Robot-Assisted Intracorporeal Ileal Neobladder: The Next Step in Urinary Diversion

Georges-Pascal Haber, MD, PhD; Jihad Kaouk, MD; and Robert Stein, MD

Robot-assisted laparoscopic radical cystectomy and pelvic lymph node dissection (PLND) have been developed as an extension of the conventional laparoscopic approach, with the primary aim of replicating open surgery principles in a minimally invasive fashion. More recently, robotic intracorporeal urinary diversions, including ileal conduit (IC) and neobladder (NB), have been performed in a few high-volume robotic centers worldwide. Here we describe our simplified original surgical technique of robotic intracorporeal NB and present our preliminary outcomes.

Surgical procedure/perioperative care

On the day before surgery, the bowel is prepared with osmotic laxative and a stoma site is marked in case conversion to IC is necessary. A single antibiotic shot is administered at the procedure’s onset.

The patient is placed in the lithotomy position, draped in standard sterile fashion, and an 18F Foley catheter is placed. An incision is rendered two fingerbreadths above the umbilicus and a Veress needle is inserted to establish the pneumoperitoneum. Through this incision, a 12-mm camera port trocar is placed and the laparoscope is introduced. Three 8-mm robotic ports and a 12-mm assistant port on the left side are placed under direct vision. The patient is then placed in steep Trendelenburg position and the robot is docked.

After cystectomy and PLND, specimens are placed in an Endobag for later extraction through the midline camera port site in males, and through the vagina in females. A 40-cm distal ileum loop approximately 15 cm from the ileal-colic junction is selected. The bowel loop and its attached mesentery mobility are tested using traction toward the urethral stump to mimic a tension-free ileo-urethral anastomosis. The mesentery is divided using the Caiman sealing and cutting device, and the distal end is marked with a silk suture. The bowel is divided with the Endo GIA 60 stapling device.

Bowel continuity is re-established with a standard side-to side anti-mesenteric ileo-ileal anastomosis using an Endo GIA 60 stapling device cephalad to the transected bowel loop selected for diversion. The open end of the ileum is closed transversely with an additional firing of the Endo GIA 60 (Figure 1). The selected tubularized bowel segment is incised at the level of the urethral anastomosis (mid-distance from edges) (Figure 2). A running suture, starting from the posterior wall and circumferentially approaching the anterior aspect, is performed with a 3-0 barbed V-LocTM incision closure device. The final 22F Foley catheter is placed (Figure 3). Guided with the suction device, the bowel segment is divided along the anti-mesenteric line, leaving the chimney segment (5 cm) intact (Figure 4A). At the level of the previously performed ileo-urethral anastomosis, the division line is moved posteriorly and distant from the anastomosis suture line to leave enough space between the two sutures (the already performed ileo-urethral anastomosis and the anterior wall closure suture of the NB to come) at this level. The anterior and posterior walls of the detubularized bowel are sewn in a running fashion using 3-0 V-Loc sutures to shape the pouch (Figure 4B). Ureteroileal anastomoses are performed at the level of the chimney using 4-0 VicrylTM running sutures. Two 7F x 90 mm ureteral stents are advanced into the renal pelvis bilaterally and fixed to the mucosa of the diversion using 3-0 Chromic sutures (Figure 5A). The stents are delivered through the right-side 8 mm port site. A suprapubic Malecot catheter is inserted in the NB and secured to the skin (Figure 5B). The NB is completely closed and flushed with 100 mL of saline to ensure water-tightness. If leakage is observed, extra sutures must be executed.

Early mobilization is recommended. The nasogastric tube is removed on postoperative day 1, and diet is advanced for return of bowel function. The NB is manually irrigated three times daily. The two Jackson-Pratt drains, respectively placed in the pelvis and along the bowel anastomosis, are removed when the output is < 100 mL/day, after checking creatinine levels of the drain. Ureteral stents and urethral and suprapubic catheters are removed on postoperative weeks two, three and four.

Outcomes

Between February 2011 and October 2013, 14 intracorporeal NBs following robot-assisted laparoscopic radical cystectomy and PLND for bladder cancer were performed at Cleveland Clinic. Perioperative outcomes are presented in Table 1. All patients achieved negative surgical margins and remained disease-free at last follow-up. Daytime continence was reported in 11 of 14 patients and nighttime continence in 9 of 14 patients.

Dr. Haber (haberg@ccf.org) is a Physician in Cleveland Clinic’s Department of Urology.

Dr. Kaouk (kaoukj@ccf.org) is Director of the Department of Urology’s Center for Robotic and Image Guided Surgery.

Dr. Stein (steinr@ccf.org) is a Physician in Cleveland Clinic’s Department of Urology.

Also collaborating on the article: Vishnu Ganasan, MS; Idir Ouzaid, MD; and Riccardo Autorino, MD, Ph.D.

Figure 1: Loop isolation and bowel anastomosis. A: distal segment. B: proximal segment. C: latero-lateral anastomosis using an Endo GIA. D: Final aspect.

Figure 2: Ureteroileal anastomosis preparation. The site of the anastomosis is marked and the mobility of the loop is checked to ensure a tension-free suture.

Figure 3: Posterior (A) and anterior (B) suture of the ureteroileal anastomosis. Of note, the selected loop for the neobladder is still tubularized.

Figure 4: Detubularization of the bowel loop (A)and reconstruction of the neobladder (B).

Figure 5: Ureteroileal anastomosis (A) and cystostomy insertion (B). The final aspect of the neobladder as projected in the pelvis (C).