a 180°5 Riedmiller H, Burger R, Muller SC, Thuro� J, Hohenfellnerrotation and reimplantation of the appendix, with the

R. Continent appendix stoma — a modification of therisk of compromising the blood supply at each step.MAINZ-Pouch technique. J Urol 1990; 143: 1115–7

Preserving the anatomical connection between appendix6 Woodhouse CRJ, MacNeily AE. The Mitrofano� principle:

and caecal pole and positioning the continence mechan- expanding upon a versatile technique. Br J Urol 1995;ism inside the caecal pole with a short appendicular 74: 447–53portion outside the intestinal segment guarantees maxi- 7 Gerharz EW, Kohl U, Weingartner K, Melekos MD, Bonfig R,mal ease of catheterization. Riedmiller H. Stoma correction in ileocecal reservoirs — a

It has been recognized in large series of urinary comparison of appendix-stoma and ileal-nipple. Eur Urol1996; 30 (Supp): A195reservoirs with appendiceal outlets that stomal stenosis

at the appendicocutaneous junction may be troublesome[7]. In these applications the intermittent passage of thecatheter through the conduit (4–6 times per 24 h) dilates Authorsthe lumen repetitively and may successfully prevent,

E.W. Gerharz, MD, Research Fellowdecrease or delay encroachment of the appendiceal

V. Vik, MD, Senior House O�cerlumen, the infrequent catheterization in the MACE might G. Webb, MD, Senior Registrarslightly increase the risk of stenosis. Gri�ths and Malone C.R.J. Woodhouse, FRCS, Senior Lecturer[4] therefore now recommend daily or twice-daily cath- Correspondence: Dr.med. E.W. Gerharz, The Institute of Urologyeterization to keep the channel patent. However, in and Nephrology, University College London Medical School,

48 Riding House Street, London W1P 7PN, UK.most cases a gradually stenosing stoma requires simple

© 1997 British Journal of Urology 79, 985–986