V3-01: Robotic Young-Dees-Leadbetter Bladder Neck Reconstruction in the Exstrophy-Epispadias Population: An Initial Report

Video

Introductions and Objectives
The modified Young-Dees-Leadbetter (mYDL) bladder neck reconstruction (BNR) is an effective means of correcting urinary incontinence and promoting volitional voiding in the exstrophy-epispadias population. Herein is the first reported description of a mYDL BNR performed through a robotic-assisted laparoscopic approach.

Methods
The 10 year-old patient had complete male epispadias with continuous incontinence and no volitional urinary control. Preoperative bladder capacity was 150mL with no vesicoureteral reflux. The child was emotionally mature with a desire to be dry. Preoperative pelvic floor conditioning was completed. He underwent robotic mYDL BNR. The child was positioned in dorsal lithotomy with a camera port at the umbilicus and the robotic trocars and assistant port spaced across the lower abdomen. The bladder was dissected from the abdominal wall and opened in the midline. Bladder neck exposure was maximized with the third arm holding the bladder cephalad and hitch sutures retracting it laterally. Exposure was excellent and the urethra was visualized to the superior aspect of the verumontanum. The neourethral mucosa was marked 3cm long by 16mm wide and with improved visualization distally, ureteral reimplantation was not required. The neourethra was closed over an 8Fr feeding tube. The bladder neck was demucosalized and reconstructed in standard mYDL fashion. Suspension sutures were placed in the bladder neck. The third arm elevated the bladder neck to a point where saline injected per urethra ceased the free flow of urine. The suspension sutures were secured to the posterior pubis and lower midline fascia. A 16Fr suprapubic tube was placed. The bladder was closed in 2 layers and a drain was inserted. The neourethra was left unstented.

Results
Total surgical time was 5:40 with an estimated blood loss of 50mL. The patient recovered bowel function on post-operative day (POD) 1 and was discharged on POD 4. The patient is now performing bladder training and can hold urine for up to 3 hours and generate a volitional stream. An ultrasound at six weeks showed no urinary retention or hydronephrosis.

Conclusions
The major surgical advantage of a robotic approach to BNR is the excellent visualization of the proximal urethra and bladder neck under the pubic bone. In this case, it allowed for ample length of the tubularized neourethra without the need for ureteral reimplantation or stents. This initial report of robotic mYDL BNR is a promising minimally invasive modification in the surgical repertoire for exstrophy-epispadias continence reconstruction.

Funding: none