Robot-Assisted Laparoscopic Augmentation Ileocystoplasty and Appendicovesicostomy (RALIMA) – Recent Modifications to the University of Chicago Technique to Reduce Operating Time

Abstract

Introduction: Neurogenic high-pressure bladders may lead to incontinence and upper tract deterioration. Bladder augmentation with creation of a catheterizable channel helps protect the upper tracts and provide patients with a mechanism for social continence. RALIMA offers patients the potential benefits of minimally invasive surgery during major genitourinary reconstruction. We present modifications to our previously described technique to reduce surgical time and for ease of adoption of RALIMA. Patient and Surgical Procedure: An 11-year-old female with a poorly compliant, high pressure, small capacity (73 cc) neurogenic bladder, with detrusor leak point pressure of 8 cm of water, failed conservative measure and subsequently underwent RALIMA, bladder neck reconstruction, and ACE channel creation with cecal flap. Results: Total operative time was 615 minutes, EBL 50 cc, and patient was discharged home on postoperative day 6. Several modifications to our initial technique were utilized to improve operative efficiency, including 1) use of the robotic fourth arm to assist with retraction; 2) relocation of the camera port above the umbilicus to assist with visualization; 3) use of percutaneous stay sutures placed in the ileum to allow for isolation and facilitate bowel-bowel anastomosis; 4) performing the posterior wall bowel anastomosis prior to anterior; 5) utilizing the harmonic scalpel to detubularize ileum, take down bowel mesentery, and perform the cystostomy; and 6) utilizing barbed suture to perform the bowel-bladder anastomosis. Conclusion: The video demonstrates RALIMA with bladder neck reconstruction and ACE channel creation for a high-pressure, refractory neurogenic bladder.

Keywords

• Bladder augmentation
• appendicovesicostomy
• ileocystoplasty
• RALIMA