Robot in Neurogenic Bladder

Robot in Neurogenic Bladder; Robotic Appendicovesicostomy, Robotic Bladder Neck Reconstruction, Robotic Bladder Neck Suspension, Robotic Bladder Augmentation, Robotic Augmentation Ileocystoplasty


What is neurogenic bladder?

Nerves controlling the bladder exit from the waist. These nerves may be affected due to congenital diseases such as meningomyelocele developing in this region or trauma or surgery to the lumbar region. When these nerves that control the functioning of the bladder are affected, urinary bladder dysfunction, which we call neurogenic bladder, occurs. The bladder cannot fully empty urine. When urinating, the pressure inside the bladder may become too high and it may not be possible to hold the urine.


What is the importance of neurogenic bladder?

If the bladder is not able to empty the urine completely, the residual urine remaining inside becomes infected easily. Therefore, urinary tract infection is common in children with neurogenic bladder. Keeping the bladder full makes it difficult to pass urine from the kidneys to the bladder, causing the ureters and kidneys to expand and disrupt their work. High pressure storage of urine in the bladder or discharge of urine causes the urine to flow back from the bladder to the kidneys, called vesicoureteral reflux (VUR). When urinary tract infection and VUR come together, the infected urine reaches the kidneys and causes an infection of the kidneys called pyelonephritis. If damage to the kidneys by VUR and infection is not prevented, high blood pressure or kidney failure may develop over time.


What is Bladder Augmentation?

Bladder augmentation, which is surgery in which the bladder is enlarged using the bowel; it is a preferred surgical approach in patients with high intravesical pressure but low bladder capacity, despite frequently clean intermittent catheterization and drug treatments that prevent bladder contraction (figure 1). Classically, it is necessary to make large abdominal incisions to solve these problems. The use of laparoscopy in such an operation has taken a long time because of the length of the learning curve and potential complications.

Figure 1: Bladder augmentation technique. Approximately 40 cm of small intestine is taken, opened, and reshaped to protect the vessels and used to enlarge the bladder.


What are the minimal invasive surgery options in neurogenic bladder problems?

I offer the following minimally invasive surgical options to families in neurogenic bladder problems:

  • Robotic appendicovesicostomy: In this method, also known as the Mitrofanoff procedure, the child's appendix is mouthed between the bladder and the abdominal skin, and after urine accumulation in the urinary bladder, the child can evacuate by catheterization through the hole in the abdominal skin.
  • Robotic bladder neck reconstruction/ bladder neck suspension procedures: In some children, the structure called the urinary sphincter, which keeps the urine in the bladder, does not work normally. These procedures help prevent urine leakage from the bladder.
  • Robotic bladder augmentation: Some children may have very small bladders that store urine. In this procedure, the intestines are used to enlarge the bladder.


Robotic bladder augmentation technique

Robotic surgery, which has become popular in recent years, has shortened the rather long learning curves of laparoscopic operations. However, the experience in the literature is still limited and there are few series and case reports. Studies with long-term follow-up are needed to compare the success rate and advantages compared to open surgery.

I applied robotic augmentation ileocystoplasty to 11 patients I followed up for neurogenic bladder. The ages of the patients ranged between 8 and 14 years. No complications developed during or after the operation. The first case I made among these children is the first case of children in Europe and our country, in which all stages are performed in the body, according to the literature (figures 2, 3, 4 and 5).

Figure 2: The cystographicappearance of the bladder of a 12-year-old male patient with a diagnosis of neurogenic bladder.
Figure 3: Placement of trocars and position of the child for robotic augmentation ileocystoplasty.
Figure 4: Image after robotic augmentation ileocystoplasty
Figure 5: Cystographic view of my robotic case 1 year later, in which I had robotic augmentation


Is the doctor important in robotic neurogenicbladder surgery?

As in all urological surgeries, it is very important that the surgeon performing the surgery is experienced. After all, the one who controls the robot is a surgeon. For a successful and smoother operation, it is necessary to have an operation with a doctor who is specialized in robotic surgery.