V7-07: Robotic Bladder Neck Reconstruction with Sling and Split Appendix Technique for Appendicovesicostomy and MACE
Robotic surgical techniques have been adopted for procedures in pediatric urology even in reconstruction for neurogenic bladder. Our aim was to expand on the previously described bladder neck reconstruction with sling and Appendicovesicostomy (APV), by showing that the well described open split appendix technique can also be perform robotically, allowing for the creation of both APV and MACE. This video is to our knowledge, the first to demonstrate the use of robotic split appendix technique.
A 6 year-old male with myelomeningocele, neurogenic bladder and bowel was not able to achieve urinary continence on a standard regiment of IC and anticholinergic. Urodynamic showed adequate bladder capacity at 300 ml with low storage pressure and adequate compliance. Unfortunately he had a low leak point pressure indicating poor outlet resistance. Thus indication for a bladder neck reconstruction with APV was made. There was also a need for implementing a good bowel regiment and after evaluation at our Center for Colorectal and pelvic Reconstruction by the colorectal surgeon, indication for a MACE was also made. We selected to utilize 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 placed ureteral catheter for easy ureteral orifice identification during bladder neck reconstruction and an 8 French Foley catheter. 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.
The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning he was taken to the operating room for the procedure. Total operative time was 7 hours. Total console time was 6 hours. A 10 French Foley catheter was placed through the APV channel and an 8 French feeding tube was placed through the MACE. A 5 French feeding tube was left stenting the urethra and was removed prior to discharge. He 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.
Robotic assisted bladder neck reconstruction with split appendix technique to create both APV and MACE is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery will continue to be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer.