V7-02: Robotic Assisted Ileovesicostomy & Cecostomy Tube
Robotic surgical techniques have been adopted for procedures in pediatric urology but reconstruction for neurogenic bladder has been an area where it is underutilized. The reasons for this may include the need to create a bowel anastomosis, relative inexperience with robotics or perceived limitations of the technology. Our objective is to demonstrate the successful use of robotics in creating an ileovesicostomy incontinent urinary diversion with a complete intra corporeal bowel anastomosis and cecostomy tube placement.
A 15 year-old female with myelomeningocele and neurogenic bladder had multiple failed attempts at compliance with clean intermittent catheterization program. She developed acute kidney injury and it was recommended that she undergo incontinent urinary diversion. We utilized the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of botox into the detrusor muscle. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance. A cecostomy tube was also placed robotically to manage the patient’s neurogenic bowel. The ileovesicootomy stoma was created in the left lower quadrant by extending the left arm robotic port site.
The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning she was taken to the operating room for the procedure. Total operative time was 406 minutes. Anesthesia induction was 17 minutes, cystoscopy and botox injection was 10 minutes and port placement and laparoscopic dissection took 22 minutes. Total console time was 244 minutes and closure time was 14 minutes. The remaining 96 minutes was for patient positioning and preparation. A foley catheter was placed per her urethra temporarily to keep her bladder decompressed to aid in wound healing and was removed prior to discharge. She was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4 with no surgical drainage tubes except for her urostomy. At 5-month follow-up her creatinine remains at her baseline of 0.9 and her ultrasound shows no hydronephrosis. She has no leakage per urethra.
Robotic assisted ileovesocostomy is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery can be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer.