Robotic augmentation ileocystoplasty with bilateral ureteric reimplantation in a young child with neuropathic bladder.

Neuropathic bladder in children is most commonly secondary to spina bifida. The management starts early in life. The modalities of treatment vary depending on the severity of the symptoms. A proportion of children inspite of adequate medical management need augmentation ileocystoplasty later in life. The open surgery has proven safety and success over many decades. Earlier attempts to perform augmentation cystoplasty by the laparoscopic approach were limited by steep learning curve, long operating times, and technical difficulties in intracorporeal anastomosis. The emergence of robotic technology has revived the interest in minimally invasive approach for complex pediatric urological reconstructions. In the recent times, there has been only one reported case report and small series of pediatric robotic augmentation cystoplasty from Chicago. We report the first minimally invasive robotic reconstruction in a child with neuropathic bladder and early renal decompensation despite appropriate medical treatment, from our country.

INTRODUCTION

The worldwide incidence of spina bifida ranges from 0.3 to 4.5 per thousand live births. Renal damage leading to renal failure is one of the most severe complications of spina bifida, which usually sets in the second decade of life. However, the renal damage may start as early as 6 months of life, with reported deaths due to renal failure in the first year itself.[1] In order to prevent the renal damage the treatment should commence after early diagnosis soon after birth.[2] Early institution of medical therapy can delay or obviate the need for augmentation cystoplasty. Despite this, 10-20% of children will still need an augmentation cystoplasty in the long run.[3] Minimally invasive robotic approach can decrease the surgical morbidity of open surgery and allows this complex reconstruction to be done elegantly with minimal collateral trauma.

CASE REPORT

A 2-year-old male child with neuropathic bladder was referred to us for surgery after having failed medical treatment for more than a year. He was operated for lumbo-sacral meningomeylocele in the newborn period. In the follow-up period, he developed repeated urinary tract infection and dribbling micturition. He also had symptoms of paraparesis and soiling. The child had history of seizures for which he was on antiepileptics. The child was being managed on anticholinergics and clean intermittent catheterization for the last 6 months with repeated urinary tract infections, dribbling incontinence, and progressive drop in differential renal function.

A thorough and complete workup of the child was carried out. Renal function tests were in the normal range. Routine examination of urine revealed pus cells in full field. Ultrasound of the abdomen revealed right-sided hydroureteronephrosis with thinned out renal parenchyma and thick-walled bladder. Micturating cystourethrogram revealed a small capacity trabeculated bladder with right-sided grade V reflux and left-sided grade III reflux. The bladder capacity was only 30 ml and bilateral reflux appeared at this volume. DMSA renal scan was suggestive of right scarred kidney with severely impaired cortical function (DRF 18%) and left kidney with significant cortical volume loss in upper half with upper pole scarring. MRI spine was suggestive of spina bifida at L5-S3 level with tethering of spinal cord. Neurosurgical consultation was done and their opinion was that there was going to be no benefit from any further spinal surgery. Urodynamic study showed that his functional bladder capacity was only 40 ml against an expected bladder capacity of 100 ml. The detrusor pressures were crossing 50-cm water with fill of above 25 ml [Figure 1]. Cystoscopy revealed normal anterior and posterior urethra, severely trabeculated bladder mucosa and golf hole-like ureteric orifices. The bladder neck was closing satisfactorily on withdrawing the scope precluding the need for adding any bladder outlet procedure.

Figure 1

Preoperative cystometry showing functional bladder capacity of 40 ml with high detrusor pressure

The medicosocial condition of the family and their originating from a remote location was considered in the decision process. Botox and deflux injection was one option. The other option was ileocystoplasty with bilateral ureteric re-implantation; the family chose the latter option. We decided to carry out the reconstructive surgery by the minimally invasive robotic approach.

The steps of open surgery were reviewed and modifications for robotic approach were planned for each surgical step. Total gut irrigation with polyethylene glycol solution was carried out the day before surgery and child was kept on clear liquid diet.

After general anesthesia and endotracheal intubation the child was placed in the lithotomy position. Cystoscopy and bilateral DJ stenting was done before starting the procedure.

The 12-mm camera port was placed midway between the umbilicus and the xiphisternum. Pneumoperitoneum was created by carbon-dioxide insufflation at a pressure of 12 cm of water. Two 8-mm working ports were placed in the right and left iliac fossa in the anterior axillary line at the level of umbilicus. A 5-mm assistant port was placed midway between the umbilicus and pubic symphisis.

Lower ends of both the ureters were dissected medially down to vesicoureteric junction sparing lateral neurovascular web. Vas deferens was identified and protected. The vesicoureteric junction was displayed. A transabdominal transvesical stay suture was taken lifting the anterior wall of the bladder. Extramucosal detrusor muscle split was done for 2-3 cm to allow easy wrap around the ureter. The bladder was distended with betadine-stained saline during this step to help in dissecting the detrusor and avoiding inadvertent opening of bladder mucosa. The well-distended bladder keeps the wound margins of the detrusor retracted and the mucosa pouts out as soon as the detrusor is split. The detrusor was re-approximated over the ureters for a length of 2-3 cm as in hiatal recession extramucosal re-implantation.

Now, the ileal loop for augmentation was assessed and the most mobile segment with good vascular arcade was isolated and marked with two stay sutures 15-20 cm apart. This loop was harvested about 20 cm proximal to ileo cecal junction with preserved vascular pedicle. That ileal segmented isolated was allowed to fall in the pelvis with its vascular arcade. The two ends of bowel were anastamosed intracorporeally with 3-0 interrupted vicryl extramucosal sutures. The isolated loop was detubularized and betadine irrigation was done. The thick-walled bladder was divided with scissors and diathermy in the sagittal section from nearly the bladder neck to trigone. The detubularized bowel was sutured in two layers with continuous and interrupted 4-0 vicryl suture. Before completing the anterior anastomosis, transabdominal, and transvesical suprapubic drain was established. Transurethral Foley catheter and abdominal drain placed and wound closure done. Intraoperative distension of bladder by injecting betadine saline in the urethral catheter was done to check for any anastomotic leak [Table 1].

Table 1

Operative time for each surgical step of robotic ureteric re-implantation and ileocystoplasty

In the postoperative period morphine infusion was given for pain relief for 48 hours. The abdominal drain was removed on third postoperative day. Oral feedings were started on fifth postoperative day. A check Cystogram was done at 2 weeks which revealed no vesicoureteric reflux and a bladder capacity of 100 ml. The suprapubic drain and DJ stents were removed. The urethral catheter was removed and child was started on intermittent clean catheterization per urethrally. Anticholinergics were started in the postoperative period. With anticholinergics and clean intermittent catheterization the child has a dry interval of 4 hours. Postoperative urodynamic study was done in the fourth week after surgery and revealed a functional bladder capacity of 100 ml with detrusor pressures in a physiologically safe range [Figure 2].

Figure 2

Postoperative cystometry showing functional bladder capacity of 100 ml with detrusor pressure in physiological limits

DISCUSSION

Neuropathic bladder contributes significantly as a cause of ESRD in children in India. The disease burden in India is largely undiagnosed and children receive inappropriate or incomplete treatment in early stages leading to irreversible renal failure by the time they reach tertiary hospitals. Early diagnosis and management are the corner stone to prevent recurrent UTI and end stage renal disease leading to need for kidney transplant. The concept of clean intermittent catheterization and application of urodynamic techniques in deciding appropriate medical or surgical management in children changed the long-term outlook in these babies.[45]

Clean intermittent catheterization with or without anticholinergics is usually the first line of treatment in neuropathic bladder. Total endoscopic management combining antireflux procedure, bladder neck injection and botulinum toxin has been reported to be rewarding but requires close follow-up and multiple repeat procedures. Botulinum toxin suppresses the detrusor contractility for 6 to 9 months and requires repeated injections. The long-term effects and adverse effects of repeated use in children are still unknown.

Kaefer et al. reported that despite optimal medical management 16% children will still need augmentation cystoplasty to maintain a reasonable organ for storage.[3] Most commonly a segment of ileum is used to increase the storage capacity of the bladder and ileocystoplasty is considered as the most effective method to increase the reservoir capacity. The reported success rate is more than 90% with overall complication rate of 40% reported in a series with longest mean follow-up.[67]

With the advent of minimally invasive surgery, it became an interesting preposition to attempt this complex reconstruction by this approach. In 1995 Docimo et al. first reported laparoscopic bladder augmentation using the greater curvature of the stomach.[8] In 2000, Gill et al reported three cases of laparoscopic bladder augmentation using different segments of bowel.[9] Subsequently virtually no series or case report on minimally invasive ileocystoplasty appeared until the report of robotic ileocystoplasty by Gundeti et al. in 2008.[10]

Pediatric robotic ileocystoplasty was demonstrated to be a safe, feasible, and effective with the first case reported in 2008 and subsequently Gundeti et al. from Chicago reported the first series with minimal morbidity and all the benefits of minimally invasive surgery.[1011] Our initiation in robotic reconstructions in children is recent and started with pyeloplasty and ureteric re-implantation, but has well crossed the initial learning curve. This was based on foundation of significant existing experience of laparoscopic surgery.[12]

We were performing five to six augmentation ileocystoplasty and two to three Indiana pouch for complex problems of the lower urinary tract every year over the last 10 years.[13] After our initial experience and success with robotic surgery in children over several other complex surgeries of the upper and lower tract including heminephrectomy, uretero-uretrostomy, vaginoplasty, it was natural to extend its application to complex reconstruction like ileocystoplasty.

The family education, counselling and compliance regarding intermittent catheterization were not a problem as the mother was already well versed with clean intermittent catheterization for the last 6 months. Furthermore, the child had paraparesis and the urethra was insensate so, the child also tolerated the CIC very well. In view of these we did not need a Mitrofanoff's procedure to create a catheterizable channel, thus minimizing the surgical morbidity.

The ureteric reimplant in the open procedure is typically transtriagonal Cohen's procedure. For the robotic approach we preferred the extravesical detrusorraphy as it was technically easier in our patient with massively dilated ureters. The ileoileal anastomosis needs proper displaying and stabilization of both the ends. Similarly, at each surgical step proper retraction is required for dissection and suturing which requires preoperative planning and can be done by transabdominal stay sutures or retraction through the assistant port.

CONCLUSIONS

The robotic technology has allowed this complex reconstruction to be done successfully by a minimally invasive approach. The advantages of robotic technology i.e., three-dimensional view, tremor-free movements, motion scaling, seven degrees of movement, and access to difficult areas allow such reconstructions to be done by minimal access approach replicating the results of open surgery. The completion of this complex surgery by the robotic approach in our unit takes our minimally invasive program in pediatric urology to the next orbit.