Robot-Assisted Surgery for Benign Disease of the Bladder

Fig. 19.1

Port placement for access to the bladder and ureter

For the female simple cystectomy, a discussion with the patient regarding urinary diversion type is important. If an ileal conduit or non-orthotopic diversion is chosen, the patient and surgeon should decide if the patient wants to keep her urethra. Frequently the reasons for simple cystectomy often involve urethral pain and/or recurrent infections, so en-bloc removal of the entire urethra with the bladder is a good option. We approach this vaginally in our patients, and the periurethral and retropubic dissection is quite simple and straightforward from this direction. This approach also lends itself nicely if the patient has chosen a vaginal-sparing cystectomy as well. Simple vaginal wall advancement is all that is necessary to cover the defect left by removing the urethra. We liberally mobilize the vaginal wall and use a multilayered closure to prevent any possibility for later prolapse or herniation, using an interrupted absorbable suture on the deep and periostial structures, and a running absorbable suture on the vaginal mucosal edges.

Vaginal sparing is also easily initiated from a vaginal approach and can be done in conjunction with urethrectomy. In either case, we use a distal horizontal vaginal incision and then completely dissect the anterior vaginal wall from the bladder all the way to the vaginal cuff or cervix. If performing a urethrectomy as well, the urethra should be circumscribed, with the horizontal vaginal incision marking the inferior edge of the urethral incision. After carrying out the dissection and freeing the vagina from the bladder, the vagina is closed as described above in multiple layers. Later, when the bladder is approached robotically, it should already be completely free from the vagina. All that is necessary is to open the peritoneum over the vaginal cuff, and the space can easily be entered to take the bladder pedicles. The remainder of the operation is essentially the same as the previously described radical cystectomy.

It is important to recognize the potential for vaginal bleeding during vaginal sparing. Due to the fact that the vagina is extensively vascularized, the surgeon must pay attention to meticulous hemostasis following removal of the bladder. This will prevent delayed bleeds and pelvic hematomas which can complicate recovery. In addition, if the anterior vaginal wall dissection is approached vaginally, bleeding can occur within the vagina that may go unrecognized once the robot is docked and the robotic portion of the procedure is undertaken. Be sure to have all vaginal and pelvic bleeders controlled before proceeding with the robotic portion; otherwise one may find a pool of blood at the foot of the bed on the floor once the robot is undocked.

Whether performing sparing of the anterior vaginal wall or removing it, pelvic organ prolapse occurs at a high rate following simple or radical cystectomy. This is a product of disruption of the anterior and lateral support structures of the pelvic organs. One option is to perform a paravaginal repair using nonabsorbable suture to any available later support structures. The authors currently use zero polypropylene interrupted sutures at four points (two on each side) of the vagina. Unfortunately this only provides lateral support and anterior weakness can result in prolapse in some patients.

Another important consideration is the closure of the vaginotomy. The surgeon must remember that magnification can give the impression of large bites during closure and it is important to have a very strong closure of the vaginal wall. Herniation of intestinal contents as well as omentum through the vaginal closure has been anecdotally reported. In order to avoid this, the authors currently perform a “clam-shell” closure of the vagina in multilayer fashion with zero polyglactin suture. We also make sure to reinforce with interrupted sutures and manually check the integrity of the closure transvaginally at the completion of the procedure.

Important Technical Considerations

The prostate may be left in situ in male patients allowing for minimal risk of post-op bleeding
Vaginal approach to the anterior vaginal wall dissection and urethral dissection prior to robotic dissection
Meticulous hemostasis of anterior vaginal wall following cystectomy to avoid delayed post-op bleeds
Multilayer closure of vaginotomy if anterior vaginal wall not spared key to avoid post-op herniation

Ureteral Reimplantation

Stricture or fistula of the distal ureter is a rare outcome after pelvic surgery. Unfortunately, it is often discovered days to weeks after the inciting procedure has occurred, thus sometimes making management difficult. Regardless, even if it is recognized intraoperatively, it should be managed by ureteral reimplantation with or without a psoas hitch, or possibly even a Boari flap. This section will deal with techniques and pearls when performing reimplantation of the ureter for distal ureteral pathology.

Given the delicate nature of operating on the ureter, the procedure has not typically been performed in a pure laparoscopic approach, although it has been described [1]. Generally speaking, this is a pelvic operation, and the robotic approach suits this procedure very well. It has been described in multiple case series, with seemingly good efficacy [2]. Again, the main indications are distal ureteral stricture, distal ureteral TCC requiring reimplantation, and ureterovaginal fistula. All of these disease entities have been described being managed with robotic ureteral reimplantation [3, 4]. It should be noted that the authors would not recommend robot-assisted reimplantation of a ureter for upper tract urothelial cancer due to the risk of intraperitoneal spillage of cancer cells and limit this procedure for benign purposes.

The surgical approach for a robotic ureteral reimplant is similar to that of other pelvic operations, and standard robotic instrumentation is all that is typically necessary. One or two assistant ports are utilized as well, depending on the complexity of the procedure. Port placement is similar to that used for robot-assisted radical or simple cystectomy (Fig. 19.1). The third working robotic arm (fourth arm) should be placed to the opposite side of the ureter being reimplanted in order to be available for retracting the bladder. While this is technically a pelvic operation, on occasion, the laterality of the procedure can come into play, especially if the stricture is higher and a psoas hitch or Boari flap will be necessary. In these instances, it is better to rotate port placement towards the side of the reimplant slightly. Camera placement should also be sufficiently high as to not place the surgeon in a position where visualization becomes difficult.

The procedure typically begins with medial mobilization of the colon from either side in order to gain exposure of the ureter over the course of the psoas muscle before it courses over the iliac vessels. For the purposes of distal strictures, this is often a nonviolated plane, and dissection should be quite feasible here. The ureter should be circumferentially mobilized with care being taken not to skeletonize it. The ureter then should be traced into the pelvis to the level of the offending pathology and transected. Place a stay suture on the ureter to aid in delicate manipulation of the ureter as well as identification later.

Assessment of the type of reimplant needed should be made. The bladder should be prepared for this at this point in time. For a long ureter, simple mobilization of the bladder by releasing its anterior and superior attachments from the space of retzius and contralateral side may be all that is required. Once it is certain that the ureter can be reimplanted in a tension-free manor, a lateral trough through the peritoneum and detrusor should be made to the level of the mucosa. Generously spatulate the ureter and open the bladder mucosa the same distance. The ureteral mucosa should then be anastomosed to the bladder mucosa using a fine absorbable suture (4-0 polyglactin or similar). Following closure of one side of the anastomosis, a double-J stent should be passed into the ureter over a wire that is inserted through an assistant port and guided into the ureter by the robotic surgeon. The mucosal anastomosis can be completed and the overlying muscle and peritoneum may be reapproximated over the closure to provide additional security and to ensure a watertight closure.

More typically, the bladder will need to be mobilized more, and a psoas hitch or Boari flap will be necessary. The bladder should first be appropriately mobilized from the anterior and contralateral side, ligating and dividing the obliterated umbilical ligament and/or superior vesical pedicle if necessary. Filling the bladder will aid in this and will also give the surgeon an idea of how well mobilized the bladder is and whether it will reach adequately. After this, the psoas hitch should be done by suturing the bladder to the psoas muscle and tendon with a permanent suture, taking care to avoid the genitofemoral nerve.

If a Boari flap is necessary, the flap should be opened from about 3 cm cephalad from the bladder neck at this point. This should be done with the bladder full in order to estimate the size of the flap and location. It is very important to make a sufficiently wide flap in order to be able to roll into a tube following anastomosis of the ureter to the flap. A dreaded complication is a leak due to inability to close external layers of detrusor over the mucosal tube. The ureter should then be anastomosed in an end-to-side fashion laying the flap on the anteriorly spatulated ureter. A stent should be inserted as one would do open, and the Boari flap can be closed using a running absorbable 3-0 suture [5]. After completing the reimplant, the closure should be tested for leaks, and a catheter should be left in the bladder for 7–14 days, and a cystogram checked before removing the catheter. The stent should remain in place for 6 weeks, typically.

Important Technical Considerations