Initial Experience With a Step-Specific Reconstructive Strategy During Robot-Assisted Radical Cystectomy Using the da Vinci SP System

Objective

To evaluate the technical feasibility, perioperative safety, and short-term reconstructive outcomes of a step-specific reconstructive strategy during robot-assisted radical cystectomy (RARC) using the da Vinci SP system.

Methods

We retrospectively reviewed 17 consecutive patients who underwent single-port RARC (SP-RARC) with ileal conduit diversion. Extracorporeal bowel isolation and ileoileal anastomosis were performed in all patients. After confirmation of negative ureteral margins and adequate perfusion using indocyanine green fluorescence imaging, extracorporeal ureteroileal anastomosis was performed when tension-free anastomosis was feasible; otherwise, the robot was re-docked and intracorporeal ureteroileal anastomosis was selectively performed. Robot-assisted retroperitonealization of the ureteroileal anastomosis was attempted in all patients.

Results

Median operative time was 405 min and median estimated blood loss was 345 mL. Bilateral extracorporeal ureteroileal anastomosis was completed in nine patients, whereas selective intracorporeal anastomosis of one or both ureters was performed in eight. In five of these eight patients, additional ureteral resection based on frozen-section or perfusion assessment resulted in insufficient length for tension-free extracorporeal anastomosis. Retroperitonealization was completed in 14 patients. No conversion to open surgery occurred. Clavien–Dindo grade ≥ II and ≥ III complications occurred in seven and three patients, respectively. At the most recent imaging follow-up, no renal unit had Society for Fetal Urology grade ≥ 3 hydronephrosis.

Conclusion

This step-specific strategy was technically feasible, preserving extracorporeal bowel reconstruction as the standard approach while allowing selective intracorporeal ureteroileal anastomosis when required. It prioritized negative margins, ureteral perfusion, anastomotic tension, and operative safety over rigid adherence to a single reconstructive method.