Bladder Neck Repairs

There are various bladder neck reconstructive procedures that are available to increase the resistance at the bladder outlet. Perhaps the most common are the Young-Dees Leadbetter (YDL), the Pippi-Salle, the Kropp repair, and the modified LM repair. Various studies have looked at outcomes with these different techniques, but unfortunately all of the published literature suffers from multiple limitations, including retrospective studies with significant confounders, nonstandardized protocols, and multiple definitions of what constitutes urinary continence. Most articles also combine patients with different primary diagnoses and some do not differentiate between BNR with and without augmentation cystoplasty. For example, in a retrospective study of 49 continence procedures in patients with multiple etiologies for their incontinence, Cole and colleagues showed continence rates for YDL at 79%, and 75% for Kropp and Pippi-Salle repairs. Another retrospective review involved 18 children who underwent a Pippi-Salle reconstruction with neurogenic incontinence and showed a dry rate (4 hours or more between catheterizations) of 61%. One of the few prospective studies by Snodgrass and Barber compared initial and long-term continence in 37 consecutive patients with neurogenic bladder undergoing LM plus a BNS with 34 previous consecutive patients undergoing sling alone. The cohorts were equivalent with regard to gender, ambulatory status, and preoperative urodynamic parameters. Initial continence (dry, no pads) determined at 6 months after surgery was significantly different: 29 (78%) of 37 in the LM reconstruction with sling versus 18 (53%) of 34 with sling alone ( P = .04). Kaplan-Meier curves showed initially dry sling patients to have recurrent incontinence during follow-up, leaving fewer than 25% dry long term, versus no loss of continence in LM plus sling patients after 18 months, with 60% still dry at maximum follow-up of 55 months. As can be seen, in spite of the multiple limitations, studies reviewing these BNR techniques report reasonable continence rates ranging from 50% to 85%.

Bladder Neck Closure

Perhaps the most radical option for achieving continence is closure of the bladder neck. A retrospective review by Bergman and colleagues included 52 patients with mixed etiology incontinence undergoing bladder neck closure as primary surgery after failed medical therapy and showed an 88% dry rate. Another study by Liard and colleagues involving 21 patients with bladder neck closure as primary surgical therapy showed an 80% dry rate. Finally, another retrospective study by Hoebeke and colleagues in 17 children undergoing bladder neck closure showed a dry rate of 100% but difficulty with catheterization in 47% of patients.

Laparoendoscopic Procedures for Urinary Continence

Robotic-Assisted Bladder Neck Reconstruction

Establishing urinary continence in pediatric patients with sphincteric incompetence usually involves a combination of medical therapy, CIC, and sometimes surgical intervention. This condition is most often encountered in children with spina bifida, and is diagnosed by persistent incontinence despite CIC and anticholinergics in patients with detrusor areflexia and detrusor leak point pressure less than 50 cm H2O on urodynamic testing. Cystography demonstrates a smooth-walled bladder and, typically, an open bladder neck. The most commonly used procedure to gain continence in these patients is BNS. However, our data indicate that an LM BNR to reduce the caliber of the outlet, plus sling (LMS) has higher continence rates than a sling alone. Consequently, we perform this procedure and APV (or Monti channel when the appendix is inadequate) to achieve urinary continence in this patient population using robotic assistance. Whether or not an augmentation ileocystoplasty should be concomitantly performed is beyond the scope of this article, but the techniques described later in this article can be implemented and easily modified to accommodate an augmentation when indicated.

It is clear from our data (see later in this article) that the robotic approach offers the same continence for an LMS with the added advantages of small “band aid” incisions, less postoperative pain, and shorter hospitalization. We now almost exclusively do these operations robotically at our institution. We have previously reported our initial results and provide our technique and outcomes.

Patient Positioning

The child is placed supine on a padded bean-bag patient positioner ( Fig. 1 ). Alternatively, the legs can be placed in lithotomy stirrups. It is imperative to pad all pressure points, including the heels ( Fig. 2 ). The patient is secured to the bed using wide tape. The shorter end of the base of the operating room (OR) table should be oriented toward the patient’s feet to allow as much space as possible for the base of the robot ( Fig. 3 ). Along these lines, the patient should be moved down on the operating table as much as possible. The patient is prepped and draped. The head of the operating table is lowered (Trendelenburg position) for the bladder neck portion of the surgery. A Foley catheter is inserted transurethrally and the balloon inflated to later help identify the bladder neck. This is done sterile on the field. Before positioning, it is recommended (especially early in the surgeon’s experience) to cystoscopically place externalized ureteral catheters to aid in ureteral orifice identification during the BNR. They are secured to the Foley and prepped onto the field.

Patient positioning. It is imperative to meticulously pad every possible pressure point. Alternatively, the patient can be placed in lithotomy, although we do not recommend it, given the potential for lower extremity nerve injury during long cases.

Padding at the ankles and heels.

Docking. The shorter end of the base of the OR table should be oriented toward the patient’s feet to allow as much space as possible for the base of the robot.

Skin Incision and Port Placement

An inverted “V”-shaped incision is made in the umbilicus with the apex of the “V” at the base of the umbilicus. The umbilical stalk is grasped with a Kocher clamp and access is obtained with a Veress needle technique. A 5-mm VersaStep (Covidien, Mansfield, MA, USA) trocar is placed and a 5-mm laparoscopic camera is used to place the remaining ports. Port placement is as shown in Fig. 4 . The robotic ports are secured to the patient’s skin as shown in Fig. 5 using two 0.5-inch Steri-Strips which are wrapped around the trocar and a small Tegaderm adhesive dressing is used to secure them to the skin. A 2-0 Vicryl suture on a UR6 needle is then used to secure the dressing to the skin and deep subcutaneous tissues. These sutures are then wrapped around the 8.5-mm trocars.

Port placement. We use a 12-mm camera and two 8.5 working ports. If any bowel work is going to be performed or if a sling is going to be used we use a 12-mm assist in the left upper quadrant. If just an APV is going to be performed, a 5-mm assist port can be used.

The robotic ports are secured to the patient’s skin as shown using two 0.5-inch Steri-Strips that are wrapped around the trocar and a small Tegaderm adhesive dressing is used to secure them to the skin. A 2-0 Vicryl suture on a UR6 needle is then used to secure the dressing to the skin and deep subcutaneous tissues. These sutures are then wrapped around the 8.5-mm trocars.

(3M, St. Paul, MN.)

Dissection of the Appendix

Before the robot is docked, the entire right and mid transverse colon are mobilized laparoscopically to allow for the appendix to be dissected as inferiorly in the pelvis as possible. The appendix is harvested with a 12-mm laparoscopic Endo-GIA stapler. A cecal extension of the stable line can be used at this point and is particularly helpful in obese patients or in patients with a short appendix.

Robotic Docking

The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA) is docked either directly in the midline from inferior (if the patient is in lithotomy) or slightly from the patient’s right side and inferior ( Fig. 6 ). The second position allows the surgeon a bit more flexibility to work above the pelvis and to the right of the patient in cases in which the appendix needs to be further mobilized. In the second method, the base of the robot should straddle the right corner of the operating table (see Fig. 3 ). Ports are secured to the robotic arms. A 12-mm camera at the 30° up position is used.

The Da Vinci robot is docked either directly in the midline from inferior (if the patient is in lithotomy) or slightly from the patient’s right side and inferior.

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