V10-04: Robotic Assisted Abdominoperineal Vesicourethral Anastomotic Reconstruction with Urethral Pull Through
Complete bladder neck disruption and contracture is rare but can occur after trauma or radical prostatectomy. Management is controversial but typically includes open surgical reconstruction using abdominal and/or perineal approaches, albeit with poor continence outcomes. We report the reconstruction of a disrupted vesicourethral anastomosis secondary to bleeding from undiagnosed hemophilia requiring open re-exploration and pudendal artery embolization, previously managed with nephrostomy, suprapubic, and surgical drains. The vesicourethral anastomosis was reconstructed with a robotic assisted abdominoperineal approach utilizing a urethral pull-through.
Preoperative evaluation included a combined cystogram and retrograde urethrogram and pelvic MRI to estimate anastomotic defect length. A robotic assisted abdominal vesicourethral anastomotic reconstruction was performed 6 months post-prostatectomy in lithotomy position, docking the da Vinci Xi® robot on the right side of the patient and including the perineum in the surgical field to allow for simultaneous perineal urethral mobilization if necessary. Cystoscopy with insertion of a 22-gauge 4 mm needle, followed by &[prime]cutting to light,&[prime] was used to guide dissection through dense scar to the urethral stump. Concurrent perineal urethral mobilization with urethral pull-through and splitting of the corpora cavernosa was necessary to complete a tension-free anastomosis.
Total operative time was 7 hours and 22 minutes, with an estimated blood loss of 300 mL. Postoperative pain was minimal, with a mean of 5 mg oral hydromorphone required daily for analgesia. The patient was medically fit for discharge on post-operative day 2 after removal of nephrostomy and surgical drains (suprapubic catheter was removed intra-operatively). A cystogram obtained two weeks postoperatively revealed no contrast extravasation, and his Foley catheter was removed. The patient reports stress urinary incontinence with the use of 2 pads per day.
Vesicourethral anastomotic defects present a significant reconstructive challenge. By mobilizing both the bladder and urethra using a robotic assisted abdominoperineal approach with urethral pull-through, this vesicourethral anastomosis was reconstructed in a tension-free manner while avoiding an inferior pubectomy and concomitant postoperative morbidity. Side docking of the robot allowed for simultaneous access to the perineum, and represents a novel approach to complex bladder neck reconstruction.