# Minimally Invasive Mitrofanoff in Children: Versatile Laparoscopic Strategies—From Low-Resource to Non-Robotic High-Cost Settings in an Exploratory Case Series

## TL;DR

This study explores laparoscopic techniques for Mitrofanoff surgery in children, showing they are effective and accessible alternatives to robotic surgery, especially in low-resource settings.

## Contribution

The paper introduces laparoscopic and laparoscopic-assisted Mitrofanoff techniques as cost-effective and feasible alternatives to robotic surgery in pediatric urology.

## Key findings

- Laparoscopic Mitrofanoff had longer operative times but similar functional outcomes compared to laparoscopic-assisted Mitrofanoff.
- Both techniques provided excellent continence and cosmetic satisfaction in children.
- Laparoscopic approaches are viable in resource-limited settings, offering high-quality care without robotic systems.

## Abstract

Background/Objectives: The Mitrofanoff appendicovesicostomy (MAV) is the gold standard for creating a continent catheterizable channel in children unable to perform clean intermittent catheterization (CIC) through the native urethra. Minimally invasive surgery has progressively replaced open techniques in pediatric urology, offering improved recovery and favorable cosmetic outcomes, and robotic-assisted Mitrofanoff has gained popularity in recent years. However, the high costs and limited availability of robotic systems create disparities in access to pediatric urologic reconstruction, particularly in low- and middle-income countries. In this context, the laparoscopic Mitrofanoff (MAV-L) and the laparoscopic-assisted Mitrofanoff (MAV-LA) represent practical, cost-effective alternatives, valuable in institutions without robotic platforms or in resource-limited settings. Recent evidence demonstrates that advanced laparoscopic approaches remain feasible even for complex urological procedures, supporting their continued relevance in the robotic era. Methods: We conducted a retrospective case series including seven male children (aged 9–12 years) who underwent MAV between 2018 and 2023. Peri-operative data included demographics, operative time, length of hospitalization, and complications. Functional and aesthetic outcomes were assessed during long-term follow-up. Statistical analysis accounted for the small sample size by using non-parametric tests where appropriate. Results: Three patients (43%) underwent MAV-L and four (57%) MAV-LA. Mean operative time appeared longer in MAV-L (273.3 ± 20.5 min) than in MAV-LA (203.8 ± 24.3 min; exploratory p = 0.019). Hospital stay was 9 ± 0.8 days vs. 7.5 ± 0.5 days (p = 0.026). During follow-up (43.3 ± 10.9 vs. 26.3 ± 5.4 months; p = 0.034), two complications occurred, both in the MAV-L group (stomal stenosis and channel leakage). All patients reported excellent continence, ease of catheterization, and high cosmetic satisfaction. Conclusions: Both laparoscopic and laparoscopic-assisted Mitrofanoff techniques are safe, feasible, and effective in children. Favorable cosmetic satisfaction was reported in the fully laparoscopic subgroup, based on subjective assessment. Importantly, these laparoscopic techniques are sustainable alternatives to robotic surgery, offering accessibility and high-quality reconstructive care even in centers with limited financial and technological resources.