Patient and Preoperative Preparation
Patients being considered for laparoscopic radical cystectomy (LRC) or robot-assisted radical cystectomy (RARC) should undergo complete metastatic and staging evaluation. Particular attention needs to be paid to abdominal and pelvic computed tomography (CT) or magnetic resonance imaging (MRI) to evaluate for lymphadenopathy, local extension of tumor, and anatomic abnormalities. Neoadjuvant chemotherapy may be considered for any patient with muscle invasive disease with or without clinical evidence of regional or systemic extension of disease. Currently, it is the not the practice of the authors to perform any preoperative bowel preparation. If small intestine is to be used for an ileal conduit or ileal neobladder, then a bowel preparation is not needed. Simply making the patients NPO, or nothing by mouth, after midnight before surgery is all that is needed. Although the current literature supports that even for elective colorectal surgery, mechanical bowel preparation is not necessary, many urologists still use some version of a mechanical bowel preparation for urinary diversions that use the colon. Most recommend the use of enemas, especially in the preoperative holding area, if a patient has had pelvic radiation to eliminate most fecal contents from the rectum and sigmoid colon. All patients should be strategically marked immediately before surgery for the potential urostomy site. All patients are educated preoperatively regarding care and maintenance of a urostomy or neobladder based on choice of urinary diversion.
Preoperative Preparation and Checklist
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Laboratory
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Basic metabolic panel
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Liver transaminases
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Complete blood count
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Radiologic imaging
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Chest radiograph
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CT or MRI of abdomen and pelvis
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Additional
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Electrocardiogram
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Anesthesia and cardiac clearance
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Anesthesia and Patient Positioning
Broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms are administered 60 minutes before skin incision. Long sequential compression stockings are placed on the lower extremities. The preoperative initiation of an opioid receptor antagonist (alvimopan) to decrease the duration of postoperative ileus is currently routinely used by the authors unless it is contraindicated. Preoperative deep vein thrombosis prophylaxis should be used per institutional practice (standard heparin or low-molecular-weight heparin). A nasogastric tube is placed for decompression of the stomach. An arterial line may be inserted to monitor blood gases for potential acidosis and hypercapnia. The urethral catheter is placed after the patient is prepped and positioned. The patient is placed in low lithotomy position with the arms tucked to the side. Care must be taken to ensure the patient’s hands and elbows are adequately padded because they often lie between the patient’s thigh and attachment of the stirrup. This will allow access to the abdomen and perineum. The patient will be placed in extreme or maximal Trendelenburg during the case, and this must be tested before prepping and draping the patient. A chest strap may be used; however, patients rarely move on the bed with the arms tucked and the legs in low lithotomy stirrups. Shoulder harnesses are not needed and may actually cause impingement complications.
Positioning of Operating Room Equipment and Personnel
The required instruments are as follows:
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Monopolar robotic scissors on the first robotic arm
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Maryland bipolar forceps or vessel sealer on the second robotic arm
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ProGrasp forceps on the fourth robotic arm
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Two needle drivers
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Endovascular GIA stapler (optional)
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Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC)
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Suction-irrigation device
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Atraumatic grasper
The da Vinci system is docked between the patient’s legs with the robotic arms oriented in a cephalad direction. The primary assistant operates from the patient’s right. The robotic fourth arm is positioned on the patient’s right side if an intracorporeal diversion is to be performed. If an extracorporeal diversion is to be performed, then it can be positioned based on surgeon preference. The control tower for the da Vinci system is placed just left of the patient’s left leg. Adjacent to the control tower are the instrument table and the scrub nurse. This leaves ample room for the scrub nurse and a second assistant, if needed, to be positioned on the left side of the patient. A viewing monitor is located on top of the control tower as well as one to the opposite side of the first assistant. (It is preferable if this second monitor is on a ceiling boom.) The surgeon console may be placed according to surgeon preference.
Technique
In female patients undergoing a cystourethrectomy, periurethral incision can be performed before the cystectomy portion of the procedure to facilitate the vaginal dissection during the robotic approach.
The steps for LRC are the same as described below for RARC. If performing an LRC, one may elect to add additional instrumentation such as additional laparoscopic sealing devices and nonrobotic instruments.
Port Placement
A total of six ports are used during the operation. There are one 12-mm camera port, three 8-mm robotic arm ports, and two assistant ports on the side opposite the fourth robotic arm. The assistant ports should be a 15-mm port in the lower quadrant and a 5 mm port in the upper quadrant (12 mm can be used in cases with anticipated difficulty). A 15-mm port is mandatory in these cases for easier extraction of the specimen during lymph node dissection, The ports are arranged in an “inverted-V” fashion as diagrammed ( Fig. 54.1 ). The camera port is placed in the midline cephalad to the umbilicus. The port is 3 to 4 cm cephalad for ileal conduits and lowered slightly to 3 cm for neobladder diversions. The two 8-mm robotic ports are placed 8 to 9 cm lateral from the midline and approximately 1 cm above the superior aspect of the umbilicus to allow for proximal ureteral and lymphadenectomy dissection. With newer da Vinci Surgical Systems, the cephalad placement still allows for access to the deeper pelvic structures. The two assistant ports are placed lateral and caudad to the robotic port. The fourth robotic arm port is placed directly lateral to the left robotic port. Access and establishment of the pneumoperitoneum can be performed with a Veress or Hassan technique depending on surgeon preference. An important point is to avoid going out of the way to make one of the working robotic ports to serve as the conduit site. In general, patients are marked so as to be through the rectus muscle and a working port in this location would be too medial and result in external collision.
Mobilization of the Sigmoid and Left Colon
After ports are in place and the robot is docked, the surgeon should orient him- or herself to the pelvic anatomy by identifying specific landmarks. A 30-degree down lens is used at the outset of the procedure and allows for better visualization of the pelvic structures. This will be changed to a 0-degree lens after the posterior and lateral portions of the bladder are dissected. Identification of the urachus and its relationship to the internal inguinal ring is helpful. By following the peritoneal fold of the medial umbilical ligaments posteriorly, the lateral aspect of the bladder and the umbilical ligaments become apparent. The relationship of the iliac vessels to the internal inguinal ring and umbilical ligaments is easier to identify on the right because the sigmoid colon obscures the left iliac vessels on the left. The procedure is begun by incising peritoneum lateral to the left colon ( Fig. 54.2 ). The left colon and sigmoid colon should be released from the left side wall to allow access to the left iliac vessels and left ureter. This is done along the white line of Toldt where the sigmoid colon is separated from the lateral abdominal wall as high as possible and reflected medially and superiorly out of the surgical field.
Development of the Left Paravesical Space
The left medial umbilical ligament should be identified and retracted medially with the help of the assistant. The peritoneum just lateral to the ligament and medial to the left iliac vessels should be incised. The incision extends from the anterior abdominal wall to the bifurcation of the common iliac artery and just parallel to the ligament itself. Care should be taken to make this incision as superficial as possible to avoid injury to underlying vascular structures. After an incision is made, the pneumoperitoneum will help with delineating the potential paravesical space, and blunt dissection can be used to develop it. The dissection can often be carried caudad to expose the endopelvic fascia. There is a general tendency to dissect toward the anterior abdominal wall instead of redirecting the plane posteriorly and inferiorly toward the pelvis. This may result in injury to the inferior epigastric artery, which can result in troublesome bleeding. In male patients, dividing the vas deferens early during this step and as soon as it is encountered is necessary to allow the bladder to be retracted medially and will significantly widen the paravesical space which will subsequently make the lymphadenectomy easier. During this maneuver, the sigmoid colon is retracted medially.
Identification, Mobilization and Division of the Left Ureter
The left ureter is identified crossing over the iliac vessels at the bifurcation of the common iliac artery ( Fig. 54.3, A ). The ureter should be dissected free of its underlying structures while as much periureteral tissue as possible is preserved. The distal end can be dissected down to its insertion into the bladder. The left umbilical artery or left superior vesical artery should be seen just lateral to the insertion of the ureter into the bladder and can be clipped and divided to allow for greater ureteral length. The ureter can be clipped with a locking clip that has a pretied suture to the crotch of the clip ( Fig. 54.3, B ). One may use a different color suture for the left- and right-sided clips. The ureter is divided, and a margin may be sent for frozen section. The ureter should be dissected free of its lateral attachments as far cephalad as possible, but preservation of some medial blood supply from the common iliac artery is preferred. Again, the surrounding periureteral tissue should be preserved. If a pretied suture of the clip is not used, then the distal ureter can be tagged with an 8- to 10-cm 2-0 suture
Identification of the Left Iliac Vessels
Optimal visualization of the left iliac vessels is achieved with medial retraction of the sigmoid colon and the bladder. The surgeon should be oriented by the lateral aspect of the bladder and umbilical artery that have already been identified.
Perform the Left Pelvic Lymphadenectomy
The left pelvic lymphadenectomy can be performed with a variety of instruments. The authors currently use a Maryland bipolar in one hand and monopolar scissors in the dominant hand. The dissection is begun on the left external iliac artery. A “split-and-roll” technique is used. A small piece of lymphatic tissue overlying the middle part of the artery is elevated with the Maryland forceps. A small window is created and bluntly widened until the wall of the artery is identified. After this is accomplished, splitting and rolling proceeds both proximally and distally along the shaft of the external iliac artery. The Maryland forceps is serving as if it is a right-angle forceps in open surgery. It is used to elevate the lymphatic tissue off the surface of the artery, and then the tissue is cut with the monopolar scissors. The dissection should be carried proximally along the common iliac artery up to the bifurcation of the aorta. Great care should be taken during dissection along the external and common iliac veins because of the collapsed nature of the veins from the pressure of the pneumoperitoneum. A space between the lateral aspect of the external iliac artery and the medial wall of the psoas muscle is developed. By developing this space and retracting the vessels medially, a more extensive pelvic dissection can be performed. Please note that the obturator nerve can in fact be identified lateral to the external iliac vessels with this dissection. Furthermore, the obturator nerve dissection will be much more complete when approached from the medial aspect again after retracting the vessels laterally. The obturator nerve is easily identified by orienting oneself with the pubic ramus. By following a line directly posterior to the point where the external iliac vein crosses the pubic ramus, one can find the obturator nerve and vessels. No blind cutting should be done until adequate visualization of the obturator nerve is achieved. We highly encourage splitting and rolling the nerve as one would do for any vessels to prevent injury. Use of cautery can help identify the nerve when the obturator reflex is triggered. The hypogastric artery can be skeletonized down to the take-off of the umbilical artery. Lymph nodes can be removed in separate packets with 10-mm specimen retrieval bags. There are multiple use specimen retrieval bags such as the Anchor tissue retrieval system (Anchor, Addison, IL) that prevents the need to open several different bags.
Development of the Right Paravesical Space
After the left pelvic lymphadenectomy is completed, attention is directed to the right hemipelvis. The right paravesical space is developed similar to the left paravesical space. The peritoneum is incised between the right medial umbilical ligament and right iliac vessels ( Fig. 54.4 ).
