Step-by-step robotic intracorporeal ileal conduit urinary diversion

Abstract

Background: Radical cystectomy with urinary diversion is the standard surgical treatment for muscle invasive bladder cancer. The use of the robotic approach, including performing an intracorporeal urinary diversion, has increased in recent years. Intracorporeal urinary diversion has been shown to be safe and effective [1], with shorter operative time, lower blood loss and fewer blood transfusions when compared to extracorporeal urinary diversion [2]. Objectives: To describe our approach for intracorporeal ileal conduit urinary diversion and highlight key aspects of our surgical technique. Methods: We report the case of a 79-year-old male with bacillus Calmette-Guerin refractory, high grade T1 non-muscle invasive bladder cancer who underwent a robotic radical cystectomy with intracorporeal ileal conduit urinary diversion. The robotic ports are placed 6 cm more cephalad than the standard prostatectomy configuration and the left lateral 12-mm robotic fourth arm/stapler port is placed one handbreadth toward the anterior superior iliac spine. Although this orientation is not the standard robotic port configuration for cystectomy, it is otherwise optimized for stapler maneuverability during formation of the diversion. Intraoperatively, we utilize a 20-centimeter non-absorbable suture as a measuring ruler to designate the proximal and distal ends of the ileal conduit and ensure appropriate orientation. A 60-mm robotic stapler is utilized to isolate the ileal loop and then to form the side-to-side ileo-ileal anastomosis. We inject 2 mL of indocyanine green [IC-Green TM Akorn Inc, Lake Forest, USA] followed by 10 mL of saline intravenously to assess for adequate distal ureteral perfusion under near infrared fluorescence prior to formation of a Bricker [3] ureteroileal anastomoses. A double-J stent is placed in each ureter and sutured to the ileal conduit to prevent stent migration. Finally, we close the retroperitoneal space to reduce the risk of internal bowel herniation under the ileal-ureteric anastomosis. Results: Intraoperatively, estimated blood loss was 250 mL and total operative time was 401 min. The intracorporeal ileal conduit urinary diversion took 142 min to perform. There were no intraoperative complications and the patient was discharged on postoperative day 4 after an uneventful hospital course. At 5 weeks postoperatively, both double-J stents were removed in the outpatient setting via a flexible pouchoscopy. At 6 months follow-up, there were no major (Clavien>2) postoperative complications. Conclusion: Intracorporeal ileal conduit formation is a feasible technique for urinary diversion in patients who undergo robotic radical cystectomy for bladder cancer.

Keywords

• Intracorporeal ileal conduit
• Robotic urinary diversion
• Robotic cystectomy