Continent cutaneous urinary diversions are sometimes necessary in neurogenic bladder patients unable to perform urethral self-catheterization. The objective of this video was to present a technique of robotic Mitrofanoff appendicovesicostomy creation.
We present the case of 27-year-old female patient with a C6 spinal cord injury since 2019. Urodynamics showed neurogenic detrusor overactivity which was effectively treated by intradetrusor botulinum toxin injections and anticholinergics. She also has detrusor-sphincter dyssynergia with chronic urinary retention and is unable to do urethral self-catheterizations due to upper limb neurological impairment and she refused the idea of non-continent urinary diversion (ileal conduit). A robotic Mitrofanoff appendicovesicostomy was planned.
We start by placing the five ports: one camera port above the umbilicus, one in the right pararectal line, one in the left pararectal line and one in the left iliac fossa for the robotic arms and a 12 mm assistant port in the right iliac fossa. The appendix is found and appears to be of good size and caliber. It is separated from the caecum proximally taking great care of preserving the meso appendix to ensure proper blood supply. The appendix is then catheterized with a 12-F catheter. The bladder is completely widely dissected and freed from the abdominal wall and peritoneum to mobilize it as much as possible towards the umbilicus. A longitudinal incision of the detrusor muscle is made at the top of the anterior aspect of the bladder until the bladder mucosa is reached. A 2 cm caudal incision of the bladder mucosa is done and anastomosed to the tip of the appendix using two running sutures of 5/0 PDS. An antirefluxing mechanism is created by closing the detrusor above the appendix with interrupted sutures of 3/0 Polysorb on a 4 cm distance. The bladder is attached to the abdominal wall about 3 cm below the umbilicus and 3 cm on either side of the midline using a Reverdun needle. The appendix is externalized through an additional 10 mm port place in the umbilicus by progressively decreasing the pneumoperitoneum and tensioning the sutures applying the bladder dome to the abdominal wall. The proximal aspect of the appendix It is hooked up to the fascia and then anastomosed to the skin. Ports’ incisions are closed. There was no postoperative complications. The cystostomy catheter was removed at 3 weeks and the patient started clean intermittent stomal catheterization with no issues. After 3 months, there was no additional complication, especially no stomal incontinence nor issues with catheterization.
Robot-assisted Mitrofanoff appendicovesicostomy appears feasible and may be useful in selected neurourological patients. Studies are needed to determine whether it could reduce perioperative morbidity compared to the open approach.