There is growing interest in applying robotic-assisted laparoscopic techniques to complex reconstructive pelvic surgery owing to inherent benefits of precision, tissue handling, and articulating instruments for suturing. This review examines preliminary experiences with robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA) as either an isolated or combined procedure. These series suggest RALIMA is feasible, with the benefit of early recovery and improved cosmetic results in selected patients. The robotic approach incurs functional outcomes and complication rates similar to those of open techniques. Given the steep learning curve, only surgeons with extensive robotic experience are currently adopting this technique.
Key points
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Surgeons are gaining robotic experience from pyeloplasty and ureteral reimplantation, and are now performing more complex pediatric cases robotically, such as augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy.
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Data from early case series demonstrate adequate safety and efficacy with outcomes and complication rates similar to those of open techniques.
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The benefits of robotic surgery, including decreased pain, decreased length of stay in hospital, and improved cosmesis, must be balanced with the learning curve, cost, and operative time.
Introduction
Robotic techniques are being increasingly used in minimally invasive pediatric urology. Pediatric surgeons have gained experience with robotic procedures in children, and are beginning to apply these techniques in more complex cases, such as robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA). Historically, ileocystoplasty and Mitrofanoff appendicovesicostomy (IMA) have been performed as an open procedure, but a robotic approach in children yields the benefits of minimally invasive surgery; this includes decreased incisional pain, shorter length of stay in hospital, and improved cosmesis.
Laparoscopic-assisted appendicovesicostomy was first described in 1993. That procedure involved laparoscopic mobilization of the colon and appendix followed by implantation of the appendix in the bladder using a lower abdomen incision. Evolution of the technique eventually resulted in the first completely laparoscopic Mitrofanoff appendicovesicostomy, reported in 2004. These investigators describe the use of carbon dioxide pneumovesicum to achieve bladder wall distension, which facilitated creation of an extravesical detrusor trough and appendicovesical anastomosis.
The first robotic-assisted laparoscopic appendicovesicostomy was performed in 2004, and the first completely intracorporeal RALIMA was reported in 2008. Several challenges have hindered the wide application of these complex techniques in pediatric urology, including historical preference for open techniques in children, a lack of standardized training in pediatric robotic surgery, and inherently smaller working spaces in children. Despite these obstacles, pediatric robotic surgery has advanced to become more widely used, even in infant populations. Although the open approach for IMA remains the most common technique, RALIMA has established itself as a viable option for pediatric urologists with considerable robotic expertise. This article presents a detailed review of RALIMA, including a discussion of indications, techniques, technical considerations, outcomes, and future directions.
Introduction
Robotic techniques are being increasingly used in minimally invasive pediatric urology. Pediatric surgeons have gained experience with robotic procedures in children, and are beginning to apply these techniques in more complex cases, such as robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA). Historically, ileocystoplasty and Mitrofanoff appendicovesicostomy (IMA) have been performed as an open procedure, but a robotic approach in children yields the benefits of minimally invasive surgery; this includes decreased incisional pain, shorter length of stay in hospital, and improved cosmesis.
Laparoscopic-assisted appendicovesicostomy was first described in 1993. That procedure involved laparoscopic mobilization of the colon and appendix followed by implantation of the appendix in the bladder using a lower abdomen incision. Evolution of the technique eventually resulted in the first completely laparoscopic Mitrofanoff appendicovesicostomy, reported in 2004. These investigators describe the use of carbon dioxide pneumovesicum to achieve bladder wall distension, which facilitated creation of an extravesical detrusor trough and appendicovesical anastomosis.
The first robotic-assisted laparoscopic appendicovesicostomy was performed in 2004, and the first completely intracorporeal RALIMA was reported in 2008. Several challenges have hindered the wide application of these complex techniques in pediatric urology, including historical preference for open techniques in children, a lack of standardized training in pediatric robotic surgery, and inherently smaller working spaces in children. Despite these obstacles, pediatric robotic surgery has advanced to become more widely used, even in infant populations. Although the open approach for IMA remains the most common technique, RALIMA has established itself as a viable option for pediatric urologists with considerable robotic expertise. This article presents a detailed review of RALIMA, including a discussion of indications, techniques, technical considerations, outcomes, and future directions.
Indications and contraindications
Bladder augmentation is indicated in disease states that impair bladder function, often through diminished bladder capacity, and/or reduced compliance associated with high-pressure voiding. Potential underlying abnormalities that affect bladder function include spina bifida, neurogenic bladder, nonneurogenic bladder, bladder exstrophy, prune belly syndrome, and posterior urethral valves. Ileocystoplasty increases bladder capacity, improves compliance, and reduces voiding pressures, thus protecting against renal deterioration and improving continence. Mitrofanoff appendicovesicostomy simplifies and facilitates clean intermittent catheterization (CIC). In many patients, CIC via the urethra becomes difficult or impossible because of discomfort, trauma, urethral stricture disease, disability, or noncompliance.
Patient selection is critical when considering bladder augmentation or creation of a continent catheterizable channel. Especially in young children, considerable preoperative counseling must be given to parents and caregivers before embarking on any procedure. Absolute and relative contraindications to IMA include prior appendectomy, inability to perform catheterization, poor access to caregivers, inflammatory bowel disease, and short or irradiated bowel. Lack of an appendix may lead to a Monti catheterizable channel using ileum, although this is not preferred, as it requires a bowel anastomosis and may be associated with a slightly higher complication rate. Significant renal impairment is a controversial relative contraindication to bladder augmentation. A recent study found that bladder augmentation did not appear to accelerate progression of renal insufficiency in a cohort of children with chronic kidney disease and neurogenic bladder. Specific to the robotic approach, prior multiple abdominal surgery and severe kyphoscoliosis may increase the likelihood of conversion to an open procedure, owing to extensive adhesions or inability to achieve adequate pneumoperitoneum.
Technical considerations
The surgical technique described herein has been previously published by the authors’ institution, which to their knowledge has the largest body of experience with RALIMA to date.
Preparation
Patients are not typically given mechanical or oral antibiotic bowel preparation before surgery. Perioperative antibiotics are administered within 1 hour of incision to all patients (typically cefazolin, gentamicin, and metronidazole unless allergies are present). If a ventriculoperitoneal shunt is present, the antibiotic regimen is broadened to include vancomycin.
Positioning and Port Placement
The patient is placed in a low lithotomy position with the arms tucked at the side. Appropriate foam padding of the torso, arms, and legs is applied to prevent injury. Padded foam is used to protect the face from collision with robotic arms. The patient is prepped and draped with a Foley catheter placed on the sterile field. Ports are placed as described in Fig. 1 . Ports include a 12-mm port for the camera, 2 ports for the robotic arms (5–8 mm), and a 10-mm assistant port in the left upper quadrant port to pass sutures and irrigate. Occasionally an additional 5-mm port is placed in the right lower quadrant, and can be used later for maturation of the stoma if required. The umbilical stoma is typically used for the maturation of stoma. A minimum puboumbilical distance of 10 to 12 cm is maintained for the camera port. A supraumbilical port site can also be used, which can allow access to both the bowels and bladder.
Operative Technique
The initial 12-mm trocar placement is performed using an open Hassan technique. Once pneumoperitoneum is established, diagnostic peritoneoscopy allows identification of the appendix and its length assessment. In general, the appendix should be approximately 5 to 6 cm and capable of accepting a 10F to 12F catheter to be considered adequate. Of note, numerous substitutions have been described in the literature including ureter, fallopian tubes, tubularized bladder, or colonic flaps. However, there are no published reports of such use during a robotic approach. At this point, the additional robotic and assistant ports are placed under direct vision. If a ventricoperitoneal shunt is present, the end of the shunt can be placed in an Endopouch retrieval bag (Ethicon, Somerville, NJ, USA) to avoid contamination of the shunt with bowel contents. The appendix is mobilized at the appendicular/cecal junction while maintaining its blood supply ( Fig. 2 ). The addition of cecal flap may reduce the future risk of stomal stenosis. This action may be required when limited by appendiceal length or if both appendicovesicostomy and antegrade colonic enema are planned for management of the bladder and bowel.
The appendix is mobilized at the appendicular/cecal junction while maintaining its blood supply (see Fig. 2 B). A 3-0 polyglactin purse-string suture is placed at the base of the appendix and the appendix is then separated from the cecum. The purse-string suture is tied and the cecal opening closed in a second layer with the same suture.
The appendiceal mesentery is then mobilized, and the 1-cm segment of the distal appendix is removed to generate an adequate lumen. The mobility of the appendix is evaluated to confirm it will reach from the bladder to the anterior abdominal wall without tension. Further mobilization of the cecum and right colon can be performed to gain additional mobility. If an augmentation cystoplasty is to be performed, the authors have recently modified the steps of the operation to defer implantation of the appendix until after cystotomy. In this way, an intravesical reimplantation is performed, which seems to decrease the required operative time.
If no additional procedure is planned, the anterior bladder wall is chosen as the insertion site for implantation of the appendix ( Fig. 3 ). This technique is technically easier than placing the anastomosis on the posterior wall, especially in patients with a large bladder. It also shortens the required length of the appendix, as the distance to the abdominal wall is less.
Attention is then turned to implantation of the appendix into the bladder. After distending the bladder with sterile water, detrusorotomy of approximately 4 cm in length is performed, without entering the mucosa. This action is carried out along the right posterior wall of the bladder if the stoma is matured to skin in the right iliac fossa; otherwise the midline bladder wall is used if creating an umbilical stoma. The first anastomotic suture is placed at the caudalmost apex of the detrusorotomy and then through the spatulated, apical tip of the appendix. The bladder mucosa is incised about 1 cm in length and the appendicovesical anastomosis is completed over an 8F feeding tube. The appendix is next placed in the trough, and the detrusor imbricated over it with a running 4-0 polyglactin suture. A stay suture is placed proximally between the appendix and the proximal extent of the detrusorrhaphy to prevent slippage of the appendix out of the submucosal tunnel. The final appearance is as shown in Fig. 2 A. In those patients undergoing concomitant cystoplasty, after appendix harvest and the bowel segment for augmentation is isolated, bowel continuity is restored, cystotomy is performed ( Fig. 4 ), and the appendix is implanted, followed by detubularized bowel to bladder anastomosis ( Fig. 5 ). The authors have previously reported their technique of combined robotic ileocystoplasty and Mitrofanoff appendicovesicostomy.
The proximal end of the appendix is next brought through the umbilical port site or the right lower quadrant through the 8-mm right robotic arm port. Stoma creation is then performed by spatulation of the appendicovesicostomy followed by cutaneous anastomosis using a V flap or a VQZ flap, which provides the advantage of cutaneous coverage of the intestinal mucosa.
Postoperative Care and Follow-Up
Postoperative care is typical of other minimally invasive surgeries, with goals to minimize narcotics, encourage early diet advancement, and promote ambulation ( Box 1 ). In brief, patients are given intravenous ketorolac for 48 hours followed by ibuprofen administration as needed 6 hours after the last dose of ketorolac. A regular diet is started immediately in patients with Mitrofanoff alone, and typically started within 24 hours if undergoing concomitant ileocystoplasty. Patients with baseline constipation are restarted on their home bowel regimen. Discharge criteria include ability to tolerate diet, pain control, and family comfort with drainage tubes.
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