V10-09: Robot-Assisted Laparoscopic Bladder Neck Sling in Male Epispadias in the Pediatric Patient

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Introductions and Objectives
Male epispadias represents the least severe phenotypic defect of the exstrophy-epispadias complex. Its presentation is variable, but can be associated with significant functional problems due to bladder neck incompetence. Though there are no reliable medical treatments for this condition, there are several options for surgical intervention including bladder neck sling placement. The advantage of the sling procedure is its relative straightforward application. Typically, this procedure is performed using an open approach in children. However, a robotic approach would provide advantages for access and mobility to deep pelvic structures. We aim to demonstrate the application and safety of a robotic approach to the bladder neck sling procedure in the pediatric population.

Methods
A 5 year old male (23kg) with penopubic epispadias status post repair at 5 months of age was found to have persistent urinary incontinence for >1 year. Voiding cystourethrogram was performed and demonstrated bladder neck incompetence. The patient underwent robot-assisted laparoscopic bladder neck sling placement, utilizing dorsal lithotomy positioning and two working ports with a single assistant port. A suprapubic tube (SPT) was placed at the time of the procedure. Clamp trials were started 2 weeks post-operatively and the SPT was removed 4 weeks post-operatively after documentation of adequate voiding and bladder emptying.

Results
There were no immediate complications to the procedure, and operative time was 3.5 hours. The patient was discharged to home on post-operative day 4. In the 6 months following surgery, the patient reported subjective improvement in urinary incontinence with increased dry intervals and quality of life.

Conclusions
The robot-assisted laparoscopic sling procedure appears to be safe and technically feasible in small children. This procedure provides a good option for managing bladder neck incompetence in pediatric males with epispadias. This use of the robotic approach demonstrates versatility, as this can be applied to other bladder neck or deep pelvic procedures in pediatric patients. Long-term studies will be needed to validate this technique and to assess durability of symptom improvement.

Funding: None