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Continence Outcomes in Patients Undergoing Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy
Continence Outcomes in Patients Undergoing Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy Mark A. Wille,* Gregory P. Zagaja, Arieh L. Shalhav and Mohan S. Gundeti From the Department of Surgery, Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
Abbreviations and Acronyms ACE ⫽ antegrade continence enema EBL ⫽ estimated blood loss RALMA ⫽ robotic assisted laparoscopic Mitrofanoff appendicovesicostomy Submitted for publication July 27, 2010. * Correspondence: Section of Urology, University of Chicago, 5841 S. Maryland Ave. MC6038, Chicago, Illinois 60637 (telephone: 773-7954549; FAX: 773-702-1001; e-mail: mark.wille@ uchospitals.edu).
See Editorial on page 1184.
Purpose: Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. Materials and Methods: Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). Results: Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). Conclusions: We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence. Key Words: robotics; catheterization; urinary reservoirs, continent
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www.jurology.com
IN children the goal of appendicovesicostomy is to allow for efficient lower urinary tract emptying in the face of a neurogenic bladder, with the patient undergoing augmentation cystoplasty or primary bladder dysfunction with failure to empty. Clean intermittent catheterization may not be feasible in some cases. Traditionally appendicovesicostomy would be per-
formed using an open surgical approach. With the development of laparoscopic techniques and advances in robotics a minimally invasive approach is an option. The potential benefits of this approach include decreased postoperative pain, shorter hospital stay and improved cosmesis.1 We have used a robotic assisted laparoscopic approach in patients who require ap-
0022-5347/11/1854-1438/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 185, 1438-1443, April 2011 Printed in U.S.A. DOI:10.1016/j.juro.2010.11.050
AND
RESEARCH, INC.
Flap
EBL (cc)
Length of Detrusor Backing (cm)
24 20 29 9 24 18 21 6 25 5 3
Mos Followup
Preoperative evaluation was performed as required for augmentation cystoplasty or appendicovesicostomy. Patients underwent urodynamics, ultrasound examination and technetium dimercaptosuccinic acid scan (to evaluate for renal scarring and split renal function) (table 1). In patients undergoing augmentation cystoplasty, appendicovesicostomy was chosen as standard to allow for efficient bladder emptying. In other patients the reasons for appendicovesicostomy included pain with urethral catheterization, physical or developmental disability requiring caregiver dependence, or urethral stricture. A summary of patient demographics, diagnoses, EBL, operative time, followup and complications is presented in table 2. We did not perform bowel preparation in any patient. A total of 13 patients were considered for the robotic assisted laparoscopic approach. However, 2 patients requiring concomitant augmentation cystoplasty were converted to an open approach. In 1 patient there was failure to progress secondary to significant adhesions. In the other patient there was a short appendiceal length, and considering the patient also required a Malone antegrade continence enema, ileum was used in a Yang-Monti procedure.
4 4 4 3.5–4 3 4–5 4 4 4 4 4
Patient Selection/Preoperative Management
50 100 100 20 50 20 20 50 200 20 50
MATERIALS AND METHODS
VQZ VQZ VQZ V VQZ V VQZ V VQZ V V
Complications
pendicovesicostomy with or without augmentation cystoplasty. We present our technique, and perioperative and postoperative outcomes, with specific attention to continence outcomes using this approach.
False passage of appendicovesicostomy Revision of stoma Revision of stoma None Incontinence (Deflux injection) None Wound infection None Revision of stoma, false passage of appendicovesicostomy None None
CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
Capacity (cc)
Post-Void Residual (cc)
Detrusor Leak Point Pressure (cm H2O)
1 2 3 4 5 6 7 8 9 10 11
No Yes Yes No Yes No No Yes Yes No No
880 140 200 900 170 750 500 90 225 600 600
— 0 150 — 80 — — 10 60 — —
Failure to empty 120 65 Failure to empty 61 Failure to empty Failure to empty 50 59 Failure to empty Failure to empty
cystoplasty, cecal flap ACE cystoplasty
cystoplasty
cystoplasty cystoplasty
None Augmentation Augmentation None Augmentation None None Augmentation Augmentation None None
Concomitant Procedures
Nonneurogenic neurogenic bladder Neurogenic bladder/tethered cord Neurogenic bladder/spina bifida Neurogenic bladder/Arnold-Chiari Neurogenic bladder/sacral agenesis Neurogenic bladder/prune-belly syndrome Neurogenic bladder/prune-belly syndrome Neurogenic bladder/sacral agenesis Neurogenic bladder/myelomeningocele Neurogenic bladder/prune-belly syndrome Neurogenic bladder/myelomeningocele
Concomitant Augmentation?
1—13 2—7 3—10 4—14 5—12 6—5 7—14 8—8 9—10 10—10 11—11
Pt No.
Diagnosis
Table 1. Preoperative urodynamic findings
Pt No.—Age
Patients were placed in a modified lithotomy position. Ports were triangulated toward the right lower quadrant to allow access to the appendix and bladder (fig. 1). They included a 12 mm port for the camera and 2, 5 to 8 mm ports for the robotic arms. A minimum of 10 to 12 cm puboumbilical distance was ensured. Placing patients in the Trendelenburg position helped displace the small bowel from the pelvic area. A fourth port (5 mm) in the left lower quadrant was helpful for passing sutures and for irrigation. Preoperative antibiotics were administered (cefazolin and gentamicin routinely, or vancomycin, gentamicin and metronidazole if the patient had a ventriculoperitoneal
Table 2. Patient demographics and outcomes with robotic surgery
Surgical Technique
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CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
shunt). A Foley catheter was placed in the surgical field so that bladder volume could be regulated by the surgical assistant. Diagnostic peritoneoscopy was performed to identify the appendix to assess its length (needing approximately 5 to 6 cm) and adequacy as a catheterizable limb (accepted 10 or 12Fr catheter). In all patients with ventriculoperitoneal shunts, the end of the shunt was placed in an ENDOPOUCH RETRIEVER® Specimen Retrieval Bag to avoid contamination of the shunt with bowel contents. The appendix was mobilized at the appendicular/ cecal junction while maintaining its blood supply (fig. 2, A). A 3-zero polyglactin purse-string suture was placed at the base of the appendix and the appendix was then separated from the cecum. The purse-string suture was tied and the cecal opening was closed in a second layer with the same suture. The appendiceal mesentery was then mobilized and the 1 cm segment of the distal appendix was removed to generate an adequate lumen. The mobility of the appendix was evaluated to determine if it could reach the bladder and anterior abdominal wall without tension. Further mobilization of the cecum and right colon could be performed to gain additional mobility. In the event augmentation cystoplasty was to be performed, the appendix was placed on the posterior wall before performing a cystotomy for the augmentation cystoplasty. If no additional procedure was performed, then the anterior bladder wall was chosen as the insertion site for implantation of the appendix (fig. 3). This technique was technically easier than placing the anastomosis on the posterior wall, especially in patients with a large bladder. This also shortened the required length of the appendix as the distance to the abdominal wall was less. The bladder was partially filled with normal saline through the Foley catheter and a stay stitch was passed through the anterior abdominal wall. Using electrocautery the detrusor layer of the bladder wall was incised, exposing the bladder mucosa and creating a tunnel of at least 4 cm. The tunnel direction was determined according
Figure 1. Patient position and port placement
Figure 2. Appendix isolation (A) and placement of appendicovesicostomy on posterior bladder wall (B).
to the stomal location (craniocaudal for umbilical stomas, oblique for right lower quadrant stomas). An incision was made in the bladder mucosa at the location of the apex and the appendix tip was spatulated. After placing a stitch in the base of the spatulated appendix and at the base of the mucosal incision, a 5Fr feeding tube was placed across the future anastomosis. The appendicovesicostomy anastomosis was then performed circumferentially with interrupted 5-zero BIOSYN™ suture. The appendix was next placed in the trough, and the detrusor was reapproximated over it with 4, 4-zero polyglactin interrupted suture and secured with Lapra-Ty® clips. A stay suture was placed proximally between the appendix and the proximal extent of the detrusorraphy to prevent slippage of the appendix out of the
Figure 3. Placement of appendicovesicostomy on anterior bladder wall.
CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
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submucosal tunnel. The final appearance was as shown in figure 2, B. We have previously reported our technique for patients undergoing concomitant augmentation cystoplasty.2 The proximal end of the appendix was next brought through the 12 mm umbilical port site or to the right lower quadrant through the 8 mm right robotic arm port. A V, VQ or VQZ-shaped skin flap was created at the stoma site and the appendicovesicostomy was spatulated, allowing the flap to be placed into the more proximal portion of the appendicovesicostomy. The appendicovesicostomy was then matured into the skin site.
secondary to skin level scarring. A false passage of the appendicovesicostomy developed in 2 patients (at 2 months in 1 and at 17 months in the other, who required an indwelling catheter for 1 month but has subsequently healed). One patient had a superficial wound infection. All patients are currently catheterizing without difficulty and are continent.
Postoperative Care
The appendicovesicostomy is an effective means of providing a continent conduit for bladder catheterization. Complications of this operation include infection, upper tract deterioration, skin level scarring and stone formation, with the most frequent being skin level scarring, occurring in approximately 10% of patients.3,4 A minimally invasive approach would be of significant benefit in reducing the morbidity associated with appendicovesicostomy creation. The advantages of robotic surgery (decreased overall recovery time, bleeding and postoperative pain) that have been demonstrated in other procedures such as pyeloplasty can be applied to various techniques in pediatric urology. We previously presented a case report on robotic assisted laparoscopic augmentation cystoplasty and appendicovesicostomy creation.2 To our knowledge there are 2 case reports and 2 series in which laparoscopic appendicovesicostomy using the da Vinci® robotic system was performed with good results.1,5–7 There are also several case reports of appendicovesicostomy creation using a pure laparoscopic approach.8 –10 In addition, several case reports have described combined procedures involving pure laparoscopic and robotic assisted techniques, including appendicovesicostomy with concurrent augmentation, nephrectomy, orchiopexy, ACE and cecostomy tube placement.2,11,12 Several technical comments can be made based on this report. Diagnostic peritoneoscopy should be performed first to assess the length of the appendix. If the appendix length is not adequate, we do not proceed with a robotic assisted laparoscopic approach. A pubo-umbilical distance of 10 to 12 cm should be ensured and this is where the 12 mm camera port should be placed. The direction of and location of the submucosal tunnel should be addressed depending on stoma location. Umbilical stoma sites require a midline detrusorotomy and right lower quadrant stoma sites require an oblique detrusorotomy. Finally, when performing concomitant augmentation cystoplasty it is vital to place the appendicovesicostomy on the posterior wall of the bladder to facilitate the augmentation cystoplasty anastomosis which is performed after the appendicovesicostomy anastomosis. Otherwise
The patients were given intravenous ketorolac and oral acetaminophen as needed for the first 48 hours, and ibuprofen was started as needed 6 hours after the last dose of ketorolac. A liberal diet was started immediately and patients with constipation resumed their usual bowel regimen. Patients were discharged home once they tolerated a regular diet, pain was well controlled and when the family was comfortable managing the urinary drainage tubes.
Followup Postoperatively the appendicovesicostomy and suprapubic catheters were maintained for 4 weeks. At 4 weeks the appendicovesicostomy catheter was removed and the patient was taught clean intermittent catheterization via the appendiceal stoma while the suprapubic catheter was maintained as a pop-off valve for 1 week. Followup urodynamics were not routinely performed. However, we performed followup renal ultrasound to evaluate the upper urinary tract postoperatively.
RESULTS Patient demographics and operative outcomes are summarized in table 2. Overall mean operative time was 347 minutes for patients undergoing isolated appendicovesicostomy (including docking of the robot). Operative times improved only slightly with more cases. Mean operative time was 351.3 minutes for the first 3 RALMA cases and 344.3 minutes for the last 3 RALMA cases. Six patients underwent isolated robotic assisted laparoscopic appendicovesicostomy and 5 patients underwent concomitant augmentation cystoplasty. Total mean operative time for patients undergoing concomitant augmentation cystoplasty (1 patient also had a cecal flap ACE) was 639.8 minutes (range 609 to 711). Mean EBL was 61.8 cc (range 20 to 200). There were no intraoperative complications. Median length of hospitalization was 6 days (range 3 to 8). Median followup was 20 months (range 3 to 29). One patient had incontinence at 230 cc (assessed during urodynamics) and required dextranomer/hyaluronic acid (Deflux®) injection into the appendicovesicostomy anastomosis. The patient had complete resolution of the incontinence with a resultant increase in bladder capacity to 300 cc without leakage. Three patients required revision of the stoma
DISCUSSION
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CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
the appendicovesicostomy can be placed on the anterior wall. One patient had incontinence at 230 cc (assessed during urodynamics) and required dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. The patient had complete resolution of the incontinence with a resultant increase in bladder capacity to 300 cc without leakage. Chabchoub et al recently reported that submucosal appendix length is the most important factor contributing to the proposed flap valve mechanism of continence.13 In our study the patient in whom incontinence developed had only 3 cm of submucosal tunnel, which was a possible cause of the incontinent channel. In an open series Kaefer and Retik demonstrated that continence can be achieved with only a 2 cm appendiceal tunnel.14 It is likely that a submucosal length less than 4 cm will allow for continence with the robotic approach, but this is our observation early in our experience and further study is indicated. We included the length of the detrusor hiatus when calculating our submucosal tunnel length, so this may artificially add to the length we calculated as necessary for the submucosal tunnel. In their open series Roth et al described the injection of continent urinary channels (1 of which was appendicovesicostomy) with a variety of injectables in patients who had undergone open reconstruction.15 The patient with the appendicovesicostomy underwent injection of dextranomer/hyaluronic acid but the incontinence persisted. In the study by Nguyen et al incontinence developed in 2 of 10 patients, 1 who underwent correction with dextranomer/hyaluronic acid (Deflux) injection and 1 who required open revision.1 They did not hypothesize regarding the cause of the incontinence. Cutaneous level scarring is historically the most common complication following appendicovesicostomy, occurring at a rate between 8% and 40%.3,4,16 –18 In a series of 112 continent catheterizable channels McAndrew and Malone reported a cutaneous level scarring rate of 31%.19 In our series cutaneous level scarring requiring open revision occurred in 3 of 11 patients (27.2%) with 2 having a previous history of severe keloid formation. Surgical modifications designed to maximize the mucocutaneous junction (V-shaped flap, VQZ-plasty and VQ-plasty) can decrease the rate of cutaneous level scarring. Another option is to harvest the appendix with a small cecal cuff.3,20 Despite adherence to these surgical principles, one must avoid tension on the channel and have maximal preservation of the appendiceal blood supply. Because this occurred at the skin level, we do not believe it is a significant factor related to the robotic assisted minimally invasive approach. The rate of cutaneous level scarring in our series was consistent with that of the open literature.
Thomas et al reported an incidence of false passages using continent catheterizable channels of 6% occurring between 1 and 13 months (mean 6.5) following surgery.21 Two patients had false passages of the appendicovesicostomy (18.2%) 2 and 17 months (mean 9.5) postoperatively. Management consisted of prolonged catheter drainage. Our patients undergoing augmentation cystoplasty do not undergo bowel preparation. No gross spillage of fecal contents was noted but the potential for intraperitoneal bowel spillage is an important issue, especially for patients with ventriculoperitoneal shunts. To prevent spillage the tip of the ventriculoperitoneal shunt is placed in an ENDOPOUCH RETRIEVER Specimen Retrieval Bag. These patients receive vancomycin, gentamicin and metronidazole for 72 hours around the time of surgery. There were no infections of ventriculoperitoneal shunts in our series. The procedure length was similar to that of other series in the literature. In our series the operative time for isolated appendicovesicostomy was 347 minutes. Nguyen et al reported an operative time of 323 minutes.1 We believe this reflects our initial experience and with more experience we expect this time to decrease. This time also includes formation of the stoma at skin level. The setup and robotic learning curve as well as resident education influence the time required to complete the operation. The limitations of this study are that it is retrospective in nature with small numbers. In addition, because we are now performing these procedures exclusively using the robotic assisted laparoscopic approach, we do not have appropriate age matched controls for comparison. One of the investigators (MSG) performed open appendicovesicostomy in 4 patients during the study period. Of these patients 3 had major congenital abnormalities (cloacal anomaly, anorectal malformation and bladder exstrophy) and 1 was on peritoneal dialysis. We do not believe these patients serve as adequate numbers or controls for a historical open cohort. Cadeddu and Docimo compared standard surgery to laparoscopic assisted (not robotic) surgery for the creation of continent stomas.22 Patients required 2.3 vs 5.6 days, respectively, to achieve a regular diet (p ⬍0.05). The operative times were similar but the length of stay was shorter in the laparoscopic group (4.1 vs 7.4 days, p ⬍0.05). To our knowledge no data currently exist comparing the open to the robotic laparoscopic approach. The latter approach replicates the open surgical approach but only a randomized controlled trial will adequately address those questions.
CONCLUSIONS We are encouraged by our preliminary experience with RALMA continent urinary diversion with or
CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
without ileocystoplasty. Although the concept of applying robotic assisted laparoscopy to pediatric urological reconstructive surgery is still novel, there is great potential for it to reduce the morbidity as-
1443
sociated with these complex procedures. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence.
REFERENCES 1. Nguyen HT, Passerotti C, Penna FJ et al: Robotic assisted laparoscopic Mitrofanoff appendicovesicostomy: preliminary experience in a pediatric population. J Urol 2009; 182: 1528. 2. Gundeti MS, Eng MK, Reynolds WS et al: Pediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy: complete intracorporeal–initial case report. Urology 2008; 72: 1144. 3. Da Silva EA on Harris CF, Cooper CS, Hutcheson JC et al: Appendicovesicostomy: the mitrofanoff procedure-a 15-year perspective. J Urol 2000; 164: 2029. 4. Liard A, Séguier-Lipszyc E, Mathiot A et al: The Mitrofanoff procedure: 20 years later. J Urol 2001; 165: 2394. 5. Lendvay TS, Shnorhavorian M and Grady RW: Robotic-assisted laparoscopic mitrofanoff appendicovesicostomy and antegrade continent enema colon tube creation in a pediatric spina bifida patient. J Laparoendosc Adv Surg Tech A 2008; 18: 310. 6. Pedraza R, Weiser A and Franco I: Laparoscopic appendicovesicostomy (Mitrofanoff procedure) in a child using the da Vinci robotic system. J Urol 2004; 171: 1652. 7. Storm DW, Fulmer BR and Sumfest JM: Laparoscopic robot-assisted appendicovesicostomy: an initial experience. J Endourol 2007; 21: 1015.
8. Jordan GH and Winslow BH: Laparoscopically assisted continent cathterizable cutaneous appendicovesicostomy. J Endourol 1993; 7: 517. 9. Casale P, Feng WC, Grady RW et al: Intracorporeal laparoscopic appendicovesicostomy: a case report of a novel approach. J Urol 2004; 171: 1899. 10. Hsu TH and Shortliffe LD: Laparoscopic Mitrofanoff appendicovesicostomy. Urology 2004; 64: 802. 11. Rosito T, Andreoni CR, Iizuca F et al: Combined laparoscopic appendicovesicostomy (Mitrofanoff) with nephrectomy and orchidopexy in an 8-yearold boy. J Pediatr Urol 2008; 4: 317. 12. Lorenzo AJ, Chait PG, Wallis MC et al: Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida. Urology 2007; 70: 568. 13. Chabchoub K, Ketata H, Fakhfakh H et al: Continent urinary diversion (Mitrofanoff principle). Physical mechanisms and urodynamic explanation of continence. Prog Urol 2008; 18: 120. 14. Kaefer M and Retik AB: The Mitrofanoff principle in continent urinary reconstruction. Urol Clin North Am 1997; 24: 795. 15. Roth CC, Donovan BO, Tonkin JB et al: Endoscopic injection of submucosal bulking agents for
the management of incontinent catheterizable channels. J Pediatr Urol 2009; 5: 265. 16. Van Savage JG, Khoury AE, McLorie GA et al: Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol 1996; 156: 1794. 17. Driver CP, Barrow C, Fishwick J et al: The Malone antegrade colonic enema procedure: outcome and lessons of 6 years’ experience. Pediatr Surg Int 1998; 13: 370. 18. Narayanaswamy B, Wilcox DT, Cuckow PM et al: The Yang-Monti ileovesicostomy: a problematic channel? BJU Int 2001; 87: 861. 19. McAndrew HF and Malone PS: Continent catheterizable conduits: which stoma, which conduit and which reservoir? BJU Int 2002; 89: 86. 20. Keating MA, Rink RC and Adams MC: Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J Urol 1993; 149: 1091. 21. Thomas JC, Dietrich MS, Trusler L et al: Continent catheterizable channels and the timing of their complications. J Urol 2006; 176: 1816. 22. Cadeddu JA and Docimo SG: Laparoscopic-assisted continent stoma procedures: our new standard. Urology 1999; 54: 909.
Abbreviations and Acronyms ACE ⫽ antegrade continence enema EBL ⫽ estimated blood loss RALMA ⫽ robotic assisted laparoscopic Mitrofanoff appendicovesicostomy Submitted for publication July 27, 2010. * Correspondence: Section of Urology, University of Chicago, 5841 S. Maryland Ave. MC6038, Chicago, Illinois 60637 (telephone: 773-7954549; FAX: 773-702-1001; e-mail: mark.wille@ uchospitals.edu).
See Editorial on page 1184.
Purpose: Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. Materials and Methods: Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). Results: Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). Conclusions: We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence. Key Words: robotics; catheterization; urinary reservoirs, continent
1438
www.jurology.com
IN children the goal of appendicovesicostomy is to allow for efficient lower urinary tract emptying in the face of a neurogenic bladder, with the patient undergoing augmentation cystoplasty or primary bladder dysfunction with failure to empty. Clean intermittent catheterization may not be feasible in some cases. Traditionally appendicovesicostomy would be per-
formed using an open surgical approach. With the development of laparoscopic techniques and advances in robotics a minimally invasive approach is an option. The potential benefits of this approach include decreased postoperative pain, shorter hospital stay and improved cosmesis.1 We have used a robotic assisted laparoscopic approach in patients who require ap-
0022-5347/11/1854-1438/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 185, 1438-1443, April 2011 Printed in U.S.A. DOI:10.1016/j.juro.2010.11.050
AND
RESEARCH, INC.
Flap
EBL (cc)
Length of Detrusor Backing (cm)
24 20 29 9 24 18 21 6 25 5 3
Mos Followup
Preoperative evaluation was performed as required for augmentation cystoplasty or appendicovesicostomy. Patients underwent urodynamics, ultrasound examination and technetium dimercaptosuccinic acid scan (to evaluate for renal scarring and split renal function) (table 1). In patients undergoing augmentation cystoplasty, appendicovesicostomy was chosen as standard to allow for efficient bladder emptying. In other patients the reasons for appendicovesicostomy included pain with urethral catheterization, physical or developmental disability requiring caregiver dependence, or urethral stricture. A summary of patient demographics, diagnoses, EBL, operative time, followup and complications is presented in table 2. We did not perform bowel preparation in any patient. A total of 13 patients were considered for the robotic assisted laparoscopic approach. However, 2 patients requiring concomitant augmentation cystoplasty were converted to an open approach. In 1 patient there was failure to progress secondary to significant adhesions. In the other patient there was a short appendiceal length, and considering the patient also required a Malone antegrade continence enema, ileum was used in a Yang-Monti procedure.
4 4 4 3.5–4 3 4–5 4 4 4 4 4
Patient Selection/Preoperative Management
50 100 100 20 50 20 20 50 200 20 50
MATERIALS AND METHODS
VQZ VQZ VQZ V VQZ V VQZ V VQZ V V
Complications
pendicovesicostomy with or without augmentation cystoplasty. We present our technique, and perioperative and postoperative outcomes, with specific attention to continence outcomes using this approach.
False passage of appendicovesicostomy Revision of stoma Revision of stoma None Incontinence (Deflux injection) None Wound infection None Revision of stoma, false passage of appendicovesicostomy None None
CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
Capacity (cc)
Post-Void Residual (cc)
Detrusor Leak Point Pressure (cm H2O)
1 2 3 4 5 6 7 8 9 10 11
No Yes Yes No Yes No No Yes Yes No No
880 140 200 900 170 750 500 90 225 600 600
— 0 150 — 80 — — 10 60 — —
Failure to empty 120 65 Failure to empty 61 Failure to empty Failure to empty 50 59 Failure to empty Failure to empty
cystoplasty, cecal flap ACE cystoplasty
cystoplasty
cystoplasty cystoplasty
None Augmentation Augmentation None Augmentation None None Augmentation Augmentation None None
Concomitant Procedures
Nonneurogenic neurogenic bladder Neurogenic bladder/tethered cord Neurogenic bladder/spina bifida Neurogenic bladder/Arnold-Chiari Neurogenic bladder/sacral agenesis Neurogenic bladder/prune-belly syndrome Neurogenic bladder/prune-belly syndrome Neurogenic bladder/sacral agenesis Neurogenic bladder/myelomeningocele Neurogenic bladder/prune-belly syndrome Neurogenic bladder/myelomeningocele
Concomitant Augmentation?
1—13 2—7 3—10 4—14 5—12 6—5 7—14 8—8 9—10 10—10 11—11
Pt No.
Diagnosis
Table 1. Preoperative urodynamic findings
Pt No.—Age
Patients were placed in a modified lithotomy position. Ports were triangulated toward the right lower quadrant to allow access to the appendix and bladder (fig. 1). They included a 12 mm port for the camera and 2, 5 to 8 mm ports for the robotic arms. A minimum of 10 to 12 cm puboumbilical distance was ensured. Placing patients in the Trendelenburg position helped displace the small bowel from the pelvic area. A fourth port (5 mm) in the left lower quadrant was helpful for passing sutures and for irrigation. Preoperative antibiotics were administered (cefazolin and gentamicin routinely, or vancomycin, gentamicin and metronidazole if the patient had a ventriculoperitoneal
Table 2. Patient demographics and outcomes with robotic surgery
Surgical Technique
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CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
shunt). A Foley catheter was placed in the surgical field so that bladder volume could be regulated by the surgical assistant. Diagnostic peritoneoscopy was performed to identify the appendix to assess its length (needing approximately 5 to 6 cm) and adequacy as a catheterizable limb (accepted 10 or 12Fr catheter). In all patients with ventriculoperitoneal shunts, the end of the shunt was placed in an ENDOPOUCH RETRIEVER® Specimen Retrieval Bag to avoid contamination of the shunt with bowel contents. The appendix was mobilized at the appendicular/ cecal junction while maintaining its blood supply (fig. 2, A). A 3-zero polyglactin purse-string suture was placed at the base of the appendix and the appendix was then separated from the cecum. The purse-string suture was tied and the cecal opening was closed in a second layer with the same suture. The appendiceal mesentery was then mobilized and the 1 cm segment of the distal appendix was removed to generate an adequate lumen. The mobility of the appendix was evaluated to determine if it could reach the bladder and anterior abdominal wall without tension. Further mobilization of the cecum and right colon could be performed to gain additional mobility. In the event augmentation cystoplasty was to be performed, the appendix was placed on the posterior wall before performing a cystotomy for the augmentation cystoplasty. If no additional procedure was performed, then the anterior bladder wall was chosen as the insertion site for implantation of the appendix (fig. 3). This technique was technically easier than placing the anastomosis on the posterior wall, especially in patients with a large bladder. This also shortened the required length of the appendix as the distance to the abdominal wall was less. The bladder was partially filled with normal saline through the Foley catheter and a stay stitch was passed through the anterior abdominal wall. Using electrocautery the detrusor layer of the bladder wall was incised, exposing the bladder mucosa and creating a tunnel of at least 4 cm. The tunnel direction was determined according
Figure 1. Patient position and port placement
Figure 2. Appendix isolation (A) and placement of appendicovesicostomy on posterior bladder wall (B).
to the stomal location (craniocaudal for umbilical stomas, oblique for right lower quadrant stomas). An incision was made in the bladder mucosa at the location of the apex and the appendix tip was spatulated. After placing a stitch in the base of the spatulated appendix and at the base of the mucosal incision, a 5Fr feeding tube was placed across the future anastomosis. The appendicovesicostomy anastomosis was then performed circumferentially with interrupted 5-zero BIOSYN™ suture. The appendix was next placed in the trough, and the detrusor was reapproximated over it with 4, 4-zero polyglactin interrupted suture and secured with Lapra-Ty® clips. A stay suture was placed proximally between the appendix and the proximal extent of the detrusorraphy to prevent slippage of the appendix out of the
Figure 3. Placement of appendicovesicostomy on anterior bladder wall.
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submucosal tunnel. The final appearance was as shown in figure 2, B. We have previously reported our technique for patients undergoing concomitant augmentation cystoplasty.2 The proximal end of the appendix was next brought through the 12 mm umbilical port site or to the right lower quadrant through the 8 mm right robotic arm port. A V, VQ or VQZ-shaped skin flap was created at the stoma site and the appendicovesicostomy was spatulated, allowing the flap to be placed into the more proximal portion of the appendicovesicostomy. The appendicovesicostomy was then matured into the skin site.
secondary to skin level scarring. A false passage of the appendicovesicostomy developed in 2 patients (at 2 months in 1 and at 17 months in the other, who required an indwelling catheter for 1 month but has subsequently healed). One patient had a superficial wound infection. All patients are currently catheterizing without difficulty and are continent.
Postoperative Care
The appendicovesicostomy is an effective means of providing a continent conduit for bladder catheterization. Complications of this operation include infection, upper tract deterioration, skin level scarring and stone formation, with the most frequent being skin level scarring, occurring in approximately 10% of patients.3,4 A minimally invasive approach would be of significant benefit in reducing the morbidity associated with appendicovesicostomy creation. The advantages of robotic surgery (decreased overall recovery time, bleeding and postoperative pain) that have been demonstrated in other procedures such as pyeloplasty can be applied to various techniques in pediatric urology. We previously presented a case report on robotic assisted laparoscopic augmentation cystoplasty and appendicovesicostomy creation.2 To our knowledge there are 2 case reports and 2 series in which laparoscopic appendicovesicostomy using the da Vinci® robotic system was performed with good results.1,5–7 There are also several case reports of appendicovesicostomy creation using a pure laparoscopic approach.8 –10 In addition, several case reports have described combined procedures involving pure laparoscopic and robotic assisted techniques, including appendicovesicostomy with concurrent augmentation, nephrectomy, orchiopexy, ACE and cecostomy tube placement.2,11,12 Several technical comments can be made based on this report. Diagnostic peritoneoscopy should be performed first to assess the length of the appendix. If the appendix length is not adequate, we do not proceed with a robotic assisted laparoscopic approach. A pubo-umbilical distance of 10 to 12 cm should be ensured and this is where the 12 mm camera port should be placed. The direction of and location of the submucosal tunnel should be addressed depending on stoma location. Umbilical stoma sites require a midline detrusorotomy and right lower quadrant stoma sites require an oblique detrusorotomy. Finally, when performing concomitant augmentation cystoplasty it is vital to place the appendicovesicostomy on the posterior wall of the bladder to facilitate the augmentation cystoplasty anastomosis which is performed after the appendicovesicostomy anastomosis. Otherwise
The patients were given intravenous ketorolac and oral acetaminophen as needed for the first 48 hours, and ibuprofen was started as needed 6 hours after the last dose of ketorolac. A liberal diet was started immediately and patients with constipation resumed their usual bowel regimen. Patients were discharged home once they tolerated a regular diet, pain was well controlled and when the family was comfortable managing the urinary drainage tubes.
Followup Postoperatively the appendicovesicostomy and suprapubic catheters were maintained for 4 weeks. At 4 weeks the appendicovesicostomy catheter was removed and the patient was taught clean intermittent catheterization via the appendiceal stoma while the suprapubic catheter was maintained as a pop-off valve for 1 week. Followup urodynamics were not routinely performed. However, we performed followup renal ultrasound to evaluate the upper urinary tract postoperatively.
RESULTS Patient demographics and operative outcomes are summarized in table 2. Overall mean operative time was 347 minutes for patients undergoing isolated appendicovesicostomy (including docking of the robot). Operative times improved only slightly with more cases. Mean operative time was 351.3 minutes for the first 3 RALMA cases and 344.3 minutes for the last 3 RALMA cases. Six patients underwent isolated robotic assisted laparoscopic appendicovesicostomy and 5 patients underwent concomitant augmentation cystoplasty. Total mean operative time for patients undergoing concomitant augmentation cystoplasty (1 patient also had a cecal flap ACE) was 639.8 minutes (range 609 to 711). Mean EBL was 61.8 cc (range 20 to 200). There were no intraoperative complications. Median length of hospitalization was 6 days (range 3 to 8). Median followup was 20 months (range 3 to 29). One patient had incontinence at 230 cc (assessed during urodynamics) and required dextranomer/hyaluronic acid (Deflux®) injection into the appendicovesicostomy anastomosis. The patient had complete resolution of the incontinence with a resultant increase in bladder capacity to 300 cc without leakage. Three patients required revision of the stoma
DISCUSSION
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CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
the appendicovesicostomy can be placed on the anterior wall. One patient had incontinence at 230 cc (assessed during urodynamics) and required dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. The patient had complete resolution of the incontinence with a resultant increase in bladder capacity to 300 cc without leakage. Chabchoub et al recently reported that submucosal appendix length is the most important factor contributing to the proposed flap valve mechanism of continence.13 In our study the patient in whom incontinence developed had only 3 cm of submucosal tunnel, which was a possible cause of the incontinent channel. In an open series Kaefer and Retik demonstrated that continence can be achieved with only a 2 cm appendiceal tunnel.14 It is likely that a submucosal length less than 4 cm will allow for continence with the robotic approach, but this is our observation early in our experience and further study is indicated. We included the length of the detrusor hiatus when calculating our submucosal tunnel length, so this may artificially add to the length we calculated as necessary for the submucosal tunnel. In their open series Roth et al described the injection of continent urinary channels (1 of which was appendicovesicostomy) with a variety of injectables in patients who had undergone open reconstruction.15 The patient with the appendicovesicostomy underwent injection of dextranomer/hyaluronic acid but the incontinence persisted. In the study by Nguyen et al incontinence developed in 2 of 10 patients, 1 who underwent correction with dextranomer/hyaluronic acid (Deflux) injection and 1 who required open revision.1 They did not hypothesize regarding the cause of the incontinence. Cutaneous level scarring is historically the most common complication following appendicovesicostomy, occurring at a rate between 8% and 40%.3,4,16 –18 In a series of 112 continent catheterizable channels McAndrew and Malone reported a cutaneous level scarring rate of 31%.19 In our series cutaneous level scarring requiring open revision occurred in 3 of 11 patients (27.2%) with 2 having a previous history of severe keloid formation. Surgical modifications designed to maximize the mucocutaneous junction (V-shaped flap, VQZ-plasty and VQ-plasty) can decrease the rate of cutaneous level scarring. Another option is to harvest the appendix with a small cecal cuff.3,20 Despite adherence to these surgical principles, one must avoid tension on the channel and have maximal preservation of the appendiceal blood supply. Because this occurred at the skin level, we do not believe it is a significant factor related to the robotic assisted minimally invasive approach. The rate of cutaneous level scarring in our series was consistent with that of the open literature.
Thomas et al reported an incidence of false passages using continent catheterizable channels of 6% occurring between 1 and 13 months (mean 6.5) following surgery.21 Two patients had false passages of the appendicovesicostomy (18.2%) 2 and 17 months (mean 9.5) postoperatively. Management consisted of prolonged catheter drainage. Our patients undergoing augmentation cystoplasty do not undergo bowel preparation. No gross spillage of fecal contents was noted but the potential for intraperitoneal bowel spillage is an important issue, especially for patients with ventriculoperitoneal shunts. To prevent spillage the tip of the ventriculoperitoneal shunt is placed in an ENDOPOUCH RETRIEVER Specimen Retrieval Bag. These patients receive vancomycin, gentamicin and metronidazole for 72 hours around the time of surgery. There were no infections of ventriculoperitoneal shunts in our series. The procedure length was similar to that of other series in the literature. In our series the operative time for isolated appendicovesicostomy was 347 minutes. Nguyen et al reported an operative time of 323 minutes.1 We believe this reflects our initial experience and with more experience we expect this time to decrease. This time also includes formation of the stoma at skin level. The setup and robotic learning curve as well as resident education influence the time required to complete the operation. The limitations of this study are that it is retrospective in nature with small numbers. In addition, because we are now performing these procedures exclusively using the robotic assisted laparoscopic approach, we do not have appropriate age matched controls for comparison. One of the investigators (MSG) performed open appendicovesicostomy in 4 patients during the study period. Of these patients 3 had major congenital abnormalities (cloacal anomaly, anorectal malformation and bladder exstrophy) and 1 was on peritoneal dialysis. We do not believe these patients serve as adequate numbers or controls for a historical open cohort. Cadeddu and Docimo compared standard surgery to laparoscopic assisted (not robotic) surgery for the creation of continent stomas.22 Patients required 2.3 vs 5.6 days, respectively, to achieve a regular diet (p ⬍0.05). The operative times were similar but the length of stay was shorter in the laparoscopic group (4.1 vs 7.4 days, p ⬍0.05). To our knowledge no data currently exist comparing the open to the robotic laparoscopic approach. The latter approach replicates the open surgical approach but only a randomized controlled trial will adequately address those questions.
CONCLUSIONS We are encouraged by our preliminary experience with RALMA continent urinary diversion with or
CONTINENCE AND ROBOTIC ASSISTED LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY
without ileocystoplasty. Although the concept of applying robotic assisted laparoscopy to pediatric urological reconstructive surgery is still novel, there is great potential for it to reduce the morbidity as-
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sociated with these complex procedures. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence.
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8. Jordan GH and Winslow BH: Laparoscopically assisted continent cathterizable cutaneous appendicovesicostomy. J Endourol 1993; 7: 517. 9. Casale P, Feng WC, Grady RW et al: Intracorporeal laparoscopic appendicovesicostomy: a case report of a novel approach. J Urol 2004; 171: 1899. 10. Hsu TH and Shortliffe LD: Laparoscopic Mitrofanoff appendicovesicostomy. Urology 2004; 64: 802. 11. Rosito T, Andreoni CR, Iizuca F et al: Combined laparoscopic appendicovesicostomy (Mitrofanoff) with nephrectomy and orchidopexy in an 8-yearold boy. J Pediatr Urol 2008; 4: 317. 12. Lorenzo AJ, Chait PG, Wallis MC et al: Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida. Urology 2007; 70: 568. 13. Chabchoub K, Ketata H, Fakhfakh H et al: Continent urinary diversion (Mitrofanoff principle). Physical mechanisms and urodynamic explanation of continence. Prog Urol 2008; 18: 120. 14. Kaefer M and Retik AB: The Mitrofanoff principle in continent urinary reconstruction. Urol Clin North Am 1997; 24: 795. 15. Roth CC, Donovan BO, Tonkin JB et al: Endoscopic injection of submucosal bulking agents for
the management of incontinent catheterizable channels. J Pediatr Urol 2009; 5: 265. 16. Van Savage JG, Khoury AE, McLorie GA et al: Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites. J Urol 1996; 156: 1794. 17. Driver CP, Barrow C, Fishwick J et al: The Malone antegrade colonic enema procedure: outcome and lessons of 6 years’ experience. Pediatr Surg Int 1998; 13: 370. 18. Narayanaswamy B, Wilcox DT, Cuckow PM et al: The Yang-Monti ileovesicostomy: a problematic channel? BJU Int 2001; 87: 861. 19. McAndrew HF and Malone PS: Continent catheterizable conduits: which stoma, which conduit and which reservoir? BJU Int 2002; 89: 86. 20. Keating MA, Rink RC and Adams MC: Appendicovesicostomy: a useful adjunct to continent reconstruction of the bladder. J Urol 1993; 149: 1091. 21. Thomas JC, Dietrich MS, Trusler L et al: Continent catheterizable channels and the timing of their complications. J Urol 2006; 176: 1816. 22. Cadeddu JA and Docimo SG: Laparoscopic-assisted continent stoma procedures: our new standard. Urology 1999; 54: 909.