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  • Robotic Ileovesicostomy

    About The Author

    Dr. John Stoffel is an Associate Professor at the University of Michigan in the Department of Urology. He is the physician director of the Ambulatory Care Unit at the University of Michigan Hospital and is the departmental director of networks and standards. He trained as an intern at Massachusetts General Hospital in Boston MA, residency at the Lahey Clinic in Burlington MA, and completed a fellowship in female urology, neurourology, and reconstructive surgery under Dr. Edward McGuire at the University of Michigan. Prior to his current position at the University of Michigan, Dr. Stoffel practiced at the Lahey Clinic and directed a specialty Continence Center.

    Dr. Stoffel current clinical interests include urinary incontinence, neurogenic bladder pathologies, and complex urogenital reconstructive surgery.

    Current research interests include:

    • Outcome assessment for urinary incontinence. Currently, outcomes for treating urinary incontinence include objective measures (weight or amount of urine leaked) and subjective measures (patient assessment on symptom impact/quality of life). I have been investigating how these subjective measures impact objective findings. Past projects have included investigating the impact of depression and sexual function on treatment outcomes for urinary incontinence and vaginal vault prolapse. I have also evaluated the effectiveness of specific endpoints (pad weight, urodynamic findings) for assessing these diseases.
    • Determining optimal care for patients with a neurogenic bladder. In addition to outcome assessments in this patient population, I have also been investigating the efficacy of robotic assisted surgery for performing urinary diversions and bladder augmentations. . Other projects involve investigating new techniques for emptying a neurogenic bladder, including a novel urinary catheter, continent bladder stoma, and neuromodulation.
    • Transitional care for pediatric neurogenic patients. We are examining long term outcomes of pediatric myelodysplasia patients and studying model to develop a stratified risk model for long term morbidity
    • Impact of fibrosis on bladder compliance and infection. Currently studying the pathologic relationship between infection, bladder function, and progression of bladder fibrosis.

    INTRODUCTION

    Management goals for patients with neurogenic bladder focus on maintaining urinary continence, prevention of urinary tract infections, and preservation of renal function. Most neurogenic bladder patients can achieve these goals through a combination of behavioral modification, pharmacologic therapy, and indwelling or clean intermittent catheterization. Patients who are unable to achieve these goals through conventional conservative pathways may benefit from an ileovesicostomy diversion. First described by Hinman and Smith over fifty years ago1, ileovesicostomy can improve urinary continence by diverting urine from the bladder through an incontinent afferent ileal conduit that connects the bladder to the abdominal wall. A properly functioning ileovesicostomy will have a lower detrusor leak point pressure than either the urethra or ureters, thus allowing the urine egress through the loop much like a chimney vents smoke from a fireplace. Compared to an ileal loop diversion, ileovesicostomy preserves the native ureterovesical junction and can reduce operative times. Additionally, a lack of enteric-ureteral anastomosis lowers the potential for post operative reflux nephropathy or ureteral strictures.

    However, ileovesicostomy is also associated with post operative morbidity. After surgery, patients can develop wound infections, bowel complications, or drainage problems due to post operative scarring2. Lapraoscopic techniques have been proposed, but the technical skills required to perform a watertight vesico-enteric anastomosis have prevented these procedures from becoming mainstream3,4. We have developed a robotic ileovesicostomy procedure that preserves the efficacy associated with the open technique and but does not require an extended learning curve5.

    INDICATIONS/EXCLUSION CRITERIA

    Indications for ileovesicostomy begin with a patient who is unable (or unwilling) to tolerate intermittent catheterization or an indwelling catheter. In order for an ileovesicostomy to function properly, the bladder should have some detrusor contractility or bladder compliance low enough to generate pressure for a leak point pressure through the ileal limb. If the patient has pre-existing stress incontinence, bladder neck damage, or a urethral detrusor leak point pressure less than 10cm H20, a concomitant bladder neck closure is indicated during the procedure. Likewise, we have found that patients with severe detrusor overactivity (contractions greater than 50cm water) will also leak per urethra despite a functioning ileovesicostomy. Although other authors have reported successful neurogenic bladder neck closure with a concomitant suburethral sling, we have not had much success with this method and generally perform a formal bladder neck closure at the time of ileovesicostomy when indicated. If a patient develops persistent urethral incontinence after ileovesicostomy, we will generally perform a secondary perineal urethral closure with either a Martius labial or tunica vaginalis interposition flap.

    A contraindication for ileovesicostomy includes a maximal cystometric capacity under 50 cc. We have found that patients with very low compliance and capacity are at great risk for persistent urethral incontinence or perineal fistula after ileovesicostomy and bladder neck closure. For these patients, ileal loop with or without cystectomy likely yield better outcomes. Conversely, patients with a detrusor a-contractility or a maximal cystometric capacity greater than 500cc will suffer from high bladder residuals and incomplete bladder emptying. Regarding the robotic ileovesicostomy technique, we prefer the quicker open approach instead of robotic assisted for patients with extensive previous abdominal surgery or pre-existing pulmonary compromise that may be compromised by a pneumoperitoneum.

    SURGICAL TECHNIQUE

    The robotic ileovesicostomy technique can be broken down into 6 steps:

    Access

    We utilize the da Vinci S (Intuitive, CA) robot and orient the third arm off the patient’s left side and position the assistant off the right. Six ports are placed for robotic access in an inverted U pattern, with the 12mm center camera port inserted 5cm above the umbilicus. Nine mm robotic arm trocars are placed 9 cm lateral from the central trocar. The third arm 9mm trocar and 12mm assistant trocar are placed 9cm lateral to these.

    Development of the posterior bladder flap

    A 16 French catheter is placed per urethra and the bladder is filled with sterile water to 150cc. A full thickness bladder flap measuring 8cm at the base, 5cm in length, and 2 cm at the tip of the flap is then developed through the posterior bladder wall using cautery. After the flap is elevated, the urethral catheter is clamped to prevent loss of pneumoperitoneum.

    Intracorporeal ileal harvest

    A site approximately 20cm proximal to the terminal ileum is identified and a 15cm ileal segment is marked with absorbable sutures. Mesenteric windows at the proximal and distal end of the segment are developed using blunt dissection and vessels are cauterized using bipolar forceps. Alternatively, the assistant laparoscopic Ligasure V (Covidian) can be used to create the windows. The assistant then harvests the segment using an endo-GIA stapler (Covidian). The loop is oriented in a peristaltic direction (proximal toward bladder) and the distal end is tagged with a colored suture. This suture is then pulled through the marked stoma site on the abdominal wall with a Carter-Thomas needle to be used for counter tension during the vesico-enteric anastomosis. The native ends of the bowel are pexed together with a suture and this suture is likewise pulled through the stoma site so the ends can be easily found during extra-corporeal bowel anastomosis.

    Vesico-Enteric Anastomosis

    The staple line is excised from the isolated ileal segment and the segment is irrigated. The proximal end of the ileal segment is then spatulated for 5 cm on the antimesenteric border. After the bladder flap is elevated with the third robotic arm, an interrupted 2-0 vicryl suture between the 6 O’Clock positions on the flap cystostomy and the proximal ileal segment is placed to orient the segment for anastomosis. The loop is retracted through counter traction on the distal end holding suture. Two running sutures, starting on either side of the 6 O’clock suture, are used to perform the vesico-enteric anastomosis. As the anastomosis nears completion, the bladder flap is laid on top of the antimesenteric spatulated region on the ileal segment and the 2 suture lines are run toward this apex and then tied together.

    Extracorporeal bowel anastomosis

    A counter-incision is made over the marked stoma site on the patient’s abdomen and the rectus fascia incised. The suture holding the pexed native bowel segments is identified and these segments are pulled through the counter-incision. A standard stapled side-to-side bowel anastomosis is performed and the completed anastomosis is returned to the abdomen. The mesenteric trap is not routinely closed.

    Stoma Maturation

    The distal holding suture is then identified and pulled through the stomal counter incision. The stoma is matured in a standard everting fashion and a 16 French catheter is passed through it into the bladder.

    Post Operative

    Hospital stay is approximately 6 days in our series. The urethral and stoma catheters are left in place for 7 and 21 days, respectively. Residual volumes are checked at all post operative visits and we perform urodynamics at approximately 3 months after surgery. A functioning ileovesicostomy usually has residual volumes of less than 100cc and a detrusor leak point pressure through the ileal segment of less than 10cm H20.

    SURGICAL PEARLS

    When learning to perform robotic ileovesicostomy, it is helpful to choose patients with urethral obstruction detrusor-external dyssynergia so a bladder neck closure or secondary urethral closure is not necessary for urethral continence.

    It is useful to mark the stoma site in the patient’s right lower quadrant since the mesentery for the terminal ileum is in this region. In our experience, left lower quadrant stoma marks require a more proximal ileal segment harvest so as not to place excessive tension on the segment mesentery.

    In contrast to a robotic prostatectomy, the robotic ileovesicostomy procedure does not require any trendelenberg positioning. In fact, positioning the patient “head down” will cause the bowels to retract out of the surgical field.

    For patients with a short ileal mesentery, mobilizing the cecum along the white line of toldt can yield extra mesenteric length.

    The third arm is useful to elevate the bladder flap so the bladder mucosa can be fully visualized for the full thickness vesico-enteric anastomosis.

    REFERENCES

    1. Smith GI and Hinman F, Jr.: The intussuscepted ileal cystostomy. J Urol. 73: 261-9, 1955.
    2. Tan HJ, Stoffel J, Daignault S, et al: Ileovesicostomy for adults with neurogenic bladders: complications and potential risk factors for adverse outcomes. Neurourol Urodyn. 27: 238-43, 2008.
    3. Hsu TH, Rackley RR, Abdelmalak JB, et al: Laparoscopic ileovesicostomy. JUrol. 168: 180-1, 2002.
    4. Abrahams HM, Rahman NU, Meng MV et al: Pure laparoscopic ileovesicostomy. J Urol. 170: 517-8, 2003.
    5. Vanni AJ, Cohen MS and Stoffel JT: Robotic-assisted ileovesicostomy: initial results. Urology. 74: 814-8, 2009.

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