Introduction & Objective :
Robotic surgical techniques are becoming increasingly utilized in pediatric surgery including in cases of complex reconstruction. However, an open approach is oftentimes taken in patients with a history of previous surgeries. Our aim is to demonstrate the use of robotic surgery in bladder neck reconstruction with sling placement in a patient with previous bladder exstrophy closure and appendicovesicostomy (APV).
Methods : The patient is a 9 year old female with neurogenic bladder and urinary incontinence despite the use of anticholinergics, behavior modifications, and self catheterization via Mitrofanoff stoma. She has a history of classic bladder exstrophy status post primary closure shortly after birth. She subsequently developed bilateral vesicoureteral reflux and underwent bilateral cross-trigonal ureteral reimplantation along with an APV. Urodynamics showed normal bladder compliance but a low detrusor leak point pressure at low bladder volumes. She underwent robotic-assisted bladder neck reconstruction and cadaveric sling placement. A catheter was placed and secured in her Mitrofanoff stoma. Dissection was carried out circumferentially around the stoma until it was eventually dropped into the peritoneal space. The void left behind was then used as our 12mm camera port. Two additional 8mm robotic ports and a 12mm assistant port were also used. At the conclusion of the case, the secured catheter was pulled back through the umbilical port site and the Mitrofanoff stoma was then matured.
Results : Total operative time was approximately 7 hours. Estimated blood loss was 50cc. A 12-French Foley catheter was placed through the APV and a 5-French feeding tube was secured in the urethra. The patient was discharged from the hospital on postoperative day #1 without incident.
Conclusions : Robotic-assisted bladder neck reconstruction and sling placement in children with previous complex bladder surgeries is technically feasible and may provide acceptable outcomes with excellent cosmesis.
Department of Urology, Mayo Clinic, Rochester, MN