Radical Cystectomy

Fig. 7.1

Representation of the regions and boundaries of the recommended lymphadenectomy

Many authors have proposed that lymph node yield may indeed be a surrogate of surgical quality since it correlates with survival outcomes [45]. However, consensus opinions on the superiority of survival outcomes in extended PLND note the low level of evidence, but cite the improved diagnostic results and trend toward improved disease-free survival in extended PLND [46].

The ability of robotic surgery to recapitulate the technique of open PLND has been investigated. In a study by Davis et al., the authors performed robotic extended PLND for bladder cancer in 11 patients with open extended PLND performed directly afterward in the same patients [47]. In 80% of patients, no additional lymph nodes were detected with the open technique, verifying that a high-quality dissection is possible using a robotic technique. Although the indications and benefit of extended PLND will continue to be debated, it appears that robotic PLND can provide a similar lymph node dissection to open techniques.

Preoperative Assessment and Preparation

Enhanced recovery after surgery (ERAS) protocols have improved surgical outcomes in cystectomy. No specific protocol has been shown superior to others, but most share similar features. ERAS generally includes a combination of: pre-habilitation as possible, avoidance of bowel prep, carbohydrate and oral fluid loading up to 2 h before surgery, oral mu-opioid receptor blocker if available, immediate postoperative removal of nasogastric tube and minimization of drains, chewing gum, and rapid resumption of oral intake. Most of these interventions have been studied independently, and as an integrated protocol they appear to offer synergistic benefit [48, 49]. These interventions have been associated with decreases in LOS, complications and earlier return of bowel function, and the authors recommend an institutional adoption of such a program [50]. Core elements of our protocol are shown in Table 7.1.

Table 7.1

Core elements of enhanced recovery after surgery (ERAS) program

Initial meetings	Smoking cessation Frailty assessment Social support assessment Nutritional assessment. Add one serving of nutritional shake per day in at-risk patient Encourage exercise, increased walking, steps, physical therapy/organized programs as possible Stomal therapy visit and marking
Perioperative	No bowel prep Carbohydrate loading. Clear sugary liquids up to 2 h before surgery Alvimopan per os in pre-op area SQ heparin
Intraoperative	Avoidance of fluid overload Remove gastric tube at end of operation Consider chewing gum in evening In chair in the evening Antimicrobial prophylaxis (cefoxitin) for 24 h only Low molecular weight heparin after surgery, continue for 30 days Long-acting local anesthetic in ports; transverse abdominus block or epidural if open Minimization of narcotic and sedative usage
Postoperative day 1–3+	Alvimopan bid Scheduled ketorolac 15 mg IV q 6 h × 3 days if renal function permits Send drain fluid for creatinine on postoperative day 2; if equivalent to serum, remove drain PT, OT consultation; vigorous and frequent walking

SQ Subcutaneous, PT physical therapy, OT occupational therapy

Robot-Assisted Radical Cystectomy

Equipment List

(Note that requirements for intracorporeal diversion are not included here.)

1.

Da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) – “Si” or “Xi” recommended
2.

Veress needle or access device of choice, 2 × 10/12 mm disposable ports, 3 × 8 mm robotic ports, 5 mm assist port
3.

Da Vinci instruments – Monopolar da Vinci scissors, bipolar fenestrated grasper, 2× da Vinci Large Needle Driver. Consider da Vinci vessel sealer if available Fourth arm – “Prograsp” graspers
4.

Hem-o-lok clip appliers (2) with large clips
5.

Laparoscopic vascular staplers, articulating, “45” and “60” as desired
6.
Suture:
1. (a)
  
  Male: 2-0 Vicryl (Ethicon, Somerville, NJ) on rb-1 and SH as needed and as surgeon preference for dorsal venous complex
2. (b)
  
  Female: same as male, likely will need 9″ 2-0 Vicryl on SH for repair anterior vaginal wall
3. (c)
  
  Other: we recommend having a 4-inch, 4-0 Prolene on Rb-1 with Lapra-Ty (Ethicon) pre-affixed in the event of vascular/venous injury during lymphadenectomy
7.

5 mm suction irrigator (long)
8.

Appropriate open surgical equipment for performance of diversion.
9.

Port closure device for 12 mm ports, if desired

Technique

Positioning

Patients are positioned supine. In order to secure the patient to the table in Trendelenburg position, the use of chest straps or direct skin-to-gel adhesion may be utilized; we prefer the Pink Pad system (Xodus Medical, New Kensington, PA). Skin-to-gel positioning is effective, but for longer cases can be associated with skin traction burns on the patient’s back if steep Trendelenberg is used. If intracorporal diversion is contemplated, shallower Trendelenberg will facilitate bowel manipulation without gravitational effects pulling the bowel cephalad and out of the robotic operative field. Alternatively, surgical beds that allow repositioning while docked may enhance surgical access during different phases of the operation if necessary (Trumpf Medical, Saalfeld, Germany).

If docking from between the legs, the legs are separated on orthopedic spreader bars or placed in low lithotomy in well-padded stirrups; the thighs should be close to parallel to the abdomen to minimize distortion of the pelvic floor. Alternatively, side docking with the Xi system may be performed with the patient supine. Orogastric/nasogastric tubes and bladder drainage catheter are placed.

Ports

When planning extracorporeal urinary diversion, port placement may be performed similarly to that utilized in robotic-assisted prostatectomy but modified a few centimeters cranially to give better access to the upper pelvic vessels for thorough lymph node dissection. If contemplating intracorporeal diversion, please refer to Continent Urinary Diversion (Orthotopic Ileal Neobladder) below for different port placement.

Our approach to male cystectomy occurs in a stepwise fashion as follows:

1.

Ureteral identification and dissection

Beginning on the right, the ureters are identified at the level of the common iliac artery (Fig. 7.2). This may be used as the superior boundary for lymph node dissection template at a later point if desired. Using great care to preserve vascular tissue around the ureter as much as possible, the ureter is dissected free for a small distance above the vessels and followed into the deep pelvis to the ureterovesical junction (Fig. 7.3). Small feeder vessels originating from the iliac system are usually encountered and controlled with cautery; caution is important to avoid any cautery effect on or near the ureter and the associated extramural longitudinal blood supply. An identical procedure is completed on the contralateral side; maximization of length and blood supply on the left side are especially important given the need for tunneling at a later date. The left ureter should be mobilized a few centimeters above the common iliac artery to facilitate easy passage beneath the sigmoid colon later in the procedure.

2.

Completion of posterior plane

../images/312378_2_En_7_Chapter/312378_2_En_7_Fig2_HTML.jpg — Fig. 7.2

The parietal peritoneum is incised and the ureter on the right is identified as it crosses the common iliac artery

../images/312378_2_En_7_Chapter/312378_2_En_7_Fig3_HTML.jpg — Fig. 7.3

The ureter is circumferentially freed with maximal preservation of periureteral tissue and dissected to the hiatus of with the bladder

Once the ureters are freed to their hiatus with the bladder, the peritoneal incisions are connected and the retrovesical space developed behind the bladder. Ureters may be tagged, clipped and cut at this point; we prefer to leave them intact to assist with orientation. Dissection proceeds carefully behind the bladder and seminal vesicles to the level of the prostate; the Denonvillier fascia is traversed and at the level of the prostate the pre-rectal yellow fat is identified, and the rectum carefully dissected free from the prostate as far as possible in the distal direction. Vasa deferentia are clipped and cut, the small arterial branches to the seminal vesicles are carefully controlled with clips or cautery as appropriate. The lateral bounds of this dissection are the vascular pedicles of the bladder and prostate, beginning with the superior vesical artery. Great care is taken to widely establish separation between the rectum and bladder to minimize chances of rectal injury.

3.

Lateral space creation

Delineation of the lateral aspects of the bladder and vascular pedicles is performed at this point. The goal of this step is the identification of the vascular pedicles. Peritoneal incision is performed along the lateral aspect of the medial collateral ligament, with care taken to leave the anterior suspension of the bladder intact. Early release of the anterior bladder support will significantly increase difficulty in posterior dissection from the loss of bladder support and should be avoided. The lateral incisions are connected to the posterior incision to form a “u” and the space lateral to the bladder freed distally to the endopelvic fascia and nerve sparing/prostatic fascial release performed if nerve sparing is desired. Even with anterior anatomical support intact, the “fourth arm” can be well utilized to additionally retract the bladder so as to provide stretch on the pedicles and facilitate dissection. The endopelvic fascia is released in the fashion of radical prostatectomy. Next, the medial umbilical ligaments are transected close to their junction with the internal iliac artery. The ureters are doubly clipped, divided and tucked into the upper abdomen well away from the operative field (Figs. 7.4 and 7.5). We recommend Hem-o-Lok clips (Teleflex Medical, Research Triangle Park, NC, USA) with a color-coded 10″ suture tied to the heel of the clip that is applied proximally to facilitate manipulation of the ureter through a smaller incision at diversion.

4.

Takedown of vascular pedicles

../images/312378_2_En_7_Chapter/312378_2_En_7_Fig4_HTML.jpg — Fig. 7.4

Once the posterior and lateral spaces have been adequately developed, the ureter is doubly clipped and transected. For extracorporeal diversion, the clip on the proximal ureter is tagged with a 10″ 3-0 Vicryl for identification and manipulation

../images/312378_2_En_7_Chapter/312378_2_En_7_Fig5_HTML.jpg — Fig. 7.5

With the ureter tucked into the upper abdomen, the rectum is dissected posteriorly away from the bladder and the vascular pedicle is identified

Many different technologies are available for safe control of the superior vesical artery and vascular pedicles of the bladder. Clips, laparoscopic stapling devices and direct ablation with other hemostatic technology can be employed at surgeon discretion (Fig. 7.6). As in prostatectomy, adequate distal division of attachments facilitates mobility and completion of the apical dissection. A group at Vanderbilt compared the similar LigaSure Impact device (Medtronic, Minneapolis, MN) to stapler use and found no difference in blood loss and a simplification of vascular control during cystectomy [51].

../images/312378_2_En_7_Chapter/312378_2_En_7_Fig6_HTML.jpg — Fig. 7.6

Once the upper portion of the vascular pedicle is isolated, it can be clipped or cauterized at surgeon preference. This is shown here with the robotic vessel sealer

5.

Control of dorsal venous complex

The balance of anterior bladder suspension is now released and the anterior space of Retzius dissected. In men, the dorsal venous complex is controlled after placement of 1–2 securing sutures in the fashion of a radical prostatectomy. Placement of the suture through the pubic ostium as during prostatectomy may stabilize the urethra for neobladder procedures. A vascular stapler may be utilized alternatively.

6.

Dissection of urethra

The urethra is dissected free. If neobladder is planned, care is taken to preserve adequate urethral length. The urethral catheter is removed. The bladder side of the specimen is controlled with a Hem-o-Lok clip to prevent spillage of contents during transection. If ileal conduit is planned, the urethra is dissected as far distal as possible. The stump is carefully oversewn or clipped with a Hem-o-Lok clip to prevent persistent urethral leakage of peritoneal fluid or future urethrectomy if needed. The specimen is freed and placed in a large bag; we prefer the 12 mm Inzii device (Applied Medical, Rancho Santa Margarita, CA, USA) as it allows use of smaller 12 mm ports with full bag size.

7.

Lymph node dissection

Lymph node dissection is completed as described above. The specimen is placed in a separate smaller bag or removed with via reusable endocatch bag. Clips and energy are utilized selectively to decrease risk of lymph leak. In high-risk cases, or those felt likely to benefit from extended dissection, LND can be carried as high as the level of the inferior mesenteric artery on the aorta.

Creation of Extracorporeal Urinary Diversion

For ileal conduit , diversion may be performed either intracorporeally or extracorporeally. For surgeons newer to RARC, extracorporeal diversion is familiar and expedient. Once the lymphadenectomy has been completed, the ureters are recovered from where they have been tucked in the upper quadrants and good mobility verified. Ideally, freedom that extends a short distance above the common iliac artery will be available, especially on the left side.

The ileum and ileocecal junction should be identified; a pre-measured suture can be utilized to march out 15–20 cm of terminal ileum and a long tagging suture of 3-0 silk placed in the serosa at the distal extent of the anticipated conduit. This is left full length to allow easy extraction through a small incision. Any attachments of the cecum that may hamper terminal ileal freedom are taken down.

Next, the ureter must be passed behind the sigmoid at roughly the level of the sacral promontory. With the colon gently retracted anteriorly, a passageway can usually be developed by gently manipulation behind the incised retroperitoneum. Care should be taken to avoid vascular injury when crossing the midline, especially in the setting of aneurysmal dilatation or ectasia. Once an instrument has been easily passed from right to left and a generously sized space created behind the colon, the left ureteral tagging suture is grasped, and the ureter pulled through to the right where it can be again assessed for adequate length and freedom. Alternatively, left ureteral passage can be accomplished open, although this often requires a larger abdominal incision.

Once both ureters lie in the right paracolic gutter and the terminal extent of planned conduit is tagged, all three tagging sutures are placed in a needle driver through an assist port and secured in place. The robot is undocked, and table taken out of Trendelenberg; a small incision is made in the sub-umbilical midline and all tagging sutures passed out it. The small bowel is pulled up, and bowel resection performed to provide an adequate conduit of roughly 15 cm without unnecessary redundancy. It has been our preference to mature the ostomy at the pre-marked site prior to performing the uretero-enteric implantation. Once this is done, spatulated ureteral implants of roughly 1.5 cm are made with urinary diversion stents inserted via the matured ostomy and up each ureter. Interrupted 4-0 Monocryl (Ethicon) used for implantation with great care taken to avoid any trauma to the distal ureter. A 4-0 chromic suture is used to secure the stent to the mucosa of the ostomy. At this point a closed-suction drain is gently placed in the pelvis through a lateral port site, the fascia and incision are closed, and the patient taken to recovery.

Creation of Intracorporeal Urinary Diversion

Setup

If the DaVinci Xi robot is available it is preferred for neobladders because repositioning is easier, although both can be done on the Si. Port placement and instrument positioning is key to successful urinary diversion, port placement is shown in Fig. 7.7. The most important port is the right robotic arm, placing this high/cranially allows for bowel work to be completed over the area of the distal ileum with minimal instrument clashing.

../images/312378_2_En_7_Chapter/312378_2_En_7_Fig7_HTML.png — Fig. 7.7

Port placement for robot-assisted cystectomy. Note the cranial placement of especially the right surgical arm to facilitate intracorporeal diversion. This may not be necessary if extracorporeal diversion is planned

The stoma should be marked preoperatively. It is not necessary to have a port site be the same at the stoma site.

Mobilization of the colon, including cecum, at the beginning of the case is useful later on when preparing to perform urinary diversion.

The presacral dissection allows for the urinary diversion to be done with ease later on. If no presacral dissection has been done, then the area between the sigmoid mesentery and bifurcation of the aorta needs to be developed in order to facilitate the urinary diversion.

The bowel should be brought into the pelvis and splayed out such that the mesentery is in the center and the bowel is surrounding (Fig. 7.8).