The minimally invasive approach to urinary diversion has increased in popularity over the past decade. Earlier, the laparoscopic approach was criticized because of its steep learning curve, prolonged operative time, and limited instrument maneuverability. These challenges led to the development of hybrid approaches in which bladder extirpation was done by conventional laparoscopy followed by creation of diversion using a modified open approach. More recently, laparoscopy has been largely replaced by robot-assisted surgery, which has gained popularity among both surgeons and patients. Currently, among large-volume robot-assisted radical cystectomy programs, up to 97% of urinary diversions were performed intracorporeally. Although this increase has been primarily for ileal conduits and to a lesser extent for neobladders, the current trends suggest increased utilization with improved outcomes for intracorporeal urinary diversion (ICUD).
What Affects the Decision of Urinary Diversion Approach and Type?
ICUD is appropriate for most patients except those with decreased cardiac and pulmonary compliance. These patients may not have enough cardiopulmonary reserve to tolerate the pneumoperitoneum or the steep Trendelenburg position. However, the newer Xi model of the da Vinci Surgical System and AirSeal (Conmed, NY, USA) has mitigated this issue by decreasing the need for steep Trendelenburg angle to more manageable levels.
Neobladder creation is absolutely contraindicated if urethral/bladder neck soft tissue margins are positive, the length of the mesentery is inadequate, presence of renal/hepatic compromise, and unwillingness or inability to perform intermittent self-catheterization. Relative contraindications include adjuvant chemotherapy, locally advanced bladder cancer with high risk of recurrence, advanced age, bowel disease, prior abdominal or pelvic surgeries, prior pelvic radiation, urethral disease, comorbidities, and noncompliance with directions. Finally, patient preference and surgeon comfort with the procedure are important driving forces behind the selection of diversion type for each patient.
In addition to routine presurgical evaluation and counselling, enrollment in multimodal perioperative pathways should be encouraged. Enhanced Recovery After Surgery (ERAS) is one such pathway that has been shown to achieve early recovery after surgery with better patient satisfaction. ERAS components including early ambulation, appropriate fluid management, early oral feeding, use of chewing gum, drugs like alvimopan, and avoidance of epidurals have been shown to decreases length of stay, complications, and readmissions. Further improvements on the ERAS pathway have been suggested. The Nutrition, Exercise, patient Education and Wellness (“NEEW” pathway) has shown improved short-term perioperative outcomes. Additionally, mechanical and chemical bowel preparation should be avoided. Anticoagulant therapy should be used before and up to 4 weeks after surgery.
The patient is placed in the lithotomy position with adequate padding of pressure points. The da Vinci Xi robot has allowed for the supine position and side docking. The patient’s arms are adducted and padded, and the table is placed in the 30-degree Trendelenburg position. A 20-Fr Foley catheter and a rectal tube are inserted. A Veress needle is used to achieve the pneumoperitoneum. The standard insufflation or the AirSeal (Conmed, NY, USA) may be used (the latter can be useful, especially in female patients). A standard six-port transperitoneal approach is used. The 8-mm camera port is first placed an inch above and to the left of the umbilicus. The abdominal cavity is then inspected. All other ports are introduced under vision. Three 8-mm robotic trocars are introduced in addition to a 15-mm assistant port and a 5 mm suction port. An additional 15-mm short suprapubic port is placed to facilitate bowel anastomosis towards the end of the procedure. Placing the ports an inch higher may facilitate bowel manipulation during ICUD ( Fig. 35.1 ).
Technique of intracorporeal ileal conduit
Herein we describe the “marionette” technique. (see for Modified Studer technique.) ,
Isolation of the bowel segment
A 12–15 cm bowel segment is identified approximately 15–20 cm proximal to the ileocecal valve. A silk suture on a straight Keith needle is introduced through the abdominal wall and passed through the small bowel and back through the abdominal wall as a “marionette” stitch. The marionette stitch is not tied and is used for dynamic retraction by the bedside assistant ( Fig. 35.2 ).
Indocyanine green may be injected, and Firefly technology may be used ensure adequate blood supply of the bowel segment used for the conduit, as well as for the distal ureters. The hook cautery is used to develop two mesenteric windows ensuring a wide base at the base of the mesentery. An Endo GIA stapler is used to divide the conduit from the rest of the ileum ( Fig. 35.3 ).
Preparation of the conduit and the ureter
Using a sharp scissors, a buttonhole enterotomy is made at the proximal end of the conduit (one or two enterotomies based on the reimplantation technique). Then, using the fourth arm to hold the Hem-o-lok clip on the distal end of the ureter, the ureter is spatulated generously ( Fig. 35.4 ).
The left ureter is crossed towards the right side through the sigmoid mesentery. Caution should be used to avoid twisting of the ureter and injury to the major vessels. Also, ureteral dissection must be performed in a fashion that ensures inclusion of enough periureteral tissue to maintain vascularity.
Both ureters are aligned together using the fourth arm. The adjacent inner ends of the ureters are sutured together in a running fashion to form the Wallace plate. This is followed by ureteroileal anastomosis using 4-0 VICRYL suture in a continuous fashion ( Fig. 35.5 ).
Each ureter is sutured on its corresponding side of the conduit ( Fig. 35.6 ).