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Robotic Partial Cystectomy for Venous Malformation of the Bladder
Ramzi Jabaji, M.D., Virginia Li, M.D., Pooya Banapour, M.D., David S. Finley, M.D., Gene O. Huang, M.D..
Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA.

BACKGROUND: Congenital venous malformations of the bladder are uncommon. Hemangiomas, which have an arterial component, are the most common type of vascular malformation, yet still represent only 0.6% of all bladder lesions; venous malformations (VMs) are even rarer. Patients typically present with gross hematuria. Treatment ranges from endoscopic fulguration to excision depending on the extent of the disease. While open surgical treatment has been previously described, robotic partial cystectomy for VM of the bladder is a rare procedure.
METHODS: We highlight the case of a 15-year old female with venous malformation of the bladder treated by robotic partial cystectomy.
RESULTS: A 15-year-old female presented with severe gross hematuria for 1 week and was found to have a hemoglobin level of 7.4 g/dL. She was noted to have a history of vascular malformations of the right leg and bladder. At age 12, she underwent arteriography for the bladder malformation which revealed no arterial inflow to the mass consistent with a venous malformation, which was then treated through a combined laparocystoscopic injection of a sclerosing agent. She had also undergone multiple sclerotherapy procedures of her lower extremity lesion. Full body MRI was obtained; pelvic imaging demonstrated a 5 cm vascular bladder mass with intra- and extraluminal components, without any arterial enhancing component. Imaging also was notable for vascular lesions in her right lower extremity as well as right gluteal regions. She was taken to the operating room for cystoscopy and spot fulguration of the mass; bladder capacity was 400 mL. Her urine cleared, and she was discharged home. A genetics consultation suggested somatic mosaic mutations rather than a germline mutation in the genes involved in angiogenesis. Over the next several months she continued to have intermittent hematuria and urinary frequency, and the lesion grew slightly larger on repeat imaging. The decision was made to proceed with surgical resection of the mass via a robotic approach.
The video highlights technical considerations of robotic partial cystectomy in the setting of vascular malformation of the bladder. The sigmoid colon was noted intraoperatively to have multiple small venous blebs, without any apparent involvement with the bladder mass. Simultaneous visualization of the bladder mass both robotically and cystoscopically allowed for more precise planning and excision of the mass while also taking care to optimize postoperative bladder capacity. At the end of the case, the bladder was filled to a volume of 240 mL and noted to be leak-free. The patient was discharged home on postoperative day two. A cystogram performed 2 weeks postoperatively confirmed no leak on filling or post-drainage films, and the catheter was removed. Two months postoperatively, she was voiding every 4 to 6 hours. Currently, she is doing well.
CONCLUSIONS: We present an unusual case of venous malformation of the bladder in a 15-year-old female and highlight the technique of robotic partial cystectomy as a minimally invasive treatment option. We believe that a combined robotic and cystoscopic approach allows for clear visualization of the intravesical tumor margins to maximize postoperative bladder capacity.

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