V10-04: Robotic Assisted Abdominoperineal Vesicourethral Anastomotic Reconstruction with Urethral Pull Through
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INTRODUCTION
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.
METHODS
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.
RESULTS
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.
CONCLUSION
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.
Funding: None