Urinary diversion

Introduction

Use of robot-assisted radical cystectomy (RARC) has significantly increased over the past decade in favor of open and laparoscopic approaches. Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy in Patients with Bladder Cancer (RAZOR), an open-label noninferiority study, has further confirmed the oncologic safety of the robotic approach up to 3 years after surgery. ^, Nevertheless, all the patients underwent extracorporeal urinary diversion (ECUD) in this study. There has been growing interest in intracorporeal urinary diversion (ICUD), with up to 97% of urinary diversions performed intracorporeally in high-volume programs. While there are no randomized controlled trials comparing ICUD and ECUD, evaluation of historical cohorts has suggested equivalence. Potential benefits of ICUD include lower third space fluid loss, less blood loss, perioperative transfusions, faster bowel function recovery, shorter hospital stay, and earlier recovery.

While there has been increased adoption of ICUD, it continues to be a relatively challenging addition to an already demanding procedure. The Pasadena Consensus Panel recommends only ileal reconstruction during the initial learning curve (first 20 to 30 cases), building ICUD experience (both ileal conduit and neobladder in the 30- to 100-case range), and finally using continent reconstruction in 25% to 50% cases after greater than 100 RARC case experience. In this chapter, we aim to describe the steps of ICUD, ileal conduit, and neobladder, with step-by-step instructions and illustrations.

Preoperative preparation

Enrollment in multimodal preoperative pathways should be encouraged in addition to the routine presurgical evaluation and counseling. The Enhanced Recovery After Surgery (ERAS) pathway has previously been shown to achieve quicker recovery and enhance patient satisfaction. The ERAS pathway includes components such as skipping mechanical or chemical bowel preparation, early ambulation and oral feeding, appropriate fluid management, drugs such as alvimopan, and avoidance of epidurals. It has been shown to decrease complications, shorten length of stay, and reduce readmissions. ^, The NEEW (Nutrition, Exercise, patient Education and Wellness) pathway has been suggested as a further improvement to ERAS and was shown to have better short-term perioperative outcomes. Mechanical and pharmacologic venous thromboembolism prophylaxis should be ensured and continued postoperatively for up to 4 weeks post surgery. Choice of the diversion type depends on multiple disease, patient, and surgeon factors ( Table 26.1 ).

Surgical technique

Setup and port placement

The patient is placed in dorsal lithotomy position with adequate padding of all pressure points. The patient’s arms are adducted and padded, and the table is placed in Trendelenburg position at 30 degrees. A 22-Fr Foley catheter and a rectal tube are placed. A Veress needle is used to achieve pneumoperitoneum. The standard insufflation or the AirSeal may be used (the latter can be useful especially in female patients). A standard six-port transperitoneal approach is used. The 8-mm camera port is first placed an inch above and to the left of the umbilicus. The abdominal cavity is then inspected. All other ports are introduced under vision. Three 8-mm robotic trocars are introduced in addition to 15-mm assistant port and a 5-mm suction port. An additional 15-mm short suprapubic port is placed to facilitate bowel anastomosis toward the end of the procedure. Placing the ports 2 to 3 cm higher may facilitate bowel manipulation during ICUD ( Fig. 26.1 ). Instruments and sutures used are summarized in the box that follows.

SPECIAL EQUIPMENT REQUIRED

Robotic instruments Fenestrated bipolar (or Maryland) forceps Monopolar scissors (or hook) Cobra forceps Large needle holders ×2 Sutures Marionette stitch: 1-0 silk suture on Keith needle; ureteroileal anastomosis: 4/0 Vicryl Neobladder sutures: 3/0 V-Loc; uretherovesical anastomosis: 3/0 V-Loc; mesenteric defect: 3-0 silk; stoma: 3/0 Vicryl; stent fixation: 2-0 chromic sutures. Other instruments Endo GIA stapler, Hem-o-lok clip, AirSeal insufflator Laparoscopic scissors, suction device, graspers, Hem-o-lok clip appliers

Technique of intracorporeal ileal conduit—the “marionette” technique

Isolation of the bowel segment

A 12- to 15-cm bowel segment is identified approximately 15 to 20 cm proximal to the ileocecal valve. A silk suture on a straight Keith needle is introduced through the abdominal wall and passed through the small bowel (at the distal end of the conduit) and back through the abdominal wall as a “marionette stitch.” The marionette stitch is not tied and is used for dynamic retraction by the bedside assistant ( Fig. 26.2 ). Indocyanine green (ICG) can be injected, and the FireFly technology may be used to ensure adequate blood supply of the bowel segment used for the conduit, as well as for the distal ureters. The bowel can be manipulated using the fourth arm and the marionette stitch. The hook cautery or the hot scissors is used to develop two mesenteric windows, while ensuring a wide base to maintain adequate blood flow to the conduit. An Endo GIA stapler is used to divide the conduit from the rest of the ileum ( Fig. 26.3 ).

Preparation of the conduit and the ureter

A buttonhole enterotomy is made using scissors at the proximal end of the conduit (one or two enterotomies based on the reimplantation technique). Then using the fourth arm to hold the Hem-o-lok clip on the distal end of the clipped ureter, the ureter is spatulated generously ( Fig. 26.4 ).

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