Robotic pediatric augmentation cystoplasty: Outcomes over a 15-year experience

Augmentation cystoplasty (AC) is performed for the management of neurogenic bladder in select patients with upper urinary tract deterioration and urinary incontinence refractory to conservative treatments. Traditionally, open augmentation ileocystoplasty (OAI) has been the gold standard, but growing evidence shows that performing pediatric urologic procedures robotically has been associated with shorter hospitalizations, improved cosmesis and reduced scar visibility, and reduced pain. Our institution performed the first intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA) in 2008, and subsequent refinements have shown comparable or better outcomes compared to open surgery. Despite growing evidence supporting the safety and efficacy of robotic pediatric urologic surgeries, literature comparing outcomes of robotic-assisted laparoscopic ileocystoplasty (RALI) to OAI is limited.

The objective of our study was to investigate the safety and feasibility of RALI while presenting the concomitant outcomes of OAI at our institution.

We retrospectively reviewed medical records of 45 pediatric patients who underwent AC and concomitant reconstructive procedures for neurogenic bladder and bowel between 2008 and 2021. Postoperative complications were graded with the Clavien-Dindo grade (CDG) classification system.

The cohort consisted of 19 patients in the open group and 26 patients in the robotic group. While median operative time was longer in the robotic cohort, other perioperative outcomes-including median length of stay, estimated blood loss, and time to return to a regular diet-were comparable between groups. A greater proportion of patients in the open group received epidural analgesia. Notably, the robotic group demonstrated higher rates of upper tract stabilization. Rates of augmentation revision or reversal were similar between groups. Comparable rates of 30- and 90-day CDG I-III postoperative complications were observed between groups.

To our knowledge, this serves as the largest patient cohort and longest follow-up period of any study of RALI to-date and serves as the first study to summarize long-term outcomes. However, this study is limited by the lack of direct matching of patient cohorts, the inherent selection bias of younger patients undergoing open surgery, and the inability to assess overall pain medication usage.

In this study, we show that RALI is a feasible approach and is performed in a patient population that presents with many variables that contribute to procedural complexity. We anticipate that continued refinements and added experience will reduce operative times, making RALI a suitable approach and viable alternative to OAI for management of neurogenic bladder.