Ports configuration. (a) Classic 6 port approach (b) Trocars and Alexis wound retractor placed supraumbilically (c) Alexis Laparoscopic Cap allowing pneumo-peritoneum creation
In case of extracorporeal urinary diversion (ECUD) reconfiguration, we insert through a 6 cm supraumbilical incision a medium size Alexis laparoscopic system (Alexis O wound protector/retractor and laparoscopic cap; Applied Medical, Rancho Santa Margarita, CA, USA) in order to allow faster specimen removal (Fig. 68.1b) easier bowel exteriorization, wound protection and effective pneumoperitoneum restoration to perform ileal-urethral anastomosis when a neobladder is created.
Whenever a 12-mm endoscopic stapler is planned (ICUD), we adopt the Karolinska technique  by inserting a 12-mm trocar placed in the left iliac fossa. The fourth 8-mm robotic trocar will be inserted through this trocar as long as necessary.
Extended Pelvic Lymph Node Dissection (ePLND)
We routinely perform PLND as the very first step of RARC as it allows the identification and preparation of the principal anatomical landmarks (ureters, vas deferens, hypogastric and vesical vessels) and sets-up the cystectomy part of the procedure. By lifting up umbilical ligament, bladder can be easily translated ensuring better exposure of iliac and obturator areas.
An extended or super-extended template is adopted (Fig. 68.2). From an oncological point of view we are keen to remove all lymph nodes with an en-block fashion trying to avoid any nodal incision and manipulation in order to avoid disease spread during the procedure.
Pelvic Lymph-node dissection patterns. (a) The limits of Extended PLND. Cranial border: ureter and common iliac artery; lateral border: psoas muscle and genitofemoral nerve; medial border: umbilical artery, peritoneum and bladder; distal border: Cloquet lymphnode. The limits of Superextended PLND extended + presacral area (b) PLND allows the identification and preparation of the principal anatomical landmarks (ureters, vas deferens, hypogastric and vesical vessels) and sets-up the cystectomy
Robotic Radical Cystectomy
Ureters are bilaterally identified at their crossing on the iliac vessels and carefully dissected towards the bladder. It is mandatory to handle ureters with care and to prevent the excessive skeletonization in order to preserve vascular integrity and therefore avoiding the dreaded risk of ureteral stenosis at follow-up. For oncological reasons the section of the ureters should always performed through 2 hem-o-lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) and the most cranial clip has a pre-placed tie, which will facilitate subsequent handling of the ureters. Intraoperative frozen section of distal ureteric-margin is always performed.
Prior to the bladder “take down” (Retzius space opening), the posterior space dissection allows the preparation of vesico-prostatic pedicles and the development of the recto-prostatic space. A transverse peritoneal incision at level of Douglas will lead to seminal vesicle and prostatic base dissection reaching the recto-urethralis muscle. Vesico-prostatic pedicles are commonly transected by the assistant using vessel-sealer devices (Fig. 68.3a, b). In case of nerve-sparing procedure an antegrade, energy- and traction-free approach is performed as commonly adopted during radical prostatectomy.
Robotic radical cystectomy. (a) Pedicle section with Ultrasonic SonoSurg G2 (Olympus Corp., Tokyo, Japan). (b) Pedicle section with Advance Bipolar Caiman vessel Sealer (Bbraun, Aesculap, Center Valley PA, USA). (c) Transvaginal extraction of the specimen. (d) Female sexual-sparing approach: After suture of the anterior vagina wall ($), uterus (§), cervix (Ω) and fallopian tubes (β) are shown
In female patients, a transvaginal-retractor facilitates the dissection of the recto-vaginal plane. A transvaginal extraction of the specimen (Fig. 68.3c) is performed in case of ICUD. In case of a sexual-sparing approach the ovaries, fallopian tubes, uterus, and cervix, and most of the vaginal wall may be completely spared (Fig. 68.3d).
Robotic Intracorporeal Ileal Conduit
Once the cystectomy part has been completed, the robot is undocked and the Trendelenburg position is minimized. Bowel manipulation should be performed with caution, avoiding direct grasping with robotic instruments. Pro-grasp forceps and needle driver can exert extremely high-force leading to direct or delayed intestinal lesion or mesentery bleeding. A coordinated work with the assistant is necessary, in order to reduce tensions through the synchronous use of two atraumatic Johan Grasping and Cadier robotic forceps. The left ureter is generally passed below the sigmoid. A 20 cm long ileal segment is isolated (Endo-GIA 60) and ileo-ileal side-to-side anastomosis (Fig. 68.4a) is obtained (Endo-GIA 60 + 45). Some author described near infrared fluorescence after injection of indocyanine green  or lighting from urethra with cystoscope  in order to obtain a better visualization of the mesenteric vascular arcade. Ureters are spatulated for 1.5–2 cm and catheterized with Single-J inserted percutaneously. An “head-to-head” (Wallace I) uretero-ileal anastomosis (Fig. 68.4b) is performed after extraction of single-J through the isolated bowel tract. Ileocutaneous-stoma is performed only after the final decompression of pneumoperitoneum (Fig. 68.4c).