V08_No_1_Print_3.pdf Point of Technique 66 Urology Journal Vol 8 No 1 Winter 2011 Ureteroscopically Assisted Totally Laparoscopic Appendicocecostomy A Minimally-Invasive Approach to an Intra-operative Complication Alireza Aminsharifi, Reza Niroomand, Firoozeh Afsar Urol J. 2011;8:66-8. www.uj.unrc.ir Keywords: neurogenic urinary bladder, appendix, laparoscopy, urinary diversion,cystostomy, urologic surgical procedures Department of Urology, Shiraz Nephrology Urology Research Center, Comparative Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Corresponding Author: Alireza Aminsharifi, MD Department of Urology, Faghihi Hospital, Zand Boulevard, Shiraz, Iran Tel: +98 917 700 0656 Fax: +98 711 233 0724 E-mail:aminsharifi_ar@yahoo.com Received June 2010 Accepted November 2010 INTRODUCTION Mitrofanoff appendicocecostomy technique, as an efficient and durable continent catheterizable stoma to the urinary reservoir, has been traditionally done through an open Pfannenstiel or low midline abdominal incision.(1) However, in recent years, anecdotal cases of laparoscopic-assisted, robotic- assisted, and totally laparoscopic Mitrofanoff appendicovesicostomy have been reported.(2-5) Here, we describe a patient treated using a totally laparoscopic appendicovesicostomy procedure with free-hand intracorporeal bowel repair. CASE REPORT The patient was a 13-year-old boy suffered from insulin-dependent diabetes mellitus since infancy. He had a 1-year history of frequent episodes of urinary retention with overflow urinary incontinence. Urodynamic studies showed flaccid neurogenic bladder and post-void residual urine of more than 2 liters. Because of difficulties with self- catheterization through the urethra, he was scheduled for laparoscopic appendicovesicostomy after providing informed consent for the possible need for open conversion. TECHNIQUE In the right lateral position, through 4-port transperitoneal laparoscopy, after applying a laparoscopic Satinsky clamp at the base of the appendix with a 5-mm cecal cuff, the appendix with its cecal cuff was harvested while preserving the mesoappendix. The cecum was repaired with free- hand intracorporeal laparoscopic suturing and knot-tying techniques with 3-0 polyglycolic acid stitches in two layers (Figure 1-a). The tip of the appendix was excised and catheterized with an 8-F feeding tube to ensure patency, but the catheter could not be passed through the appendix. The appendix lumen was evaluated by passing an 8-F ureteroscope through a 5-mm laparoscopic port (Figure 1-b), which revealed a hard fecalith at the base of the appendix. The fecalith was fragmented with a pneumatic lithotripter under direct vision via ureteroscope, and ease of catheterization was then checked and confirmed. After bladder mobilization, tunneled appendicovesical anastomosis was done over a 10-F catheter using 4-0 polyglycolic acid intracorporeal running stitches (Figure 1-c). The flush stoma was Laparoscopic Appendicocecostomy—Aminsharifi and Niroomand 67Urology Journal Vol 8 No 1 Winter 2011 created in the right upper quadrant area at the site of the 5-mm trocar (Figure 1-d). RESULTS The operation lasted 240 minutes. The bladder was drained with a Foley catheter for 4 weeks when the internal Foley as well as the appendiceal catheter were removed and the patient was able to catheterize his bladder via appendix stoma without difficulty every 4 hours (Figure 2). No urine incontinence or stomal stenosis has occurred within the 6-month follow-up period. DISCUSSION In the past three decades, the Mitrofanoff procedure has been shown to be efficient for reservoir drainage and to protect the upper urinary tract from the detrimental effects of a neurogenic bladder as well.(1) Performing this procedure in a minimally-invasive manner is the ultimate goal. Jordan and the colleagues were the first to introduce laparoscopy for this technique. They mobilized the cecum and the appendix laparoscopically and completed the procedure through a Pfannenstiel incision.(2) Because of the complexity of intracorporeal suturing during this technique, robotic-assisted laparoscopic appendicovesicostomy has been tried in recent years with successful outcome.(3) Casale and associates were the first to report the feasibility of intracorporeal totally laparoscopic Figure 1. a) Cecal repair with free-hand intracorporeal laparoscopic suturing with Vicryl 3-0 stitches. b) Intraluminal visualization of the appendix with ureteroscope to relieve obstruction. c) Appendiculovesical anastomosis with 4-0 polyglycolic acid intracorporeal running stitches. d) The flush stoma in the right upper quadrant at the site of the 5-mm trocar. a b c d Appendix Bladder Laparoscopic Appendicocecostomy—Aminsharifi and Niroomand 68 Urology Journal Vol 8 No 1 Winter 2011 appendicovesicostomy in 2004. They transected the appendix with an endoscopic stapling device, and tunneled appendicovesical anastomosis was done with intracorporeal suturing.(4) Here, we presented our first experience with totally laparoscopic appendicovesicostomy in a child with flaccid neurogenic bladder. Unlike others, we did not use an endoscopic stapler to transect the appendix, and we opted for intracorporeal bowel repair. Appendiceal obstruction was successfully managed in a minimally-invasive manner. Although laparoscopic appendicovesicostomy is a demanding procedure that requires experience with intracorporeal suturing and tying techniques, its clinical outcome is highly rewarding due to its minimally-invasive nature. ACKNOWLEDEGMENTS We thank Ehsan Ghanbarifard for his aid in obtaining figures and editing the video and K. Shashok (Author AID in the Eastern Mediterranean) for help with the English in the manuscript. CONFLICT OF INTEREST None declared. REFERENCES 1. Tekant G, Emir H, Eroglu E, et al. Catheterisable continent urinary diversion (Mitrofanoff principle)-- clinical experience and psychological aspects. Eur J Pediatr Surg. 2001;11:263-7. 2. Jordan GH, Winslow BH. Laparoscopically assisted continent catheterizable cutaneous appendicovesicostomy. J Endourol. 1993;7:517-20. 3. Storm DW, Fulmer BR, Sumfest JM. Laparoscopic robot-assisted appendicovesicostomy: an initial experience. J Endourol. 2007;21:1015-7. 4. Casale P, Feng WC, Grady RW, Joyner BD, Lee RS, Mitchell ME. Intracorporeal laparoscopic appendicovesicostomy: a case report of a novel approach. J Urol. 2004;171:1899. 5. Rosito T, Andreoni CR, Iizuca F, Ortiz V, Macedo A, Jr. Combined laparoscopic appendicovesicostomy (Mitrofanoff) with nephrectomy and orchidopexy in an 8-year-old boy. J Pediatr Urol. 2008;4:317-8. Figure 2. After laparoscopic appendicovesicostomy, the patient could catheterize himself easily and he was continent.