Robot-assisted bladder neck reconstruction, bladder neck sling, and appendicovesicostomy in children: Description of technique and initial results

Purpose: To describe robot-assisted complex reconstruction of the lower urinary tract in children with neurogenic bladder and sphincteric incompetence. Patients and Methods: Four sequential patients with spinal dysraphism, neurogenic bladder, and sphincteric incompetence based on urodynamic parameters had persistent urinary incontinence on maximal anticholinergic therapy and clean intermittent catheterization (CIC). They underwent robot-assisted Mitrofanoff appendicovesicostomy along with Leadbetter/Mitchell bladder neck reconstruction and bladder neck sling. All patients received cystography 3 weeks postoperatively. Patient demographics, medical history, perioperative parameters, and urinary continence status were collected prospectively. Results: Mean predicted bladder capacity was 353 mL (range 210-450 mL) while actual preoperative bladder capacity was 216 mL(range 180-275 mL). Preoperatively, one-patient demonstrated uninhibited bladder contractions; none had trabeculated bladders. Mean detrusor leak point pressure was 29 cm H ₂0. Three of four (75%) cases were completed robotically; one necessitated conversion to open and Monti channel creation because of a marginal appendix. Mean operative time (hours:minutes) was 7:45 (range 5:56-12:18). Mean length of stay and blood loss were 85.7 hours and 117.8 mL, respectively. Postoperatively, all patients were completely dry on CIC and anticholinergics. None of the bladders demonstrated trabeculation on follow-up cystography. Unilateral de novo grade II vesicoureteral reflux developed in two patients, and anticholinergics were dose escalated. Conclusion: Our initial series of robot-assisted appendicovesicostomy with bladder neck reconstruction and sling placement expands the scope of complex robotic reconstruction in children. The preliminary data demonstrate the procedure to be feasible and safe. Comparison with traditional "open" series of the same procedure is necessary.