robotic appendicovesicostomy · historical perspectives neurogenic bladder pre-surgical patient...
TRANSCRIPT
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Robotic
Appendicovesicostomy
Cheryl Baxter, MSN,RN,CPNP
Daniel DaJusta, MD
Kristina Booth, MSN,RN,FNP
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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
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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
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)
Spina Bifida (SB)
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 yearSource: CDC
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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. 2010 Aug;6(4):330-7. doi: 10.1016/j.jpurol.2010.01.015. Epub
2010 Feb 25. Review. PubMed PMID: 20188633.
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
Historical Perspective
Neurogenic Bladder in SB
McGuire EJ, Woodside JR, Borden TA, Weiss RM. Prognostic
value of urodynamic testing in myelodysplastic patients. The
Journal of Urology. 1981 Aug;126(2):205-9.
Preservation of
renal function
Promoting
urinary
continence
Goals of Neurogenic Bladder
(NB) Urinary Management
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
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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. 2005 Oct;174(4 Pt
2):1637-43; discussion 1643. PubMed PMID: 16148671
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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)
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Why is My Patient
Incontinent?• Is it detrusor overactivity causing leaking?
• Is the sphincter incompetent?
• Is it both?
• 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
Mitrofanoff TechniqueAbdomen
Tunneled appendix
Stoma
Bladder
1) Continent,
catheterizable
channel
2) Accessible,
cosmetically
acceptable stoma
3) Good capacity, low
pressure reservoir
4) Ability to perform
CIC (self or parent)
4 Components of the Channel
• 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
Bowel Incontinence
Management
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Congruence for Success
Patient
Parent
Provider
Patient readiness
Parent readiness
Age
BMI
Desired continence
Comorbidities
Previous surgeries
Access to care (distance traveled to tertiary
care)
Factors to Consider
in Surgical Management
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Factors to Consider
in Surgical Management
Biggest risk is ?
and the answer is….
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POOR
COMPLIANCEcom·pli·ance
kəmˈplīəns/
noun
• the action or fact of complying with a wish or command
Factors to Consider
in Surgical Management
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Non Elective Bladder
Reconstruction Indications• Deterioration of the upper tract (kidneys)
• Soft indications may include:
– Elevated resting bladder pressures
– Incomplete bladder emptying
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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. 2002 Oct;168(4 Pt 1):1537-40;
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Limitations
• Decision making for ELECTIVE
reconstruction is somewhat subjective
• Surgical outcomes are influenced by
disease processes and severity