Introduction: A recent comparison between open, semi-robotic and totally robotic cystectomy with ileal conduit (IC), demonstrated that robotic intracorporeal IC is a complex procedure with increased operation time, but lower estimated blood loss, transfusion rates, complications and hospital stays. Moving towards a minimally invasive approach for all kind of urinary diversions, we recently standardized our technique for intracorporeal IC. In this video, we describe our surgical technique, reporting perioperative, functional and oncologic outcomes.
Methods: With patient in steep Trendelenburg position, 6-trocars access was used. Ureters were gently mobilized and isolated, avoiding tractions or manipulations. Distal ureters were clipped with hem-o-lok and a terminal specimen was sent for frozen section. Cystectomy with extended pelvic lymphadenectomy was completed, before transposing left ureter to the right side under the sigmoid mesentery. A 60 mm robotic stapler was used to congure the future IC and to perform a latero-lateral ileal-ileal anastomosis. Ureters were spatulated and, under ICG guidance to check ureters vascularity, a typical Wallace I anastomosis was performed. Two single J stents were positioned through a 5 mm trocar. The proximal end of the IC was opened and the posterior aspect of the uretero-ileal anastomosis was performed with a 3/0 monocryl running suture. The distal end of the IC was exteriorized by a Rampley forceps, together with the two single J stents. The anterior aspect of the uretero-ileal anastomosis was completed and a water tightness test was performed to prove the sealing of the suture. In this phase, camera port and right robotic arm were repositioned, in order to have a better visualization and an improved freedom of movements. Finally, peritoneum defect was closed in order to leave the IC in the retroperitoneum space.
Results: Overall, 61 patients with a median of 69 yr were treated. 36 patients had cT3 disease, 11 had evidence of lymphadenopathy and 2 had suspicious metastasis at preoperative imaging. Median operative time was 290 minutes. LOS was 9 days. Only 16.4% of patients required transfusion. 39.3% of patients experienced a perioperative complications of any grade, while severe complications (CD grade =3) occurred in only 2 patients. Overall, 50.8% of patients had a pT>2, while PSM were reported in 1.6% of patients. At a median follow up time of 23 months, we registered a median last creatinine of 1.33 mg/dL. Only 5 patients developed a grade 2 or 3 hydronephrosis, which required nephrostomy placement in 3 cases. 3-yr OS, DFS and MFS were 52.9, 43.9 and 47.6%, respectively.
Conclusions: Robotic radical cystectomy with intracorporeal IC is a safe and feasible procedure, with minimized blood loss, improved convalescence and reduced complications rate in tertiary referral centers.