This video presents the surgical management of an obese female with intrinsic sphincter deficiency and paraparesis, rendering perurethral CIC unfeasible. It aims to demonstrate the creation of a tension-free Mitrofanoff channel in the setting of thick abdominal pannus, highlighting preoperative planning, intraoperative technical modifications, and the use of indocyanine green (ICG) dye to assess vascularity. The video also emphasizes the advantages of robotic-assisted surgery in enhancing precision, maneuverability, and surgical outcomes in complex urinary reconstructive procedures. (1,2)

A 21-year-old obese female (BMI: 31 kg/m²) presented with continuous urinary and feacal incontinence and bilateral lower limb weakness after D11-L3 laminectomy for spinal teratoma a year ago. Examination revealed a patulous urethra. Videourodynamics showed a hyposensory bladder and intrinsic sphincter deficiency.
Due to obesity, perineal hypoesthesia, and challenges with perurethral CIC, a robotic Mitrofanoff appendicovesicostomy with a pubovaginal sling using an autologous tensor fascia lata graft was planned to enhance continence and facilitate easy CIC. The autologous graft minimized the risk of erosion, and rectus sheath harvesting was avoided due to her thick pannus and central obesity.
The robotic approach improved precision, maneuverability, and recovery. A tension-free Mitrofanoff channel was created by dropping down the bladder, removing one row of staples to extend channel length and using the umbilicus as the catheterization site to bypass the thick pannus. Intraoperative indocyanine green (ICG) dye assessed vascularity. Robotic ports were placed in a semicircular configuration above the umbilicus, with assistant ports on each side. The procedure was performed in a low lithotomy position, allowing seamless completion of both the Mitrofanoff and pubovaginal sling, and tensor fascia lata graft retrieval was achieved through a small incision using a wound protector.
 VIDEO Link 
https://drive.google.com/file/d/1-S8YsXYYJLwwZ8zo_5aki6IjkECJda2r/view?usp=share_link

The total operative time was 180 minutes, with an estimated blood loss of 200 ml. Postoperative recovery was uneventful, and the patient was discharged on day 6 with a Foley catheter and IFT in the Mitrofanoff channel, both removed after two weeks. The patient subsequently performed CIC comfortably through the Mitrofanoff. At the 3-month follow-up, she remained completely continent and reported being highly satisfied with her ability to perform CIC with ease.

This video highlights the effectiveness of robotic-assisted Mitrofanoff appendicovesicostomy and autologous pubovaginal sling in achieving continence and improving quality of life in complex cases of obesity, paraparesis, and intrinsic sphincter deficiency. The meticulous preoperative planning, technical modifications, and use of intraoperative ICG dye ensured optimal outcomes, demonstrating how robotic precision and innovation can overcome anatomical challenges in reconstructive urology.

Suhaib Abdulfattah, Sahar Eftekharzadeh, Emily Ai et al ‘Is robot-assisted appendicovesicostomy equivalent to the current gold standard open procedure? A comparative analysis’,Journal of Pediatric Urology,Volume 21, Issue 1,2025,Pages 87-92,ISSN 1477-5131
Myers, J. B., Mayer, E. N., Lenherr, S., & Neurogenic Bladder Research Group (NBRG.org) (2016). Management options for sphincteric deficiency in adults with neurogenic bladder. Translational andrology and urology, 5(1), 145–157. https://doi.org/10.3978/j.issn.2223-4683.2015.12.11