Hypothesis / aims of study
Augmentation cystoplasty (AC) with supra-trigonal cystectomy (SC) consists of performing cystectomy while preserving the bladder trigone, ureters and urethra and then harvesting a segment of bowel, which is detubularized and sutured to the bladder trigone.
AC with SC may be recommended in patients with neurogenic lower urinary tract dysfunction (NLUTD) who are still able to self-catheterize, in case of refractory neurogenic detrusor overactivity, low bladder capacity or low bladder compliance, after failure of conservative therapies(1). It is also mentioned in all guidelines as the last option in case of Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC), in some selected patients with low bladder capacity, poor bladder compliance and Hunner lesions(2).
Robotic-assisted surgery overcomes the limitations of laparoscopy (3D vision, articulation, and precision of instruments), while preserving the advantages of minimally invasive surgery (shorter hospital stay, less postoperative pain and surgical scars. AC with SC in patients with NLUTD was recently described by a robotic-assisted laparoscopic approach, with short-term results (functional outcomes and complications) and only in a small cohort. To our knowledge, this approach has never been reported in BPS/IC.
The aim of the current study was to report long-term functional outcomes, quality of life and complications of robotic-assisted supra-trigonal cystectomy with AC (RASCAC) in patients with NLUTD and BPS/IC.
Study design, materials and methods
All consecutive patients with NLUTD or BPS/IC who underwent RASCAC between December 2012 and December 2020 were included. All patients who underwent a concomitant surgery (aponeurotic sling, artificial urinary sphincter, continent urinary diversion,..) were excluded.
The surgical technique whose short-term outcomes has already been published, combined robotic‐assisted laparoscopy and mini-laparotomy. The first step was supratrigonal cystectomy which was performed with a robotic-assisted laparoscopic approach. Then, the robot was disconnected and the cystectomy specimen was taken through the umbilical incision, which was enlarged to a maximum of 5 cm below the umbilicus. A 40 cm ileal loop was harvested via this mini‐laparotomy, and intestinal continuity was restored by end‐to‐end anastomosis with absorbable braided suture material (Vicryl 3/0). The ileal loop was detubularized and a Z‐plasty was performed with absorbable braided suture material (Vicryl 3/0). Two absorbable V‐lock 3/0 sutures, which were tied together, were then placed around the posteriormost part of the ileal graft. The graft was reinserted into the abdominal cavity and robotically anastomosed to the trigone with 2 simple V‐lock 3/0 running sutures starting at 6 on the posterior surface, then ascending to 12 on the anterior surface.
In patients with NLUTD, underlying disease, pre-operative data (clinical data, urodynamics), and peri-operative data including early postoperative complications were reported. We also evaluated late postoperative complications and long-term functional outcomes: Continence, urodynamic parameters, upper urinary tract function, upper urinary tract function, and quality of life. In patients with BPS/IC, pain (numeric rating scale), daytime urinary frequency and bladder capacity (bladder diary), voiding mode, urodynamic parameters, and quality of life were assessed. Satisfaction with PGI-I was also assessed in both populations.
Results
71 patients (41 with NLUTD and 30 BPS/IC) with a median age of 39 years (+/- 24.5) and 63.5 years ( +/-17.5) were included. The median follow-up was 4.8 years (+/-2.2).
For patients with NLUTD, underlyling diseases were as follows: 27 (65%) spinal cord injuries, 6 (15%) spina bifida, 6 (15%) multiple sclerosis, 2 (6%) sacro-coccygeal teratoma surgeries. Intermittent self-catheterization was the mode of voiding in all patients with NLUTD.
The median operative time was 184 minutes (49) for BPS/IC and 252.2 min (34.8) for patients with NLUTD (NS).
Complications
In the overall population, the rate of early complication was 36%, including 32% Clavien 1 and 2 (n=28) and 4% grade 3 (n=3). No deaths were reported.
Three severe late complications were observed: 1 bladder perforation at 1 year, and 2 bowel obstructions at 6 and 18 months.
Functional outcomes and QoL
In patients with NLUTD, all urodynamic parameters were significantly improved (Table 1). At last follow-up, 90% of patients had a low-pressure bladder with an overall continence rate of 93% (n = 38). Quality of life was improved in 72% of patients.
In patients with BPS/IC, pain improved significantly postoperatively, as did maximum cystometric capacity (304mL vs. 112ml; p<0.01) (Table 2). Daytime urinary frequency was also significantly reduced (100% vs. 63%; p<0.01). 4 patients were considered failures, and radical cystectomy with non-continent urinary diversion (ileal conduit) was proposed in 2 of them. 11 (37%) patients required de novo intermittent self-catheterization.
Quality of life was improved in 73% of patients.
Interpretation of results
To our knowledge, this series is the first to report on robotic-assisted laparoscopic augmentation cystoplasty in adult patients with BPS/IC. It also reports the results of the largest cohort of adult patients with NLUTD.
In both populations, quality of life was significantly improved postoperatively
Concluding message
In patients with neurogenic lower urinary tract dysfunction, robotic-assisted supra-trigonal cystectomy with augmentation cystoplasty (RASCAC) is feasible and has an acceptable complication rate. This technique provides satisfactory long term functional outcomes, particularly a long-term low-pressure reservoir, protection of the upper urinary tract, and significant improvement in continence in patients with NLUTD. It also provides improvement in pain and in increased daytime frequency in patients with BPS/IC
In both populations, a significant improvement of the quality of life was reported.