V3-03: ROBOTIC ASSISTED LAPAROSCOPIC ANTERIOR BLADDER WALL APPENDICOVESICOSTOMY

Video

Introductions and Objectives
During appendicovesicostomy inevitably variable sizes of appendix are encountered. Herein, we introduce a modification to the previously described robotic assisted laparoscopic (RAL) approach in order to account for a shorter appendix by using the anterior bladder wall as the site of neocystostomy.

Methods
Overall, nine patients with mean age of 10.5 years (±3.5)and roughly equal gender distribution underwent the modified technique of extravesical anterior bladder wall neocystostomy between 2008 and 2013 by a single surgeon. Preoperative assessment included renal ultrasound, voiding cystourethrogram, and videourodynamics. All patients had failure to empty type of bladder dysfunction with average residual urine volume of 678 ml (±387). No bowel preparation was administered prior to surgery. The appendix was reimplanted on the anterior bladder wall applying the extravesical technique. A detrusorotomy trough of at least 4cm length was ensured to provide for adequate continence mechanism. Special attention was directed to the mobilization of the appendix and cecum to avoid tension on the mesentry.

Results
In all cases the procedures were performed without major perioperative complications. Mean operative time was 294 minutes (± 68) with decreasing trend towards more recent cases. In one case, a temporary suprapupic catheter was placed during the hospital stay due to lack of drainage through the appendicovesicostomy channel. One patient developed postopeative ileus that resolved on conservative measures. Patients were discharged home on average between 3 to 4 days after the surgery. Clean intermittent catheterization was initiated 3 weeks after surgery while allowing for continuous drainage overnight. On a mean follow-up of 21 months (±14.5) no strictures of the channel were observed. One patient developed a stenosis at the skin level 3 years after the surgery due to lack of use of the channel . Two patients developed leakage from the channel around 1 year after surgery due to mild detrusor istability . In both cases the sypmtoms were well controlled by antichiolinergic therapy.

Conclusions
Modified RAL appendicovesicostomy using the anterior bladder wall as the implantation site is feasible. The technique might be advantageous because of technical ease while accommodating for shorter appendical length.

Funding: none