Minimally Invasive Bladder Procedures: Radical Cystectomy, Partial Cystectomy, Urachal Excision, Diverticulectomy



Minimally Invasive Bladder Procedures: Radical Cystectomy, Partial Cystectomy, Urachal Excision, Diverticulectomy


ANDRE LUIS DE CASTRO ABREU

SAMEER CHOPRA

INDERBIR S. GILL



It is estimated that 72,570 new cases of bladder cancer (BCa) with 15,210 deaths due to this disease occurred in the United States during 2013. Excluding dermatologic malignancies, BCa is the fourth most common cancer and eighth most common cause of death in American men (1). Radical cystectomy (RC) remains the gold standard for treatment of muscle-invasive or refractory non-muscle-invasive BCa (2). It provides satisfactory long-term oncologic outcomes, as it is curative for most patients who have localized disease, with 5- and 10-year recurrence-free survival rates approaching 70% (3). Minimally invasive RC has emerged as an alternative to open radical cystectomy (ORC). It successfully duplicates all technical aspects of the open approach and achieves similar functional and oncologic outcomes while minimizing blood loss, transfusion rates, and potentially, procedural morbidity.

The first laparoscopic radical cystectomy (LRC) with extracorporeal ileal conduit was reported in 1995 (4). Gill et al. (5,6) reported the first cases of LRC with ileal conduit and orthotopic ileal neobladder performed completely intracorporeally in 2000 and 2002, respectively. The first robot-assisted radical cystectomy (RARC) was performed in Germany in 2002, and in 2003, Menon et al. published the first case series of RARC (7,8). Like other robot-assisted surgeries, RARC is gaining popularity. In fact, the proportion of RARCs has consistently increased from 0.6% in 2004 to 12.8% in 2010, and more than 2,101 RCs were performed with robotic assistance to date (9,10). We perform RARC and urinary diversion routinely at our institution and herein present our step-by-step technique.






ALTERNATIVE THERAPY

Bladder-preserving protocols using external beam and chemotherapy are available for those who may not be considered for radical cystectomy.



ENHANCED RECOVERY AFTER SURGERY PROTOCOL

Table 28.1 emphasizes part of our Enhanced Recovery after Surgery (ERAS) protocol.


RADICAL CYSTECTOMY

Thorough preoperative evaluation is necessary, including cardiac and medical clearance. The patient starts with a clear liquid diet the day prior to surgery. A stoma site is marked before RARC for all patients by an enterostomal therapist. Heparin is administered 1 hour prior to surgery and intravenous antibiotic (typically cefoxitin) is administered at induction until 24 hours postoperatively. As such, the patient preparation is similar as for ORC.


Patient Positioning and Port Placement

Under general anesthesia, the patient is placed in supine position with abducted legs in the appropriate securely fashioned leggings (Fig. 28.1A). All pressure points are meticulously padded and the patient is secured to the surgical table. Sequential compression stockings are applied prior to induction. The patient is prepared from the nipples down to the midthighs, including the genitalia. A warming blanket covers the upper chest and shoulders. After sterile preparation and draping of the patient, a 20Fr Foley urethral catheter is inserted.








TABLE 28.1 ENHANCED RECOVERY AFTER SURGERY PROTOCOL









Preoperative




  • 2-3-hour precystectomy educational class



  • Carbohydrate loading for 2-3 days prior to surgery



  • No mechanical or antibiotic bowel preparation preoperatively



  • Alvimopan



  • No epidural analgesia


Intraoperative




  • Opioid-sparing anesthesia



  • Minimize intravenous fluid based on stroke volume/central venous pressure


Postoperative




  • No nasogastric tube



  • Nausea and vomiting prophylaxis



  • Alvimopan



  • Neostigmine



  • H2 blocker and proton pump inhibitor



  • Early enteral feeding



  • Nonnarcotic pain control



  • 24-hour perioperative antibiotics



  • Home intravenous hydration



  • Prophylactic antibiotics



  • Oral sodium bicarbonate at time of discharge if needed



  • Regular phone calls to check on the patients at home


A 15 mm Hg pneumoperitoneum is created with a 2-mm MiniPort and is maintained at this pressure, even during active suction, by a high-flow insufflator. Six transperitoneal ports (four ports of 8 mm for the robot) are placed more cephalad than the port position commonly used for robotic prostatectomy, with the camera port placed in the midline, 5 to 10 cm above the umbilicus (Fig. 28.1B). A 15-mm port is placed in the left iliac fossa and a 12-mm port is placed in the upper left quadrant; the positioning of these two ports is important for allowing a favorable angle for the staplers during small bowel transection and reconstruction, as well as for the removal of lymph nodes in packets, according to node templates dissection. This configuration allows for the dissection of the urachus, extended or superextended lymphadenectomy (if necessary), and adequate intestinal mobilization. With the patient placed in steep Trendelenburg, the robotic platform da Vinci Si Surgical System is then positioned between the patient’s legs and the robot is docked. The first assistant stands on the left side of the patient.


Anatomic Orientation

Upon initial inspection, the surgeon must identify five important landmarks:



  • The medial umbilical ligaments


  • The peritoneal folds overlying the ureters close to the bladder


  • The vasa on each side


  • The posterior cul-de-sac of the rectovesical pouch


  • The iliac vessels

Identification of these landmarks is essential because it allows for precise orientation throughout the procedure and expeditious dissection.


Mobilization and Division of the Ureters

The ureters are identified at the level where they cross the iliac vessels and the posterior peritoneum is incised. The ureters, along with their surrounding fat, are dissected distally until their insertion into the bladder. It is important to maintain an adequate cover of periureteric fatty tissue. Close to the vesicoureteric junction, the superior vesical artery and the vas deferens are visualized crossing the ureter. These are mobilized away from the ureteric surface to obtain maximum ureteric length. The ureters are then divided just before they enter the bladder (prior to the ureteral orifice) between Hem-O-Lok clips and a sample of each proximal portion is sent for pathologic assessment. The Hem-O-Lok clips on the bladder side of the transected ureter serve as critical landmarks during the subsequent dissection, as they provide a readily identifiable visual clue during transection of the lateral pedicles. The ureters remain clipped throughout the procedure to create proximal ureteral hydrodistention, which facilitates later ureteroenteric anastomosis.


Retrovesical Dissection

With the robotic arm retracting the bladder anteriorly, the lateral peritoneotomies of the rectovesical pouch that were previously performed are now joined across the midline. It is
important that the peritoneotomy across the cul-de-sac be created distally, such that it is only 1 to 2 cm anterior to the surface of the rectum. Often, there is a subtle transverse peritoneal fold at this location (we refer to it as the “second peritoneal fold”). This plane is now developed between the vasa and seminal vesicles anteriorly and the anterior surface of the rectum posteriorly. The vessels supplying the seminal vesicles are controlled, and bilateral vasa and vesicles are maintained en bloc with the bladder. Continued dissection brings the posterior layer of Denonvilliers fascia into view, which is incised with cold Shears (monopolar curved scissors) to reveal the yellow prerectal fat posterior to the prostate. This is an important landmark guiding the posterior dissection; the plane must remain between the prostate anteriorly and the prerectal fat posteriorly toward to the prostate apex, thus minimizing chance of rectal injury (Fig. 28.2).






FIGURE 28.1 A: Patient is placed in supine position with abducted legs in steep Trendelenburg. B: Port placement for RARC is similar to robot-assisted radical prostatectomy; however, the ports are placed more cephalad and an additional 15-mm port is placed in the left inferior quadrant. 4th, fourth robotic arm; As, assistant port; Cam, camera; Rb, robotic arm.


Lateral Dissection of the Bladder and Control of Vascular Pedicles

The parietal peritoneum lateral to the medial umbilical ligaments is incised from the vas deferens as it crosses the pelvic brim toward the peritoneotomy across the rectovesical cul-de-sac. The vasa are clipped and divided at the pelvic brim. The space between the bladder and the lateral pelvic wall is now developed bluntly, retracting the bladder medially away from the iliac vessels and the obturator nerve. As the bladder is still anteriorly attached to the abdominal wall, this allows the lateral pedicles to be clearly identified bilaterally. The lateral pedicles are now divided with 60-mm laparoscopic vascular staplers (Fig. 28.3). Once again, the
two clips on the bladder end of the transected juxtavesical ureters serve as critical landmarks for the anteromedial limit of resection; the laparoscopic stapler is deployed just posterolateral to these clips. Usually, two or three stapler cartridge firings are necessary on each side to control the entire width of the lateral pedicles down to the endopelvic fascia on either side.






FIGURE 28.2 Dissection of the rectovesical space. The bladder is retracted anteriorly by the fourth arm, and a plane between the prostate (anterior) and prerectal fat (posterior) is developed toward the apex of the prostate. SV, seminal vesicles.






FIGURE 28.3 Ligation of the left bladder pedicle during cystoprostatectomy (A) and of the right bladder pedicle during anterior pelvic exenteration (B), with the use of a vascular stapler.

The posterior pedicles are now visualized coursing from just lateral to the rectum toward the urinary bladder. These are controlled with the stapler or divided between sequentially applied Hem-O-Lok clips. Usually, only the cephalad part of the posterior pedicles can be controlled at this stage; the caudal aspect is addressed after releasing the bladder from the anterior abdominal wall and completing the anterior dissection. At this point, the dissection is within proximity to the anterolateral surface of the rectum.


Anterior Dissection

A liberal inverted U incision is made with the hot Shears electrocautery, starting lateral to each medial umbilical ligament, with the limbs of the U joined anteriorly across the midline at the umbilicus. The urachus and medial umbilical ligaments are divided just caudal to the umbilicus. The bladder is dynamically pulled posteriorly, an avascular plane between the muscles aponeurosis and prevesical fat is dissected caudally toward the pubic bone and endopelvic fascia. The bladder is then released from the anterior abdominal wall; care is taken to protect the inferior epigastric vessels as they course up from the external iliac vessels to enter the posterior rectus sheath.

The space of Retzius is developed behind the pubic bone. Areolar tissue is dissected away to expose the anterior surface of the prostate and the endopelvic fascia on each side. The endopelvic fascia is incised down to the region of the dorsal venous complex. The superficial dorsal vein is coagulated and the fat overlying the anterior surface of the prostate is cleared off with the bipolar forceps. The puboprostatic ligaments are divided with cold Shears.


Transection of Dorsal Vein Complex and Membranous Urethra and Specimen Entrapment

The dorsal vein complex (DVC) is now ligated, using a 0-Vicryl on a CT-1 needle and carefully transected with cold scissors toward the anterior surface of the urethra. The remaining posterior pedicles are then clipped and divided. If an orthotopic neobladder reconstruction is planned, a long urethral stump is required. Thus, a meticulous dissection with small cuts surrounding the urethra is performed, releasing the urethra from the prostate apex. An anterior urethrotomy is performed, and the Foley catheter is then divided between Hem-O-Lok clips to avoid local spillage of urine. The urethra is now transected just proximal to the verumontanum and biopsies of the proximal and distal urethra are sent for frozen section evaluation. The free specimen is entrapped in an Endo Catch bag (II Endo Catch bag 15 mm) and parked in one side within the abdomen for later retrieval.


MODIFICATIONS FOR NERVE-SPARING CYSTECTOMY IN MEN

Once the ureters are divided and posterior dissection commences, care is taken to stay closely along the surface of the seminal vesicles, as the neurovascular bundles run lateral to the apical tip of the vesicles distally toward the prostate-vesicular junction. Thermal energy is avoided in the vicinity of the bundles. The plane of dissection is closer to the bladder and further away from the rectum. The bundle on either side is dissected away with cold Shears, and hemostasis is secured with Hem-O-Lok clips. This is in contrast to the non-nerve-sparing technique, in which a laparoscopic stapler is used for en masse transection of the lateral pedicle more posterolaterally, closer to the rectum, and at a considerable distance from the bladder. During the anterior dissection, the endopelvic fascia is maintained intact, and the lateral
pelvic fascia is incised high on the prostate to drop the bundles posteriorly. The DVC is then divided as previously described. The bundles on either side are released from the prostate apex using cold Shears, and the urethra is divided. The remainder of the operation proceeds in the usual fashion.






FIGURE 28.4 Cystectomy in women. A: During anterior pelvic exenteration, gauze is inserted in the vulva to help identify the vagina (arrow). B: In reproductive organ-sparing cystectomy, the dissection is created between the bladder and the uterus (dotted line and insert).


MODIFICATIONS FOR CYSTECTOMY IN WOMEN


Pelvic Exenteration

For cystectomy in women, the procedure begins with the dissection of the ureters as previously described. The uterus is pulled proximally by the fourth robotic arm and Endo GIA staplers transect the infundibulopelvic ligaments and the uterine arteries. An incision is made in the posterior peritoneum near the uterine cervix. A stick sponge previously inserted into the vagina facilitates visualization of the vaginal fornix (Fig. 28.4). The remaining posterior dissection and the vaginal incision are made after preparing the DVC. The lateral pedicles are transected with laparoscopic staplers and the bladder is dropped in the usual fashion as described earlier. The DVC is suture-ligated with a 2-0 polyglactin suture on a CT-1 needle.

Attention is now returned to the posterior dissection. With the uterus anteverted, a transverse incision of the posterior vaginal fornix is completed at the previously scored site. The vaginal incision is extended distally on either side of the urethra, excising a narrow central strip of vagina en bloc with the bladder specimen. Using a perineal approach, the external meatus and distal urethra are circumferentially cored out using electrocautery. The urethra is then resected along with the bladder, the anterior two-third portion of the vagina, the uterus, and the ovaries. The specimen is entrapped in an Endo Catch bag and extracted through the vulva (Fig. 28.5). A minipad is placed in the vulva to minimize the loss of CO2 and the pneumoperitoneum is maintained by a high-flow insufflator. These allow for vaginal reconstruction using 2-0 V-Loc sutures on a CT-1 needle via robotic technique before proceeding with urinary diversion.

If a urinary orthotopic neobladder reconstruction is planned, the distal urethra must be preserved (Fig. 28.5). Thus, the urethra must be carefully dissected and sectioned allowing for a sufficiently long stump for neobladder-urethral anastomosis. In these cases, it is recommended to pad the remainder of the vagina with the omental patch positioned between the neobladder and the vagina to prevent urinary fistula formation.






FIGURE 28.5 In women, an excellent choice for extraction of the surgical specimen is through the vagina. If an orthotopic neobladder is planned for UD, an adequate urethral stump is preserved.



REPRODUCTIVE ORGAN-SPARING CYSTECTOMY

In carefully selected, sexually active women with less aggressive organ-confined disease, a reproductive organ-sparing cystectomy can be an option. In these cases, the suspensory ligaments of the ovaries and the uterine arteries and ligaments are preserved. Precise dissection of the bladder away from the uterus and vagina is critically important. With a stick sponge inserted through the vulva, the vagina is pulled posteriorly and the uterus is retroverted using the robotic fourth arm. The bladder is identified, and the peritoneum on the anterior surface of the uterus is incised transversely using hot scissors (Fig. 28.4). With the bladder now retracted anteriorly, dissection is performed along and close to the anterior surface of the uterus, developing this avascular plane. Typically, dissection proceeds smoothly until the cervix is reached, where adhesions are often dense. At this point, care is taken not to thin the vaginal wall or enter the bladder. This dissection is carried distally down to the bladder neck, which is the landmark of posterior dissection. Anterior dissection is now performed and the lateral pedicles are divided with a stapler. The urethra is prepared in the usual fashion and the rest of the procedure is followed as previously described. As the vagina is not opened, the specimen is entrapped in an Endo Catch II bag for later retrieval.


EXTENDED AND SUPEREXTENDED LYMPHADENECTOMY


Surgical Technique

Although the extent of lymphadenectomy is debatable, it is noteworthy that not only the lymph node yield but also the quality of resection, including skeletonization of the arteries is important (16).






FIGURE 28.6 A: Extended pelvic lymphadenectomy. Note the “skeletonization” of the external iliac arteries (EIA), internal iliac arteries (IIA), common iliac arteries (CIA), and proximal lymph node dissection extension above the aortic (Ao) bifurcation. B: Lymphadenectomy of the left obturator fossa.

Also relevant is the ligation of the larger lymphatic vessels to prevent formation of lymphocele or chylous ascites, and care must be taken to avoid cutting into any enlarged lymph nodes to minimize the risk of tumor spillage. We perform lymph node dissection after the robotic cystectomy. The landmarks (template) for superextended lymphadenectomy are distally the lymph nodes of Cloquet, laterally the genitofemoral nerve, medially the perivesical fat, and proximally the inferior mesenteric artery (IMA). Therefore, the anterior surface of the aorta and vena cava up to the IMA, along with the para-aortic, preaortic, interaortocaval, precaval, and pericaval lymphatic fatty tissue/nodes, are excised. The aortic bifurcation and the presacral area are also dissected (17). The technique mimics the “split-and-roll” technique used during ORC. Right lymphadenectomy is performed first. Using the 30-degree camera lens, the lymphadenectomy begins distally with the dissection of the lymph nodes of Cloquet. It then continues proximally toward the bifurcation of the aorta up to the IMA (Fig. 28.6A). To obtain a good dissection of the obturator fossa, lateral dissection is necessary up to the external iliac vessels allowing for direct visualization of the obturator nerve (Fig. 28.6B). The right ureter should be dissected cranially to avoid inadvertent proximal damage. The lymphadenectomy then continues in the left pelvic region, which is initially performed from proximal to distal (aorta to iliac vessels), as opposed to the technique on the right side. The mesosigmoid is retracted laterally to the left allowing lymphadenectomy of the left internal iliac vessels and presacral region. This maneuver facilitates the creation of a “window” below the sigmoid colon for later transposition of the left ureter to right during ureteral bowel anastomosis (Fig. 28.7). The remainder of the left pelvic lymphadenectomy is performed in the same fashion as the right lymphadenectomy. The sigmoid colon is now retracted to the right and the dissection begins distally and continues proximally toward the already skeletonized internal iliac vessels. The removal of the lymph nodes occurs in packets, according to the templates, and the nodes are placed in the appropriate bag at the time that each region is dissected, as this may influence the number of lymph nodes removed (18).







FIGURE 28.7 During the course of lymphadenectomy, a “window” in the mesosigmoid (MS) is created to allow the passage of the left ureter from left to right. CIA, common iliac artery; IIA, internal iliac artery.


URINARY DIVERSION


Surgical Technique


Intracorporeal Orthotopic Ileal Neobladder

In order to create a spherical orthotopic ileal neobladder (OIN) with a good filling capacity while maintaining a low pressure, the principles of ORC should be replicated and applied to the robotic approach (19,20). Here, we describe our updated technique for OIN (20). For the urinary diversion (UD), the use of atraumatic Cadiere forceps instead of a Pro-Grasp Forceps is essential to avoid intestinal injury during bowel manipulation.


Isolation of the Small Bowel Intestine

A total of 65 cm of small bowel segment is isolated as follows: 44 cm of the reservoir, 16 cm of the chimney, and 5 additional cm are discarded (“discarded segment”) during the small bowel anastomosis (Fig. 28.8). Using the 30-degree camera lens, the first step in creating the neobladder is to identify a loop of ileum that reaches the urethra without tension, which is usually located 25 to 30 cm proximal to the ileocecal valve. This point is marked with a 3-0 V-Loc barbed stitch in the antimesenteric edge of the bowel and it will be the site of neobladder-urethral anastomosis. This is a major step of the UD because it saves time and ensures the feasibility of performing neobladder-urethral anastomosis without tension. From this point, we measure 11 cm distally (toward to the ileocecal valve) and 11 cm proximally (total 22 cm). The use of a previously metered Penrose is important because it ensures accurate measuring and, because it is malleable, it facilitates intracorporeal manipulation. This point (22 cm) is marked with an undyed 2-0 Vicryl and is pulled distally toward the pelvis by the fourth arm (denoting the apex of the posterior plate). An additional 22 cm is measured proximally to this point (total 44 cm) and is also marked with an undyed 2-0 Vicryl to signify the end of the reservoir and beginning of the chimney. An additional 16 cm (total: 60 cm) is measured proximal to this point (44 cm) for the chimney. Finally, 5 cm (total: 65 cm) of proximal ileum (“discarded segment”) is resected and discarded. This discarded segment helps “keeping out” the neobladder, preventing neobladder-bowel fistula, and ensuring good vascularization to the ends of the bowel during the intestine reconstruction (anastomosis). To avoid confusion during the intestine reconstruction, the ends of the intestine are marked with undyed Vicryl for the UD (undyed for UD) part and with dyed Vicryl for the gastrointestinal part.

Inserting a 60-mm laparoscopic stapler through the 15-mm port in the left iliac fossa allows for a good angle for isolation and reconstruction of the small bowel intestine. Normally, one cartridge of staples is enough to allow adequate bowel mobilization without compromising its vascularization. Indocyanine green (“firefly”) can be used to facilitate visualization of mesentery vascularization and ensure no vascular injury occurred while firing the stapler through the bowel and mesentery (Fig. 28.9). The isolated intestinal segments are now properly marked and transected, and the surgery proceeds with the bowel continuity reconstruction. For this, the suture lines of the staples are removed, the bowel edges are aligned, and the side-to-side intestinal anastomosis is performed with the 60-mm laparoscopic stapler firing along the antimesenteric border and then across the open intestinal borders. The mesenteric window is closed with an interrupted suture.


Bowel Detubularization and Suture of the Posterior Plate of the Neobladder

With the fourth robotic arm pulling the 22-cm point (apex of the posterior plate) toward the pelvis, a 24Fr chest tube is inserted through the 12-mm port in the upper left quadrant and inserted into the small intestine. This greatly facilitates the longitudinal opening of the intestine (with hot scissors) in the antimesenteric border but near to the medial part of the mesentery. The medial edges of the intestinal segments are aligned and interrupted sutures (2-0 Vicryl) are placed to allow handling and symmetry of the pouch. A running suture using a 2-0 V-Loc stitch on a CT-1 needle is carried out from distal to proximal and the posterior plate of the neobladder is created. A “free-hands” suture is performed during the entire pouch creation and, in order to save time, it can be facilitated by (a) the assistant pulls the stitch with the hook for every needle during the running suture and (b) the use of a barbed V-Loc stitch avoids losing the stitches, therefore keeping the suture line watertight.


Neobladder-Urethral Anastomosis and Folding the Pouch

After suturing the posterior plate of the neobladder, it is rotated 90 degrees counterclockwise to align the previously placed 3-0 V-Loc stitch (neobladder-urethral anastomosis point; 11 cm) with the urethra. At this point, the antimesenteric edge that was previously marked with 3-0 V-Loc is sutured to the distal Denonvilliers fascia, adjacent to the rectourethralis muscle, to decrease tension on the anastomosis. The urethra-neobladder anastomosis is then performed with a double-armed 3-0 Monocryl suture on a RB-1 needle. The anastomosis begins at the posterior edge of the urethra (“6 o’clock”) and continues anteriorly in a running fashion over a urethral
catheter (22Fr Couvelaire) (Fig. 28.10). The anastomosis is completed when the left and right running sutures reach the midline. This is followed by the anterior folding of the lateral edge of the intestine, performed by a running suture using barbed 2-0 V-Loc on a CT-1 needle to create a spherical configuration for the neobladder. A small opening is left in the anterior suture line to allow passage of bilateral ileoureteral stents.






FIGURE 28.8 Intracorporeal ileal neobladder: duplicating the open technique. A: A total of 65 cm of small bowel segment is isolated as follows: 44 cm of the reservoir, 16 cm of the chimney, and 5 cm for discard (“discarded segment”). B: A loop of ileum that reaches the urethra without tension is identified and marked with a barbed stitch as the neobladder-urethral anastomosis (NUA) location. From this point, 11 cm distal (toward to the ileocecal valve) and 11 cm proximal (apex of the posterior plate [APP]) are measured. This additional 22 cm is marked. A chest tube is inserted into the intestine to facilitate its detubularization. C: The medial edges of the intestine are sutured and the posterior plate of the neobladder is then rotated 90-degree counterclockwise. D: The neobladder is anastomosed to the urethra (square) and the lateral edges of the intestine are anteriorly folded. E: Final configuration of the neobladder and ureteral-chimney anastomosis (insert).


Ureteral-Chimney Anastomoses

For ureteral anastomoses using the chimney of the neobladder, the distal parts of the ureters that were clipped with Hem-O-Loks are resected. A guide wire is inserted through a 2-mm MiniPort located in the right inferior quadrant to facilitate insertion of a 7Fr double-J ileoureteral stent (Fig. 28.11). The ureters are spatulated and separately anastomosed over the stents at the antimesenteric border of the chimney using 4-0 Vicryl on a RB-1 needle with interrupted sutures as described by Bricker (21). A running suture using 3-0 Vicryl is performed at the proximal end of the chimney to avoid contact of urine/mucus with the staples, preventing stone formation. The remaining portion of the pouch that was left open is now closed and 180 mL of saline is injected into the neobladder to confirm no leak (Fig. 28.12). A closed suction drain system is inserted through the portal in the right iliac fossa and positioned in the pelvis.

The previously bagged specimen is removed through an enlargement incision in the midline camera port (or through the vagina in women as previously described). The port placement incisions are sutured with the Carter-Thomason CloseSure System, and the patient is sent to the recovery room.







FIGURE 28.9 A: Bowel division using intestinal stapler. B: The use of Indocyanine green (“green dye”) under infrared light permits the identification of mesentery vascularization.


Intracorporeal (Bricker) Ileal Conduit

For the urinary ileal conduit (IC), a stoma site is marked prior to RARC for all patients by an enterostomal therapist in a location separate from the patient’s skin folds or bone eminences (21). The technique for the intracorporeal robotic IC replicates the open procedure with a few minor modifications (7). A 15-cm ileal segment 15 cm proximal to the ileocecal valve is isolated using two applications of 60-mm laparoscopic staples; the isolated segment is then dropped posteriorly. Ileoileal continuity is restored with a side-to-side anastomosis using the Endo GIA stapler, as described earlier for the ileal neobladder. The mesenteric window is closed with interrupted suture. The proximal end of the conduit is closed with a 3-0 Vicryl running suture to exclude the staples, avoiding their contact with urine/mucus and preventing stone formation. The distal ends of the ureters are spatulated and two separate anastomoses are performed over 7Fr double-J ileoureteral stents using interrupted sutures as described earlier. The stoma is then fashioned for IC maturation. With Allis forceps, the assistant holds and pulls out the distal part of the IC. The staple line of the distal part of the ileal segment is resected and the IC is matured in the previously marked location on the patient’s skin. The ports are then closed and the drain is placed as previously described for the neobladder.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Minimally Invasive Bladder Procedures: Radical Cystectomy, Partial Cystectomy, Urachal Excision, Diverticulectomy
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