Robot-assisted single-port radical cystectomy and intracorporeal urinary diversion

Multiple medical conditions require urinary diversion including radical cystectomy due to bladder cancer, refractory hematuria, radiation cystitis, or chronic pelvic pain. John Simon performed the first urinary diversion in 1851. Sixty years later in 1911, Zaayer described the first ileal conduit. Since then, urinary diversion has become a widely known procedure and despite multiple techniques described in the literature, ileal conduit is the most used technique to this day.

The evolution of robotic techniques has shown significant benefits in terms of postoperative recovery and reduction of complications. The US Food and Drug Administration (FDA) approved the Da Vinci robotic system by Intuitive Surgical Inc. in Sunnyvale, CA in 2000 for use in urologic cases. Robotic surgeries were performed with multiple small incisions in the torso to accommodate the robotic arms. Menon described the first robotic-assisted laparoscopic radical cystectomy in 2003. The robotic approach has dominated the field of radical cystectomy with multiple trials showing no differences in recurrence and overall survival including the RAZOR (Randomized Open versus Robotic Cystectomy) trial comparing the open approach to the robotic-assisted approach. While diversion was done externally during this period, recent studies have shown that intracorporeal diversion can be as effective as extracorporeal diversion. Recent papers and metaanalyses have also provided evidence that intracorporeal diversion is more beneficial than external diversion. As such, in our institution, we have transitioned to robotic radical cystectomy with intracorporeal diversion. Internal review and published data of our outcomes show similar or improved when compared to current literature.

The robotic approach has evolved overtime with progression of the robotic systems. With the introduction of the Single Port Robot, we have transitioned from multiple small incisions to a single port. The single-port robotic system was introduced by Intuitive and approved for use by FDA in 2018. Kaouk reported the first use of single-port technology for urinary diversion in 2019. Ahmed provided further description of its use in urinary diversion in 2020. Single-port technology is now being used to harvest the bowel for creation of ileal conduits, neobladder, and Indiana pouch whether the native bladder is removed or not.

7.1 Access

A midline incision is made through or above the umbilicus for the robotic access port. The optimal working length of the SP robot instruments is 10–25 cm. There are multiple access platforms that are described for single-port robotic system. In the hrein reported experience by Ahmed et al., the authors initially started with using GelPort (Applied Medical, Rancho Santa Margarita, CA), which is the access platform that was also initially used for multiarms access through a single incision, when using the older generation robotic platforms. It provided good flexibility and prevented pneumoperitoneum. This device enables the concept of a “floating trocar” in which a cap known as “GelSeal” is used to top a sleeve designed to be above the incision housing the trocar of the robotic arms and providing freedom of movement with facilitation of extracorporeal resection and improved articulation of instruments. This allows adjusting the distance of the robot to the target organ. The robot needs to be 10–25 cm from the target organ and floating the trocar allows the ideal positioning and quick intraoperative adjustments.

In more recent days, the authors are using the new SP Access Port Kit (by Intuitive Inc.) ( Fig. 7.1 ), which provides further benefits associated with the single-port system. The distance between trocar and surgical field is usually short but this new access system provides more freedom of movement and reduced incidents of collision among the robotic arms.

This new access system also provides a 12 mm assistant access port and another 8 mm access port on the side of the system. This side port is used to allocate the Airseal (CONMED Corporation, Utica, NY), which is an access management platform that provides stable pneumoperitoneum with smoke evacuation using a valve-free port. It maintains pneumoperitoneum by circulating CO ₂ and creating a barrier equal to intraabdominal pressure. Valve-free ports help with providing an access without obstacles. The authors recommend the use of Airseal as it provides stable pneumoperitoneum regardless of rigorous or continuous suction.

Providing a suction technique that is utilized through the single access is also different from the multiport system. Given that there is only one access port, which will be difficult for the bedside assistant to utilize without crowding with the console surgeon control of the arms, a new suction system is introduced. Its name is “Remotely Operative Suction Irrigation System,” known as (ROSI), which is composed of a flexible tubing along with a plastic piece at the distal end that can be grasped and moved around using one of the arms of the robot controlled by the console surgeon. If ROSI is not available, flexible suction catheters as is often used by anesthesia for oral airway suction may be used in place of the ROSI system. Other suction techniques have been described like using a urethral catheter with the tip in the pelvis after transecting the urethra controlled by the console surgeon using a robotic arm with suction at the external end of the catheter. An extra assistant port where a regular suction arm by an assistant surgeon can pass is recommended for surgeons with novel experience in the single-port system to provide assistance with retraction and suctioning until the learning curve is achieved.

7.2 Radical cystectomy

The patient is placed in Trendelenburg position. Access is obtained as described earlier. This access allows the robotic trocar to be moved in and out of the body. As a result, the instruments have a wider range of movement, and this range is crucial for reaching deep into the pelvis to perform dissection at the most distal points as well as retracting backwards to retrieve and work with bowel in the proximal abdomen. Instrument positions in the single port are robotic camera at the 12 o’clock position, a monopolar scissor at the 6 o’clock position, a bipolar grasper at the 9 o’clock position, and the Cadiere forceps at the 3 o’clock position. The authors use this instrument configuration but it can be changed as needed. Their preference is to maintain the same position throughout the case to minimize time lost in exchanging instruments.

The procedure begins with incising the peritoneum over the ureter. The ureter is then dissected up proximally and down distally to the level of the bladder sparing the periureteral tissues. The lateral walls of the bladder are then freed following the medial umbilical ligament posteriorly. At this point, the lateral pedicle of the bladder is resected. The ureter is then transected after clipping it at the ureterovesical junction. After the lateral sidewall is dissected and the ureter ligated and the median umbilical ligament are ligated, standard extended lymph nodes dissection proximally from common iliac to distally including the space of Marseille is performed. Posteriorly for male the seminal vesicles and vas is a good landmark to identify and keep them above and avascular plane is mobilize toward the apex of the prostate. The Single-port robot provides additional advantage as the camera angle can be changed according to the need and target relocation helps to move the entire unit of the robot.

In radical cystectomy procedures for men, a combination of bipolar dissector and sharp dissection with scissors is used to remove the prostate and transect the urethra at the space of Retzius. In females, the infundibulopelvic ligament is divided, as the ureter runs underneath it. Females with low volume and no involvement of the posterior bladder, entering in anterior plane of the vagina can preserve the uterus thus configuring the so-called “uterine-sparing” cystectomy. A 12 mm robotic assistant trocar can be placed at the site of the intended stoma at the beginning of the case ( Fig. 7.2 ). For female patients, a 12 mm assistant trocar is optional as the vaginal orifice can be used for bowel stapling.

7.3 Harvesting the bowel

Using the length of the robotic instruments, a coarse measurement of the ileum is made, which is harvested about 15–20 cm proximal to the ileocecal junction. For example, 45–50 cm of the ileum is needed to create a neobladder. The distal and proximal ends of the segment are stitched with 3–0 Silk and Vicryl stitches as a mark and as handles for manipulation of the bowel. Staplers are introduced through the vaginal orifice in females ( Fig. 7.3 ), while 12 mm Airseal trocars are commonly used in males ( Fig. 7.4 ).

The ileum is transected on either side, and then the free bowel is anastomosed to the ileum by using 3–0 Vicryl stay sutures to aid in bowel grasping. To create the anastomosis, a second 3–0 Vicryl stitch is placed approximately 6 cm from the free ends of the bowel. Both the jaws of the stapler are advanced through an open end of the bowel to achieve the anastomosis followed by closing the distal end with a stapler in addition to closing it with 3–0 Vicryl sutures.

7.4 Ileal conduit

Incontinent diversion with using ileum to direct urine from a reservoir to an external collecting bag via a stoma is one of the most common techniques for urinary diversion. Similar bowel harvesting techniques are used as described earlier.

After performing the radical cystectomy, attention is turned to create the ileal conduit. The appendix is identified and then the terminal ileum. From there, 15 cm are measured proximally. A 3–0 Vicryl stitch is placed to mark the distal portion of the conduit. A 3–0 Silk stitch is placed 15 cm proximal to that to mark out the proximal portion of the conduit ( Fig. 7.5 ).