Pediatric Urology Pediatric Robotic-Assisted Laparoscopic Diverticulectomy Joshua J. Meeks, Jennifer A. Hagerty, and Bruce W. Lindgren Congenital bladder diverticula are rare anomalies of the bladder. Patients present with infection, hematuria, and/or urinary obstruction. We report on the case of a 12-year-old boy who developed gross hematuria and recurrent infection owing to a 12-cm bladder diverticulum. Robotic-assisted laparoscopic diverticulectomy was performed. We describe the first reported robotic-assisted laparoscopic diverticulectomy in a pediatric patient. UROLOGY 73: 299 –301, 2009. © 2009 Published by Elsevier Inc.
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ladder diverticula in children can be congenital, acquired, or genetic in origin and occur with an incidence of 0.7%-1.7%.1 Acquired diverticula are the result of herniation of bladder mucosa through the detrusor muscle, often because of persistently high voiding pressures. Alternatively, congenital bladder diverticula (CBD) often involve both the mucosa and the muscular layers of the bladder and develop from an unknown etiology. Bladder diverticula often present with symptoms related to urinary stasis, such as infection or hematuria.2 Very large diverticula can prolapse and cause urethral obstruction or perforate and result in urinary ascites.3,4 The standard treatment of CBD is open surgical excision.5 Laparoscopic diverticulectomy has been described in children; however, this procedure is technically difficult owing to the intracorporeal suturing required to close the bladder after CBD excision.6 Robotic-assisted laparoscopy combines the benefits of minimally invasive surgery, such as small incision size, with the potential technical advantages of increased articular motion for delicate dissection and bladder reconstruction. We report the first pediatric robotic-assisted laparoscopic diverticulectomy in a patient with CBD.
CASE REPORT The patient was a 12-year-old boy with no previous medical problems. He presented with gross hematuria and foul-smelling urine. His clinical history did not suggest dysfunctional elimination or raise the concern for a neurogenic bladder. Voiding cystourethrography demonstrated a 12-cm bladder diverticulum on the right posterior-lateral portion of the bladder, not involving the From the Division of Urology, Children’s Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago; and Division of Urology, Children’s Memorial Hospital, Loyola University Stritch School of Medicine, Maywood, Illinois Reprint requests: Bruce W. Lindgren, M.D., Division of Urology, Box 24, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. E-mail:
[email protected] Submitted: May 22, 2008, accepted (with revisions): June 11, 2008
© 2009 Published by Elsevier Inc.
ureter (Fig. 1A). No reflux was evident, his urethra was normal, and his kidneys had no evidence of hydronephrosis on ultrasonography. The patient underwent cystoscopy, and a widemouthed bladder diverticulum was identified (Fig. 1B). A 6F Foley catheter was placed in the diverticulum to assist in identification during diverticulectomy (Fig. 1C). A second Foley catheter was placed into the bladder, alongside the catheter in the diverticulum, for bladder drainage. The patient was placed in the lithotomy position with the table in the Trendelenburg position. A 12-mm robotic camera port was placed in the midline superior to the umbilicus. Two 8-mm ports were then placed 2 fingerbreadths above the anterior superior iliac spines, approximately 4 finger breadths from the midline. An additional 5-mm assistant port was placed inferior to the 8-mm left trocar. The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) robot was docked, and the Maryland bipolar forceps and monopolar scissors were used for dissection. The peritoneum was incised over the right side of the bladder. The ureter was identified, and the vas deferens was carefully swept away from the bladder (Fig. 2A). The catheter in the diverticulum was infused with saline for identification, and dissection proceeded around the full extent of the diverticulum until the neck was identified (Fig. 2B). The muscle of the detrusor was delineated surrounding the neck of the diverticulum (Fig. 2C), which was confirmed to be well away from the ureterovesical junction. An Endoloop (Ethicon; Brunswick, NJ) was placed around the neck of the diverticulum. The catheter within the diverticulum was deflated and removed and the Endoloop secured. A second Endoloop was then placed around the neck of the diverticulum (Fig. 2D). The diverticulum was then excised and removed through a laparoscopic port. The edges of the detrusor were reapproximated with 3-0 Vicryl suture in a running fashion (Fig. 2E), and the catheter was irrigated to demonstrate watertight closure of the bladder. The peritoneum was then closed over the bladder with a running 3-0 Vicryl suture (Fig. 2F). A 10F 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.06.068
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Figure 1. Congenital bladder diverticulum. (A) Voiding cystourethrography identifying large (12 cm) bladder diverticulum (D) posterior-lateral to bladder (B). (B) Large mouth of diverticulum on cystoscopy. (C) Catheter placed in mouth of diverticulum for identification during diverticulectomy.
Figure 2. Robotic-assisted laparoscopic diverticulectomy. (A) After incision of peritoneum, vas deferens is swept away from bladder. (B) Identification and dissection of bladder diverticulum. (C) Dissection of diverticulum down to neck. (D) Sequential Endoloops placed around neck of diverticulum. (E) Defect in bladder closed. (F) Peritoneum reapproximated.
Foley catheter was left overnight and removed before discharge on postoperative day 1. At 7 months of followup, the patient was without symptoms.
COMMENT CBD are a rare cause of hematuria and infection in pediatric patients.1 More common in boys, CBD can be associated with the ureter and result in urinary reflux. Although a familial association has been described, most genetic causes of CBD are related to Ehlers-Danlos syndrome.7 Acquired bladder diverticula occur in children with high voiding pressures from neurogenic bladder or bladder outlet obstruction. Far more common is an idiopathic presentation of CBD. Several reports have described the successful extravesical and intravesical management of bladder diverticula.5 If associated with a ureter, reimplantation is often required. In adults, diverticulectomy has been approached laparoscopically, both intra- and extravesically. Laparo300
scopic diverticulectomy has also been reported in the pediatric population.6 According to the reports, laparoscopic diverticulectomy requires almost twice the operative time of open diverticulectomy.8,9 Recently, however, a case series of 5 robotic-assisted bladder diverticulectomies in adult men was described,10 with reported operative times more similar to those for open diverticulectomy. Two procedures performed during the robotic diverticulectomy aided in the identification, dissection, and excision of the CBD. First, a Foley catheter was placed in the diverticulum to allow for infusion of saline to expand the diverticulum intraoperatively, and an additional catheter was used to drain the bladder. Instillation of saline in the CBD allowed the full area of the CBD to be identified during excision, and the second catheter was used to keep the bladder empty, allowing for a larger working space in the abdomen. Second, a laparoscopic Endoloop was placed around the neck of the diverticulum, allowing for easy manipulation of the CBD in an atraumatic manner during dissection. Additionally, placeUROLOGY 73 (2), 2009
ment of the endoloop around the neck of the CBD allowed for a clear separation from the bladder during excision and prevented spillage of urine and saline from the bladder into the surgical field once the CBD was excised. The use of the da Vinci robot has several advantages compared with pure laparoscopy in performing diverticulectomy. The articulation of the robotic instruments aids in the dissection of the bladder and diverticulum. The three-dimensional visualization allows for better view of the diverticulum and surrounding structures, allowing for safe dissection from the nearby vas deferens and/or ureter. The dexterity and range of motion of the robotic instruments significantly increase the ease and precision of the intracorporeal suturing required for closure of the bladder, which is particularly important when suturing deep within the pelvis.
CONCLUSIONS We have demonstrated successful robotic-assisted laparoscopic diverticulectomy in a pediatric patient with a 12-cm bladder diverticulum. The use of robotic instrumentation and three-dimensional visualization aided in safe and complete diverticulum excision and bladder reconstruction. References 1. Garat JM, Angerri O, Caffaratti J, et al. Primary congenital bladder diverticula in children. Urology. 2007;70:984-988. 2. Sarihan H, Abes M. Congenital bladder diverticula in infants. Eur Urol. 1998;33:101-103. 3. Shukla AR, Bellah RA, Canning DA, et al. Giant bladder diverticula causing bladder outlet obstruction in children. J Urol. 2004; 172:1977-1979. 4. Stein RJ, Matoka DJ, Noh PH, et al. Spontaneous perforation of congenital bladder diverticulum. Urology. 2005;66:881-882. 5. Pieretti RV, Pieretti-Vanmarcke RV. Congenital bladder diverticula in children. J Pediatr Surg. 1999;34:468-473. 6. Kok KY, Seneviratne HS, Chua HB, et al. Laparoscopic excision of congenital bladder diverticulum in a child. Surg Endosc. 2000;14: 500-502. 7. Eadie DG, Wilkins JL. Bladder-neck obstruction and the EhlersDanlos syndrome. Br J Urol. 1967;39:353-358. 8. Nadler RB, Pearle MS, McDougall EM, et al. Laparoscopic extraperitoneal bladder diverticulectomy: Initial experience. Urology. 1995;45:524-527. 9. Porpiglia F, Tarabuzzi R, Cossu M, et al. Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: Comparison with open surgery. Urology. 2002;60:1045-1049. 10. Myer EG, Wagner JR. Robotic assisted laparoscopic bladder diverticulectomy. J Urol. 2007;178:2406-2410.
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EDITORIAL COMMENT This case report describes the use of the da Vinci Surgical System to perform a repair of a CBD in a child. The authors describe their technique clearly and provide excellent images of this procedure. As with all applications of a new technology, we are compelled to ask whether the use of this new technology leads to equivalent or better outcomes than existing procedures. To paraphrase Willet Whitmore “Is it possible to perform this procedure with the robot? Is the robot necessary for this procedure?” I believe, in well-selected patients with CBD, that the answer to the first question is “yes.” Clearly, this procedure can be done as an open procedure. However, the ease of suturing afforded by the da Vinci system allows for much more rapid and accurate repair of the bladder than traditional laparoscopy. With increased experience using the da Vinci system, I believe most urologists will come to recognize the advantages of this technology and answer the second question “yes” as well. Jeffrey A. Stock, M.D., Pediatric Urology, West Orange, New Jersey doi:10.1016/j.urology.2008.07.015 UROLOGY 73: 301, 2009. © 2009 Published by Elsevier
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REPLY We thank the reviewer for his comments and certainly agree with the idea that the advantages of the robotic surgical system are becoming increasingly recognized by urologists. Although the use of the robotic surgical system is often cited as a method to “shorten the learning curve” and allow those less-skilled in laparoscopy to use the laparoscopic approach, we believe there are certainly other distinct advantages to the dexterity and visualization offered by the da Vinci Surgical System, and this case illustrated those benefits nicely. Joshua J. Meeks, M.D., Ph.D. and Jennifer A. Hagerty, D.O., Division of Urology, Children’s Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois Bruce W. Lindgren, M.D., Division of Urology, Children’s Memorial Hospital, Loyola University Stritch School of Medicine, Maywood, Illinois doi:10.1016/j.urology.2008.07.014 UROLOGY 73: 301, 2009. © 2009 Published by Elsevier
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