Spinal injury caused in children mostly by myelomeningocele results in urinary bladder and anal canal dysfunction (1). The lack of sensation and lower urinary tract control can lead to upper urinary tract damages and consequently to renal failure. Therefore the prevention of the upper urinary tract deterioration is the most important aim of the management of neurogenic bladder. Urinary and fecal continence as well as adequate voluntary bladder and bowel emptying are equally important for school and kindergarten age children. These aims can be achieved in the majority of children by means of intermittent catheterization and the use of anticholinergic medications (1-3). This treatment should be introduced immediately after birth, especially in children with high-pressure bladder and detrusor-sphincter dyssynergia, because renal damage starts often within the first half year of life (2, 4). The anticholinergic drug used since the infant age is oxybutinine chloride in the dosage of 0.3-0.4 mg/kg body weight, divided over 3-4 doses per day (4, 5). Besides that, the children are put on prophylaxis of urinary tract infections, mostly furaginum 1-2 mg/kg body weight per day. Intermittent catheterization, oxybutinine and prophylaxis of infections since early infancy allow obtaining normal bladder capacity, its compliance and consequently preventing progressive renal damage. Moreover, this approach has significantly reduced the need for bladder augmentation in these children (2). Small children are catheterized by their parents and other caregivers. Since about 6 years of life, sufficiently intellectually and manually dexterous children are taught to catheterize themselves. A creation of the continent appendico-vesicostoma (Mitrofanoff procedure) is an optional solution in children in whom self-catheterization through their native urethra is difficult e.g. in girls with severe deformations of lower limbs (2). Malone antegrade continence enema through the appendicular stoma is an efficient management option for children with severe constipations and bowel incontinence due to neurogenic dysfunction of anal canal (6).

The aim of the paper is the assessment of the appendicular stomas in treatment of children with neurogenic dysfunction of bladder and anal canal.

The Mitrofanoff stoma is constructed utilizing the appendix which is detached from the cecum but its vascularization is preserved. Distal end of the appendix is sutured through the submucosal tunel into the bladder. The other end of the appendix is connected to the umbilicus or to the skin in the right lower quadrant. Till 2009 we created a V-shape skin flap which was anastomosed into an incised proximal part of the appendix. Since 2010 we have used VQZ plasty for the connection of the appendix into the skin. In this technique, besides a V-flap, a parallel quadrilateral flap is created from the skin. This flap is inverted and anastomosed to the edge of the appendix and to the V-flap. With this technique the stoma is more aesthetic and its mucosa is hidden in the skin tunnel. Currently we keep catheter in the stoma for 6 weeks after the procedure. After this period, the stoma is catheterized every 3 hours.

We create the Malone stoma using the appendix which is not detached from the cecum. We do a window in the mesentery of the base of the appendix. Then the cecum is wrapped around the base of the appendix to form the antireflux mechanism. The distal end of the appendix, incised along its anti-mesenteric border, is connected to the V-shape skin flap or with VQZ technique. We keep catheter in the stoma also for 6 weeks after this procedure. The antegrade enemas are done through the catheter left in the stoma beginning from the second day after the operation. After 6 weeks the stoma is catheterized once a day for performing enema.