V09-12: Robotic Assisted Neo-Malone, Bladder Neck Reconstruction with Sling and Mitrofanoff in a Patient with Myelomeningocele
Previously we reported on a Robotic split appendix technique for creation of a Mitrofanoff and Malone. Yet often time the appendix may not be long enough to create both. To overcome this in open case a neo-Malone based on a cecal flap can be created. This video depicts the case of a 3 year old who underwent a robotic assisted bladder neck reconstruction with sling and Mitrofanoff and creation of a neo-Malone.
A 3 year old female with a history of myelomeningocele with shunted hydrocephalus and neurogenic bowel and bladder with urinary and fecal incontinence on daily rectal enemas, underwent urologic reconstruction with an antegrade option for her enema program. UDS showed low leak point pressure and adequate bladder capacity.
After a V-shaped flap incision in the umbilicus. Umbilical, right upper and lower quadrant and left upper quadrant robotic ports allowed for right colon mobilization. The appendix was 6 cm long and was considered too short to do a split technique Malone-Mitrofanoff. The bladder neck reconstruction with sling was perform in a similar manner as previously described. The appendix was them used for the Mitrofanoff alone and a neo Malone was created using a cecal flap. A feeding vessel was identified on the medial side of the cecum and a cecal flap created around the vessel. The colotomy was closed with 4-0 vicryl and then the flap was tubularized around an 8 Fr feeding tube. Plication sutures created a valve around the appendix base. The Mitrofanoff stoma was created using the previously created V flap incision of the umbilicus. The neo-Malone-skin anastomosis was performed in the right lower quadrant at the site of the third robotic arm port. She had an uneventful post-op course, began Malone flushes in the early postoperative period and Mitrofanoff cathing after 1 month. She is dry for urine ono CIC every 2 hours and clean for stools on daily bowel flushes 6 months after the procedure.
A neomalone is a novel and feasible robotic technique with a good postoperative result. This technique can be used to create a Malone channel when the appendix is too short for the split technique or when there is no appendix exist.