title: Robot-assisted laparoscopic ileal bladder augmentation: defining techniques and potential pitfalls.
abstract: OBJECTIVE
  Laparoscopic bladder augmentation has been limited because of the extensive suturing required. The use of robot-assisted laparoscopic (RAL) procedures may circumvent this limitation and allow more efficient suturing. The purpose of the study is to define the techniques and the potential pitfalls in performing RAL bladder augmentation in an animal model.
  
  
  METHODS
  Ten swine underwent RAL bladder augmentation using 20 cm of ileum. In five animals, the bowel anastomosis was performed intracorporeally. In the others, the bowel ends were externalized through one of the ports, and a free-hand bowel anastomosis was performed. The operative time was recorded. The anastomoses were evaluated for patency and leakage.
  
  
  RESULTS
  The mean procedure time was 6 hours 44 minutes (range 5 hours 50 min-8 hours 5 min) with a rapid learning curve. We identified minor technical modifications that were helpful, such as placement of "hitch stitches," irrigation of the isolated bowel loop extracorporeally, and leaving the bladder wall attachment intact to maintain bladder suspension. Leakage at the bowel-bowel anastomosis occurred in one animal with use of a stapling technique. Because this could be a potentially fatal complication, we altered our technique to perform the bowel-bowel anastomosis outside the peritoneal cavity. Subsequently, there was no further incidences of bowel leakage, and all anastomoses were patent. The mean bowel-bowel anastomosis time was equivalent to using the two techniques. Leakage at the bowel-bladder anastomosis was seen in two animals, both occurring early in the series.
  
  
  CONCLUSIONS
  RAL bladder augmentation can be safely and efficiently performed. There is a rapid learning curve. We identified minor technical modifications in techniques to help reduce operative time and potential complications. We recommend performing the bowel-bowel anastomosis outside the peritoneum to avoid the risk of leakage. Leakage at the bowel-bladder anastomosis may occur but can be managed with simple catheter drainage.
authors.affiliation: Robotic Research and Training Center, Department of Urology, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Carlo C
authors.initials: CC
authors.lastname: Passerotti
authors.forename: Hiep T
authors.initials: HT
authors.lastname: Nguyen
authors.forename: Alberto
authors.initials: A
authors.lastname: Lais
authors.forename: Patricia
authors.initials: P
authors.lastname: Dunning
authors.forename: Bruce
authors.initials: B
authors.lastname: Harrell
authors.forename: Carlos
authors.initials: C
authors.lastname: Estrada
authors.forename: Richard
authors.initials: R
authors.lastname: Lee
authors.forename: Alan B
authors.initials: AB
authors.lastname: Retik
authors.forename: Craig A
authors.initials: CA
authors.lastname: Peters
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D005240:Feasibility Studies; D007082:Ileum / Q000601:surgery; D010535:Laparoscopy / Q000379:methods*; D012371:Robotics / Q000379:methods*; D013536:Suture Techniques; D013552:Swine; D016896:Treatment Outcome; D001745:Urinary Bladder Diseases / Q000601:surgery; D014547:Urinary Diversion / Q000379:methods*