Continent Urinary Diversion




Urinary diversion is a necessity after cystectomy. For the proper candidate, continent urinary diversion (CUD) may offer significant quality-of-life advantages. Several versions of continent diversion have been described, including the ileal orthotopic neobladder (ONB), Indiana pouch, and ureterosigmoidostomy, among others.


Laparoscopic radical cystectomy (LRC) with extracorporeal urinary diversion was first reported in 1995. LRC with extracorporeal urinary diversion and follow-up has also been reported with satisfactory oncologic and quality-of-life improvement. LRC with a completely intracorporeal ileal neobladder was first reported in two patients in 2002. The first case report of a robotic-assisted, fully intracorporeal procedure was published soon after in 2003. In the same year the first multipatient case series of robotic-assisted radical cystectomy (RARC) with extended pelvic lymph node dissection (ePLND) and urinary diversion was reported in 17 patients. This report detailed three variations of extracorporeal diversion achieved via the 5- to 6-cm incision used to extract the bladder, including the ileal conduit and the W-pouch and double-chimney (or T-pouch) neobladders. The neobladder was constructed extracorporeally through the site of specimen extraction and then was placed back into the pelvis. After the incision was closed, the neobladder-urethral anastomosis was performed robotically. This seminal publication served as the proof of concept for a robotic-assisted operation, which has since evolved.


Since that time, multiple high-volume centers and experienced surgeons have started to perform RARC with completely intracorporeal ONB, the majority of whom use some variation of the Studer pouch. The first multipatient case series was reported in 2010. More recently, a 132-patient series was reported from two institutions, demonstrating improvements in operative times, blood loss, hospital stay, and prevalence of late complications with surgeon experience.


Indications and Contraindications


All patients who are eligible for radical cystectomy should at least be considered as candidates for continent diversion, including ONB reconstruction. However, patients must meet certain criteria, including intact urethral function, absence of stress urinary incontinence, and absence of tumor infiltration into the distal prostatic urethra in men and bladder neck in women. Presence of tumor in the aforementioned areas, either on preoperative biopsy or intraoperative frozen section, contraindicates ONB. In these cases an alternative diversion such as ileal conduit or catheterizable pouch can be pursued. Patients should also be intellectually and physically capable in their understanding of their operation and postoperative care, including voiding behaviors and catheterization if necessary. ONB is also contraindicated in patients with chronic kidney disease and serum creatinine levels above 2 mg/dL (or glomerular filtration rate [GFR] <40 mL/min/1.73 m 2 ), although the procedure can occasionally be offered in the setting of recovered renal function if the condition was caused by obstruction that has since been alleviated.


Reabsorption of ammonia via ileal mucosa in patients with preexisting liver dysfunction can lead to toxic hyperammonemia, thus effectively excluding patients with cirrhosis as candidates. Furthermore, ONB should not be offered to patients with inflammatory bowel disorders such as Crohn disease. Patients of advanced age or poor functional status or those who have undergone previous radiation therapy should be selected carefully, although these factors do not absolutely contraindicate continent diversion.




Preoperative Evaluation and Preparation


The preoperative evaluation of patients undergoing planned RARC followed by ONB is largely similar for most patients as in open surgery but varies slightly depending on the operative indications. All patients should undergo a full and thorough physical examination, including assessment by a preoperative clinic for medical clearance, particularly if the patient is American Society of Anesthesiologists (ASA) class III or greater. Basic laboratory studies to assess for renal function and to rule out metabolic and hematologic abnormalities should be performed. Preoperative urine cultures, review of previous positive cultures, or both are also recommended so that appropriate prophylactic antibiotics can be administered perioperatively. If no positive cultures are available, a third-generation cephalosporin with metronidazole is commonly given on the day of surgery and stopped on postoperative day 2. If malignancy has been diagnosed, standard staging workup including chest radiograph and abdominal computed tomography (CT) are required. Bone scan may be reserved for patients with an elevated alkaline phosphatase level. All patients undergoing radical cystectomy are seen by a medical oncology team to consider neoadjuvant chemotherapy.


A stoma site should be marked in all patients in the event that the procedure is converted to an ileal conduit or catheterizable stoma. Mechanical bowel preparation and preadmission the night before surgery are routinely practiced but are omitted in some series. The patient is allowed clear liquids starting the day before surgery and then nothing by mouth beginning at midnight. During this time, the patient can also be taught clean intermittent catheterization, should the need arise at a later date.




Operating Room Configuration and Patient Positioning


The patient is placed in the supine position and general endotracheal anesthesia is administered. Intravenous antibiotics are administered. An orogastric or nasogastric tube is placed intraoperatively. A Foley catheter is placed per urethra in preparation for radical cystectomy.


The patient is positioned in the dorsal lithotomy position with the arms tucked, ensuring adequate padding of all extremities to avoid potential compartment syndrome and neurapraxia. The lateral aspects of the patient’s knees are appropriately padded. The patient is adequately secured to the table and placed in steep Trendelenburg position (15 to 45 degrees) for RARC ( Fig. 37-1 ). The Trendelenburg position is applied to slide the bowel out of the pelvis and provide adequate exposure. Before proceeding to ONB construction, Trendelenburg should be reduced to 10 to 15 degrees and the robot can be docked traditionally between the patient’s legs. Alternatively, the patient can be left supine and the robot can be side docked to avoid prolonged lithotomy position ( Fig. 37-2 ). After induction of general anesthesia, the patient is prepared and draped in the usual sterile fashion. A preparation time-out is performed, and a sterile field is created by preparing the patient’s penis or vagina, perineum, and proximal thighs up to the infraxiphoid abdomen after clipper shaving.




Figure 37-1


The patient is positioned in steep Trendelenburg position (30 to 45 degrees) for robotic-assisted radical cystectomy, which is later reduced to 10 to 15 degrees for the neobladder reconstruction.



Figure 37-2


The procedure may be performed with the patient in the low Trendelenburg position (30 degrees) to avoid prolonged lithotomy position. The da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, Calif.) may be docked between the patient’s legs (A) or optionally side docked (B).


All required instrumentation for RARC with intracorporeal ileal neobladder is listed in Box 37-1 .



BOX 37-1


Nondisposable Instrumentation





  • Four-arm da Vinci Si system (Intuitive Surgical, Sunnyvale, Calif.)



  • PlasmaKinetic bipolar generator (Gyrus ACMI PK; Gyrus ACMI, Norwalk, Ohio)



  • Laparoscopic grasper



  • Laparoscopic scissors



  • Laparoscopic KOH Macro Needle Holder (Karl Storz, Tuttlingen, Germany)



  • Hot Shears (Monopolar Curved Scissors) (Intuitive Surgical, Sunnyvale, Calif.)



  • Maryland (bipolar forceps) (Intuitive Surgical, Sunnyvale, Calif.)



  • Atraumatic Cadiere forceps (Intuitive Surgical, Sunnyvale, Calif.)



  • Large SutureCut needle driver (Intuitive Surgical, Sunnyvale, Calif.)



  • LigaSure (Valleylab, Boulder, Colo.)



  • 16-mm stapler (Endo GIA ; Covidien, Dublin, Ireland)



  • Lapra-Ty absorbable clips (Ethicon, Cincinnati, Ohio)



  • Laparoscopic Kelly



  • Ligaloop Strings (Braun-Dexon, Spangenberg, Germany)



  • 10-mm Stryker suction tip (Stryker, Kalamazoo, Mich.)



  • 5-mm-long Stryker suction tip (Stryker, Kalamazoo, Mich.)



  • Small, large, and extra-large laparoscopic Hem-o-lok appliers (Weck Closure Systems, Research Triangle Park, N.C.)



  • Three 8-mm cannulas with obturator and seals (Intuitive Surgical, Sunnyvale, Calif.)



Disposable Instrumentation





  • Basic accessory kit and drapes (Intuitive Surgical, Sunnyvale, Calif.)



  • Camera head (Intuitive Surgical, Sunnyvale, Calif.)



  • 0-degree and 30-degree endoscopes (Intuitive Surgical, Sunnyvale, Calif.)



  • StrykeFlow 2 suction/irrigation system (Stryker, Kalamazoo, Mich.)



  • Echelon Flex Powered Endopath stapler (Ethicon, Cincinnati, Ohio)



  • Weck Hem-o-lok Ligating Clips (Teleflex, Wayne, Penn.)



  • Ultra Veress needle (Ethicon, Cincinnati, Ohio)



  • One Endopath Xcel 12-mm bladeless bariatric trocar for camera port (Ethicon, Cincinnati, Ohio)



  • One Endopath Xcel 12-mm bladeless trocar (Ethicon, Cincinnati, Ohio)



  • One Endopath Xcel 15-mm bladeless trocars (Ethicon, Cincinnati, Ohio)



  • Endo Catch II 15-mm specimen pouch (Covidien, Dublin, Ireland)



  • Two extra-large Hem-o-lok clips prepared with suture attached (Weck Closure Systems, Research Triangle Park, N.C.) for clipping and tagging of the ureters



  • AirSeal trocar (Surgiquest, Milford, Conn.)



Optional Instrumentation





  • ProGrasp forceps (Intuitive Surgical, Sunnyvale, Calif.)



  • 0-Vicryl on CT-1 needle (Ethicon, Cincinnati, Ohio)



  • Echelon Endopath 45-mm stapler (Ethicon, Cincinnati, Ohio)



  • 1-0 V-Loc 90 (glycolic acid–trimethylene carbonate, Covidien, Dublin, Ireland) for vaginal reconstruction



  • Harmonic ACE Curved Shears 8-mm (Ultrasonic Energy Instrument, Intuitive Surgical, Sunnyvale, Calif.)



  • Large robotic clip applier (Intuitive Surgical, Sunnyvale, Calif.)



  • EndoWrist One Suction/Irrigator (Intuitive Surgical, Sunnyvale, Calif.)



  • EndoWrist Vessel Sealer (Intuitive Surgical, Sunnyvale, Calif.)



  • EndoWrist Stapler (Intuitive Surgical, Sunnyvale, Calif.)



  • LigaSure Atlas (Covidien, Dublin, Ireland)



  • Enseal Tissue Sealing Device (Ethicon, Cincinnati, Ohio)



  • Silicone vessel loops (Aspen Surgical Products, Caledonia, Mich.)



  • Endo GIA Ultra Universal stapler (Covidien, Dublin, Ireland)



  • Lapro-Clip (Covidien, Dublin, Ireland)



  • Firefly near infrared fluorescence visualization system (Novadaq Technologies, Mississauga, Ontario, Canada)



Instrumentation for Robotic-Assisted Radical Cystectomy with Intracorporeal Ileal Neobladder




Trocar Placement


da Vinci S and Si Robotic Systems


With a Veress needle, the abdomen is insufflated to 15 mm Hg. An Endopath Xcel 12-mm bladeless bariatric trocar (Ethicon, Cincinnati, Ohio) is inserted about 5 cm above the umbilicus. The camera is then inserted and the abdomen and pelvis are inspected for injuries to structures from insertion of the Veress needle, adhesions, and metastatic disease. Under endoscopic guidance, the remaining three 8-mm robotic ports and the two assistant ports are placed ( Fig. 37-3, A ). Two robotic ports are placed on each side of the camera port approximately 7 to 10 cm lateral and above the level of the umbilicus. The additional robotic port is placed in the right lower quadrant of the abdomen approximately 7 to 10 cm lateral to the right-sided robotic port and 5 to 7 cm superior to the iliac crest. This may be inline with or just below the other robotic ports.




Figure 37-3


A, da Vinci S/Si robotic system (Intuitive Surgical, Sunnyvale, Calif.) port placement for the ileal neobladder. The 5/12-mm assistant port may be placed either on the left (shown) or right. B, da Vinci Xi robot port placement for the ileal neobladder. The 5/12-mm assistant port may be placed either on the left (shown) or right. C, Image showing robotic port placement in an actual patient (Si robot).


An AirSeal trocar (SurgiQuest, Milford, Conn.) is then inserted on the left side 5 to 7 cm superior to the iliac crest. The use of the fourth arm on the right and 12-mm assistant port on the left facilitates bowel manipulation by avoiding acute-angle stapling. A second assistant port can be placed through the premarked stomal site when an ileal conduit is contemplated as an alternative, or it can be placed on the left side, which allows the assistant to have control of both ports from one side. Having an additional 12-mm assistant port close to the midline greatly simplifies pedicle stapling during extirpative cystectomy. The robot is then docked.


We typically use three instruments: Hot Shears (Intuitive Surgical, Sunnyvale, Calif.) in the right robotic arm, PK dissecting forceps (Intuitive Surgical, Sunnyvale, Calif.) in the left robotic arm, and Cadiere forceps (Intuitive Surgical, Sunnyvale, Calif.) in the third robotic arm. RARC can be performed entirely with these three instruments to help cut down on operative costs. However, for intracorporeal ONB, two needle drivers inclusive of one suture cut are used. The 0-degree camera lens can be used for a majority of the dissection, but the 30-degree downward lens is helpful for dissecting deep within the pelvis and for the ePLND high up to the aortic bifurcation or inferior mesenteric artery. The 30-degree upward lens may be helpful for dissecting behind the prostate, for retroapical dissection for providing additional urethral length, and for dropping the bladder.


da Vinci Xi Robotic System


As mentioned earlier, a six-port transperitoneal approach is used and all ports are placed about 5 cm cephalad to the umbilicus. On the Xi system the 12-mm camera port is replaced by a da Vinci 8-mm universal camera-robotic port ( Fig. 37-3, B and C ). The Xi also lends itself more easily to supine positioning, which may decrease positioning complications.


Laparoscopic Port Placement


A six-port transperitoneal approach is used for LRC with intracorporeal ONB creation ( Fig. 37-4 ). The five previously placed ports for LRC are used as follows: a 10- or 11-mm port above the umbilicus for the camera port; two 12-mm ports, one at the lateral edge of each rectus muscle on the left and right, just inferior to the umbilicus; a 10-mm port in the left iliac fossa; and a 5-mm port on the right at the level of the anterior superior iliac spine. A final 5-mm port is placed midway between the umbilicus and symphysis pubis. While creating the neobladder, instruments can be swapped among the different ports.




Figure 37-4


Laparoscopic port placement for the laparoscopic intracorporeal ileal neobladder procedure.




Procedure (see )


RARC is performed as described in Chapter 35 . Attention is then turned to the urinary continent diversion. Several different techniques are available to the urologist.


Completely Intracorporeal Ileal Neobladder


Historically different types of the neobladder can be constructed by using different intestinal segments. We prefer to use ileum whenever possible. We typically place sutures in the urethra in a single pass at the 5 and 7 o’clock positions in an inside-out manner at the start of this portion of the procedure, then pass them through the anterior abdominal wall so they can be retrieved later for the neobladder-urethral anastomosis.


Bowel Isolation


To construct the neobladder, we use 60 cm of distal ileum beginning 15 cm proximal to the ileocecal junction. These segments are identified and then marked with the use of two red vessel loops for the distal segment and two blue vessel loops for the proximal segment, placed through the mesentery ( Fig. 37-5 ). A sterile flexible tape measure, premeasured silk suture, or premeasured open-ended ureteral catheter is used to facilitate measurement of bowel segment length ( Fig. 37-6 ). Atraumatic Cadiere forceps are used on the right and fenestrated bipolar forceps on the left robotic arms for bowel manipulation. If needed, double fenestrated forceps or a needle driver can be used to save on cost.




Figure 37-5


Schematic representation of isolated segment of ileum with distal and proximal vessel loops (A). Neobladder configuration after bowel isolation and pouch folding (B).

Sep 11, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Continent Urinary Diversion
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