Robotic Appendicovesicostomy

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1 Robotic Appendicovesicostomy Cheryl Baxter, MSN,RN,CPNP Daniel DaJusta, MD Kristina Booth, MSN,RN,FNP

2 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

3 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

80 per 10,000 live births Non-Hispanic black or African- American: 2.

4 Spina Bifida (SB) 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)

5 Source: CDC 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 year

6 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 Aug;6(4): doi: /j.jpurol Epub 2010 Feb 25. Review. PubMed PMID:

7 Historical Perspective Neurogenic Bladder in SB 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 McGuire EJ, Woodside JR, Borden TA, Weiss RM. Prognostic value of urodynamic testing in myelodysplastic patients. The Journal of Urology Aug;126(2):205-9.

8 Goals of Neurogenic Bladder (NB) Urinary Management Preservation of renal function Promoting urinary continence

9 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

10 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 Oct;174(4 Pt 2): ; discussion PubMed PMID:

11 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)

12 Why is My Patient Incontinent? Is it detrusor overactivity causing leaking? Is the sphincter incompetent? Is it both?

Mitrofanoff Technique Tip of appendix into the

13 Mitrofanoff Technique 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 Tunneled appendix Stoma Abdomen Bladder

14 4 Components of the Channel 1) Continent, catheterizable channel 2) Accessible, cosmetically acceptable stoma 3) Good capacity, low pressure reservoir 4) Ability to perform CIC (self or parent)

15 Bowel Incontinence Management 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

16 Congruence for Success Patient Parent Provider

17 Factors to Consider in Surgical Management Patient readiness Parent readiness Age BMI Desired continence Comorbidities Previous surgeries Access to care (distance traveled to tertiary care)

18 Factors to Consider in Surgical Management Biggest risk is? and the answer is.

19 Factors to Consider in Surgical Management POOR COMPLIANCE com pli ance kəmˈplīəns/ noun the action or fact of complying with a wish or command

20 Non Elective Bladder Reconstruction Indications Deterioration of the upper tract (kidneys) Soft indications may include: Elevated resting bladder pressures Incomplete bladder emptying

21 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 Oct;168(4 Pt 1): ;

22 Limitations Decision making for ELECTIVE reconstruction is somewhat subjective Surgical outcomes are influenced by disease processes and severity

CHAPTER 1 INTRODUCTION

Introduction 1 CHAPTER 1 INTRODUCTION 8 Introduction Spina bifida is a congenital defect of the spine in 1-3 out of 1000 live born children 1 and still is one of the most common serious congenital malformations.