V05-09: Robotic bladder neck closure in the complex neurogenic bladder patient
The management of the lower urinary tract continence can be complex in patients with neurogenic bladder. Oftentimes, many procedures maybe attempted in an effort to achieve social continence. Often when antispasmodics and urethral bulking agents fail, the native urethra must be abandoned and a bladder neck closure is needed. Traditionally, bladder neck closure has been performed as an open procedure, however, when coupled with a minimally invasive approach, bladder neck closure can be safely and effectively performed in the neurogenic bladder patient while maintaining the advantages associated with robotic surgery. Robotic isolation of the bladder neck is routine for several urologic procedures such as robotic radical and simple prostatectomy and a cystectomy, and therefore we felt that we could easily apply the principles of these techniques to performing a robotic bladder neck closure.
We present a case of a SCI patient with neurogenic bladder and a complex history of bladder management. The patient was initially managed by a sphincterotomy and external condom catheter. However, when he began to have issues with the condom catheter, the desire was to restore continence to his bladder outlet. A SPT was placed and despite a trial of anticholinergics and multiple attempts at bulking agents placed at the urethra and bladder neck, the patient continued to have intractable urinary incontinence and the decision was made to proceed with a bladder neck closure. Pre-operative UDS demonstrated an adequate bladder capacity and low storage pressures.
The total operative time was 169 minutes, 134 minutes of which was robotic time. The estimated blood loss was 75ml. Dense scar tissue was noted near the prostatic apex consistent with the prior sphincterotomies. The patient had an uncomplicated postoperative course. He was maintained on his scheduled anticholinergics and at his post-operative visit at 2 and 6 months was noted to not have any leakage per urethra.
Robotic surgery has transformed many urology surgical procedures which are traditionally performed deep within the pelvis. The benefits of using a robotic surgical approach is even more apparent in situations where there is complex anatomy or where prior surgical procedures make an open approach more challenging. Given the similarities in bladder neck isolation with other standard robotic urologic procedures, robotic bladder neck closure is an appropriate extension of this technique. Robotic bladder neck closure can be a safe treatment option for the complex neurogenic bladder patient.