V7-06: Pediatric Robotic-Assisted Laparoscopic Appendicovesicostomy Revision
Robotic surgery for reconstructive pediatric urology is an emerging technique, and robotic-assisted Mitrofanoff appendicovesicostomy is associated with relatively high stomal continence rates. However, some children experience incontinence, which may be related to inadequate support and resistance at the anastomosis of the appendix to the bladder. While endoscopic injection is often recommended first, some patients require surgical revision. We demonstrate our approach to surgical revision of a Mitrofanoff appendicovesicostomy in a pediatric patient.
A 14 year old wheelchair bound male (BMI 42) with muscular dystrophy who previously underwent a robotic-assisted laparoscopic appendicovesicostomy creation experienced stomal incontinence at low volumes. Urodynamics demonstrated stomal incontinence at 175mL at low pressures without detrusor instability. Bulking agent injection was attempted first without relief. He was scheduled to undergo robotic revision. He was placed in semi-lithotomy position with minimal Trendelenburg. A 12mm camera port was placed superior and lateral to the umbilicus, given the umbilical stoma. Additionally, two 8mm robotic ports and a 5mm assistant port were placed. Great care was used to avoid disruption of the mesentery to the appendix and umbilical stoma. The appendix and a portion of the bladder was dissected from the anterior abdominal wall. The bladder, which was floppy, was wrapped around the proximal appendiceal channel and secured in place using 2-0 vicryl interrupted sutures without disrupting the previous anastomosis.
A 3cm bladder wrap was created around the proximal appendiceal channel. After completion of a successful wrap, continence was confirmed with 250mL of fluid. Operative time was 128 min. Estimated blood loss was 20mL. The patient was discharged on postoperative day 1, and a catheter was left in the Mitrofanoff for 20 days. At one month, continence was maintained. He awaits additional follow-up.
Stomal incontinence can occur after Mitrofanoff appendicovesicostomy. After failed endoscopic injection, a robotic approach represents a minimally invasive alternative to open revision. A bladder wrap offers additional support to the junction of the appendix to the bladder, which improves continence. Longer follow-up is needed to determine a durable outcome.