Introduction: RARC is a complex and morbid procedure, even when performed in a minimally invasive fashion. It is affected by a 90-day complication of approximately 59%, with an high-grade complication rate which ranges from 15 to 30%. Many of this postoperative complications, occasionally necessitate re-exploration, which could benet in turn from a minimally invasive approach. In this video, we describe our surgical technique used to manage two relatively frequent complications.
Methods: In both cases, patient was placed in steep Trendelenburg position and a conventional 5 or 6 trocars access for pelvic surgery was adopted. The rst case is a reimplantation for uretero-ileal anastomosis stricture after RARC with orthotopic neobladder. Ureter was gently isolated and ICG near infrared uorescence imaging was used to better individuate the ischemic portion of distal ureter. Ureter was clipped with hem-o-lok, transected and spatulated. Cystostomy was performed before proceeding with a direct reimplantation with 3/0 interrupted sutures. A double J stent was placed over a guide wire, through a 5 mm trocar and cystostomy was closed with a 2/0 monocryl running suture. A water tightness test proved the suture sealing. A nal check with ICG near infrared uorescence demonstrated a normal vascularity of the re-anastomosis area.
The second case is an ileal-neobladder stula in a 66-yr old male, who underwent RARC. Ports placement was particularly dicult due to multiple and extensive adhesions. A meticulous adhesiolysis was performed in order to expose the neobladder and individuate the stula location. Neobladder was irrigated with a mixture of ICG and saline solution and near infrared uorescence imaging allowed to individuate the afferent and the efferent ileum loop stulized with neobladder, which were both divided with a 60 mm laparoscopic stapler. A new latero-lateral ileal-ileal anastomosis was then performed. A 2/0 monocryl running suture was used to cover the surgical staples, in order to prevent further future adhesions. Ileal loop stulized with the neobladder was completely excluded from intestinal transit and bowel continuity restored.
Results: Conversion to open surgery was not necessary in any procedures. Operative time was 146 and 120 minutes, respectively, with negligible EBL. No intra- nor perioperative complications were reported and patients were discharged on 4th and 5th POD, respectively.
Conclusions: In selected cases, robotic approach can be successfully used in management of surgical complication after RARC, in tertiary referral centres. ICG near infrared uorescence is a useful tool in identication of anatomical structures and allows a real-time assessment of tissue vascularity, in order to prevent complications strictly related to ischemic injuries.