© Springer International Publishing AG 2017
Siamak Daneshmand (ed.)Urinary Diversion 10.1007/978-3-319-52186-2_55. Robot-Assisted Intracorporeal Urinary Diversion
(1)
Department of Urology, Roswell Park Cancer Institute, Elm & Carlton St, Buffalo, NY 14263, USA
(2)
Department of Urology, Cairo University, Giza, Egypt
Keywords
IntracorporealUrinary diversionIleal conduitRobot assistedRoboticRadical cystectomyIntroduction
Radical Cystectomy (RC) with pelvic lymph node dissection represents the cornerstone for treatment of muscle invasive bladder cancer, as well as refractory non-muscle invasive disease. RC remains a major procedure that bears a high rate of complications and 5-year overall survival of 50–70% [1–3]. Ongoing attempts have been made with the aim of improving outcomes following RC, including use of neoadjuvant chemotherapy (NAC) and performing a more thorough lymph node dissection [4]. A robot-assisted approach to RC has gained much popularity in the last decade with a dramatic increase from <1% in 2004 to 13% in 2010. Robot-assisted radical cystectomy (RARC) offers advantages in terms of blood loss, transfusion rates, and potentially hospital stay, in addition to improved ergonomics and visualization without jeopardizing oncological outcomes [4].
The choice of urinary diversion after RC is dependent on multiple factors including the patient’s quality of life (QoL), preference, and associated short- and long-term complications [5]. Deciding the most appropriate method of urinary diversion is usually individually tailored according to the patient’s choice and disease characteristics [6]. Surgeon experience and training also have a substantial influence in the presentation of the available options to patients and therefore significantly affect the decision for urinary diversion as previously described in this book [6].
Although orthotopic bladder substitution (OBS) may represent the new gold standard, ileal conduit (IC) remains the most popular diversion method in the United States (>80%) [7]. OBS gained more popularity as it offers the potential for normal voiding without an abdominal stoma. However, it is not feasible for all patients, especially for those with compromised renal function (serum creatinine 150–200 mmol/l) and severe hepatic disease. Other relative contraindications include the presence of urethral stricture, intellectual disability, or the lack of manual dexterity [8]. After RARC, urinary diversion is mostly performed extracorporeally [9]. In this chapter we will discuss and describe a step-by-step approach to intracorporeal urinary diversion.
Preoperative Preparation
Patients undergoing RARC should provide an informed consent after being thoroughly counseled and fully understand the risks, benefits, and possible complications. The patient should also be counseled about their future lifestyle changes including stoma management and the possibility of self-catheterization. Working with the stoma therapist in the preoperative and postoperative period represents a crucial part for the success of the procedure.
A complete preoperative anesthesiology assessment including cardiac testing, renal and hepatic function, and correction of modifiable medical disease should be performed. Careful consideration of the patient’s pulmonary functions is vital to tolerate the steep Trendelenburg position, especially with the prolonged operative duration of the intracorporeal diversion. The “fast track” combines innovative aspects such as limited bowel preparation and allowing clear liquid diet up to 12 h before surgery. Scant evidence supports bowel preparation, and a simple cleaning enema the night before surgery as part of fast track seems to be sufficient [10].
Thromboembolic complications are not uncommon after RC [11]. Mechanical methods (as compression stockings and intermittent pneumatic compression devices) and low molecular weight heparin are important for measures for thromboembolic prophylaxis [12]. Broad-spectrum intravenous antibiotics are preferably administered 1 h before the start of the procedure.
Positioning and Port Placement
The patient is positioned in the Trendelenburg position with the feet higher than the head with around 10–15°. This position provides more working space by displacing the intestinal loops upward. The abdomen is insufflated using the Veress needle or Hassan technique. After placing the camera port, all ports are placed under direct vision. Ports should be placed more cephalad to facilitate bowel maneuvering and performing extended pelvic lymph node dissection. A standard 6-port transperitoneal approach is used with an additional 12-mm-short suprapubic port placed later to facilitate bowel anastomosis.
Intracorporeal Ileal Conduit (The “Marionette” Technique)
Marionette Stitch and Identification of the Bowel Segment
After RARC, the left ureter is crossed to the right side by incising the sigmoid mesentery. After identification of the ileocecal valve, a 12-cm ileal segment is measured at least 15–20 cm from the ileocecal valve. The “Marionette” stitch is made using a 60-cm silk suture on a Keith needle to suspend the bowel loop from the anterior abdominal wall. The Keith needle is passed through the hypogastrium of the anterior abdominal wall, the distal end of the bowel segment, and then brought back through the same location on the anterior abdominal wall. The stitch is not tied but held in position with a clamp. This allows raising and lowering of the bowel segment (similar to moving a marionette) to facilitate bowel manipulation.
Isolation of the Bowel Segment
The mesentery is stretched by putting the Marionette under tension. Two mesenteric windows are created using the hook cautery making sure an adequate width of its base is maintained. The mesenteric fat is incised in a progressive fashion rather than deep cuts to avoid injury to adjacent structures. Care should be taken to avoid stretch injury of the mesenteric vessels. The mesenteric vessels can be controlled by hook cautery, bipolar grasper, hem-o-lok clips, vascular stapler, or ligature.
Once the two mesenteric windows are created, an Endo GIA stapler is introduced through the 15-mm assistant port to divide and isolate the ileal conduit. An enterotomy on the distal end of the conduit is made for the introduction of the ureteral stents using the hook cautery. Two other enterotomies on either side of the proximal end are also made for the ureteroileal anastomosis. A 0-silk suture is taken to approximate the two bowel ends to ensure proper orientation and avoid malrotation.
Ureteroileal Anastomosis
The ureters are anastomosed to the isolated bowel segment either using Wallace or Bricker technique. Appropriate length of the ureters can be ensured by aligning the ureteric ends with their corresponding enterotomies. The distal ureter should be excised if scarred or with questionable vascularity, until the healthy end is encountered to avoid ureteroileal narrowing. Ensuring a wide, tension-free, and water-tight anastomosis is crucial to avoid stricture or leakage. During the Wallace anastomosis, the ureters joined together at their posterior walls and are sutured into single enterotomy on the conduit. In the Bricker anastomosis, the left ureteroileal anastomosis is performed first. The fourth arm can be used to steadily hold the ureteral end. The ureter is partially transected and spatulated for a wide anastomosis. The marionette stitch is manipulated to align the conduit with the ureter to facilitate the anastomosis. A single armed 4-0 absorbable suture (5 cm long) is used for an interrupted anastomosis. The first anchoring stitch is placed in an “outside-in” manner on the ureter side at the angle of the spatulation and then “inside out” on the conduit side, perpendicular to the proximal staple line. Then, the fourth arm is used to approximate the ureteral end to the conduit before tying the suture for a tension-free mucosa-to-mucosa anastomosis.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
