Spina bifida is a congenital birth defect that affects the development of the spinal cord and its protective covering. This condition often leads to neurogenic lower urinary tract dysfunction (nLUTD), including neurogenic detrusor overactivity and neurogenic sphincter deficiency. When conservative methods are insufficient, bladder augmentation and placement of an artificial urinary sphincter have been shown to improve bladder function and quality of life of these patients. 
Such procedures were typically performed by traditional open surgery but during the last decades, robotic-assisted laparoscopic surgery has gained popularity for its minimally invasive approach and improved patient outcomes. However, the use of robotics in the field of neuro and functional urology is still in its infancy, especially when considering patients who may need combined complex surgical techniques as described here.

In this video abstract, we present a case of a spina bifida patient who underwent robotic-assisted laparoscopic bladder augmentation and placement of an artificial urinary sphincter at the level of the bladder neck. The procedure was performed using the da Vinci Xi surgical system. The patient was a 23-year-old male with a history of spina bifida and neurogenic bladder. He presented with small bladder capacity and instabilities, mixed incontinence despite optimal medical management. The patient was performing intermittent self-catheterization (ISC) to empty his bladder.

The surgery was a single-stage procedure. Four robotic and two assistant ports were placed under direct vision. 
The first stage consisted of the dissection of the bladder neck, starting posteriorly, above the seminal vesicles, followed by bilateral anterolateral dissection.
Diameter was measured and the corresponding cuff was placed (7,5 cm).
The bladder was then mobilized using robotic instruments, and the bowel was prepared for augmentation. The bowel segment was harvested, and the bladder was first opened (“clamp cystotomy”) and then augmented using robotic suturing.
The pressure regulating balloon (71-80mmHG) was placed in the abdomen and peritoneum was sutured in order to isolate the operated zone.
The tubing and pump of the AUS were placed in the scrotum and connected extracorporeally. The system was desactivated at the end of the surgery.The full procedure was completed in 9 hours, estimated blood loss was 150 mL.

Early postoperatively, the patient experienced bilateral compartment syndrome of the calves, for which he received bilateral fasciotomy. There was full recovery with no motor or sensory loss and closure after 7 days. There were no further complications. He was able to tolerate a regular diet on the third postoperative day and was discharged on postoperative day 8. His postoperative pain was well controlled, and he required minimal opioid medication. He was able to resume his regular activities within two weeks of surgery.

At the 3-month follow-up, the patient reported significant improvement in his urinary symptoms, with no more episodes of incontinence and resumed easily ISC. He reported a great improvement of his quality of life.

Robotic-assisted laparoscopic bladder augmentation and placement of an artificial urinary sphincter in a single-stage procedure is a safe and effective option for patients with spina bifida and nLUTD. 
The use of a robot can provide greater precision and control, but it also requires skills, experience and a surgeon who is capable of handling advanced technologies.
The procedure involves placing multiple sutures to perform the bladder augmentation, and the use of prosthetic material that can be easily damaged during placement and sutures. 
The robotic approach provides several advantages, including less postoperative pain, shorter hospital stay, and faster recovery. This approach may also provide a benefit to the surgeon, allowing for a more comfortable and ergonomic position during surgery. With more procedures performed, the surgical time and risk of postoperative complications will decrease.

Continence 7S1 (2023) 100796
DOI: 10.1016/j.cont.2023.100796