V09-09: Robotic Continence Procedure in a Neurogenic Bladder Patient
Robotic-assisted techniques for the management of neurogenic bladder involve complex procedures using lower urinary tract and bowel. We describe a robotic-assisted laparoscopic bladder neck reconstruction combined with a robotic appendicovesicostomy in a 7-year-old patient with neurogenic bladder.
The patient was placed in a low lithotomy position followed by cystoscopy and bilateral double J stent placement. An 8 French Foley catheter was placed in the urethra. With an open Hassan technique, a 12-mm camera port was placed above the umbilicus. Two 8-mm and a 5-mm assistant port were positioned 6 cm away from the midline and in the left hypochondriac region, respectively. To initiate, the bladder is filled with 80 ml of saline. A cystotomy is performed and two Hitch stitches are placed for bladder retraction. A V-shaped segment is excised to create a long tubular strip of bladder neck below the ureteral orifices. The tubularization is completed in two layers using 4-0 PDS and a 3-cm tunnel is achieved. At this point, the appendix was disconnected with a cecal flap, followed by closure of the defect in two layers. The implantation of the appendix is performed in the posterior wall of the bladder and once this is achieved, the submucosal tunnel is created between the inner bladder mucosa and the outer muscle layer achieving 4 cm in length. The appendix is anchored laterally to the bladder muscle in both sides using 4-0 PDS. The tip of the appendix is excised and an 8 French feeding tube is brought across the appendix stoma into the bladder. The appendix wall is anastomosed to the bladder mucosa circumferentially using 5-0 PDS sutures. Ultimately, two suprapubic tubes are brought percutaneously for bladder drainage and the bladder is closed in a single layer using 3-0 Vicryl.
The patient tolerated the procedure well and was discharged on postoperative day 4 without any complications. Operative time was 5 hours and estimated blood loss was found to be less than 50 mL. The JP drain was removed prior to discharge. However, the Foley catheter, two suprapubic tubes and, an 8 French feeding tube (appendicovesicostomy) were left in place for continuous bladder drainage. At 1 month follow-up, the patient is catheterizing well, with good continence and well healed surgical incisions.
Robotic continence procedures have demonstrated to be safe and effective alternatives with low morbidity outcomes in patients with neurogenic bladder and persistent urinary incontinence.