Curr Urol Rep (2014) 15:457 DOI 10.1007/s11934-014-0457-7
UROSURGERY (A STENZL, SECTION EDITOR)
Tips and Tricks for Intracorporeal Robot-Assisted Urinary Diversion J. W. Collins & A. Hosseini & P. Sooriakumaran & T. Nyberg & R. Sanchez-Salas & C. Adding & Martin C. Schumacher & N. P. Wiklund
Published online: 19 September 2014 # Springer Science+Business Media New York 2014
Abstract Since 2003, Karolinska University Hospitals have performed totally intracorporeal robotic-assisted radical cystectomy (RARC) in carefully selected patients. As our technique has evolved, the proportion of patients undergoing RARC has progressively increased. Whilst open radical cystectomy remains the gold standard, several high-volume centres have now demonstrated that RARC is both feasible and safe. RARC comprises three stages: radical cystectomy, extended lymph node dissection and urinary diversion. The majority of centres in the United States currently perform RARC utilizing an extracorporeal approach for the urinary diversion stage, perceiving this to be a more accessible option with a reduced risk of complications. We assess the evidence for this perception, reviewing the literature and reporting the functional outcomes and complication rates for a totally intracorporeal RARC approach. We also describe our technique for both intracorporeal orthotopic neobladder and intracorporeal ileal conduit, identifying the potential hazard steps and the ‘tips and tricks’ to optimize outcomes. Keywords Robotic cystectomy . Totally intracorporeal . Intracorporeal diversion . Ileal conduit . Orthotopic neobladder . Bladder cancer
Joint first authors-Collins JW and Hosseini A This article is part of the Topical Collection on Urosurgery Electronic supplementary material The online version of this article (doi:10.1007/s11934-014-0457-7) contains supplementary material, which is available to authorized users. J. W. Collins : A. Hosseini : P. Sooriakumaran : T. Nyberg : R. Sanchez-Salas : C. Adding : M. C. Schumacher : N. P. Wiklund (*) Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden e-mail: [email protected]
Introduction Karolinska University Hopsitals have performed Roboticassisted radical cystectomy (RARC) with a totally intracorporeal approach in carefully selected patients, since 2003. As our technique has evolved and outcomes have been reviewed, the proportion of patients undergoing RARC has increased progressively. Whilst open radical cystectomy remains the gold standard for muscle invasive bladder cancer, several high-volume centres have now demonstrated that robotic-assisted radical cystectomy (RARC) is both feasible and safe, with medium-term oncologic outcomes comparable to those achieved using an open surgical approach [1, 2••]. Presently, the vast majority of RARC in the United States are completed with an extracorporeal approach to the urinary diversion, with a recent multi-institutional report from the United States indicating that only 3 % of patients had a totally intracorporeal approach [1]. The potential benefits of a totally intracorporeal RARC approach include the advantages of complete minimally invasive surgery, avoiding a minilaparotomy with less intra-operative blood loss, quicker return of bowel function, and shorter hospital stay with earlier return to normal activities, which would all theoretically allow more timely administration of adjuvant chemotherapy when required. Radical cystectomy with urinary diversion is a complex surgery with high associated complication rates, whatever approach is employed [3–5]. However, a recent metaanalysis concluded that RARC is a minimally invasive alternative to open radical cystectomy with less overall perioperative complications, more lymph node yields, less estimated blood loss, reduced transfusion rates, and shorter length of stay [6]. RARC may actually be advantageous in susceptible groups such as the elderly [7, 8], and operative times in larger series are now acceptable [2••]. In experienced centres, positive surgical margin rates are comparable to open series
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[9], extended pelvic lymph node dissections are providing high yields [10] and medium and long-term oncological outcomes are encouraging, indicating that patients are not sacrificing ‘cure rates’ for the sake of a minimally invasive approach [9, 11, 12]. RARC comprises three stages, namely radical cystectomy, extended pelvic lymph node dissection (ePLND) and urinary diversion. We have previously published our technique for RARC and ePLND [2••]. Can a totally intracorporeal robotic approach deliver potential advantages with equivocal functional outcomes? In this paper, we assess the current evidence for a totally intracorporeal approach in RARC, focusing on functional outcomes and complication rates. We also describe our evolved intracorporeal approach to urinary diversion in RARC.
Materials and Methods We performed a systematic literature search using the terms ‘RARC’, ‘robotic cystectomy’, ‘robot-assisted’, ‘totally intracorporeal RARC’, ‘intracorporeal neobladder’, ‘intracorporeal urinary diversion’, ‘functional outcomes’, and ‘complication rates’, in the Medline, Embase and PubMed databases. The “related articles” function was also used to broaden the search, and the computer search was supplemented with manual searches for reference lists of all retrieved studies. The literature search revealed>200 publications. Approximately 120 studies were suitable for citation; of these, less than 30 publications focused on a totally intracorporeal RARC approach. In this article, we describe our standardised approach to both intracorporeal neobladder and intracorporeal ileal conduit formation, identifying potential hazard steps and identifying strategies to help avoid complications. Patient selection, preoperative preparation, patient positioning, and the equipment required have previously been described [13]. The preceding steps of RARC and extended lymph node dissection have also previously been described, in detail [2••, 14].
Patient Selection for RARC Selecting the correct patient for totally intracorporeal RARC and optimising their peri-operative care is crucial to optimising outcomes. All major contraindications for laparoscopic surgery (pulmonary insufficiency, inability to tolerate the Trendelenburg position, multiple abdominal adhesions) also apply in robotic surgery. Relative contraindications to RARC include obesity (BMI>30) and bulky disease, which is especially important early in the surgeon’s RARC experience.
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Preoperative Workup and Patient Preparation Standard preoperative evaluation includes computed tomography (CT) of the chest, abdomen and pelvis, routine blood tests and anaesthetic review incorporating evaluation of cardiopulmonary reserve. Patients with pT2 + tumours receive preoperative neoadjuvant platinum-based chemotherapy. Options for urinary diversion (UD) are discussed. Inclusion criteria for robot-assisted formation of an orthotopic ileal neobladder are the same as for open surgery, with all suitable patients primarily considered for orthotoptic neobladder. If a neobladder is contraindicated or if patients prefer, they will then receive an ileal conduit. The absolute contraindications for neobladder formation are: disease infiltration of the urethra distal to the prostate, impaired renal (serum creatinine>2 mg/dL) and hepatic function, and decreased mental capability and hand dexterity. The relative contraindications include: inflammatory bowel disease (Crohn’s disease), non-competent external sphincter with associated urinary incontinence, history of recurrent urethral strictures, previous abdominal or pelvic irradiation and history of severe comorbidities, elderly patients (octogenarians), or morbid obesity (BMI>30). Technique for Intracorporeal Orthotopic Neobladder Formation Step 1: Port placement and lysis of adhesions if required. Appropriate port placement is critical for successful surgery. A six-port technique is used with the camera port placed 5 cm above the umbilicus in the midline. The camera port is placed by a small mini laparotomy, as described by Hasson, and the other ports are placed in view of the camera. Two robotic ports are placed level with the umbilicus on the left and right side, lateral to the rectus sheath. The left port is placed 8 cm from the midline and the right port is placed 10–11 cm from the midline, to enable more space for the assistants’ port. A third robotic instrument port is placed 2 cm above and medial to the left anterior superior iliac spine through a 15-mm port, enabling laparoscopic stapling by the assistant when the third robotic port is temporarily disconnected. Two assistant ports are placed on either side of the right robotic instrument port, with the right lateral port 2 cm above and medial to the anterior superior iliac spine [2••]. Step 2: Development of peri‐ureteral space, clipping and division of ureters. The ureters are identified and the peritoneum covering them is carefully opened. The ureters are dissected out towards the bladder, holding them by the peri-ureteric tissue and maintaining adequate
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peri-ureteral tissue. Close to the ureterovesical junction, they are divided between two Hem-o-Lok clips. To facilitate the handling of the ureter during the ureteroenteric anastomosis, the Hem-o-lok clips on the ureter end are knotted at their corner with a suture. Later, this helps prevents direct manipulation of the ureter with the robotic instruments during construction of the urinary diversion, which may result in ureteric trauma and later strictures. The distal ureteric margin may be sent for frozen section.
RARC and ePLND Following step 2, the RARC and ePLND are completed as previously described [2••]. The specimens from RARC and ePLND are placed in separate Endo Catch bags (Covidien plc, Dublin, Ireland), and the main specimen removed through the vagina in females, and through a longitudinal extension of the peri-umbilical port site in male patients. If an ileal conduit is being performed, the bagged specimen is positioned in the left upper abdominal cavity to allow room for conduit creation. Step 3: Passing the left ureter to the right side under the mesosigmoid. After completion of radical cystectomy and ePLND, the presacral area under the mesosigmoid is already prepared, as the lymph nodes below the aortic bifurcation are removed at both sides. The robotic Cadiere forceps are passed under the sigmoid from the right to the left side. The left ureter is grasped by the stay suture and brought to the right side. Step 4: Identifying and positioning the section of terminal ileum. An ileal loop with a distance of at least 35–40 cm from its tip to the caecum is selected and brought down to the urethra. Adhesions that may make the mobilization of intestine difficult are identified and freed using sharp and blunt dissection. The ileum is sufficiently mobilized so that the anastomosis between the ileum and urethra can be made without tension. To assist the manipulation and positioning of the ileum, two vessel loops are passed around the intestine through the mesentery either side of the section of ileum loop to be anastomosed to the urethra. These vessel loops are held by the Cadiere robotic forceps [see Fig. 1]. At the tip of the Ushaped ileal loop, a 20 F opening is made in the antimesentric site of ileum, using cold robotic scissors.
Fig. 1 Incising the ileum for the ileal-urethral anastomosis
Step 5: The urethral ileal anastomoses. The anastomosis is made according to the Van Velthoven technique with a two-times 16-cm 2-0 Quill® suture, allowing for 10–12 sutures. Perineal pressure, if needed, can be applied during the initial placement of the suture. The running suture is commenced by placing both needles from outside to in, through the intestine opening, which starts to form the neobladder neck [see Fig. 2]. One needle is placed at the 5:30-o’clock position and the other needle at the 6:30- o’clock position, so that the ‘middle’ sits at the 6-o’clock position on the posterior neobladder neck. The urethral ‘bites’ are then made from inside to out, at the corresponding sites. After two such placement on each side, which covers the completed posterior aspect of anastomosis, the
Fig. 2 Forming the ileal-urethral anastomosis with the ‘Van Velthoven technique’
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neobladder neck is brought down together with the major portion of the ileal loop by tightening both sutures. Progressively tightening the sutures by the robotic needle drivers reduces the risk of the suture cutting through the urethral stump. At this point, a 22FG neobladder catheter is placed into the intestinal loop. The left suture can be locked, and is then held by either the left-side assistant or the fourth arm, under gentle traction to prevent losing the posterior anastomosis lip. The right suture is run counterclockwise back to the 1-o’clock position, passing the needle from outside to in at the neobladder neck, to inside to out at the urethra side. At this point, the right suture is now held gently and we continue with suturing the left suture arm, which is run clockwise from the 7-o’clock to the 11-o’clock position, keeping the same direction when passing the needle (e.g., from outside to inside at the neobladder neck, to inside to out at the urethra side). The bedside assistant moves the tip of the catheter in and out of the urethral stump to prevent involuntary suturing of the catheter. On completion, both suture arms are tied to each other to finish the anastomosis. The catheter balloon is inflated to 5 mL. Step 6: Commencing the orthotopic neobladder. Completing the urethral–enteric anastomosis, the ileal U-shaped loop, which is going to be the orthotopic reservoir, is now fixed in the pelvis, facilitating the harvesting of the ileum and the anastomosis. Doing so, a U-shaped ileal loop is formed that is fixed at the urethra on its tip and consists of two ileum loops (see Fig. 3a). An ileal segment of 20– 25 cm from the ileocaecal valve and 15 cm from the urethral–enteric anastomosis is selected. The EndoGIA stapler is inserted through the left hybrid 15mm trocar. The selected point of ileum is caught between the jaws of the endoscopic stapler, including 3–4 cm of its mesentery. To prevent sliding of the intestine during the firing of the Endo-GIA stapler, the bowel is held just opposite to the Endo-GIA and pushed against by the robotic Cadiere forceps. For the reconstruction of the afferent reservoir loop, a distance of≈40 cm from the urethral–enteric anastomosis is selected on the left intestine loop. The same resection procedure using the Endo-GIA stapler is followed. Step 7: Restoring continuity of the ileum with the enteric anastomosis. A hole of 1 cm in diameter is made at the antimesenteric bowel border just next to the staple line by the robotic scissors. Through each of these two holes, the jaws of the stapler are inserted to restore the continuity of the bowel (see Table 1 for
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Step 8:
Step 9:
Step 10:
Step 11:
important considerations). The transverse opening between the two ileum segments is held up by the robotic instrument and closed by a last firing of the stapler. The completed side-to-side ileum anastomosis is checked for its wideness and integrity. The mesenterium gap between the anastomosis remains almost closed and doesn’t require reconstruction. Detubularisation of ileum on antimesenteric border (see Fig. 3b). The right intestinal loop, which is fixed on its tip at the urethra, is detubularised on the antimesenteric border. The distal 40 cm of the isolated ileal segment is detubularized along its anti-mesenteric border with cold scissors. Close to urethral–enteric anastomosis, the ileum is incised just next to the mesenteric border, keeping a distance from the anastomosis and avoiding destruction of the catheter balloon. Then, the left ileum loop is detubularised, preserving a 12cm, intact, proximal iso-peristaltic afferent limb for the ureteral anastomosis. To avoid bleeding from the incision line of bowel and to keep the operation field clear, the detubularisation is carried out using the robotic hot scissors. Construction of the posterior wall of the reservoir (see Fig. 3c). By putting traction sutures every 5– 7 cm at the posterior wall of the reservoir, an exact approximation of the bowel edges is achieved, facilitating the robotic suturing. The posterior part of the Studer reservoir is closed using a multiple running suture (15 cm 3-0 V-Loc ®) in a seromuscular fashion, avoiding suturing the mucosa. Special attention is paid to leaving no gap in the suture line, by keeping a constant distance between needle passes. Folding and constructing the anterior wall of the reservoir (see Fig. 3c–e). After completion of the posterior wall of the reservoir, the right upper bottom of the U is folded over approximating diagonally to the left limb of reservoir loop, at 7–10 cm from the urethral–enteric anastomosis. Doing so results in a spherical reservoir consisting of four cross-folded ileal segments, similar to the Studer neobladder [13]. The distal half of the anterior part of the reservoir is sutured, using the same suture as that is used on the posterior wall. The proximal half of the anterior part of the reservoir is left open, leaving the last uppermost 5 cm open. This open part of the anterior reservoir wall facilitates the passage of ureter stents through the abdominal wall. The staple line of the afferent reservoir loop is excised. The ureteroenteric anastomosis. The anastomosis between the ureters and the
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Fig. 3 Forming the modified Studer neobladder from the ileum
afferent limb is performed using the Wallace technique. Using the fourth arm the ureters are aligned holding the ties attached to the Hem-o-lok clips. The ureters are then incised and spatulated 2 cm. The posterior walls of ureters are sutured side-toside, using a 15-cm running 5-0 Biosyn suture. Before the anastomosis between the ureters and
the intestinal loop is made, two single-J, 40-cm ureteric stents are introduced with the Seldinger technique through two separate 4-mm incisions at the lower part of abdominal wall. Using the Cadiere forceps, the stents are pulled through the afferent limb and pushed up into the ureters on each side. The ureters are then sutured to the afferent limb of
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Table 1 “Tips and tricks” for intracorporeal urinary diversion
Table 1 (continued) “Tips and tricks”
Stage of procedure
“Tips and tricks”
Stage of procedure
Patient selection
Careful patient selection is essential. Avoid obese patients and those with bulky disease early in your series. 1. The head and shoulders are protected by anatomic pillows. 2. Adequately pad and support the patient to avoid neuromuscular injury. 3. Elastic drapes are wrapped around the upper and lower extremities to secure the patient. 4. A special warm-air blanket covers the patient’s chest and face to avoid hypothermia. 5. A metallic bar supported at the operation table is positioned over the patient’s head to protect the head from the robotic camera and arms, and to protect the endotracheal tube.
may give you precious millimetres to get the ileum down to the urethra. However, trauma to the mesenteric vessels will result in the section of bowel being redundant. The urethral–neobladder Use gentle traction alternatively on anastomosis left and right needle to get the ileum to ‘snug down,’ taking care not to tear the urethra or neobladder neck. Removing the specimen Specimen is removed through an extended camera port in men, and the vagina in women. To prevent rupturing the specimen bag or damage to the mesentery of the ileal conduit, make sure the incision is large enough. The specimen can be removed under direct vision, with the camera placed in a 15-mm hybrid port. Restoring continuity of the ileum Three points are critical when with the enteric anastomosis performing the stapler bowel anastomosis: 1. Only the antimesenteric ileum border must be included between the jaws of stapler. 2. Each jaw must be inserted completely into the ileum lumen to secure a wide intestinal anastomosis. 3. A counter-traction must be applied to the edges of ileum by the robotic Cadiere instrument to prevent sliding of bowel during firing of the stapler. Intracorporeal neobladder Stay sutures placed every 5–7 cm in formation the posterior wall of the neobladder help to orientate the surgeon before the running 3.0 V-Loc suture is placed. Make sure no gaps are left between the suture line, keeping constant distance between needle passes. Intracorporeal ileal conduit To prevent Leakage from uretero-ileal formation anastomoses, the camera can be placed through a 15-mm hybrid port after removal of the specimen to verify that the mesentery is not malrotated and anastomoses are not under tension. Single J stents, with the end of the stent brought through the stoma, prevent temporary occlusion at the level of the abdominal wall caused by postoperative oedema. The ileal stoma should be formed after removal of the specimen and decompression of pneumoperitoneum.
Patient positioning (Because of the possible long operative duration, the patient set-up is important to prevent compartment syndromes, neural plexus lesions and hypothermia.)
Port placement
The first port is placed with the Hasson technique. All further ports are placed under direct vision, after division of adhesions as required. During placement of the ports, a pressure of 18 mmHg is advantageous. Remember to reduce the pneumoperitoneum to between 10 and 12 mmHg before commencing the operation. Dissection of ureters Avoid excessive dissection of the peri-ureters, as this causes increased risk of strictures. Passing the left ureter to the right When passing the robotic Cadiere side under the mesosigmoid forceps under the sigmoid from the right to left side, make sure the instruments move in a horizontal direction and do not damage the vessels or nerves that lie posteriorly. Isolation of terminal ileum loops Make sure it is possible for the identified section of ileum to be brought down into the pelvis to the site of the anastomosis. This is probably the most important limiting step in the whole procedure. If the ileum is unable to come down into the pelvis sufficiently despite dissection of all adhesions and suitable mobilisation, then an ileal conduit may be necessary. Reasons include short mesentry or fatty mesentry. In experienced hands, the peritoneal layer on the mesentry may be incised in a line parallel with the ileum, making sure that the incision is not damaging the mesenteric vessels below. This
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the Studer pouch. Similarly to urethral–intestinal anastomosis, the ureteroenteric anastomosis is made according to a modified van Velthoven et al. technique, using two-times 16-cm 3-0 Quill suture. After the ureteroenteric anastomosis is completed, the stents are sutured and fixed to the skin. Step 12: Construction of the final part of the reservoir anterior wall and fixation of ureter stent on the neobladder wall. The remaining part of the neobladder is then closed with a running 3-0 V-Loc suture. Both ureter stents are fixed separately using a suture around each stent to avoid dislocation. The reservoir is flushed to remove any clots and intestinal contents. The neobladder is filled with 50 mL of saline to test the integrity of both anastomoses and reservoir. Special attention is paid to check the ureteroenteric anastomosis for leakage. No cystostomy tube is placed. A 21 F passive drain is introduced and placed in the small pelvis through the right robotic port and is secured to the skin with a number 1 silk suture.
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Fig. 4 Placing the ureteric stents in an ileal conduit urinary diversion
end of the conduit is gently externalized through the stoma site and the stoma is fashioned in the standard way.
Results Technique for Intracorporeal Ileal Conduit Formation Steps 1–3 are as described above. Step 4: Connecting ureters to proximal end of conduit. A 20-cm length of intestine segment is harvested, approximately 15 cm away from the ileocecal valve, using the Endo-GIA with a 60-mm intestinal stapler. The continuity of the small bowel is restored as described above. The left ureter is tunnelled under the sigmoid mesentery to the right side. The ureters are then incised and spatulated 2 cm [see Fig. 4]. The ‘Wallace plate’ is then formed as described above (Step 11). Single-J, 40-cm ureteric stents are then introduced through the isolated ileal segment (ileal conduit), and using the Cadiere forceps, the stents are pulled through the afferent limb and pushed up into the ureters, and the entero-ureteric anastomosis is completed, using a two-times 16-cm 3-0 Quill suture [see Fig. 5]. Step 5: Formation of the ileal stoma. After removal of the specimen and decompression of the pneumoperitoneum, the marked stoma site is opened. A Babcock forceps is then passed into the peritoneal cavity and used to grasp the distal end of the ileum and the ureteral stents, and to bring them out through the stoma site. Subsequently, the distal
Our literature research concluded there is currently a limited amount of data on functional outcomes following totally intracorporeal continent urinary diversion [15]. We found four papers that reported functional outcomes with a totally intracorporeal RARC approach with neobladder formation. Most published series have created a Studer neobladder [16•, 17–19]. Continence following orthotopic bladder substitution has been shown to improve up to 12 months after surgery, with recommended standardised reporting by gender and by daytime versus nocturnal continence [16•, 20].
Fig. 5 The uretero-ileal anastomosis between the Wallace plate and the ileum
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Functional results and the associated complication rates have been summarised in Table 2.
Discussion Since 2003, robot-assisted radical cystectomy (RARC) has been gradually adopted as a surgical alternative to open cystectomy. However the rate of uptake and the number of centres performing RARC have been modest compared to robotic-assisted radical prostatectomy (RARP) [21]. In the last 25 years, there have been dramatic changes in the management of urological pelvic oncology, with open surgery being increasingly replaced by various minimally invasive techniques [22]. The changes to surgical technique have often been a step-wise evolution, especially in more complex surgery. In 1997, Ralph Clayman’s group published their early experience of Laparoscopic radical prostatectomy, and concluded that although the technique was feasible, it offered no advantage over open surgery with regard to tumour removal, continence, potency, length of stay, convalescence, and cosmetic result [23]. Likewise, the early pioneers of laparoscopic radical cystectomy who performed a totally intracorporeal approach reached similar conclusions. In 2007, Haber et al. reported a non-randomised but matched group of patients undergoing laparoscopic radical cystectomy with intracorporeal and extracorporeal urinary diversion, concluding that patients with an intracorporeal urinary diversion approach had significantly higher operative time, blood loss, transfusion rate, time to oral intake, time to ambulation, and postoperative complications compared to those having an extracorporeal urinary diversion [24]. Increased complications in the intracorporeal diversion group included anastomotic leaks, bowel obstruction and sepsis. Consequently, the authors “abandoned” the intracoproreal approach. These early findings led many centres to commence their RARC service with
an extracorporeal urinary diversion [25]. Despite RARC being a minimally invasive procedure, the majority of cases in the United States are currently completed with an extracorporeal approach to the urinary diversion [1]. However, there is accumulating evidence that increasing numbers of cases of both RARC and totally intracorporeal RARC are being performed in the US and Europe [21]. Functional outcomes following RARC depend largely on surgical choices, i.e., continent versus non-continent diversion with additional variables such as natural voiding versus required intermittent self-catheterisation. However, continence rates after RARC are influenced by multiple factors, including patient age and mental status, an intact and innervated urethral sphincter, urethral length, low-pressure/large-capacity reservoir (>300 ml), absence of bacteriuria, and completeness of voiding [20]. Patient selection for both RARC and appropriate urinary diversion is crucial to optimising outcomes. A recently published article on RARC showed that both urinary diversion type and patient comorbidity were related to complication rates. Although patients receiving ileal conduit had more comorbidities, they experienced fewer complications overall compared to those with an orthotopic bladder substitution [26]. The International Robotic Cystectomy Consortium (IRCC) published overall data on complication rates following RARC [5], finding that 41 % (n=387) and 48 % (n=448) of patients experienced a complication within 30 and 90 days of surgery, respectively. Twenty-nine percent had Clavien grade 1–2, and 19 % had Clavien grade 3–5. Gastrointestinal, infectious, and genitourinary complications were most common (27 %, 23 %, and 17 %, respectively). On multivariable analysis, increasing age group, neoadjuvant chemotherapy, and receipt of blood transfusion were independent predictors of any and high-grade complications, respectively. 30-day and 90-day mortality was 1.3 % and 4.2 %, respectively. In a second paper, the IRCC looked at the difference in
Table 2 Extracted functional results and complication rates from published data at 12 months post-totally intracorporeal RARC with neobladder formation Author
Evaluated patients (n)
Day-time continence
Night-time continence
Overall nerve sparing
Potent + Complication rates
Tyritzis et al. [16•] 70 (62 male)
88 %
72 %
69.5 %
58 %
Goh et al. [17]
8
75 %
NR
NR
NR
Canda et al. [18]
17
64.7 %
17.6 %
92 %
NR
Sala et al. [19]
1
100 %
0%
NR
NR
Clavien I–II complications for30 d) were 13 % and 11 %, respectively, while Clavien III–V complications were 31 % and 19 %, respectively. Clavien I–II complications for
UROSURGERY (A STENZL, SECTION EDITOR)
Tips and Tricks for Intracorporeal Robot-Assisted Urinary Diversion J. W. Collins & A. Hosseini & P. Sooriakumaran & T. Nyberg & R. Sanchez-Salas & C. Adding & Martin C. Schumacher & N. P. Wiklund
Published online: 19 September 2014 # Springer Science+Business Media New York 2014
Abstract Since 2003, Karolinska University Hospitals have performed totally intracorporeal robotic-assisted radical cystectomy (RARC) in carefully selected patients. As our technique has evolved, the proportion of patients undergoing RARC has progressively increased. Whilst open radical cystectomy remains the gold standard, several high-volume centres have now demonstrated that RARC is both feasible and safe. RARC comprises three stages: radical cystectomy, extended lymph node dissection and urinary diversion. The majority of centres in the United States currently perform RARC utilizing an extracorporeal approach for the urinary diversion stage, perceiving this to be a more accessible option with a reduced risk of complications. We assess the evidence for this perception, reviewing the literature and reporting the functional outcomes and complication rates for a totally intracorporeal RARC approach. We also describe our technique for both intracorporeal orthotopic neobladder and intracorporeal ileal conduit, identifying the potential hazard steps and the ‘tips and tricks’ to optimize outcomes. Keywords Robotic cystectomy . Totally intracorporeal . Intracorporeal diversion . Ileal conduit . Orthotopic neobladder . Bladder cancer
Joint first authors-Collins JW and Hosseini A This article is part of the Topical Collection on Urosurgery Electronic supplementary material The online version of this article (doi:10.1007/s11934-014-0457-7) contains supplementary material, which is available to authorized users. J. W. Collins : A. Hosseini : P. Sooriakumaran : T. Nyberg : R. Sanchez-Salas : C. Adding : M. C. Schumacher : N. P. Wiklund (*) Department of Urology, Karolinska University Hospital, 171 76 Stockholm, Sweden e-mail: [email protected]
Introduction Karolinska University Hopsitals have performed Roboticassisted radical cystectomy (RARC) with a totally intracorporeal approach in carefully selected patients, since 2003. As our technique has evolved and outcomes have been reviewed, the proportion of patients undergoing RARC has increased progressively. Whilst open radical cystectomy remains the gold standard for muscle invasive bladder cancer, several high-volume centres have now demonstrated that robotic-assisted radical cystectomy (RARC) is both feasible and safe, with medium-term oncologic outcomes comparable to those achieved using an open surgical approach [1, 2••]. Presently, the vast majority of RARC in the United States are completed with an extracorporeal approach to the urinary diversion, with a recent multi-institutional report from the United States indicating that only 3 % of patients had a totally intracorporeal approach [1]. The potential benefits of a totally intracorporeal RARC approach include the advantages of complete minimally invasive surgery, avoiding a minilaparotomy with less intra-operative blood loss, quicker return of bowel function, and shorter hospital stay with earlier return to normal activities, which would all theoretically allow more timely administration of adjuvant chemotherapy when required. Radical cystectomy with urinary diversion is a complex surgery with high associated complication rates, whatever approach is employed [3–5]. However, a recent metaanalysis concluded that RARC is a minimally invasive alternative to open radical cystectomy with less overall perioperative complications, more lymph node yields, less estimated blood loss, reduced transfusion rates, and shorter length of stay [6]. RARC may actually be advantageous in susceptible groups such as the elderly [7, 8], and operative times in larger series are now acceptable [2••]. In experienced centres, positive surgical margin rates are comparable to open series
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[9], extended pelvic lymph node dissections are providing high yields [10] and medium and long-term oncological outcomes are encouraging, indicating that patients are not sacrificing ‘cure rates’ for the sake of a minimally invasive approach [9, 11, 12]. RARC comprises three stages, namely radical cystectomy, extended pelvic lymph node dissection (ePLND) and urinary diversion. We have previously published our technique for RARC and ePLND [2••]. Can a totally intracorporeal robotic approach deliver potential advantages with equivocal functional outcomes? In this paper, we assess the current evidence for a totally intracorporeal approach in RARC, focusing on functional outcomes and complication rates. We also describe our evolved intracorporeal approach to urinary diversion in RARC.
Materials and Methods We performed a systematic literature search using the terms ‘RARC’, ‘robotic cystectomy’, ‘robot-assisted’, ‘totally intracorporeal RARC’, ‘intracorporeal neobladder’, ‘intracorporeal urinary diversion’, ‘functional outcomes’, and ‘complication rates’, in the Medline, Embase and PubMed databases. The “related articles” function was also used to broaden the search, and the computer search was supplemented with manual searches for reference lists of all retrieved studies. The literature search revealed>200 publications. Approximately 120 studies were suitable for citation; of these, less than 30 publications focused on a totally intracorporeal RARC approach. In this article, we describe our standardised approach to both intracorporeal neobladder and intracorporeal ileal conduit formation, identifying potential hazard steps and identifying strategies to help avoid complications. Patient selection, preoperative preparation, patient positioning, and the equipment required have previously been described [13]. The preceding steps of RARC and extended lymph node dissection have also previously been described, in detail [2••, 14].
Patient Selection for RARC Selecting the correct patient for totally intracorporeal RARC and optimising their peri-operative care is crucial to optimising outcomes. All major contraindications for laparoscopic surgery (pulmonary insufficiency, inability to tolerate the Trendelenburg position, multiple abdominal adhesions) also apply in robotic surgery. Relative contraindications to RARC include obesity (BMI>30) and bulky disease, which is especially important early in the surgeon’s RARC experience.
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Preoperative Workup and Patient Preparation Standard preoperative evaluation includes computed tomography (CT) of the chest, abdomen and pelvis, routine blood tests and anaesthetic review incorporating evaluation of cardiopulmonary reserve. Patients with pT2 + tumours receive preoperative neoadjuvant platinum-based chemotherapy. Options for urinary diversion (UD) are discussed. Inclusion criteria for robot-assisted formation of an orthotopic ileal neobladder are the same as for open surgery, with all suitable patients primarily considered for orthotoptic neobladder. If a neobladder is contraindicated or if patients prefer, they will then receive an ileal conduit. The absolute contraindications for neobladder formation are: disease infiltration of the urethra distal to the prostate, impaired renal (serum creatinine>2 mg/dL) and hepatic function, and decreased mental capability and hand dexterity. The relative contraindications include: inflammatory bowel disease (Crohn’s disease), non-competent external sphincter with associated urinary incontinence, history of recurrent urethral strictures, previous abdominal or pelvic irradiation and history of severe comorbidities, elderly patients (octogenarians), or morbid obesity (BMI>30). Technique for Intracorporeal Orthotopic Neobladder Formation Step 1: Port placement and lysis of adhesions if required. Appropriate port placement is critical for successful surgery. A six-port technique is used with the camera port placed 5 cm above the umbilicus in the midline. The camera port is placed by a small mini laparotomy, as described by Hasson, and the other ports are placed in view of the camera. Two robotic ports are placed level with the umbilicus on the left and right side, lateral to the rectus sheath. The left port is placed 8 cm from the midline and the right port is placed 10–11 cm from the midline, to enable more space for the assistants’ port. A third robotic instrument port is placed 2 cm above and medial to the left anterior superior iliac spine through a 15-mm port, enabling laparoscopic stapling by the assistant when the third robotic port is temporarily disconnected. Two assistant ports are placed on either side of the right robotic instrument port, with the right lateral port 2 cm above and medial to the anterior superior iliac spine [2••]. Step 2: Development of peri‐ureteral space, clipping and division of ureters. The ureters are identified and the peritoneum covering them is carefully opened. The ureters are dissected out towards the bladder, holding them by the peri-ureteric tissue and maintaining adequate
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peri-ureteral tissue. Close to the ureterovesical junction, they are divided between two Hem-o-Lok clips. To facilitate the handling of the ureter during the ureteroenteric anastomosis, the Hem-o-lok clips on the ureter end are knotted at their corner with a suture. Later, this helps prevents direct manipulation of the ureter with the robotic instruments during construction of the urinary diversion, which may result in ureteric trauma and later strictures. The distal ureteric margin may be sent for frozen section.
RARC and ePLND Following step 2, the RARC and ePLND are completed as previously described [2••]. The specimens from RARC and ePLND are placed in separate Endo Catch bags (Covidien plc, Dublin, Ireland), and the main specimen removed through the vagina in females, and through a longitudinal extension of the peri-umbilical port site in male patients. If an ileal conduit is being performed, the bagged specimen is positioned in the left upper abdominal cavity to allow room for conduit creation. Step 3: Passing the left ureter to the right side under the mesosigmoid. After completion of radical cystectomy and ePLND, the presacral area under the mesosigmoid is already prepared, as the lymph nodes below the aortic bifurcation are removed at both sides. The robotic Cadiere forceps are passed under the sigmoid from the right to the left side. The left ureter is grasped by the stay suture and brought to the right side. Step 4: Identifying and positioning the section of terminal ileum. An ileal loop with a distance of at least 35–40 cm from its tip to the caecum is selected and brought down to the urethra. Adhesions that may make the mobilization of intestine difficult are identified and freed using sharp and blunt dissection. The ileum is sufficiently mobilized so that the anastomosis between the ileum and urethra can be made without tension. To assist the manipulation and positioning of the ileum, two vessel loops are passed around the intestine through the mesentery either side of the section of ileum loop to be anastomosed to the urethra. These vessel loops are held by the Cadiere robotic forceps [see Fig. 1]. At the tip of the Ushaped ileal loop, a 20 F opening is made in the antimesentric site of ileum, using cold robotic scissors.
Fig. 1 Incising the ileum for the ileal-urethral anastomosis
Step 5: The urethral ileal anastomoses. The anastomosis is made according to the Van Velthoven technique with a two-times 16-cm 2-0 Quill® suture, allowing for 10–12 sutures. Perineal pressure, if needed, can be applied during the initial placement of the suture. The running suture is commenced by placing both needles from outside to in, through the intestine opening, which starts to form the neobladder neck [see Fig. 2]. One needle is placed at the 5:30-o’clock position and the other needle at the 6:30- o’clock position, so that the ‘middle’ sits at the 6-o’clock position on the posterior neobladder neck. The urethral ‘bites’ are then made from inside to out, at the corresponding sites. After two such placement on each side, which covers the completed posterior aspect of anastomosis, the
Fig. 2 Forming the ileal-urethral anastomosis with the ‘Van Velthoven technique’
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neobladder neck is brought down together with the major portion of the ileal loop by tightening both sutures. Progressively tightening the sutures by the robotic needle drivers reduces the risk of the suture cutting through the urethral stump. At this point, a 22FG neobladder catheter is placed into the intestinal loop. The left suture can be locked, and is then held by either the left-side assistant or the fourth arm, under gentle traction to prevent losing the posterior anastomosis lip. The right suture is run counterclockwise back to the 1-o’clock position, passing the needle from outside to in at the neobladder neck, to inside to out at the urethra side. At this point, the right suture is now held gently and we continue with suturing the left suture arm, which is run clockwise from the 7-o’clock to the 11-o’clock position, keeping the same direction when passing the needle (e.g., from outside to inside at the neobladder neck, to inside to out at the urethra side). The bedside assistant moves the tip of the catheter in and out of the urethral stump to prevent involuntary suturing of the catheter. On completion, both suture arms are tied to each other to finish the anastomosis. The catheter balloon is inflated to 5 mL. Step 6: Commencing the orthotopic neobladder. Completing the urethral–enteric anastomosis, the ileal U-shaped loop, which is going to be the orthotopic reservoir, is now fixed in the pelvis, facilitating the harvesting of the ileum and the anastomosis. Doing so, a U-shaped ileal loop is formed that is fixed at the urethra on its tip and consists of two ileum loops (see Fig. 3a). An ileal segment of 20– 25 cm from the ileocaecal valve and 15 cm from the urethral–enteric anastomosis is selected. The EndoGIA stapler is inserted through the left hybrid 15mm trocar. The selected point of ileum is caught between the jaws of the endoscopic stapler, including 3–4 cm of its mesentery. To prevent sliding of the intestine during the firing of the Endo-GIA stapler, the bowel is held just opposite to the Endo-GIA and pushed against by the robotic Cadiere forceps. For the reconstruction of the afferent reservoir loop, a distance of≈40 cm from the urethral–enteric anastomosis is selected on the left intestine loop. The same resection procedure using the Endo-GIA stapler is followed. Step 7: Restoring continuity of the ileum with the enteric anastomosis. A hole of 1 cm in diameter is made at the antimesenteric bowel border just next to the staple line by the robotic scissors. Through each of these two holes, the jaws of the stapler are inserted to restore the continuity of the bowel (see Table 1 for
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Step 8:
Step 9:
Step 10:
Step 11:
important considerations). The transverse opening between the two ileum segments is held up by the robotic instrument and closed by a last firing of the stapler. The completed side-to-side ileum anastomosis is checked for its wideness and integrity. The mesenterium gap between the anastomosis remains almost closed and doesn’t require reconstruction. Detubularisation of ileum on antimesenteric border (see Fig. 3b). The right intestinal loop, which is fixed on its tip at the urethra, is detubularised on the antimesenteric border. The distal 40 cm of the isolated ileal segment is detubularized along its anti-mesenteric border with cold scissors. Close to urethral–enteric anastomosis, the ileum is incised just next to the mesenteric border, keeping a distance from the anastomosis and avoiding destruction of the catheter balloon. Then, the left ileum loop is detubularised, preserving a 12cm, intact, proximal iso-peristaltic afferent limb for the ureteral anastomosis. To avoid bleeding from the incision line of bowel and to keep the operation field clear, the detubularisation is carried out using the robotic hot scissors. Construction of the posterior wall of the reservoir (see Fig. 3c). By putting traction sutures every 5– 7 cm at the posterior wall of the reservoir, an exact approximation of the bowel edges is achieved, facilitating the robotic suturing. The posterior part of the Studer reservoir is closed using a multiple running suture (15 cm 3-0 V-Loc ®) in a seromuscular fashion, avoiding suturing the mucosa. Special attention is paid to leaving no gap in the suture line, by keeping a constant distance between needle passes. Folding and constructing the anterior wall of the reservoir (see Fig. 3c–e). After completion of the posterior wall of the reservoir, the right upper bottom of the U is folded over approximating diagonally to the left limb of reservoir loop, at 7–10 cm from the urethral–enteric anastomosis. Doing so results in a spherical reservoir consisting of four cross-folded ileal segments, similar to the Studer neobladder [13]. The distal half of the anterior part of the reservoir is sutured, using the same suture as that is used on the posterior wall. The proximal half of the anterior part of the reservoir is left open, leaving the last uppermost 5 cm open. This open part of the anterior reservoir wall facilitates the passage of ureter stents through the abdominal wall. The staple line of the afferent reservoir loop is excised. The ureteroenteric anastomosis. The anastomosis between the ureters and the
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Fig. 3 Forming the modified Studer neobladder from the ileum
afferent limb is performed using the Wallace technique. Using the fourth arm the ureters are aligned holding the ties attached to the Hem-o-lok clips. The ureters are then incised and spatulated 2 cm. The posterior walls of ureters are sutured side-toside, using a 15-cm running 5-0 Biosyn suture. Before the anastomosis between the ureters and
the intestinal loop is made, two single-J, 40-cm ureteric stents are introduced with the Seldinger technique through two separate 4-mm incisions at the lower part of abdominal wall. Using the Cadiere forceps, the stents are pulled through the afferent limb and pushed up into the ureters on each side. The ureters are then sutured to the afferent limb of
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Table 1 “Tips and tricks” for intracorporeal urinary diversion
Table 1 (continued) “Tips and tricks”
Stage of procedure
“Tips and tricks”
Stage of procedure
Patient selection
Careful patient selection is essential. Avoid obese patients and those with bulky disease early in your series. 1. The head and shoulders are protected by anatomic pillows. 2. Adequately pad and support the patient to avoid neuromuscular injury. 3. Elastic drapes are wrapped around the upper and lower extremities to secure the patient. 4. A special warm-air blanket covers the patient’s chest and face to avoid hypothermia. 5. A metallic bar supported at the operation table is positioned over the patient’s head to protect the head from the robotic camera and arms, and to protect the endotracheal tube.
may give you precious millimetres to get the ileum down to the urethra. However, trauma to the mesenteric vessels will result in the section of bowel being redundant. The urethral–neobladder Use gentle traction alternatively on anastomosis left and right needle to get the ileum to ‘snug down,’ taking care not to tear the urethra or neobladder neck. Removing the specimen Specimen is removed through an extended camera port in men, and the vagina in women. To prevent rupturing the specimen bag or damage to the mesentery of the ileal conduit, make sure the incision is large enough. The specimen can be removed under direct vision, with the camera placed in a 15-mm hybrid port. Restoring continuity of the ileum Three points are critical when with the enteric anastomosis performing the stapler bowel anastomosis: 1. Only the antimesenteric ileum border must be included between the jaws of stapler. 2. Each jaw must be inserted completely into the ileum lumen to secure a wide intestinal anastomosis. 3. A counter-traction must be applied to the edges of ileum by the robotic Cadiere instrument to prevent sliding of bowel during firing of the stapler. Intracorporeal neobladder Stay sutures placed every 5–7 cm in formation the posterior wall of the neobladder help to orientate the surgeon before the running 3.0 V-Loc suture is placed. Make sure no gaps are left between the suture line, keeping constant distance between needle passes. Intracorporeal ileal conduit To prevent Leakage from uretero-ileal formation anastomoses, the camera can be placed through a 15-mm hybrid port after removal of the specimen to verify that the mesentery is not malrotated and anastomoses are not under tension. Single J stents, with the end of the stent brought through the stoma, prevent temporary occlusion at the level of the abdominal wall caused by postoperative oedema. The ileal stoma should be formed after removal of the specimen and decompression of pneumoperitoneum.
Patient positioning (Because of the possible long operative duration, the patient set-up is important to prevent compartment syndromes, neural plexus lesions and hypothermia.)
Port placement
The first port is placed with the Hasson technique. All further ports are placed under direct vision, after division of adhesions as required. During placement of the ports, a pressure of 18 mmHg is advantageous. Remember to reduce the pneumoperitoneum to between 10 and 12 mmHg before commencing the operation. Dissection of ureters Avoid excessive dissection of the peri-ureters, as this causes increased risk of strictures. Passing the left ureter to the right When passing the robotic Cadiere side under the mesosigmoid forceps under the sigmoid from the right to left side, make sure the instruments move in a horizontal direction and do not damage the vessels or nerves that lie posteriorly. Isolation of terminal ileum loops Make sure it is possible for the identified section of ileum to be brought down into the pelvis to the site of the anastomosis. This is probably the most important limiting step in the whole procedure. If the ileum is unable to come down into the pelvis sufficiently despite dissection of all adhesions and suitable mobilisation, then an ileal conduit may be necessary. Reasons include short mesentry or fatty mesentry. In experienced hands, the peritoneal layer on the mesentry may be incised in a line parallel with the ileum, making sure that the incision is not damaging the mesenteric vessels below. This
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the Studer pouch. Similarly to urethral–intestinal anastomosis, the ureteroenteric anastomosis is made according to a modified van Velthoven et al. technique, using two-times 16-cm 3-0 Quill suture. After the ureteroenteric anastomosis is completed, the stents are sutured and fixed to the skin. Step 12: Construction of the final part of the reservoir anterior wall and fixation of ureter stent on the neobladder wall. The remaining part of the neobladder is then closed with a running 3-0 V-Loc suture. Both ureter stents are fixed separately using a suture around each stent to avoid dislocation. The reservoir is flushed to remove any clots and intestinal contents. The neobladder is filled with 50 mL of saline to test the integrity of both anastomoses and reservoir. Special attention is paid to check the ureteroenteric anastomosis for leakage. No cystostomy tube is placed. A 21 F passive drain is introduced and placed in the small pelvis through the right robotic port and is secured to the skin with a number 1 silk suture.
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Fig. 4 Placing the ureteric stents in an ileal conduit urinary diversion
end of the conduit is gently externalized through the stoma site and the stoma is fashioned in the standard way.
Results Technique for Intracorporeal Ileal Conduit Formation Steps 1–3 are as described above. Step 4: Connecting ureters to proximal end of conduit. A 20-cm length of intestine segment is harvested, approximately 15 cm away from the ileocecal valve, using the Endo-GIA with a 60-mm intestinal stapler. The continuity of the small bowel is restored as described above. The left ureter is tunnelled under the sigmoid mesentery to the right side. The ureters are then incised and spatulated 2 cm [see Fig. 4]. The ‘Wallace plate’ is then formed as described above (Step 11). Single-J, 40-cm ureteric stents are then introduced through the isolated ileal segment (ileal conduit), and using the Cadiere forceps, the stents are pulled through the afferent limb and pushed up into the ureters, and the entero-ureteric anastomosis is completed, using a two-times 16-cm 3-0 Quill suture [see Fig. 5]. Step 5: Formation of the ileal stoma. After removal of the specimen and decompression of the pneumoperitoneum, the marked stoma site is opened. A Babcock forceps is then passed into the peritoneal cavity and used to grasp the distal end of the ileum and the ureteral stents, and to bring them out through the stoma site. Subsequently, the distal
Our literature research concluded there is currently a limited amount of data on functional outcomes following totally intracorporeal continent urinary diversion [15]. We found four papers that reported functional outcomes with a totally intracorporeal RARC approach with neobladder formation. Most published series have created a Studer neobladder [16•, 17–19]. Continence following orthotopic bladder substitution has been shown to improve up to 12 months after surgery, with recommended standardised reporting by gender and by daytime versus nocturnal continence [16•, 20].
Fig. 5 The uretero-ileal anastomosis between the Wallace plate and the ileum
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Functional results and the associated complication rates have been summarised in Table 2.
Discussion Since 2003, robot-assisted radical cystectomy (RARC) has been gradually adopted as a surgical alternative to open cystectomy. However the rate of uptake and the number of centres performing RARC have been modest compared to robotic-assisted radical prostatectomy (RARP) [21]. In the last 25 years, there have been dramatic changes in the management of urological pelvic oncology, with open surgery being increasingly replaced by various minimally invasive techniques [22]. The changes to surgical technique have often been a step-wise evolution, especially in more complex surgery. In 1997, Ralph Clayman’s group published their early experience of Laparoscopic radical prostatectomy, and concluded that although the technique was feasible, it offered no advantage over open surgery with regard to tumour removal, continence, potency, length of stay, convalescence, and cosmetic result [23]. Likewise, the early pioneers of laparoscopic radical cystectomy who performed a totally intracorporeal approach reached similar conclusions. In 2007, Haber et al. reported a non-randomised but matched group of patients undergoing laparoscopic radical cystectomy with intracorporeal and extracorporeal urinary diversion, concluding that patients with an intracorporeal urinary diversion approach had significantly higher operative time, blood loss, transfusion rate, time to oral intake, time to ambulation, and postoperative complications compared to those having an extracorporeal urinary diversion [24]. Increased complications in the intracorporeal diversion group included anastomotic leaks, bowel obstruction and sepsis. Consequently, the authors “abandoned” the intracoproreal approach. These early findings led many centres to commence their RARC service with
an extracorporeal urinary diversion [25]. Despite RARC being a minimally invasive procedure, the majority of cases in the United States are currently completed with an extracorporeal approach to the urinary diversion [1]. However, there is accumulating evidence that increasing numbers of cases of both RARC and totally intracorporeal RARC are being performed in the US and Europe [21]. Functional outcomes following RARC depend largely on surgical choices, i.e., continent versus non-continent diversion with additional variables such as natural voiding versus required intermittent self-catheterisation. However, continence rates after RARC are influenced by multiple factors, including patient age and mental status, an intact and innervated urethral sphincter, urethral length, low-pressure/large-capacity reservoir (>300 ml), absence of bacteriuria, and completeness of voiding [20]. Patient selection for both RARC and appropriate urinary diversion is crucial to optimising outcomes. A recently published article on RARC showed that both urinary diversion type and patient comorbidity were related to complication rates. Although patients receiving ileal conduit had more comorbidities, they experienced fewer complications overall compared to those with an orthotopic bladder substitution [26]. The International Robotic Cystectomy Consortium (IRCC) published overall data on complication rates following RARC [5], finding that 41 % (n=387) and 48 % (n=448) of patients experienced a complication within 30 and 90 days of surgery, respectively. Twenty-nine percent had Clavien grade 1–2, and 19 % had Clavien grade 3–5. Gastrointestinal, infectious, and genitourinary complications were most common (27 %, 23 %, and 17 %, respectively). On multivariable analysis, increasing age group, neoadjuvant chemotherapy, and receipt of blood transfusion were independent predictors of any and high-grade complications, respectively. 30-day and 90-day mortality was 1.3 % and 4.2 %, respectively. In a second paper, the IRCC looked at the difference in
Table 2 Extracted functional results and complication rates from published data at 12 months post-totally intracorporeal RARC with neobladder formation Author
Evaluated patients (n)
Day-time continence
Night-time continence
Overall nerve sparing
Potent + Complication rates
Tyritzis et al. [16•] 70 (62 male)
88 %
72 %
69.5 %
58 %
Goh et al. [17]
8
75 %
NR
NR
NR
Canda et al. [18]
17
64.7 %
17.6 %
92 %
NR
Sala et al. [19]
1
100 %
0%
NR
NR
Clavien I–II complications for30 d) were 13 % and 11 %, respectively, while Clavien III–V complications were 31 % and 19 %, respectively. Clavien I–II complications for
