Step-by-step robotic intracorporeal orthotopic neobladder formation

Abstract

Objective

Radical cystectomy with urinary diversion is the standard of care for management of muscle invasive bladder cancer. In appropriately selected patients, orthotopic neobladder formation may offer benefits including preserved body image and continence. We describe our approach to robotic intracorporeal orthotopic neobladder formation.

Patients and surgical procedure

We report the case of a 60-year-old male with high grade T2a muscle invasive bladder cancer who underwent robotic radical cystectomy with intracorporeal orthotopic neobladder formation. Robotic ports are placed 6 cm more cephalad than the standard prostatectomy configuration and the left lateral 12 mm robotic fourth arm is placed one handbreadth toward the anterior superior iliac spine for optimal operability of the robotic stapler. Following standard radical cystectomy and bilateral pelvic lymph node dissection, we construct the neobladder by forming a W-shaped configuration of ileum with two troughs anchored to the foley catheter. The anti-mesenteric side of the ileum is detubularized and a posterior ileal plate is formed by suturing the cut edges of the anti-mesenteric borders. A circumferential ileo-urethral anastomosis is completed, and the anterior ileal plate is formed by suturing together the lateral most cut edges of the anti-mesenteric borders. Ureteral stents are placed and the ileal neobladder is removed from continuity using a robotic stapler. Uretero-enteric anastomoses are completed over the ureteral stents and intravenous indocyanine green is visualized under near infrared fluorescence to assess for vascularization of the anastomosis.

Results

Total operative time was 500 min with estimated blood loss of 300 mL. There were no intraoperative complications, and the patient was discharged on postoperative day 5 after an uncomplicated hospitalization. The patient's foley and ureteral stents were removed on postoperative day 14. At 12-months follow-up, there were no major (Clavien > 2) postoperative complications.

Conclusions

Robotic intracorporeal orthotopic neobladder formation can be an effective technique for urinary diversion in patients with muscle invasive bladder cancer.