BACKGROUND: Robotic assisted laparoscopic surgery continues to gain popularity in pediatric urology. As a result, robotic techniques for complex bladder reconstruction procedures are becoming more commonplace. However, bladder augmentation can pose a significant challenge when performed using a laparoscopic approach, especially in the setting of prior intraabdominal surgery. In this video, we demonstrate our robotic technique for bladder augmentation in a patient with significant previous abdominal surgical history.
METHODS: The presented patient had a history of anorectal malformation (bladder neck fistula) with sacral agenesis and tethered cord. He initially underwent a diverting colostomy at birth, followed a few months later by a posterior sagittal approach rectal pull-through procedure. He also underwent tethered cord release. He did develop a neurogenic bladder managed with CIC and had a Mitrofanoff created. Due to persistent urine and fecal soiling, he underwent a redo PSARP and bladder neck repair with a sling. After that, he was noticed to have deterioration of his bladder dynamics on follow-up urodynamics testing despite maximum medical therapy. Thus, bladder augmentation was indicated.
RESULTS: The patient underwent a robotic assisted laparoscopic augmentation with intrabdominal bowel harvest and anastomosis. He did receive a mechanical bowel preparation the day before surgery at home. He was positioned supine at the table. As shown in the video, Trocar’s positions were shifted towards the upper abdomen to improve workspace and avoid his previous Mitrofanoff in the umbilicus, the Malone channel in the right lower quadrant, and his previous scars (shown in the video). The procedure follows a similar technique as the open surgery with de-tubularization of the bowel segment selected for augmentation and reconfiguring into a U patch before attaching it to the bivalved bladder. The operation was completed robotically in 9 hours. He had a 4-day hospital stay. At the 6-month follow-up, he was dry and performing CIC every 6 hours.
CONCLUSIONS: This video depicts a robotic bladder augmentation in a patient with significant previous intrabdominal surgery. This procedure is feasible and can be done safely, even in patients with complex surgical histories. While this patient had a short hospital stay, further studies with a large number of cases are required to show a potential advantage over conventional open surgery.
