Robotic Assisted Augmentation Enterocystoplasty for Neurogenic Bladder

1) Operative access
- Under general anesthesia, the patient was positioned supine with 30° Trendelenburg. Pneumoperitoneum was established using a Veress needle, followed by midline supraumbilical access and a pelvic robotic port setup.
2) Ileal segment isolation
- Approximately 22 cm of distal ileum was selected approximately 15 cm proximal to the ileocecal valve and divided with a stapling device. Mesenteric perfusion and adequate reach to the bladder are important during segment selection.
3) Restore bowel continuity
- An intracorporeal stapled side-to-side anastomosis restored bowel continuity in a functional end-to-end configuration using a 60-mm stapling device. The mesenteric defect was closed with interrupted sutures.
4) Clamshell cystotomy
- The bladder was mobilized and opened in a clamshell fashion, extending toward the bladder-neck level as documented in the operative note.
5) Ileal patch preparation
- The isolated ileal segment was opened along the antimesenteric border and reconfigured into a patch. The operative note describes two-layer closure during patch preparation; this is not described as a two-layer patch-to-bladder anastomosis.
6) Patch to bladder anastomosis
- The patch was anastomosed to the opened bladder using running absorbable 2-0 V-Loc suture. The technical priorities are close edge apposition, preserved perfusion, correct patch orientation, and avoidance of mesenteric torsion or anastomotic tension.
7) Leak test
- A 20 Fr urethral Foley catheter was placed. The reconstruction was tested with saline, with no leakage reported.
8 ) Drain placement and closure
- Hemostasis was ensured. A Jackson-Pratt drain was placed in the pelvis near the anastomosis and brought out through a separate stab incision. The abdomen was closed in layers.

The patient had six years of paraplegia and neurogenic bladder following a T7 spinal cord injury. Urinary incontinence persisted between catheterizations every 4–6 hours, with recurrent infections and difficulty performing catheterization. Oral therapies, bladder botulinum-toxin injections, and InterStim had provided inadequate control; botulinum toxin initially helped but its benefit was not sustained.
Urodynamics demonstrated low capacity, abnormal compliance, poor sensation, and phasic detrusor contractions with urge leakage. Changing to coudé and pre-lubricated catheters improved urethral access. Because urethral catheterization remained feasible, a catheterizable channel was discussed but not recommended. Augmentation was selected to address persistent storage dysfunction while maintaining urethral emptying.
Guidelines support augmentation in selected patients with refractory neurogenic detrusor overactivity and/or poor compliance after less invasive treatments are inadequate. A sustainable emptying regimen and long-term follow-up are integral to selection. [1,2]

General selection considerations include inability to tolerate major reconstruction, unsuitable bowel or inadequate remaining bowel length, and inability to maintain catheterization and follow-up without reliable assistance. Significant renal dysfunction requires individualized assessment because bowel incorporation can worsen metabolic disturbances. These are general considerations, not conditions documented in this patient. [1–3]

Instrumentation included the da Vinci Xi robotic system (Intuitive Surgical), a Veress needle and robotic ports, tip-up fenestrated grasper, Maryland bipolar forceps, monopolar curved scissors, and large needle drivers. A 60-mm stapling device was used for bowel division and anastomosis, with absorbable 2-0 V-Loc suture for the ileovesical anastomosis. Drainage included a 20-Fr urethral Foley catheter and a pelvic Jackson-Pratt drain.

General anesthesia; supine positioning with 30° Trendelenburg; sterile preparation and draping; Veress pneumoperitoneum and supraumbilical access; da Vinci Xi pelvic robotic port configuration.

Cystoscopy showed a wide-caliber bulbar urethral stricture that was easily traversed, a nonobstructing prostate, and normal bladder mucosa without tumor, stone, or diverticulum.
Urodynamic findings:
- Storage characteristics: Low capacity; abnormal compliance; poor sensation
- Detrusor activity and leakage Phasic contractions with urge leakage
- Infused and voided volume: 100 mL each
- Maximum flow rate: 0.7 mL/s
- Detrusor pressure at peak flow: 54 cm H₂O
- Postvoid residual: 100 mL
The report does not provide a confirmed maximum cystometric capacity or numerical compliance. Pressure at peak flow is a voiding measurement and is not presented as a storage pressure.
Baseline creatinine was 0.97 mg/dL and eGFR was 110 mL/min/1.73 m². The available renal ultrasound showed normal kidneys without hydronephrosis or nephrolithiasis; bladder evaluation was limited by decompression after catheterization.

The ileocecal valve guides distal ileal selection. The mesentery and its vascular supply determine segment perfusion and reach; the antimesenteric border guides detubularization. During bladder opening and patch incorporation, the native bladder, bladder neck, trigone, and ureteral orifices orient the reconstruction. Maintain the relationship of the patch to its mesentery to avoid torsion and tension.

The following are general risks and technical safeguards, rather than complications attributed to this patient. [1,3]
Bowel reconstruction: bleeding, bowel injury, ischemia, anastomotic leak, ileus, or obstruction. Preserve mesenteric perfusion, inspect the bowel anastomosis, and close the mesenteric defect; postoperative fever, pain, distension, or persistent ileus requires assessment.
Urinary reconstruction: patch torsion, ischemia, tension, urinary leakage, or catheter obstruction. Maintain orientation and perfusion, perform leak testing, and ensure drainage. Unexpected drain output, reduced urine output, or clinical deterioration warrants evaluation.
Long-term reservoir risks: recurrent infection, mucus, calculi, metabolic abnormalities, and perforation. Maintain the prescribed catheterization and irrigation regimen, monitor renal and upper-tract status, and investigate new symptoms. Severe abdominal pain or systemic illness requires urgent evaluation.

No conflicts to disclose

1. European Association of Urology. EAU Guidelines on Neuro-Urology. EAU Guidelines Office; 2026. https://uroweb.org/guidelines/neuro-urology/chapter/the-guideline
2. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up. J Urol. 2021;206(5):1106–1113. doi:10.1097/JU.0000000000002239. https://pubmed.ncbi.nlm.nih.gov/34495688/
3. Çetinel B, Kocjancic E, Demirdağ Ç. Augmentation cystoplasty in neurogenic bladder. Investig Clin Urol. 2016;57(5):316–323. doi:10.4111/icu.2016.57.5.316. https://icurology.org/DOIx.php?id=10.4111/icu.2016.57.5.316
4. Yee CH, Tam MHM, Hong YL, et al. Robotic Augmentation Cystoplasty: Outcome of the Anterior and Posterior Approaches. J Endourol. 2025;39(4):356–363. doi:10.1089/end.2024.0485. https://doi.org/10.1089/end.2024.0485