Mohan S. Gundeti, MD, discusses Robotic Assisted Laproscopic Cystoplasty and Cathetrisable Channels.
[MUSIC PLAYING] MOHAN S. GUNDETI: Hello, good day. Welcome to University of Chicago Medicine Comer Children's Hospital. I'm Mohan Gundeti. I'm going to talk on the reconstruction of the bladder and catheterizable channels with the robotic laparoscopic approach. As we know, neurogenic bladder is a debilitating condition which involves urinary incontinence and fecal incontinence. Most of the time, the children are managed with the medical management in the form of anticholingeric medications and intermittent cell catheterization. But when this fails and the upper tracks are showing the hydronephrosis or compromised renal failure, then we have to do the bladder reconstruction. The traditional approach has been open approach with [INAUDIBLE] of the augmentation cystoplasty and catheterizable channels. The problem with this is a [INAUDIBLE] morbidity associated with this approach in that terms of the pain, and recuperation, and hospitalization. Can we decrease this pain and the associated morbidity with the newer technology? As we know, robotic assisted laproscopic surgery is slowly making its way into the realm of the pediatric urology. As shown here, we have, and the other authors, have published multiple articles of reconstruction of the kidneys, reconstructions of the urethral [INAUDIBLE] reflux, and the outcomes have been compatible. Thinking the way we do it, can we move forward and apply these reconstructive surgical principles and the knowledge gained in the minimal and major surgery for complex reconstruction? Previously it's been shown that when we do about the bowel anastomosis in the [INAUDIBLE] for cystoplasty, there is a complication associated with the bowel anastomosis, especially leak. And this has helped this procedure to be reconstructed with the open approach and the minimal invasion approach was not possible. We with our team here at the University of Chicago Medicine, we do excellent training with the excellent infrastructure available and the resources for the [INAUDIBLE]. After accomplishing these procedures in the [INAUDIBLE], we first time ever have performed the complete reconstruction of the bladder and catheterizable channel with the robotic laproscopic approach. The first case was successful in 2008. Now who are the patients? Who benefit from this procedure? First of all, all the patients who are failed with the medical management, those who are showing the upward trend deterioration in the form of hydronephrosis, children who want to get continent of urine and feces, or the family wants to have the child to grow and be self-sufficient. So these are the children who need this surgical reconstruction. Can this be applied to all patients? Unfortunately, not. Those who had previous multiple surgeries or patients with extropy or chronic renal failure may not be an ideal candidate because of the complexity of the procedure and associated risk involved, especially the long hours of surgery. It's smart practice to do the preoperative or dynamic work up in all the patients so that we have the assessment of the bladder capacity, compliance, pressure, and especially the bladder neck. Because if we do have to do a bladder neck surgical reconstruction, this is a time we can do a complete reconstruction. And my preference is to do a video [INAUDIBLE] dynamics. The most important thing in the whole process of this reconstruction is the family complex. The family or the caregivers have to invest in the child management and so also the child needs to determine that he wants to get dry of urine and feces, and he wants to be self-sufficient. After this initial counseling and discussion of the procedure and the pros and cons, the surgery starts with the no bowel preparation. Because we have seen that previously without bowel preparation, there had been no change in the outcomes. And this reduces the hospitalization and the economy burden on the whole health care society. Now once the patient is prepared and the preoperative consultation is made, and also the neurosurgical input because these patients may have [INAUDIBLE]. They may be wheelchair bound, so [INAUDIBLE] consultation. And after all discussion at this point, patient is brought to the operating room. his is operating room setup. And the most important thing I want to emphasize is a good surgery starts with the room set up first, because you are preparing the ground for the next couple hours or play to be successful. So first of all, the patient-- this is the operating table where the patient is capable of surgery. And the surgical cart, or the information system of the robot, is brought from the foot end of the table. The most important thing I want to emphasize here is the surgeon, the assistant, the assisting nurse should be on one side of the patient so that the communication is easy, especially the noisy operating environment. You do not want to have a missed communication, which may lead to some complications. So this is room set up, and a proper good sized room with the proper training and the good teamwork is very important as I said previously for a good, successful procedure. This is a small clip showing you the port placement and the positioning for the patient who is here for the robotics cystoplasty and the catheterizable channel formation. Patient is placed in a supine semi-lithotomy position with the low knee joints. A foam is placed on the chest and the face as a protection so that in that [INAUDIBLE], arm injuries won't come into the action. This is under the same picture, showing the positioning, the well-padded foam over the chest and the face and securing the drapes to the patient. Using the transparent drape, across the patient and the anesthesia. So communication is much easier. A very low lithotomy, as I mentioned earlier. Securing the cords and cables away from the patient's face. So these all security points and safety points help you to complete the procedure at ease of mind. So once the patient is draped and prepped very well, with the open Hasson technique approach a primary umbilical camera port is placed. And a 12 millimeter umbilical camera port is inside there after the open Hasson technique approach. Again, this is a safety point. We use open Hasson technique approach because the [INAUDIBLE] insertion is associated with a bowel injury and vascular complications. The balloon port has an advantage that it anchors to the abdominal wall very well. And we usually inflate with about 20 ml of a balloon. So then the port can be anchored to the abdominal wall very well. Now once the port is placed and is anchored to the abdominal wall, then we inflate the abdomen with a pneumoperitoneum pressure of 12 meters of mercury and a flow of 5 liters per minute. Now as you want to go ahead and put the assistant ports or the working ports, you need to make sure that the arm movements are very free. And you actually simulate the arm movements with your elbow as I'm doing it here. The next trick is to make an indentation with the 8 millimeter fork, give the local anesthesia for peri-operative reduction of the narcotic requirement. And then incise the radius of circle so that you can put the port snugly fitting in that the incision. Otherwise, there's a problem of the port falling on its own during the surgery. So this is very important-- snug fitting of the ports to the abdominal wall. We do not secure these with any suture or devices. Once you get the 8 millimeter ports inside, then you do the diagnostic peritoneoscopy. Often in children with a reduced space, what you can do is you dilate the 8 millimeter and 5 millimeter ports into the 12 millimeter port so that avoid the injury to the bowels. Especially 5 millimeter assistant port is my preference because to pass the needles and sutures during the procedure. Where often when you are doing cystoplasty, a 12 millimeter port may help you because to pass the bigger sutures and needles and so also the [INAUDIBLE] clips. After the port placement, the robot is brought in from the foot end of the patient. And then you engage the working the arms but not the camera arm, because you want to get the instruments under vision. Again, this is a safety point. Every step has a safety and precaution point, and we need to be thinking of these so that we avoid all the complications. So once you engage this, you're going to bring the instruments under vision and then engage the camera port and start the procedure. Now as we know that these children have [INAUDIBLE] in place, most of the children, because of their underlying neurological condition. So the first and foremost thing before we do anything is to place the low end of the shunt in an [INAUDIBLE] back so that it's not contaminated and it still continues to drain. We have shown that if we keep the pressure of 12 to 14 millimeters of mercury, there is not any drainage impediment from the VP shunt. And we have not seen so far any complications associated with these procedures especially related to the neurosurgical complications. Vancomycin prophylaxis is really helpful for the shunt infection management. After that step, the next step is assessment of the appendix. Appendix is going to be your friend here. If you have a good length of appendix, then you can create two channels if required that is appendicovesicostomy in [INAUDIBLE]. If you have a good one appendix but just near appendicovesicostomy, that is fair enough. But appendix is going to be your friend. Because if appendix is not there, then you may have to use the channel with the bowel loop, which is not that great ideal material. So after this assessment and the placement of the VP shunt, then you start the procedure. The first step in the procedure is isolation of a short loop of bowel. And usually the ilium with the long mesentery of 20 centimeters is isolated. And then ileoileal anastomosis is restored for the normal function of the GI. And this is a 20 centimeter harvester ileal loop here with will be detubularized. Once it is detubularized, then the part on the bladder on the reconstruction starts, which is usually doing the cystotomy, that is dividing the bladder in a coronal plane, from right lateral artifice to left lateral artifice. And then implanting the appendix on posterior wall of the bladder for appendicovesicostomy, those children who do not near appendicovesicostomy then we may not need to have the catheterizable channel. But usually it is my preference or my experience that most of these children with prefer appendicovesicostomy because the catheterization through the umbilicus will be much more useful rather than catheterization through the [INAUDIBLE] urethra. Because children as they grow, they may not want to handle their genitalia or they are wheelchair bound. And this gives more of a self-esteem and self-sufficience to [INAUDIBLE]. After that step, then what you do is you bring the detubularized bowel and you join the bivalve bladder. And this is a state which takes a lot of time, because a lot of suturing involved here. 20 centimeter of the bowel to be sutured to probably a 3 or 4 centimeter bladder plate. But utmost precaution and diligence is really important at this stage so you can get good outcomes from surgery. This video describes the procedural of the robotic cystoplasty and appendicovesicostomy and also is channel formation for constipation management. [VIDEO PLAYBACK] -Here we are describing the technique for augmentation cystoplasty and appendicovesicostomy. Port placement and positioning is crucial as described in this picture for the efficient performance and updating the excellent surgical outcomes of the surgery. The procedure begins with the appendix identification and mobilization and checking it for the [INAUDIBLE] mesentery. 20 centimeter of ilium loop is identified, 20 centimeter approximate to the ileocecal junction. Purcutaneous sutures helps for retraction and identification of the mesentery. Bowel is shot with [INAUDIBLE] and 20 centimeters of ileal loop is harvested to be used later on for augmentation cystoplasty. Bowel continuity is restored with the [INAUDIBLE] of [INAUDIBLE] suture, depending on the age. Anastomosis is a [INAUDIBLE] pseudomuscular singular anastomosis. Falling anterior wall, the posterior anastomosis is completed in a similar fashion, taking precautions that the pseudomuscular layer is approximated well. Following this, the mesentery defect is closed to prevent any herniation of the bowel loop. Further mobilization of the appendix is done. Often the patient may need [INAUDIBLE] channel. And a long appendix will help to create the [INAUDIBLE] channel for the bowel management. The proximal 130 is used for the [INAUDIBLE] while the distal [INAUDIBLE] for the appendicovesicostomy. In this patient, only required appendicovesicostomy, hence the appendix is isolated from cecal wall with a cecal flap to prevent the stenosis. And cecal defect is closed in a single layer. Following the appendix mobilization and harvest, attention is turned for the bowel detubularization The bowel is detubularized over a suction [INAUDIBLE] on an anti-mesentric border and then to be used for augmentation later on. This step is followed by the cystotomy of coronal plane. Pre-placed [INAUDIBLE] catheters help to identify the [INAUDIBLE] and also to extend the limit of cystotomy to the [INAUDIBLE]. This will prevent the hourglass formation. Appendix is implanted on a posterior wall with the [INAUDIBLE] technique. This is a modification from previous [INAUDIBLE] technique which used to take a longer operating time. We tried to get at least about 3 to 4 centimeters of [INAUDIBLE] to get excellent stomal content insolate. Appendix implanted on posterior wall as mentioned. The tip of the appendix is spatulated. And the anastomosis of appendix to the bladder in the course is completed with the [INAUDIBLE] suture material. Stay suture on tip of the appendix helps while the handling of the appendix without much damage to the vascularity [INAUDIBLE]. A 5 inch feeding tube or a 8 inch feeding tube is placed across to be used later on for intermittent cell catheterization which will start in about four weeks after this procedure. A small vein can bladder [INAUDIBLE] closed. We tried to get 4 centimeters of tunnel as mentioned previously. This step is followed by now suturing up the detubularized bowel to the bladder. posterior bladder plate is sutured to the posterior bowel plate. In the [INAUDIBLE] of the bladder to the bowel is taken care by creating sutures over the bowel loop. This is followed by placement of the [INAUDIBLE] catheter through the percutaneously brought [INAUDIBLE] technique. And then the anterior wall anastomosis is completed in a similar fashion. Following completion of anastomosis, the [INAUDIBLE] checked for any gas leak to be followed by bringing the appendix to the umbilical stoma for maturation to the skin and then close up the ports on the region. That completes the procedure, and this is the diagramatic representation of augmentation cystoplasty and appendicovesicostomy. [END VIDEO PLAYBACK] So what's the post-operative care of this patient? In our experience, so far we have seen that most of these children need much less pain medication compared to open approach. Probably maybe you know about 24 hours of IV antibiotics and mostly oral pain medication and less narcoctic requirement. Another advantage we have seen that these children start drinking liquids immediately, probably the restoration of GI was excellent. And so also the physiology of the whole GI system they may not have been disturbed. And they are not much in pain. So the resumption to the GI activity is much quicker. We leave all the catheters on a free drainage, that is, [INAUDIBLE] catheter for the bladder drainage, urethral catheter for the urinary drainage, and a catheter through the appendicovesicostomy channel. And all of are left for four weeks. And then once they go home after a couple of days in the hospital, probably approximately five to seven days, they come back. And our nurse practitioner will teach them CIC or intermittent cell catheterization through the newly formed channel. And once it is established, then all the catheters will come out one after another. So it's a step wise process. So hopefully about six weeks after surgery they're catheter free and they're catheterizing on their own. As we described here in this [INAUDIBLE] experience, we have seen the encouraging outcomes, especially in the form of the less pain medication, hospitalization, and [INAUDIBLE] cooperation. So also the outcomes in relation to the bladder function, in relation to the upward [INAUDIBLE] preseravation are at par with the open surgery. Though there's a downside. The surgical time is a little bit more than the open surgery. But as the experience builds up, this is going to meet the open requirement. So this is very encouraging. And further experience will be published soon in our upcoming general [INAUDIBLE] articles. Now these are the seen benefits-- that patients went home. They have [INAUDIBLE] recuperation, and the functional outcomes. What are the unseen benefits? Everything can be made here. But there are some things which are not major. Like one is a parental gain. Parents don't have to take the time off from their work. And this is a gain too. But it's not new and major in this present economy. Most of the parents-- both parents are working-- so you don't have that much time to take off and care for your child. And this is a parental capital gain. And if you talk to the economist, they will tell you how it is beneficial, shift though you know I'm not an economist. What's the unseen other benefits? We have seen by doing the laboratory procedures of this bladder reconstruction in a person rather than open and robotic approach, and what we saw that in open operation, there were multiple erosions of the bowel to the bowel and bowel to the abdominal wall compared to the robotic approach, as published in this article. So what is the benefit of neurogenic bladder patients of this approach? Neurogenic bladder patients undergo multiple surgeries because of [INAUDIBLE], because of revision of the channel, revision of the augmentation. And every time you do surgery, you are going to create erosion and cause [INAUDIBLE] intestinal obstruction. And this has a long term complication and morbidity. So probably, this may be one of the advantages of using minimal [INAUDIBLE] approach to decrease those erosions and the bowel obstruction. I'm sure there are far more unseen benefits. But still, we have to do more studies to support what we are doing currently. All right, now we're going to switch the [INAUDIBLE]. Not all patients of neurogenic bladder requires cystoplasty. That means making the bladder a big container. There are some children who have a big container that doesn't empty. And what they need is just help with the catheterizable channel. And what is a catheterizable channel? It's basically creating a conduit of your own natural tubular structures in the body. And those could be appendix, which is our favorite because its thick wall. It's a nice healthy tube with a good blood supply. It has a robustness, and it stays for a long time. The next one is the intestine, ileum. But we know ileum is really thin. It's just like our shirt material. It has a lot of complications, especially [INAUDIBLE], false, passage, diverticulum. So appendix is the gold standard for using this. And how do you use this? You can implant in the bladder, bring it to the belly button so that it's hidden there. And then you can put a catheter intermittently through that and drain the bladder. Now does all the patients with a neurogenic bladder who don't empty near this [INAUDIBLE]? May not be, but only those children who have sensitive urethra, those who are wheelchair bound, those who have a problem with their dexterity, and this is the way where you can create a catheterizable channel in these patients-- to empty the bladder, reduce the infection, and protect the kidneys. Our main aim here in neurogenic bladder population is protect the kidneys. Because in the past, as we know, not many of this population made beyond their third or fourth decade of their life. But now it's changed. Because the medicine has evolved. Our team members, physicians, nephrologists, pediatric urologists all have come together in taking care of this to be a productive member of the society. And this is where we all need to help these children. Who else need catheterizable channels? Prune belly syndrome patients. These are the patients, they do not have the abdominal muscles. Also they do not have the bladder muscles. And they have the big bladders. Like 2 liters of urine can be held in the bladder. And these children need a catheterizable channel. Or some children with a posterior urethral valve who does not empty the bladder because of the sensive urethra. they're not able to catheterized through the natural urethra route. These are all children who need catheterizable channels. This is a [INAUDIBLE] session showing you the catheterizable channels, how it could be made. As I said earlier, this is a bladder. This is an appendix along with this healthy blood supply. And once you incise the tip of the appendix, it's a hollow lumen tube. Thick, robust muscle is attached to the bladder. And then you create some support for that appendix. If you know the physics, when the bladder is full, you have created a conduit. Bladder is full, the urine wants to come out. And if you don't clear the good support or resistance, the urine will leak out through the stoma, or the end, which is implanted at the umbilical [INAUDIBLE], belly button. So you need to clear the good support of this appendix to the bladder probably about 3 to 4 centimeters so that it's resistant enough to hold bladder volume of about 300 to 400 ml. Now the next is, as I said, some children do have a constipation as well, the neurogenic bowel associated with the bladder. And those children need an ACE. What is ACE? ACE is nothing but it's antegrade colonic enema. These children who have this constipation, they are not able to gender the peristaltic activity in the bowel and empty their bowels regularly. So what we do is we use the proximal one third of appendix, bring one of that end to the skin. They'll put a small feeding tube every morning, put about 500 ml of saline. And that volume in the bowel starts the peristaltic activity and they empty their bowels and stay clean. And this is what is the ACE channel. Now when you have a long appendix of 10 centimeters, you can use the distal [INAUDIBLE] for 6 centimeters or so for the bladder drainage part and the proximal 4 meter for the constipation management as an [INAUDIBLE] channel. But some children may not be fortune. They may not have a long appendix. But it's not the end of the story. What we'll do in those cases is we'll use the appendix for the bladder drainage. And we'll use the cecal wall or the anterior wall of the cecum to make a small tube. As you see here, I have used the cecal flap from the anterior wall, created a tube out of it, and this will act as an [INAUDIBLE] channel. Because the other end is going to be brought to the skin. And that will be use for the catherizing and draining the bowels every day. So these all could be done with, again, robotic laparoscopic approach. And I'm just going to show you a small clip of how the appendicovesicostomy will be performed in this patients. So this is the appendix here. You try to minimize the handling of the appendix and keep the vascularity. So you put a small stich on tip of that appendix. Here this is a very healthy long appendix. And actually, we are going to divide the distal for 6 centimeter for appendicovesicostomy. But here it seems to be probably [INAUDIBLE] the whole that appendix because he just needed appendicovesicostomy. We're closing that cecal wall defect after harvesting the appendix along with the blood supply. And what I tried to do here is once the bladder is filled and about 200 ml of saline, you try to incise the catheterizable muscle on anterior wall of the bladder. And as I said, this is a very important state to [INAUDIBLE]. This is the appendix tip, to which is transected and then spatulated for the [INAUDIBLE] the appendix tip to the bladder mucosa [INAUDIBLE] at the distal end of the [INAUDIBLE] muscle. Once you anastomosized that, then the spatulated end of the appendix is anchored to the bladder mucosa. And then you complete the appendicovesical anastomosis. So that's the tip of that appendix which has been anastomosed to the bladder mucosa. You put a small feeding tube across to prevent stenosis. Secure the feeding tube so the feeding tube will stay for four weeks while everything is healing. And then you remove it. This completion of the rest of the appendicovesical anastomosis that is the mucosa to the anterior wall of the appendix. And then this is an important step of the procedure, that is bringing the [INAUDIBLE] muscle over the appendix so that the appendix can remain continent when the bladder is full and it won't leak through the stoma or the belly button. So that's the completion of the ditrasrotomy or ditrosoraphy. This is a modification. Here I'm going to show, instead of implanting the appendix on the anterior wall, we're going to implant the appendix on the posterior wall of the bladder, which will be the part performed when we do the robotic cystoplasty. So here if you see the bladder is by wall, the appendix is brought from the posterior wall of the bladder. This is a tunnel for that appendix to get the continence mechanism. And then the rest of the anastomosis is similar as of the anterior wall anastomosis. The appendix is getting anastomized to the bladder here. And you complete the appendicovesical anastomosis on the posterior wall. A small rend in the mucosa of the bladder is closed with the [INAUDIBLE]. These are the black diamond neural tip holders. So that's the completion of the appendicovesicostomy anterior wall or posterior wall approach. Now as I mentioned previously, prune belly syndrome patients also require appendicovesicostomy. And are those challenges to use the robotic laproscopic approach for this patient? Yes, it is a challenge, because they do not have the muscles in the anterior abdominal wall. So then you put the ports in, they actually don't get anchored well. And there's a possibility of slippage of these ports. So that's one challenge. The second challenge is the bladders, as I mentioned, is huge. Like 2 liters of urine they're holding. So most of their abdomen, when you're doing the procedure, is occupied with a big bladder. And that's a problem with a space restriction. But we have shown that in our early experience, it is possible to use this approach for creation of catheterizable channel in prune belly syndrome as well. And the functional outcomes have been excellent and at par with the open surgical approach. Now as I mentioned, what are the other outcomes of these catheterizable channels? The most important thing is how the patient is continent. That means the patient, once you have created the catheterizable channel, should not leak the urine from the stoma or from urethra. And we have shown earlier that if we can use about 3.5 to 4 centimeters of [INAUDIBLE] backing for that appendix, then the continence outcome is excellent. And further on, when we published our extensive experience, we have again emphasized this point. And the other important outcome is are the stomas getting stinosed? Because, you know, are handling. But we have not seen those stomal stenosis rate very different compared to the open surgical approach. And again, this is very encouraging for us. And we continue to do these procedures with this approach. So what can I say in conclusion? You know, complex reconstructive surgery, like robotic cystoplasty, appendicovesicostomy, is safe in experienced surgeons' hands, provided we have met all the milestone and goals of prior simple reconstructive surgeries, a proper training, and proper team. It's really important that the case selection should be a appropriate, especially in beginning of your career. You need to be really diligent and think about which procedures you can do safely and which procedures you can handle. And probably, as I say, pyeloplasty then [INAUDIBLE] plantation, then appendicovesicostomy, and then cystoplasty. Cystoplasty should be end of your spectrum to gain the mastery to complete this complex reconstructive surgery. As I said, it's very encouraging that earlier experience shows reduced pain medication and hospitalization. And this will have an impact not on just the patient but the society, the family, and the [INAUDIBLE] economics as we're running into the economy constant in the 21st century of health economics. Outcomes re very compatible with conventional open approach, though surgical time may be minimally more. But this comes at a cost of all other advantages. And time is not a limiting factor. As you design any technology, it's not going to be at par with what it is. it's going to evolve constantly. And we are very optimistic. And have shown in other procedures like robotic pyeloplasty we have recently published our times are much less than the open surgery, especially. So this will evolve slowly. Everybody likes to look normal. You do not want surgery. Gone the days, the old surgeons, big scar. Big surgeon, big scar is not the day. The day is big surgeon, no scar. And I think you and I myself want the aesthetic appearance very well. And we need to understand the psychology and the requirement of a child and the family as you would be in their shoes. Still we have a long way to go. We have seen some unseen benefits which are not measurable as we have seen in our laboratory studies. And this will evolve as well. And hopefully the 21st century will be the era of minimal invasive surgery and gone the days of the back old [INAUDIBLE] regime of big surgeries. I invite you all to our annual robotic surgery workshop on the pediatric reconstruction. This year it's going to be in July 2014. And I really warm welcome you for this excellent academic interaction. Thank you for listening, and your questions are welcome. And I'm really a proud member of our University of Chicago of Medicine and Comer Children's Hospital. Thank you.