………………..……………………………………………………………………………………………………………………………………..

Robotic

Appendicovesicostomy

Cheryl Baxter, MSN,RN,CPNP

Daniel DaJusta, MD

Kristina Booth, MSN,RN,FNP

………………..……………………………………………………………………………………………………………………………………..

Roadmap for Presentation

Part 1 Pre-surgical/historical neurogenic

bladder- Baxter

Part 2 Robotic appendicovesicostomy/

video discussion- DaJusta

Part 3 Postoperative care

and follow up - Booth

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Historical Perspectives

Neurogenic Bladder

Pre-Surgical Patient

Selection in

Robotic

Appendicovesicostomy

(Mitrofanoff) Cheryl Baxter, MSN, RN, CPNP

Pediatric Urology

Nationwide Children’s Hospital

Columbus, OH

Spina bifida is the

second most common

congenital condition

(1,500 babies/year)

• Hispanic: 3.80 per 10,000 live births

• Non-Hispanic black or African-

American: 2.73 per 10,000 live births

• Non-Hispanic white: 3.09 per 10,000 live

birth

• Source – Centers for Disease Control

(CDC)

Spina Bifida (SB)

1998

Grain products labeled

as enriched such as

breads, cereals, and

rice have folic acid

added to help reduce

the risk of SB

Risk reduction of 31%

(estimate 1,300) of SB babies

per yearSource: CDC

………………..……………………………………………………………………………………………………………………………………..

Historical Perspective

Neurogenic Bladder in SB• 1972 Dr. Lapides – Clean Intermittent

Catheterization

• 1980 Dr. Mitrofanoff – “trans-appendicular

continent cystostomy” and bladder neck

closure (Slow to acceptance until Dr. Marc Cendron

translated French paper for Dr. John Duckett)

Farrugia MK, Malone PS. Educational article: The Mitrofanoff procedure. J

Pediatr Urol. 2010 Aug;6(4):330-7. doi: 10.1016/j.jpurol.2010.01.015. Epub

2010 Feb 25. Review. PubMed PMID: 20188633.

1981 Dr. McGuire first showed increased risk for

upper tract dilation in children with SB with detrusor

leak point pressures greater than 40 cm H2O

Historical Perspective

Neurogenic Bladder in SB

McGuire EJ, Woodside JR, Borden TA, Weiss RM. Prognostic

value of urodynamic testing in myelodysplastic patients. The

Journal of Urology. 1981 Aug;126(2):205-9.

Preservation of

renal function

Promoting

urinary

continence

Goals of Neurogenic Bladder

(NB) Urinary Management

Common Diagnoses in

Surgical Urinary Continence• Neurogenic/Neuropathic bladder

• Posterior urethral valves

• Prune belly syndrome

• Nonneurogenic neurogenic bladder

• Bladder exstrophy, epispadias

• Cloacal anomalies and cloacal exstrophy

• Anal rectal malformation (ARM)

• Spinal cord injury (SCI)

• Urethral injuries and strictures

………………..……………………………………………………………………………………………………………………………………..

Major Indications for Surgical

Intervention in SB • Presence of upper tract changes and/or

renal deterioration despite maximal

medical management

• Continence and independence in older

children to enhance the Quality of Life

(QOL) Macneily AE, Morrell J, Secord S. Lower urinary tract reconstruction for

spina bifida -- does it improve health related quality of life? J Urol. 2005 Oct;174(4 Pt

2):1637-43; discussion 1643. PubMed PMID: 16148671

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Pre-Surgical Patient Selection

• Discussion points • Initial newborn urology evaluation

• Time of “toilet training” age

• Videourodynamics may provide guidance on

surgical management

• Have we maximized the medical management of

this patient?

» Medications

» CIC every 3 hours

» Nighttime bladder emptying (NBE)

………………..……………………………………………………………………………………………………………………………………..

Why is My Patient

Incontinent?• Is it detrusor overactivity causing leaking?

• Is the sphincter incompetent?

• Is it both?

• Tip of appendix into the

bladder at “the end of

an antireflux

submucosal tunnel with

the other end hemmed

to the skin”

• Antirefluxing tunnel

borrowed from Dr.

Coffey’s work in 1911

for ureteral

reimplantation

technique/sigmoid

Mitrofanoff TechniqueAbdomen

Tunneled appendix

Stoma

Bladder

1) Continent,

catheterizable

channel

2) Accessible,

cosmetically

acceptable stoma

3) Good capacity, low

pressure reservoir

4) Ability to perform

CIC (self or parent)

4 Components of the Channel

• 1990 Dr. Malone

reported on an

antegrade continence

enema (ACE)

• Commonly referred to a

MACE

• Split appendix

technique

– Portion for bladder

– Portion for the bowel

Bowel Incontinence

Management

………………..……………………………………………………………………………………………………………………………………..

Congruence for Success

Patient

Parent

Provider

Patient readiness

Parent readiness

Age

BMI

Desired continence

Comorbidities

Previous surgeries

Access to care (distance traveled to tertiary

care)

Factors to Consider

in Surgical Management

………………..……………………………………………………………………………………………………………………………………..

Factors to Consider

in Surgical Management

Biggest risk is ?

and the answer is….

………………..……………………………………………………………………………………………………………………………………..

POOR

COMPLIANCEcom·pli·ance

kəmˈplīəns/

noun

• the action or fact of complying with a wish or command

Factors to Consider

in Surgical Management

………………..……………………………………………………………………………………………………………………………………..

Non Elective Bladder

Reconstruction Indications• Deterioration of the upper tract (kidneys)

• Soft indications may include:

– Elevated resting bladder pressures

– Incomplete bladder emptying

………………..……………………………………………………………………………………………………………………………………..

Complications of Mitrofanoff

and Malone Procedures• “Complications developed in a minority of

patients, mostly in the noncompliant

group. A statistically significant difference

in outcome based on compliance status

was observed in most complication

categories.”

Clark T, Pope JC 4th, Adams mC, Wells N, Brock JW 3rd. Factors that influence

outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive

procedures in children. J Urol. 2002 Oct;168(4 Pt 1):1537-40;

………………..……………………………………………………………………………………………………………………………………..

Limitations

• Decision making for ELECTIVE

reconstruction is somewhat subjective

• Surgical outcomes are influenced by

disease processes and severity