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Appendicovesicostomy (Mitrofanoff Procedure)

Appendicovesicostomy (Mitrofanoff procedure) is a continent catheterizable urinary diversion using the vermiform appendix as a conduit between the bladder and an abdominal-wall stoma, allowing emptying by clean intermittent catheterization (CIC). First described by Paul Mitrofanoff in 1980, it implants a narrow, supple tube into a low-pressure reservoir via a submucosal flap-valve mechanism — analogous to a ureteral reimplantation — to achieve continence while permitting easy catheterization.[1][2] It is the gold standard for creating a continent catheterizable channel (CCC) in patients unable to catheterize through the native urethra.[3]

For broader CCC design rules (including Monti, double-Monti, tubularized bladder flap, and continent vesicostomy), see Catheterizable Channels.

The Mitrofanoff Principle​

Three essential components:[1][2][4]

  1. A narrow, supple conduit (appendix, ureter, Fallopian tube, or retubularized bowel) that acts as a flap valve when compressed against the reservoir wall during filling.
  2. Antireflux implantation of the conduit into a low-pressure reservoir (native bladder, augmented bladder, or continent pouch) via a submucosal tunnel.
  3. A catheterizable cutaneous stoma that is cosmetically acceptable and easily accessible.

The appendix is the preferred conduit — natural tubular shape, small caliber (10–14 Fr), reliable blood supply from the appendicular artery, and sufficient length (typically 6–10 cm).[4][5][6]

Indications​

The AUA/SUFU NLUTD guideline supports CCC in patients who can perform self-catheterization but have a devastated urethra that cannot be catheterized, require bladder neck closure, or prefer a CCC for ease of catheterization.[7]

  • Neurogenic bladder (myelomeningocele, SCI, tethered cord, sacral agenesis) — most common, >90% of cases in pediatric series.[5][8][9]
  • Bladder exstrophy / epispadias — particularly after bladder neck closure, where the appendicovesicostomy provides the sole route for emptying. Largest exstrophy series (n=432): BNC + CCC achieves 93% continence vs 64% with BN reconstruction alone.[10]
  • Cloacal anomalies.[5][11]
  • Posterior urethral valves with urethral damage.[12]
  • Urethral stricture or destruction from chronic catheterization.[7]
  • Wheelchair-bound patients for whom urethral CIC is difficult.[2][13]
  • Adult neurogenic and non-neurogenic bladder dysfunction (median age 42 in the largest adult series).[14]
  • Oncologic patients requiring continent diversion after cystectomy.[11][15]

Surgical Technique​

Step 1 — Appendiceal mobilization​

  • Identify the appendix; carefully preserve the mesoappendix to maintain blood supply from the appendicular artery.
  • Divide the appendix at its base from the cecum; close the cecal defect (purse-string suture or stapler).
  • Irrigate and calibrate the lumen (should accept a 10–14 Fr catheter).[2][6][16]

Step 2 — Submucosal tunnel (antireflux implantation)​

  • Cystotomy (or open the augmented bladder).
  • Create a submucosal tunnel 3–5 cm in length (4:1 or 5:1 tunnel-to-diameter ratio, similar to ureteral reimplantation).[2][16]
  • Draw the distal (cut) end of the appendix through the tunnel; anastomose to the bladder mucosa at the hiatus.
  • Detrusor backing ≥ 4 cm is critical for continence — Wille demonstrated that inadequate detrusor backing (< 4 cm) is the most significant predictor of stomal incontinence.[17]
  • Tunnel may be on the posterior bladder wall (intravesical approach, preferred when concomitant augmentation is performed) or the anterior bladder wall (extravesical approach, preferred for isolated appendicovesicostomy).[18]

Step 3 — Stoma creation​

  • Umbilical stoma: most popular — excellent cosmesis (hidden in the umbilicus). Used in 90% of cases in the Abdelhalim series. Higher stenosis rate than abdominal-wall stomas (25% vs lower with VQZ).[19][20][21]
  • Right lower quadrant stoma: traditional location; easier construction, less cosmetic.
  • VQZ plasty: skin-flap technique creating a concealed, skin-lined stoma in the RLQ. The V-flap creates the posterior wall, the quadrilateral (Q) flap creates a skin tube that buries the appendiceal mucosa, and the Z-plasty prevents linear scar contracture. Landau showed 0% stomal stenosis with VQZ vs 25% umbilical and 45% tubular skin flap. König 2025 confirmed no superficial stenosis in 29 patients.[21][22]
  • VQ plasty: simplified VQZ that eliminates the Z-component — neater linear scar with comparable functional outcomes.[23]
  • VR flap: González simplification with the quadrilateral flap at 90° from the V-flap, creating a linear closure.[24]

Step 4 — Concomitant procedures​

Frequently performed simultaneously:[5][11][13]

  • Augmentation cystoplasty (52% in Cain).
  • Bladder-neck reconstruction (48% in Cain) or bladder-neck closure.
  • MACE (Malone antegrade continence enema) for fecal incontinence (17% in Cain) — when both urinary and fecal channels are needed, the appendix can be split to create both channels.[5][25][26]

Stomal Stenosis Prevention​

The most common complication, reported in 10–50% depending on technique.[11][21][27]

TechniqueStenosis rateKey feature
Standard (appendiceal tip excision)13% (12/93)[27]Traditional; tip amputated, lumen matured to skin
Kurzrock tip-preservation[27]0% (0/30)Preserves distal appendiceal tip and vasculature; opens lumen proximally
VQZ plasty[21]0% (0/8)Skin-lined channel buries mucosa; prevents contracture
VQ plasty[23]Similar to VQZSimplified; neater scar
Umbilical stoma[20][21]14–25%Cosmetically superior but higher stenosis risk
Buccal mucosa graft (salvage)[29]0% re-stenosis (n=10)For established stenosis

Kurzrock 2020: preserving the distal tip and its vasculature while opening the lumen in a more proximal, better-vascularized area eliminated stomal stenosis (0/30, median 3.3 yr) vs 13% with the standard technique (p=0.04). 75% of stenoses with the standard technique occurred within the first year.[27]

Outcomes​

SeriesnAgeFollow-upContinenceRevisionStomal stenosis
Harris/Snyder 2000[12]5013.1 yr4.3 yr98%16%10%
Cain/Rink 1999[5]100 (57 appendix)10.5 yr2 yr98%20%12%
Sumfest/Mitchell 1993[6]47 (25 appendix)——96%—19%
Reuvers 2017[9]12810.1 yr10.1 yr99% (in use)32%14.8%
Faure 2017[11]548.3 yr4.3 yr—61%50%
Abdelhalim 2022[19]120 (74 appendix)6.8 yr11.4 yr90.8%21.7%—
O'Connor 2019 (adults)[14]17642 yr78.6 mo90.2% (in use)38.7% major17.2% (appendix)
Gowda 2008 (adults)[15]6538.4 yr75.2 mo95%46% catheterization problems—
Sahadevan 2008 (adults)[30]2948 yr126 mo89%54% (stomal stenosis req'g intervention)54%
König 2025 (VQZ)[22]31Pediatric—97%19%0% superficial

Timing of complications​

  • Jacobson 2017 (n=81, 119 stomas, 80.1 mo): unique complications cluster in the first 2 years, then statistically significant decline (p=0.0013); high-grade complications similarly cluster.[31]
  • Reuvers 2017 (n=128, 10.1 yr): peak re-intervention in the first year, decreased yearly thereafter; 63% of re-interventions superficial / endoscopic.[9]
  • Thomas 2006 (n=78, 117 stomas): stomal stenosis at mean 6.2–9.4 mo; most complications within the first year.[28]

Complications​

ComplicationIncidenceTimingManagement
Stomal stenosis10–54%Peak 6–13 mo; 75% within 1 yrDilation, L-stent, VQ/VQZ revision, BMG graft
Difficult catheterization10–20%Mean 29.9 moCatheter change, dilation, revision
Stomal incontinence6–8%VariableEndoscopic bulking (Deflux), revision, reimplantation with longer tunnel
False passage6–10%Mean 3.6–6.5 moCatheter drainage; rarely requires revision
Conduit stricture9–15%VariableEndoscopic incision, revision
Bladder/reservoir stones6–32%Increases with timeLithotripsy, surgical removal
Conduit angulation/kinking3–6%VariableSurgical revision
Parastomal herniaRareVariableSurgical repair
Appendiceal perforation4%VariableSurgical repair
Small-bowel obstruction2–5%EarlyConservative or surgical
Conversion to ileal conduit5–18%Late (mean 82 mo)Cystectomy + ileal conduit

References: [5][9][11][12][14][15][19][28][30]

Stomal stenosis management​

  • L-stent — short knotted catheter lying flush with skin: 100% improvement reported; significantly decreases need for surgical revision.[33]
  • Topical betamethasone cream during catheterization — common adjunct.[33]
  • Buccal mucosa grafting — salvage for refractory stenosis without creating a new channel; Radojicic reported no re-stenosis in 10 patients (mean 22 mo).[29]

Alternatives When the Appendix Is Unavailable​

Appendix may be unavailable due to prior appendectomy, use for MACE, or unsuitable anatomy. See Catheterizable Channels for full coverage of alternatives:

AlternativeDescriptionContinenceNotes
Yang-Monti channel[34][35]2–3 cm ileal segment transversely retubularized93.8%Always available; predictable length; higher subfascial revision (18.5% vs 0%)
Spiral / double Monti[35]Two ileal segments joined for lengthSimilarLonger distances (e.g., obese patients)
Casale technique[36]Single ileal segment divided and unfolded for lengthSimilarAvoids second bowel anastomosis
Tubularized bladder flap[37]Flap raised from bladder wall, tubularizedSimilarNo bowel needed; requires adequate bladder volume
Split appendix[25][26]Appendix divided for simultaneous Mitrofanoff + MACENo difference vs whole appendixShorter OR; avoids bowel anastomosis
Continent vesicostomy[5]Bladder wall to skin98%Higher stomal complication rate than appendix

Abdelhalim 2022 (n=120, median 11.4 yr): ileal channels had 3.37× higher odds of needing reoperation vs appendicovesicostomy on multivariate analysis (95% CI 1.24–9.17, p=0.037).[19] Polm: Monti channels required significantly more major revisions (27%) than appendicovesicostomy.[37] O'Connor 2019: ileal channels had higher channel-incontinence rate than appendiceal (36% vs 19.5%, p=0.03).[14]

Minimally Invasive Approaches​

Robot-assisted laparoscopic Mitrofanoff (RALMA)​

  • Gundeti's group: largest robotic experience, 38 cases. Detailed outcomes in 18: stomal continence 94.4%, mean OR 494 min, mean LOS 5.2 d.[18]
  • The appendicovesical anastomosis can be extravesical (anterior bladder, preferred for isolated appendicovesicostomy) or intravesical (posterior bladder, preferred when concomitant augmentation is performed).[18]
  • Improved cosmesis, reduced pain, shorter LOS vs open; longer OR times; technically complex.[8][38]

Laparoscopic / laparoscopic-assisted​

Cerchia 2026: both fully laparoscopic and laparoscopic-assisted Mitrofanoff techniques are safe and effective.[3] Chua: laparoscopic-assisted approach offered lower EBL (50 vs 100 mL, p=0.048) and shorter LOS (3.5 vs 6 d, p=0.029) vs open in patients with prior abdominal surgeries.[39]

Adult-Specific Considerations​

  • O'Connor 2019 (n=176, median 142 mo): 75.9% of channels remained in use with 90.2% continence among functioning channels; major revision rate 38.7%.[14]
  • Indications in adults: neurogenic bladder, urethral dysfunction, post-cystectomy continent diversion.[14][15][40]
  • Higher stomal stenosis rates in adults (up to 54%) than in pediatric series — body habitus, wound healing, longer bladder-to-skin distance.[30]
  • Quality of life generally high — 87% of adults did not regret the surgery (Rey).[40][41]
  • Conversion to ileal conduit in 5–18% of adults, typically for recurrent stomal complications or persistent incontinence; mean 82 mo postop.[15][30]

Bladder Exstrophy​

  • Largest exstrophy continence study (n=432, Johns Hopkins): 40% ultimately underwent BNC + CCC, achieving 93% continence (95% CI 87–97%) — significantly higher than isolated BN reconstruction (64%).[10]
  • Only ~25% of exstrophy patients are expected to void normally per urethra.[10]
  • The ceco-appendiceal unit can be used for both augmentation and CCC in exstrophy, with long-term continence in all 11 patients in Tillem (2–11 yr).[42]

Split Appendix Technique (Mitrofanoff + MACE)​

  • Daugherty 2021 (n=106): split-appendix had no difference in revision-free survival vs whole-appendix Mitrofanoff + Monti MACE.
  • Shorter OR (447 vs 619 min) and shorter LOS (9 vs 12–13 d).
  • More subfascial revisions of urinary CCC in Monti channels (18.5%) vs split-appendix (0%).[25]
  • Kajbafzadeh & Chubak 2001 (n=40): divided appendix with separate mesotheliums achieved 100% continence with 7.5% overall complication rate when the appendix was ≥9 cm with suitable branching mesothelium.[26]

Long-Term Surveillance​

  • Regular catheterization assessment — difficulty, bleeding, or pain should prompt evaluation for stenosis, false passage, or conduit stricture.
  • Stomal inspection at each visit for stenosis, prolapse, or skin changes.
  • Renal function monitoring and upper-tract imaging annually.
  • If augmentation cystoplasty was performed concurrently, annual cystoscopy beginning 10 yr postoperatively for malignancy screening.
  • Stone surveillance — particularly with augmented bladders (rates up to 32%).[16]
  • Patient/caregiver education — high likelihood of at least one re-intervention over the channel's lifetime.[9][11]

Key Recommendations​

  1. The appendix remains the preferred conduit — lower reoperation rates and better continence vs ileal alternatives.[14][19]
  2. Submucosal tunnel ≥ 4 cm with adequate detrusor backing is essential for stomal continence.[2][17]
  3. VQZ/VQ plasty or the Kurzrock tip-preservation technique should be considered to minimize stomal stenosis.[21][22][27]
  4. The split-appendix technique is preferred when both urinary and fecal channels are needed.[25]
  5. Counsel patients/families that approximately one-third to one-half of channels require at least one surgical revision over their lifetime.[9][11][19][37]
  6. Lifelong urological surveillance is mandatory.[9][31][32]

References​

1. Duckett JW, Snyder HM. "Continent Urinary Diversion: Variations on the Mitrofanoff Principle." The Journal of Urology. 1986;136(1):58-62. doi:10.1016/s0022-5347(17)44725-2

2. Cendron M, Gearhart JP. "The Mitrofanoff Principle. Technique and Application in Continent Urinary Diversion." The Urologic Clinics of North America. 1991;18(4):615-21.

3. Cerchia E, Serpentino M, Nguyen Duy V, et al. "Minimally Invasive Mitrofanoff in Children: Versatile Laparoscopic Strategies-From Low-Resource to Non-Robotic High-Cost Settings in an Exploratory Case Series." Journal of Clinical Medicine. 2026;15(5):1954. doi:10.3390/jcm15051954

4. Woodhouse CR. "The Mitrofanoff Principle for Continent Urinary Diversion." World Journal of Urology. 1996;14(2):99-104. doi:10.1007/BF00182565

5. Cain MP, Casale AJ, King SJ, Rink RC. "Appendicovesicostomy and Newer Alternatives for the Mitrofanoff Procedure: Results in the Last 100 Patients at Riley Children's Hospital." The Journal of Urology. 1999;162(5):1749-52. doi:10.1016/s0022-5347(05)68230-4

6. Sumfest JM, Burns MW, Mitchell ME. "The Mitrofanoff Principle in Urinary Reconstruction." The Journal of Urology. 1993;150(6):1875-7. doi:10.1016/s0022-5347(17)35921-9

7. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up." The Journal of Urology. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239

8. Barashi NS, Rodriguez MV, Packiam VT, Gundeti MS. "Bladder Reconstruction With Bowel: Robot-Assisted Laparoscopic Ileocystoplasty With Mitrofanoff Appendicovesicostomy in Pediatric Patients." Journal of Endourology. 2018;32(S1):S119-S126. doi:10.1089/end.2017.0720

9. Reuvers SHM, van den Hoek J, Blok BFM, et al. "20 Years Experience With Appendicovesicostomy in Paediatric Patients: Complications and Their Re-Interventions." Neurourology and Urodynamics. 2017;36(5):1325-1329. doi:10.1002/nau.23045

10. Maruf M, Manyevitch R, Michaud J, et al. "Urinary Continence Outcomes in Classic Bladder Exstrophy: A Long-Term Perspective." The Journal of Urology. 2020;203(1):200-205. doi:10.1097/JU.0000000000000505

11. Faure A, Cooksey R, Bouty A, et al. "Bladder Continent Catheterizable Conduit (The Mitrofanoff Procedure): Long-Term Issues That Should Not Be Underestimated." Journal of Pediatric Surgery. 2017;52(3):469-472. doi:10.1016/j.jpedsurg.2016.09.054

12. Harris CF, Cooper CS, Hutcheson JC, Snyder HM. "Appendicovesicostomy: The Mitrofanoff Procedure — A 15-Year Perspective." The Journal of Urology. 2000;163(6):1922-6. doi:10.1016/s0022-5347(05)67599-4

13. Keating MA, Rink RC, Adams MC. "Appendicovesicostomy: A Useful Adjunct to Continent Reconstruction of the Bladder." The Journal of Urology. 1993;149(5):1091-4. doi:10.1016/s0022-5347(17)36305-x

14. O'Connor EM, Foley C, Taylor C, et al. "Appendix or Ileum — Which Is the Best Material for Mitrofanoff Channel Formation in Adults?" The Journal of Urology. 2019;202(4):757-762. doi:10.1097/JU.0000000000000356

15. Gowda BD, Agrawal V, Harrison SC. "The Continent, Catheterizable Abdominal Conduit in Adult Urological Practice." BJU International. 2008;102(11):1688-92. doi:10.1111/j.1464-410X.2008.07885.x

16. Duckett JW, Lotfi AH. "Appendicovesicostomy (and Variations) in Bladder Reconstruction." The Journal of Urology. 1993;149(3):567-9. doi:10.1016/s0022-5347(17)36150-5

17. Wille MA, Zagaja GP, Shalhav AL, Gundeti MS. "Continence Outcomes in Patients Undergoing Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy." The Journal of Urology. 2011;185(4):1438-43. doi:10.1016/j.juro.2010.11.050

18. Famakinwa OJ, Rosen AM, Gundeti MS. "Robot-Assisted Laparoscopic Mitrofanoff Appendicovesicostomy Technique and Outcomes of Extravesical and Intravesical Approaches." European Urology. 2013;64(5):831-6. doi:10.1016/j.eururo.2013.05.007

19. Abdelhalim A, Omar H, Edwan M, et al. "Reoperation for Channel Complications in Children With Continent Cutaneous Catheterizable Channels: The Test of Time." Urology. 2022;159:196-202. doi:10.1016/j.urology.2021.08.015

20. De Ganck J, Everaert K, Van Laecke E, Oosterlinck W, Hoebeke P. "A High Easy-to-Treat Complication Rate Is the Price for a Continent Stoma." BJU International. 2002;90(3):240-3. doi:10.1046/j.1464-410x.2002.02805.x

21. Landau EH, Gofrit ON, Cipele H, et al. "Superiority of the VQZ Over the Tubularized Skin Flap and the Umbilicus for Continent Abdominal Stoma in Children." The Journal of Urology. 2008;180(4 Suppl):1761-5. doi:10.1016/j.juro.2008.04.070

22. König A, Wiseman AX, Wildhaber B, Vidal I, Birraux J. "Mitrofanoff Procedure in Children: Use of the Appendix and VQZ Plasty Seems to Minimize Complications." Pediatric Surgery International. 2025;41(1):304. doi:10.1007/s00383-025-06204-6

23. England RJ, Subramaniam R. "Functional and Cosmetic Outcome of the VQ Plasty for Mitrofanoff Stomas." The Journal of Urology. 2007;178(6):2607-10. doi:10.1016/j.juro.2007.08.030

24. Franc-Guimond J, González R. "Simplified Technique to Create a Concealed Catheterizable Stoma: The VR Flap." The Journal of Urology. 2006;175(3 Pt 1):1088-91. doi:10.1016/S0022-5347(05)00403-9

25. Daugherty M, Strine A, Frischer J, et al. "Outcomes According to Channel Type for Continent Catheterizable Channels in Patients Undergoing Simultaneous Urinary and Fecal Reconstruction." Journal of Pediatric Surgery. 2021;56(8):1335-1341. doi:10.1016/j.jpedsurg.2020.11.002

26. Kajbafzadeh AM, Chubak N. "Simultaneous Malone Antegrade Continent Enema and Mitrofanoff Principle Using the Divided Appendix: Report of a New Technique for Prevention of Stoma Complications." The Journal of Urology. 2001;165(6 Pt 2):2404-9. doi:10.1016/S0022-5347(05)66215-5

27. Kurzrock EA. "A New Appendicostomy Technique to Prevent Stomal Stenosis." The Journal of Urology. 2020;203(6):1200-1206. doi:10.1097/JU.0000000000000711

28. Thomas JC, Dietrich MS, Trusler L, et al. "Continent Catheterizable Channels and the Timing of Their Complications." The Journal of Urology. 2006;176(4 Pt 2):1816-20. doi:10.1016/S0022-5347(06)00610-0

29. Radojicic ZI, Perovic SV, Rados DP, Petar VM. "Buccal Mucosa Grafts for Repair of Stenotic Catheterizable Continent Stoma." The Journal of Urology. 2008;180(4 Suppl):1767-9. doi:10.1016/j.juro.2008.03.116

30. Sahadevan K, Pickard RS, Neal DE, Hasan TS. "Is Continent Diversion Using the Mitrofanoff Principle a Viable Long-Term Option for Adults Requiring Bladder Replacement?" BJU International. 2008;102(2):236-40. doi:10.1111/j.1464-410X.2008.07467.x

31. Jacobson DL, Thomas JC, Pope J, et al. "Update on Continent Catheterizable Channels and the Timing of Their Complications." The Journal of Urology. 2017;197(3 Pt 2):871-876. doi:10.1016/j.juro.2016.08.119

32. Polm PD, Christiaans CHH, Dik P, Wyndaele MIA, de Kort LMO. "Continent Catheterizable Urinary Channels: Lessons for Lifelong Urological Care From a Comparative Analysis of Very Long-Term Complications and Revision-Free Survival of Three Different Types." Neurourology and Urodynamics. 2024;43(5):1083-1089. doi:10.1002/nau.25350

33. Mickelson JJ, Yerkes EB, Meyer T, Kropp BP, Cheng EY. "L Stent for Stomal Stenosis in Catheterizable Channels." The Journal of Urology. 2009;182(4 Suppl):1786-91. doi:10.1016/j.juro.2009.02.068

34. Lemelle JL, Simo AK, Schmitt M. "Comparative Study of the Yang-Monti Channel and Appendix for Continent Diversion in the Mitrofanoff and Malone Principles." The Journal of Urology. 2004;172(5 Pt 1):1907-10. doi:10.1097/01.ju.0000140448.36332.fc

35. Leslie JA, Dussinger AM, Meldrum KK. "Creation of Continence Mechanisms (Mitrofanoff) Without Appendix: The Monti and Spiral Monti Procedures." Urologic Oncology. 2007;25(2):148-53. doi:10.1016/j.urolonc.2006.09.007

36. Casale AJ. "A Long Continent Ileovesicostomy Using a Single Piece of Bowel." The Journal of Urology. 1999;162(5):1743-5.

37. Polm PD, de Kort LMO, de Jong TPVM, Dik P. "Techniques Used to Create Continent Catheterizable Channels: A Comparison of Long-Term Results in Children." Urology. 2017;110:192-195. doi:10.1016/j.urology.2017.08.030

38. Rodriguez MV, Wallace A, Gundeti MS. "Robotic Bladder Neck Reconstruction With Mitrofanoff Appendicovesicostomy in a Neurogenic Bladder Patient." Urology. 2020;137:206-207. doi:10.1016/j.urology.2019.11.023

39. Chua ME, Ming JM, Kim JK, et al. "Laparoscopic-Assisted Versus Open Appendicovesicostomy Procedure in Patients With Prior Abdominal Surgeries: A Comparative Study." Urology. 2018;116:93-98. doi:10.1016/j.urology.2018.02.036

40. Rey D, Helou E, Oderda M, et al. "Laparoscopic and Robot-Assisted Continent Urinary Diversions (Mitrofanoff and Yang-Monti Conduits) in a Consecutive Series of 15 Adult Patients: The Saint Augustin Technique." BJU International. 2013;112(7):953-8. doi:10.1111/bju.12257

41. Cheng KW, Yip W, Shah A, et al. "Stoma Complications and Quality of Life in Patients With Indiana Pouch Versus Appendico/Neo-Appendico-Umbilicostomy Urinary Diversions." World Journal of Urology. 2021;39(5):1521-1529. doi:10.1007/s00345-020-03348-z

42. Tillem SM, Kessler OJ, Hanna MK. "Long-Term Results of Lower Urinary Tract Reconstruction With the Ceco-Appendiceal Unit." The Journal of Urology. 1997;157(4):1429-33.