Robotic Surgery Helps Girl With Neurogenic Bladder
Being a 10-year-old girl in the fifth grade with medical issues is difficult enough--as long as you can laugh about it--but try being ten without laughing. Aaliyah Dellar, 10, can tell you that's even harder when you always have to urinate.
Born with spina bifida, a birth defect that can interfere with bladder control, she overcame many difficulties early in life. "She met all her milestones," said her mother, Paula Thigpen. "She didn't have a lot of the common complications."
But soon after birth, her bladder stopped growing. Worse yet, it was always trying to contract, almost like it was having a spasm. Over time, the walls of her bladder grew thicker and more muscular from the constant contractions.
So she always had that uncomfortable feeling that she urgently had to go to the bathroom. She stopped drinking juice. She couldn't have soda. She even cut back on water, to less than two cups a day. Still, she had to be cautious. If she tensed up, if she stumbled or fell, if she laughed just a little too hard, she leaked urine. This does not go over well at school.
"We refer to this condition as neurogenic bladder," said Mohan Gundeti, MD, associate professor of surgery, pediatrics and obstetrics/gynecology and director of pediatric urology at the University of Chicago. Sometimes, in patients with spina bifida, the bladder is very small. Aaliyah's could barely hold six ounces. Worse yet, the bladder has frequent involuntary contractions. This pushes the urine back up the ureters into the kidneys, where it slowly but inevitably causes damage, including frequent infections.
Medication helped a little, said her mom, but despite two years of trying different treatments, the problem continued to get worse. Because of recurrent infections, Aaliyah was constantly on antibiotics, which ultimately damaged her hearing. Then she was found to have the first signs of kidney damage.
"We could see excess fluid in both kidneys, and significant scar tissue in one," Gundeti said. "It was time. We had to treat this problem."
Five Operations in One
An expert in minimally invasive urologic surgery, Gundeti had performed the operation to enlarge and relax tiny neurogenic bladders many times. A time-consuming, complicated procedure, "it is like doing five operations in one," he said.
It begins with a big incision, about six inches long, from above the navel down to the pubic area, followed by placement of retractors to pull the stomach muscles out of the way. Through this hole, they isolate about 12 inches of intestine, which they open lengthwise to create a large patch of tissue, all while retaining the tissue's original blood supply.
Second, they reconnect the severed ends of the intestine to re-establish the normal function of the bowel.
Third, they cut through half of the bladder, opening the sphere into a cup shape. Then they close the bladder opening with the patch of intestine.
"This makes the bladder bigger, more than twice the original size," said Gundeti. "Plus, it can no longer contract with the same force."
Fourth, they isolate the appendix, again retaining its blood supply. They snip off the tip, converting it into a hollow muscular tube. To secure good drainage of the enlarged bladder without a leak, they implant one end into the posterior wall of the bladder and connect the other end to the skin of the lower right abdomen.
Fifth, they pull the tip of the appendix through the skin. Then they assemble three little overlapping flaps, like the top of a cereal box, to close and protect the opening, keeping it clean and preventing leaks.
Robotic Approach Eliminates Large Incision
For this case, however, Gundeti decided to modify this difficult but proven surgical approach. He would eliminate the initial incision.
This required a crucial tool, the $1.5 million da Vinci robotic surgical system. The adult urologists at the University of Chicago Medicine had been using the robot since 2002, primarily to treat prostate cancer; they have performed nearly 2,000 operations with it.
Pediatric urologists, however, have been slower to adopt the technology. Last December, Gundeti became the first pediatric urologist in the region to use it.
Changing tools, and this first-time-ever approach, forced him to rethink Aaliyah's entire surgery. No one had ever done the full operation this way. For this lengthy, complicated procedure, he invited his colleague adult urologist Gregory Zagaja, MD, to assist.
When you begin an operation with so many steps, one that takes six to eight hours for the most experienced surgeons, "you can't easily stop in the middle," he said.
Making the operation even more difficult, Gundeti would take no shortcuts. "There are robotic tools to speed up the process," he said, "ways to use a stapler to put tissues back together or close a cut quickly rather than sewing each stitch by hand. But I believe meticulous hand sewing of the connections is superior."
"Dr. Gundeti told me the operation would take six-to-eight hours," her mother said. Aaliyah went to the OR at a little before 4 p.m. on February 21.
"At 10 o'clock I thought: 'OK, that's six hours.' At midnight I thought: 'OK, that's eight.' I had a lot of confidence in Dr. Gundeti, but I'm a mom and I started to get a little anxious."
Shortly after 2 a.m. they told her the operation was complete, it had gone well and she could go see her daughter.
"I expected her to be covered with bandages and gauze and tape," she recalled, "to have a big swollen belly with a big wound. But there was none of that. I was stunned. Her belly was flat and normal, no bandages, not even a band-aid, just a few little cuts that looked like they had been covered with glue."
"Oh, I thought, she's gonna like this. No big scars. She could wear a bikini. I would not want her to wear a bikini," she added," but she could. She could wear a tank top and not worry about people seeing her scars. There just were no real scars."
Faster Recovery, Much Less Pain
"Patients like that aspect," said Gundeti. Surgeons like it because the superior magnification and decreased blood loss result in a much more precise procedure. There is less risk of infection, no big wound to heal, just five small punctures, no prolonged recovery and much less pain.
After the open operation, he said, "we used to tell patients no physical activity for six weeks. Aaliyah, however, has no such restrictions." She started drinking six hours after surgery and eating within 24 hours, which she "greatly appreciated," Gundeti said. "This significantly hastened her recovery. She went home about four days after her surgery.
"She hasn't had a leak since then," her mother said. "She can drink water, or juice, even soda. She's enjoying the freedom she never had."
Aaliyah still has to use a catheter to urinate, but it's much easier now. Before the operation she had to squat in the bathroom and insert the tube into her urethra, which can be difficult. Now she inserts the tube through a tiny opening on her lower abdomen, below and to the right of her belly button. "It's much simpler and not so embarrassing," said her mother, "and she doesn't have to do it so often."
"I'm very grateful to Dr. Gundeti," said Thigpen, "and impressed by his skill." Aaliyah was happy to get home so quickly, she reports. The risk of embarrassing accidents is a thing of the past.
"Those were tough times before the surgery," recalled her mother, "But she's feeling better about a lot of things now. And we can laugh about it together."