34th ESPU Congress in Naples, Italy
S18: TIPS & TRICKS
Moderators: Emilio Merlini (Italy)ESPU Meeting on Friday 19, April 2024, 13:10 - 13:45
13:10 - 13:15
S18-1 (T&TP)
BLADDER NECK CLOSURE: MY PREFERRED APPROACH TO ACHIEVE CONTINENCE IN NEUROGENIC BLADDER WITH LOW DLPP AND BLADDER EXSTROPHY
Antonio MACEDO JR.
Federal University of São Paulo, Pediatrics/ Pediatric Urology, São-Paulo, BRAZIL
INTRODUCTION
Urinary incontinence due to urethral sphincter insufficiency and for later surgery after initial bladder exstrophy closure is a major challenge in pediatric urology. We want to present our strategy for such cases aiming for the highest probability of success possible.
METHODS
When facing the two previous described clinical conditions we explain to families that a combined procedure of bladder augmentation and bladder neck resistance surgery is always required. We then present them the expected results with bladder neck plasty (50%) and bladder neck closure (95%). My own experience supports preference of second procedure according to patient's and surgeon practice. We start by dissecting the anterior bladder wall and opening it in midline, accessing the trigonal area and bladder neck from inside. We place and fixate two 4 Fr plastic tubes in ureteral meatus for security and identification of the transection plane. A Foley tube allows secure circumcision of the proximal urethra at bladder neck level. We then define the two flaps of bladder posterior wall to be dissected from the Dennonvilliers flaps with electrocautery and to be lifted up until they are fully mobile and not tensioned. Next step is to close the bladder neck with two planes of vicryl 3.0 sutures and get the transected bladder ready for a clam enterocystoplasty. Since 1998 we have used the Macedo catheterizable ileum reservoir in combination with it. The same principle is applied to bladder exstrophy (Macedo A Jr et al, J Pediatr Urol. 2020 Aug;16(4):506-507)
RESULTS
In a recent review from just part of our personal experience in a non-teaching hospital (in publication), we identified 12 cases similar to the ones demonstrated above in the picture with 100% of urethral continence.
CONCLUSIONS
We are therefore convinced that bladder neck closure associated with enterocystoplasty with abdominal stoma is the best approach for urinary incontinence associated with low DLPP. In a recent publication of our series of incontinent neurogenic patients after in-utero MMC closure we have also demonstrated the natural history of this devastating condition (In utero myelomeningocele repair: The natural history of patients with incontinent pattern (sphincteric deficiency: leakage below 40 CMH20).
Macedo A Jr et al: Neurourol Urodyn. 2020 Nov;39(8):2373-2378)
13:15 - 13:20
S18-2 (T&TP)
BLADDER NECK CLOSURE WHEN ASSOCIATED WITH BLADDER AUGMENTATION: THE USE OF THE INTESTINAL SEGMENT FOR A SAFE CLOSURE
Alaa EL-GHONEIMI, Annabel PAYE-JAOUEN, Amane-Allah LACHKAR and Matthieu PEYCELON
Department of pediatric surgery and urology, National Reference center for Rare Urinary Tract Malformations (MARVU), University Hospital Robert Debre, APHP, University of Paris, Paris, FRANCE
OBJECTIVES
Bladder Neck closure is rarely indicated in children to treat urinary incontinence. Post-operative fistula or re-opening are still major complications. We describe here our preferred method for BNC when associated with bladder augmentation using part of the intestinal segment for the closure.
METHOD
We describe step by step the procedure in a nine-year-old male born with bladder exstrophy. He had already five bladder surgeries including two failed cervicoplasties. He was incontinent and had a large pubic fistula and 30ml bladder capacity. The decision was to perform bladder neck closure, bladder augmentation and Mitrofanoff channel.
Bladder augmentation was a W-configuration ileal segment.
The bladder was opened on the midline in a bi-valve pattern. The posterior wall of the bladder was incised then dissected to have free 1 cm edge. The urethra was not closed. The de-tubularized W-configuration ileal segment was sutured to the posterior wall of the bladder. The free edge at the midline of the ileal segment was then sutured directly to the free edge of the posterior wall of the bladder neck with running 4/0 monofilament resorbable suture. A multi-tubularized drain, without suction, was left near to the suture line. The full procedure was done entirely by Robotic-assisted laparoscopy using 4-arms Da Vinci Xi system.
An indwelling catheter through the Mitrofanoff and a suprapubic catheter were left on free drainage for three weeks before starting CIC. The night drainage was maintained for 6 weeks.
RESULTS
At 40 months of follow-up, the patient has no urine leak, CIC (Ch 14) 5 times/day through the Mitrofanoff new-umbilical stoma. The upper urinary tract is normal, and maximal bladder capacity is 500ml.
CONCLUSIONS
Bladder neck closure is a challenging procedure specifically when done in a multi-operated fragile bladder. Incorporating a well-vascularized intestinal segment might has the advantage of improving the healing process of the BNC. This procedure can be done through a robotic assisted approach while duplicating the already known open surgery technique.
13:20 - 13:25
S18-3 (T&TP)
"HORSESHOE" BLADDER NECK MOBILIZATION FOR SUCCESSFUL CLOSURE AND AVOIDING POSTERIOR INJURY
Mohan GUNDETI
University of Chicago Medicine, Paed Urology, Chicago, USA
SUMMARY
During robotic bladder neck closure, sharp transection of the bladder neck after identifying the ureteral orifices (UOs) does not allow for proper mobility of the posterior wall of the bladder neck for proper closure. Often there is too much tension and the tissues are not healthy, leading to a rate of dehiscence and leak of about 40%.
We suggest mobilizing the posterior wall of the bladder neck beyond the insertion of the UOs in the shape of a horseshoe . Once this is complete, the posterior wall is then brought anteriorly and the bladder neck is closed above the level of UOs. This will create a new, healthy and dependent area for proper healing of the bladder neck. In addition, we recommend buttressing the anastomosis with omentum if possible or peritoneum, alternatively. This has reduced the leak rate significantly.
Another tip is to avoid creating the plane between the bladder neck and the vagina in girls and rectum in males as there is potential for injury to these posterior strictures in young children. We proceed directly to division of the posterior wall of bladder neck with monopolar cautery layer by layer.
We have performed this with both open and Robotic laparoscopic approaches and will be able to show the video during our presentation.
13:25 - 13:30
S18-4 (T&TP)
ROBOTIC ASSISTED LAPAROSCOPIC BLADDER NECK CLOSURE: TIPS AND TRICKS
Daniel DAJUSTA, Molly FUCHS and Rama JAYANTHI
Nationwide Children's Hospital, Section of Urology, Columbus, USA
ABSTRACT
Robotic-assisted laparoscopic surgery has proven to be a game changer for pelvic surgery, in particular, surgeries in the deep pelvis requiring reconstruction. This is due to the advantages associated with the robot of small instruments that work like the wrist and can easily reach the deep pelvis, providing good dexterity for dissection and reconstruction. Additional benefits include lower blood loss and decreased post-operative pain due to smaller incisions and faster recovery. Robotic radical prostatectomy is a prime example of the many benefits of the robotic technique, as it has now become the preferred surgical method. Recently, the robotic technique has been applied to surgeries in children for urinary incontinence to reconstruct or close the bladder neck, hoping to obtain some of the same benefits. Bladder neck closure is often done after other surgical interventions have failed. Thus, when doing a bladder neck closure, one will likely encounter a scarred previously operated field, making good dissection with meticulous tissue handling imperative. The robotic technique can offer the surgeon precisely what is needed to perform the procedure successfully. In addition, it might provide many of the above-mentioned post-operative benefits. We aim to show tips for this innovative technique, which follows steps like those of the traditional open counterpart.
13:30 - 13:45
Discussion