title: Robot-assisted laparoscopic Mitrofanoff appendicovesicostomy technique and outcomes of extravesical and intravesical approaches.
abstract: BACKGROUND
  With growing experience in pediatric robotic surgery, select centers are now performing robot-assisted, laparoscopic Mitrofanoff appendicovesicostomy (RALMA).
  
  
  OBJECTIVE
  We present our technique and outcomes of RALMA with or without enterocystoplasties and compare stomal outcomes between two different approaches of the appendicovesical anastomosis: an extravesical (EV) anterior bladder approach and an intravesical (IV) posterior bladder approach.
  
  
  METHODS
  Data from 18 children who have undergone RALMA since 2008 were retrospectively reviewed. RALMA was performed by one surgeon in an academic setting.
  
  
  METHODS
  The appendix was anastomosed on the posterior wall of the bladder intravesically when concomitant enterocystoplasty was done. Otherwise, the appendix was anastomosed extravesically on the anterior wall of the bladder.
  
  
  METHODS
  The primary outcome measured was the overall continence rate. Secondary outcomes included the overall complication rate and stomal complications.
  
  
  CONCLUSIONS
  The entire cohort included 18 patients (10 IV, 8 EV). The mean overall operative time was 494.1 min. The mean overall length of hospitalization was 5.2 d. There were five immediate, postoperative complications (all Clavien grade 1): three postoperative ilea, one stomal site infection, and one clogged suprapubic catheter. Median follow-up was 24.2 mo. The overall stomal continence rate was 94.4%. One patient from the IV group required dextranomer/hyaluronic acid copolymer for stomal incontinence. Among the eight patients in the EV cohort, there was one stomal complication of stomal stenosis (Clavien grade 1). Among the 10 patients in the IV cohort, there were two stomal complications requiring revisions (both Clavien grade 3): parastomal hernia and stomal stenosis. Limitations of the study include retrospective design, small number of patients, and lack of direct comparison of approaches given the nature of the surgery.
  
  
  CONCLUSIONS
  Our updated outcomes of RALMA with or without enterocystoplasty continue to be encouraging, with a 94.4% continence rate. We believe that anterior EV reimplantation is a feasible option in isolated RALMA.
authors.affiliation: Section of Urology, The University of Chicago Medicine and Biological Sciences, Comer Children's Hospital, Chicago, IL, USA.
authors.forename: Olufenwa J
authors.initials: OJ
authors.lastname: Famakinwa
authors.forename: Alexandre M
authors.initials: AM
authors.lastname: Rosen
authors.forename: Mohan S
authors.initials: MS
authors.lastname: Gundeti
mesh_terms: D000293:Adolescent; D000714:Anastomosis, Surgical; D001065:Appendix / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003559:Cystostomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D007902:Length of Stay; D061646:Operative Time; D012189:Retrospective Studies; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000601:surgery*; D014549:Urinary Incontinence / Q000209:etiology / Q000628:therapy
keywords: Appendicovesicostomy; Mitrofanoff; Pediatric urology; Reconstructive urology; Robotic surgery