Continent cutaneous urinary diversions are sometimes necessary in neurogenic bladder patients unable to perform urethral self-catheterization. The Mitrofanoff appendicovesictomy is usually favored because it spares the need to use ileum which increases both the operative time and the risk of postoperative complications. However, ileal “Monti” catheterizable channel creation is a viable alternative when the appendix cannot be used. A few authors have reported robotic Monti catheterizable channel creation but with extracorporeal bowel harvesting and channel creation.  The objective of this video was to present a technique of robotic intracorporeal Monti catheterizable channel

We present the case of a 52 years old female patient with a C7 spinal cord injury. Urodynamics showed neurogenic detrusor overactivity which was effectively treated by anticholinergics. She also has detrusor-sphincter dyssynergia with chronic urinary retention and is unable to do urethral self-catheterizations due to upper limb neurological impairment. She has a past medical history of appendicectomy. After discussion in a neurourology multidisciplinary team meeting, a robotic intracorporeal Monti catheterizable channel is planned.

We start by placing the five ports. The Da Vinci Xi robot is docked on the left side of the patient (side docking).  Intravenous indocyanine green and Firefly are used to identify blood vessels while dividing the mesentery, ensuring proper vascularization of the bowel segment isolated and of the bowel anastomosis. The bowel segment is isolated using a 45-mm endo-GIA stapler and the enteric anastomosis is done using a 60 mm endo-GIA stapler. The isolated bowel segment is 5 cm long to allow the creation of two Monti catheterizable channel. The bowel segment is split into two equal parts ensuring proper blood supply of each using IV indocyanine green and Firefly. The 2.5 cm bowel segment is opened transversally and the catheterizable channel is created using two longitudinal 5/0 pds running sutures over a 12-Fr catheter. 3/0 Vicryl is used to stuture the catheter to the Monti channel.
The bladder is then widely dissected and completely freed from the abdominal wall and peritoneum to mobilize it as much as possible towards the umbilicus. Here, the bladder dome can be mobilized up to the umbilicus. A longitudinal incision of the detrusor muscle is made at the top of the anterior aspect of the bladder until the bladder mucosa is reached. A 2 cm caudal incision of the bladder mucosa is done and anastomosed to the tip of the Monti channel  using two running sutures of 5/0 PDS. 
An antirefluxing mechanism is created by closing the detrusor above the bowel with interrupted sutures on a 4 cm distance. 
The bladder is attached to the abdominal wall about 3 cm below the umbilicus and 3 cm on either side of the midline using a Reverdun needle. The Monti channel is externalized. The proximal aspect of the Monti catheterizable channel is hooked up to the fascia and then anastomosed to the skin. Ports’ incisions are closed. 

The operative time was 270 minutes with minimal blood loss. There was no postoperative complication. The patient was discharged on postoperative day 5. The cystostomy catheter was removed at 3 weeks and the patient started clean intermittent stomal catheterization with no issues. After 3 months, there was no additional complication, especially no stomal incontinence nor issues with catheterization

Robot-assisted intracorporeal Monti catheterizable channel appears feasible and may be useful in selected neurourological patients when appendix cannot be used. Studies are needed to determine whether the robotic intracorporeal approach may offer clinically significant benefits over the other surgical approaches

Continence 2S2 (2022) 100486
DOI: 10.1016/j.cont.2022.100486