V07-04: Robot-assisted laparoscopic augmentation ileocystoplasty and mitrofanoff appendicovesicostomy (RALIMA): University of Chicago experience
Robot-assisted laparoscopic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy (RALIMA) may protect the upper urinary tract and reestablish continence in patients with refractory neurogenic bladder. Robotic assistance could provide the benefits of minimally invasive surgery without the challenges of pure laparoscopy. Here we present a patient who underwent RALIMA and discuss salient tips for decreasing operative time.
A 17 year old male with history of microcephaly, chromosomal abnormality, autism, developmental delay, asthma and atrial septal defect who presented to our clinic with recurrent UTIs and urinary retention. Renal US revealed mild bilateral hydronephrosis. UDS confirmed a poorly compliant, high pressure bladder with detrusor leak point pressure of 100 cm of water and failure to empty, consistent with a neurogenic bladder. In order to prevent upper tract damage, decision was made to undergo RALIMA. We do not use a bowel preparation pre-operatively.
Total operative time was 332 minutes which is significantly reduced from our previously reported median operative time of 623 minutes when describing our initial experience from 2008-2014. This patient had a short appendix, approximately 3 cm in length. To ensure adequate length in order to mature the stoma to the skin overlying the right iliac fossa, a cuff of cecum was resected with the appendix. A stay suture is utilized to avoid excess handling of the appendix. Percutaneous stay sutures placed in the ileum allow for easier isolation and anastomosis. The harmonic scalpel can accelerate multiple aspects of this operation, as well as provide excellent hemostasis. We use the harmonic scalpel to detubularize ileum, perform a coronal cystotomy and divide the bowel mesentery.
RALIMA has been shown to offer functional outcomes similar to open ileocystoplasty and appendicovesicostomy. Although it is a significantly longer procedure, we offer our experience and surgical techniques to decrease operative times.