- To present a series of 15 laparoscopic and robot-assisted Mitrofanoff and Yang-Monti vesicostomies in an adult population, and to assess the feasibility and safety of these minimally invasive approaches.
quality of life
continent urinary diversion
Clean intermittent catheterization has been established as the standard, long-term therapy for patients with bladder emptying disorders, which can arise from neurogenic diseases, oncological surgery or idiopathic causes [1, 2]. The avoidance of bladder overdistension can protect the upper urinary tract and reduce the incidence of symptomatic UTIs. Nevertheless, a subset of patients is unable to perform clean intermittent catheterization through native urethra for various reasons, such as diminished dexterity, body habitus, extensive surgery destroying the normal urinary outflow anatomy, or even psychological problems [2, 3]. For such patients, continent urinary diversion (CUD) represents a useful alternative for bladder emptying. The cutaneous appendicovesicostomy initially described by Mitrofanoff in 1980  remains the most commonly performed CUD, followed by the Yang-Monti procedure , which uses small pieces of ileum to create cutaneous ileovesicostomy. CUDs allow the restoration of urinary continence, preserve the upper urinary tract and improve the patient's quality of life (QoL) and corporeal schema . These procedures have usually been performed through a lower abdominal incision and, recently, laparoscopic and robot-assisted minimally invasive approaches have been developed [7, 8], but technical difficulties have prevented their widespread adoption. To date, only a few case reports and small series have been reported, and these only in the paediatric setting [9-11]. We describe our surgical technique for the laparoscopic and robot-assisted creation of Mitrofanoff and Yang-Monti conduits, reporting on a series of 15 adult patients. To our knowledge, this is the first series of minimally invasive, adult vesicostomies published to date. The aim of this study was to assess the feasibility and safety of these minimally invasive procedures.
Between 2009 and 2012, 15 patients underwent minimally invasive surgery for CUD at the Department of Urology of the Clinique Saint Augustin, Bordeaux, France. All the procedures were performed by a single surgeon (D.R.). Indications for surgery included neurogenic bladder in 11 patients and urethral dysfunction in four patients. Surgery was performed using either a pure laparoscopic (n = 11) or a robot-assisted laparoscopic approach (n = 4). The type of conduit created was a traditional Mitrofanoff appendicovesicostomy (n = 11) or a double Yang-Monti ileal conduit (n = 4). Fourteen patients underwent concomitant augmentation enterocystoplasty. The patients were evaluated at 3 and 6 months after surgery and every 6 months thereafter, with their QoL also assessed by means of an internally developed questionnaire for patients undergoing CUD (Appendix 1), which comprised a series of 12 questions aimed at providing a more objective picture of patient satisfaction after surgery.
The patient was placed in a modified lithotomy position, with the legs abducted and parallel to the level of the bed. A 30° Trendelenburg position was obtained to displace the small bowel so that it was away from the pelvic area. When possible, an 18-F Foley catheter was inserted; if not, a suprapubic catheter was used. Pneumoperitoneum was established with 12 mmHg insufflation pressure.
For the laparoscopic surgery, we placed four trocars: a 10-mm camera port above the umbilicus; two 5-mm working ports on the mid-clavicular line bilaterally; and one 5-mm between the pubis and the umbilicus. For the robot-assisted surgery, we placed six trocars: a 12-mm camera port 5 cm above the umbilicus; two 8-mm robotic ports bilaterally at a distance of at least 8 cm from the camera port; a third 8-mm robotic port 5 cm above the left anterior superior iliac spine; and finally, two 5-mm assistant ports were triangulated above the right robotic port. After trocar placement, the robot (four-arm Da Vinci Si Surgical System, Intuitive Surgical, Inc, Sunnyvale, CA, USA) was docked.
The caecum was mobilized, preserving its blood supply. Two 3/0 poliglecaprone 25 sutures were placed at the base of the appendix, which was then separated from the caecum at a distance of 6 cm from its tip (Fig. 1A). Next, the tip of the appendix was sectioned and its patency verified with a 12-F self-lubricating catheter (Fig. 1B).
At 30 cm from the ileo-caecal valve, the ileum was suspended to the abdominal wall using straight needles and a 5-cm ileal segment was isolated. We manually performed the end-to-end ileal anastomosis with two running 3/0 poliglecaprone 25 sutures, starting with the posterior wall, from the farthest corner to the nearest one. A similar running suture was made for the anterior wall. The ileal segment was passed through the mesenteric hole to prevent its crossing with the ileum. The 5-cm ileal segment was completely detubularized with an incision close to the mesentery (Fig. 2A); we performed a modified technique, without dividing the ileal segment in two as is usually done in open surgery. We sutured the mesenteric side of the detubularized segment (Fig. 2B), then the antimesenteric side was sagittally sectioned up to the mesentery to obtain the T-shaped double Yang-Monti conduit (Fig. 2C). Afterwards, three 4/0 poliglecaprone 25 sutures were placed within the segment to securely hold the 12-F catheter inside the conduit during the retubularization, which was performed with two running sutures. The catheter was fixed to the conduit (Fig. 2D) with reabsorbable 3/0 polyglactin 910 sutures, to avoid its accidental displacement during the manoeuvres. After the retubularization, the conduit was ∼8 cm long (Fig. 3).
The anterior and posterior bladder walls were adequately prepared and the bladder was suspended to the abdominalwall with straight needle 2/0 nylon sutures for better posterior exposure. The bladder was filled with 200 mL of saline solution and incised on its right posterior wall up to the mucosa to create a submucosal tunnel to receive the conduit. The conduit was anastomosed to the bladder muscular layer using three interrupted 3/0 poliglecaprone 25 sutures. The anti-reflux tunnel was built according to the Lich-Gregoir technique , using three 3/0 poliglecaprone 25 inverted sutures, which allow the invagination of the tube inside the bladder while preserving the bladder mucosa. The bladder was fixed to the anterior abdominal wall with two transparietal 2/0 polyglactin 910 sutures hidden under the skin, to avoid any kinking of the conduit during catheterization. Two laparoscopic drains were placed.
In the patients who underwent concomitant bladder augmentation, a 25-cm ileal segment was taken at 30 cm from the ileo-caecal valve. The segment was then incised on the antimesenteric border over its entire length and sutured in a U-shape with poliglecaprone 25 3/0 running sutures, obtaining a square patch. Next, a sagittal cystotomy was performed according to the classical bivalve technique. The cystotomy was slightly shifted to the left to outdistance it from the anastomosis. Then, 7-F ureteric catheters were inserted through the abdominal and bladder wall to prevent mucus obstruction. The ileal patch was sutured to the bladder wall using two 3/0 poliglecaprone 25 running sutures. The watertightness was checked by filling the bladder with 200 mL saline solution.
According to the body habitus and patient's choice, the stoma can be placed either on the right abdominal wall or at the umbilical level. In both cases, a 12-mm trocar was introduced at the stoma site through a V-incision. The conduit was then extracted from the trocar and anastomosed directly to the skin with interrupted 4/0 poliglecaprone 25 sutures.
The drains were removed after at least 5 days and the ureteric catheters after 1 week. After 6 weeks, the bladder catheter and the catheter inside the conduit were removed; at the same time, the first catheterization was performed under cystoscopic control. As a precaution, the patients remained in hospital for 48 h to check the quality of the auto-catheterization. At 3 months, a cystography was performed. Follow-up visits were scheduled at 6, 9 and 12 months, and every 6 months thereafter.
A summary of patients' demographical and surgical characteristics is shown in Table 1. All the surgeries were successfully completed with no conversions to open surgery. The mean (range) follow-up was 22 (9–33) months. Early postoperative complications included formation of a deep retrovesical abscess in two patients, treated with surgical drainage and antibiotic therapy. Four patients developed upper UTIs. One patient had peri-operative cardiac failure, which needed cardiological evaluation and treatment, with a long hospital stay. Late postoperative complications were infrequent: two patients with the stoma on the right lower quadrant experienced stomal stenosis that required the execution of a Y-V plasty at 3 months, and another Y-Q-V plasty at 6 months. Bladder neck closure procedures were needed in two patients 3 months after surgery because of persistent low-pressure bladder incontinence. One patient had recurrent UTIs, treated with antibiotic therapy. In one patient, the catheter inside the Yang-Monti was accidentally displaced, causing a perforation of the conduit and consequent urinary peritonitis and finally requiring an incontinent urinary diversion. At the 3-month cystography, bladder emptying was complete in all patients, and all of them were continent. One patient was not satisfied with the aesthetics of his stoma, whereas another experienced difficulties in auto-catheterization. Overall, according to our QoL questionnaire, 13 of our 15 patients did not regret the surgery.
|Mean (range) age, years||32 (22–65)|
|Neurogenic bladder due to spinal cord lesions||11|
|Lower urinary tract dysfunction||4|
|– Previous radical prostatectomy and radiotherapy||1|
|– Failure of trans-obturatory tape (TOT) and artificial sphincter||1|
|– Failure of urethral reconstructive surgery||2|
|Type of surgery, n|
|Mitrofanoff appendicovesicostomy and bladder augmentation||10|
|Double Yang-Monti ileal conduit and bladder augmentation||4|
|Stoma placement, n|
|Right iliac fossa||13|
|Mean operating time, min|
|Mitrofanoff appendicovesicostomy and bladder augmentation||225|
|Double Yang-Monti ileal conduit and bladder augmentation||270|
|Mean (range) blood loss, mL||140 (50–300)|
|Mean (range) hospital stay, days||14 (10–35)|
The creation of a catheterizable CUD can represent a challenging task. The conduit must be easily accessible, non-leaking and cosmetic, and should guarantee a long-term continence and a low rate of complications. The Mitrofanoff appendicovesicostomy  remains the most frequently performed CUD, followed by the Yang-Monti procedure . Despite extensive data obtained in the paediatric setting [9-11] in terms of continence and complications, there were only few data regarding the adult population . Adults represent a very heterogeneous population, as they comprise neurogenic and oncological patients, so it can be difficult to make an objective analysis and draw conclusions on the success rate of these diversions. Furthermore, although laparoscopic and robotic techniques have recently been developed [7, 8], the data published in the literature refer to isolated experiences or very small series of patients, and none of them in the adult setting. Our series of 15 adults patients treated with a minimally invasive approach is, to our knowledge, the first series published to date.
Laparoscopic and robotic approaches have the benefits of reduced bleeding and postoperative pain, a quicker recovery and improved cosmesis; however, these potential advantages must be balanced against technical difficulties, limited operating space and, possibly, longer operating times. We developed a standardized technique for the internal construction of the vesicostomies for which we adapted the steps of the open procedure to the minimally invasive approach to make it feasible and reproducible. Our mean operating time was reasonable when compared with the open procedure: a recent study reported a mean operating time of 290 min for the construction of an open CUD with bladder augmentation , which was similar to our results obtained using a minimally invasive approach. The estimated blood loss, which in our series was negligible, was also consistent with other results reported in the paediatric setting [10, 11]. All our procedures were successfully completed, which confirmed the feasibility of our minimally invasive approach. We performed 11 laparoscopic and four robot-assisted procedures. The operating technique was the same in both cases, except for the trocar placement which required two additional trocars for the robotic approach. The correct placement of six trocars can sometimes be difficult, especially in patients with congenital neurologic malformations, and the conflicts between the robotic arms can represent a problem. We found, however, that the procedure was easier to perform with the robot thanks to the improved dexterity, particularly during the suturing.
For the Mitrofanoff appendicovesicostomy, we considered that a 6-cm appendix would be adequate to build a tension-free conduit with a low risk of kinking. With regard to the construction of the Monti conduit, the steps of the open procedure were adjusted to the minimally invasive approach; thus, we decided not to cut the ileal segment into two parts, as it is easier to manipulate a single ileal segment, as described by Casale . Our technique differs from the ‘spiral Monti’ described by Casale, however, in that we detubularize the segment with a unique incision on the same side. We prefer the implantation of the conduit (either Mitrofanoff or Monti) on the posterior bladder wall in order to obtain the straightest path from the abdominal wall to the bladder, favouring the complete emptying of the bladder. This choice is also supported by recent findings in the literature that would suggest that there is suboptimal bladder drainage with anterior conduits, reflected by a greater risk of UTI and bladder stone formation than there is with posterior conduits . With regard to the anti-reflux mechanism, we adopt the Lich-Gregoir technique, which is nowadays the ‘gold standard’ in the minimally invasive setting [15, 16]. The anastomosis is made to the detrusor muscle instead of the mucosa to obtain the best tensile strength. Furthermore, the three inverted sutures which invaginate the conduit inside the bladder allow tightening of the anastomosis and an increase in the area of pressure application . The fixation of the bladder to the anterior abdominal wall reduces traction and stabilizes the conduit.
Bladder augmentation was performed in patients with a high-pressure, low-capacity bladder that was refractory to or where the patients refused medical or conservative treatment. A classic bivalve technique provides good results as long as a large, sagittal incision is performed to prevent a narrow-mouthed anastomosis . Furthermore, in our opinion, the bivalve technique is easier to perform with the minimally invasive approach than by subtrigonal cystectomy. We preferred to shift the bladder incision slightly to the left to leave space for the conduit anastomosis to be performed on the right side. We chose not to perform bladder neck closure at the time of the vesicostomy as its indications are still debated; furthermore, we considered it useful to have an emergency endoscopic access for catheterization in case of complications with the CUD. In our series, only two patients experienced postoperatively persistent low-pressure incontinence that required bladder neck closure at 3 months. With regard to the stoma placement, the choice of the site must guarantee a good accessibility for the patient and the best alignment possible with the conduit . Furthermore, it must be as cosmetically pleasing as possible. The umbilicus and the right iliac fossa represent the most common sites used, keeping in mind that for obese patients the umbilicus remains the site of choice because of its easier accessibility . The cutaneous V-flap, combined with the spatulation of the conduit, is recommended as it has been shown to reduce the incidence of stomal stenosis. A large cutaneous incision is warranted to avoid stomal stenosis triggered by ischaemia.
The feasibility and safety of continent catheterizable vesicostomies in the adult population has been questioned by recent studies, which reported high complication and revision rates; however, we had only few and manageable complications. Only 2/15 patients needed stoma-related revisions, vs 10/35 patients reported in an adult, open vesicostomy series . Similarly, the excision of the conduit was necessary only in one patient in the present series vs a high 8/35 in the open series . In our series, deep abscess formation was reported in two patients. To limit the risk of this complication, we advise retaining the drain for at least 5 days in all minimally invasive surgeries where the bowel is opened. Our mean hospital stay was 14 days, which may seem excessive considering our low complication rate and young patient population, but we thought it prudent to delay the discharge of our patients to allow careful monitoring of their postoperative course, considering their particular setting, their social context and the possible complications of completely intracorporeal digestive anastomosis. Furthermore, we adopted a cautious approach for our first experience of robotic and laparoscopic CUDs.
With regard to patients' QoL, overall 87% of our patients were satisfied with the surgery. We have developed an ad hoc, internally developed questionnaire focused on CUD patients to better quantify patients' satisfaction. We composed a series of 12 questions which could give us a more objective evaluation of the patients' satisfaction after the surgery. Our results are in line with those of other studies in the literature, which reported high satisfaction rates. QoL evaluation is very important in the setting of patients who already have a diminished baseline QoL because of their underlying condition . Our promising results must be balanced against the relatively short follow-up of our series; a longer surveillance period will be needed to evaluate the durability of our outcomes.
In conclusion, while a longer follow-up is needed to assess the durability of our results, this series shows that the laparoscopic and robotic approaches for the construction of CUDs are feasible and safe in an adult population. The adoption of a standardized and reproducible technique that retraces the steps of open surgery achieves satisfactory outcomes and manageable complications.
Internally developed questionnaire for patients undergoing CUD.
|1||Number of daily auto-catheterizations|
|2||Duration of auto-catheterization (including preparation)|
|3||Presence of urinary incontinence (either from the urethra or from the stoma)|
|4||Presence of bladder spasms|
|5||Presence of UTI|
|6||Need for preventive antibiotic therapy|
|7||Need for anticholinergic therapy|
|8||Calibre (F) of the catheter used for auto-catheterization|
|9||Satisfaction index (Unsatisfied – Medium satisfied – Satisfied – Very satisfied)|
|10||Autonomy in social activities before surgery (restaurant, cinema …)|
|11||Autonomy in social activities after surgery (restaurant, cinema …)|
|12||Possibility of auto-catheterization in public toilets|