V09-08: Robot-Assisted Laparoscopic Ileovesicostomy
Ileovesicostomy provides long-term, low pressure urinary diversion while leaving the bladder intact and avoiding the need for ureteral anastomosis. This type of urinary diversion may be considered in cases of failed conservative bladder management (e.g. progressive hydronephrosis and/or recurrent urosepsis despite maximal therapy), poor patient manual dexterity, or poorly-motivated caregivers. The procedure involves harvesting approximately 15 cm of distal ileum while preserving the terminal ileum. The proximal end of the harvested segment is anastamosed to the bladder dome, while the distal aspect is fashioned into an abdominal stoma in a rosebud configuration. Stoma-related complications and persistent urethral incontinence are rare.
A candidate for ileovesicostomy was identified. Patient details and surgical approach are outlined.
The patient is an 11-year-old girl with extensive psychiatric history including bipolar disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, and depression with impulsive behavoir. She initially presented with urinary retention resulting in severe bilateral hydroureteronephrosis, renal insufficiency, and recurrent afebrile urinary tract infections. Her kidney function improved with catheter drainage and strict timed voiding, and hydroureteronephrosis resolved by discharge. However, the patient's nadir creatinine rose during 4 subsequent admissions, as she continued to retain urine and refused to participate in an intermittent catheterization program. Videourodynamics revealed no effort to void, a closed bladder neck, and a residual volume of 750 cc. She was determined to be an excellent candidate for robot-assisted ileovesicostomy. An appropriate ileal segment was identified and harvested using the robotic stapler. A wide cystotomy was made at the bladder dome, and the proximal aspect of the harvested segment was anastomosed to the bladder. Bowel continuity was re-established extracorporeally. The stoma was matured in a rosebud fashion. The patient did well after surgery and was discharged on postoperative day number 3. On 9-month follow up, Cr nadired to 0.9, and hydroureteronephrosis has resolved.
Ileovesicostomy is an option to provide low pressure, low maintenance urine drainage in patients failing conservative management. Robot assistance is technically feasible and provides improved postoperative convalescence with smaller scars compared to conventional open surgery.