Radical cystectomy is the gold standard for the management of muscle invasive bladder cancer (MIBC) as well as high-risk nonmuscle invasive bladder cancer (NMIBC). The use of robotics for radical cystectomy was first reported by . Since then, several authors have published their experience and outcomes with robotic radical cystectomy (RRC), mostly in retrospective case series.
The use of RRC has increased from 0.6% in 2004 to 12.8% in 2010, a 21-fold increase. Most of these cases, however, have been done with a hybrid approach, wherein a robotic approach is used for the extirpative part of the operation (cystectomy and lymphadenectomy) followed by an extracorporeal urinary diversion.
Three randomized trials comparing RRC with open radical cystectomy (ORC) have been published. A large multicenter randomized trial has currently completed enrollment, and the findings from this study are awaited (NCT01157676). In all the randomized trials to date, the urinary diversion has been performed extracorporeally.
As the adoption of RRC has increased, there has been an increasing interest in using an intracorporeal, purely robotic approach to urinary diversion. A recent report from the International Robotic Cystectomy Consortium (IRCC) compared the outcomes of patients undergoing a robotic cystectomy with an extracorporeal diversion versus an intracorporeal diversion. The intracorporeal group demonstrated a lower rate of overall complications ( P = 0.05), gastrointestinal complications ( P <0.001), and 30- and 90-day readmission rates ( P <0.001 and P = 0.016, respectively). There were no differences in reoperation rates and, interestingly, operating room time. These results suggest that an intracorporeal diversion may potentially add to the observed benefits of a robotic approach to the extirpative part of the operation and merits further exploration.
At our institution, since 2011, when a cystectomy is performed robotically, the diversions are also performed robotically. Although an ileal conduit and an orthotopic ileal neobladder are the most common types of robotic diversions at our institution, we have also performed continent cutaneous diversions robotically. Herein, we present our technique of robotic, purely intracorporeal radical cystectomy, lymphadenectomy (LND), and urinary diversion.
Preoperative Preparation
All patients are evaluated in the usual manner for a proposed radical cystectomy. Staging workup is completed, and the patient’s fitness for anesthesia and surgery is evaluated. Specifically, for the diversion, the patients are counseled about the available diversion types and the pros and cons are discussed in detail. All patients are provided reading materials on the three main diversion types: conduit, orthotopic neobladder, and continent cutaneous diversion. All patients attend a cystectomy class taught by a dedicated nurse and are also encouraged to attend support group meetings in preparation for the surgery. All patients see a stoma nurse preoperatively, and a stoma site is marked if there is a possibility of performing an ileal conduit.
Currently, the authors follow the enhanced recovery protocol described by colleagues at their institution. Patients are encouraged to consume a high-protein diet leading up to the day of surgery. A high-protein, high-carbohydrate supplement is recommended on the day before the surgery. Patients continue a normal diet until the night before surgery and are made NPO (nothing by mouth) after midnight. No mechanical bowel preparation is used unless a segment of large bowel is to be used for the diversion.
The µ-opioid antagonist alvimopan is started 1 hour before surgery. Patients receive a broad-spectrum antibiotic intravenously as well as 5000 units of subcutaneous heparin at induction of anesthesia. Use of opioids is minimized during the surgery, and patients receive intravenous acetaminophen for analgesia. An orogastric tube is placed intraoperatively and removed after surgery. Intravenous fluids are minimized while the ureters are clipped.
Patient Positioning and Port Placement
A nonskid foam pad is applied to the operating table before the patient is moved on to the table. This is designed to prevent the patient from sliding while in the steep Trendelenburg position. Under general endotracheal anesthesia, patients are placed in lithotomy position with the lower extremities being abducted and the legs supported in Yellowfin stirrups ( Fig. 59.1 ). All pressure points are padded, and a warming blanket (Bair Hugger) is applied to the upper body. Intermittent pneumatic compression stocking are applied to both legs. Patients are prepped and draped in the usual sterile fashion, and an 18-Fr Foley catheter is placed in the bladder and kept in the sterile operative field.
Initial access is obtained using a 2-mm MiniPort (Covidien, New Haven, CT) in the midline, approximately 4 fingerbreadths (6–7 cm) above the umbilicus. Pneumoperitoneum is established to a pressure of 15 mm Hg, and a 12-mm laparoscopic port is placed at this site. This is the site of the robotic camera port. The peritoneal cavity is now inspected, and other ports are now placed so that there are a total of six ports: three robotic 8-mm ports, two 12-mm laparoscopic ports, and one 15-mm port. The port configuration is shown in Fig. 59.2 . In general, the ports are more cephalad than the port configuration for robotic prostatectomy, and this more cephalad placement of the working ports allows extended lymphadenectomy up to the origin of the inferior mesenteric artery (IMA) as well as bowel manipulation required for various types of urinary diversion. The three 8-mm robotic ports are placed in one line, about 2 to 3 fingerbreadths cephalad to the umbilicus. The authors use two robotic arms on the right side of the patient and one on the left side. Thus, the fourth arm of the robot is on the right side of the patient. A 12-mm assistant port is placed in the left upper quadrant just caudal to the left costal margin. The 15-mm port is placed at the horizontal level of the umbilicus in the left anterior axillary line. This port is used for deployment of a 15-mm specimen retrieval bag for the cystectomy specimen as well as the reusable bag for the individual lymph node packets. This port is also used to deploy staplers for the majority of the bowel work for the diversion. The bedside assistant and the scrub technician are situated on the left side of the patient.
The port placement for continent cutaneous diversion is different and is discussed separately in that section with the operative technique.
After all ports are placed, the patient is placed in a steep Trendelenburg position ( Fig. 59.3 ), and the robot is docked from between the patient’s legs for the da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) ( Fig. 59.4 ) and from the right side of the patient for the da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA) ( Fig. 59.5 ). The steep Trendelenburg position allows the bowel loops to fall out of the pelvis and allows ready access to the pelvic structures.
Operative Technique
We first complete the cystectomy and then the extended pelvic lymph node dissection, usually up to the origin of the IMA. After the extirpative part of the operation is completed, the urinary diversion is performed. The port placement and patient positioning are the same for an ileal conduit and an orthotopic neobladder but differ for a continent cutaneous diversion.
Radical Cystectomy
For the extirpative part of the operation, the authors use a fenestrated bipolar in the left robotic arm; a monopolar scissor in the right robotic arm; and ProGrasp forceps in the fourth robotic arm, which as mentioned earlier, is on the right side of the patient.
Mobilization and Division of the Ureters
With a 30-degree down scope, the ureters are identified at the pelvic brim and mobilized all the way down to the ureterovesical junction (UVJ) with care taken not to devascularize the ureters. They are clipped and divided just proximal to the UVJ ( Fig. 59.6 ), and the distal ureteral margins are sent for frozen section. The ureters remain clipped until they are anastomosed, and this helps with proximal ureteral dilation, which in turn facilitates ureteroenteric anastomosis.
Retrovesical Dissection in Male Patients
While the fourth arm retracts the bladder anteriorly, a transverse incision is made in the peritoneum of the rectovesical cul-de-sac ( Fig. 59.7 ). The plane of dissection between the vasa and seminal vesicles anteriorly and the rectum posteriorly is carried distally at which point the posterior layer of Denonvilliers fascia is incised to enter the plane between the prostate and the rectum ( Fig. 59.8 ). This dissection is carried distally using a combination of blunt and sharp dissection down to the apex of the prostate.
Lateral Dissection of the Bladder and Control of Vascular Pedicles
The peritoneum is now incised lateral to the medial umbilical ligament, the vas deferens is divided, and careful blunt and sharp dissection is performed between the pelvic side wall and the bladder, which is retracted away from the iliac vessels and the obturator fossa ( Fig. 59.9 ) using ProGrasp forceps in the fourth arm. The obliterated medial umbilical ligament is clipped and divided at its origin from the internal iliac artery bilaterally. The pedicles of the bladder are now exposed. For a nerve-sparing RRC, the vessels are individually clipped and divided without using thermal energy. The dissection begins at the tip of the seminal vesicles and progresses toward the prostate. It is performed close to the bladder and the posterolateral surface of the prostate, carefully preserving the neurovascular bundles (NVBs). In a non–nerve-sparing cystectomy, the lateral and posterior pedicles of the bladder are divided far from the bladder and the prostate using sequential firing of a 60-mm laparoscopic stapler ( Fig. 59.10 ) with a white vascular load (Ethicon Endo-Surgery, Cincinnati, OH).
Anterior Dissection, Control of the Dorsal Vein Complex, and Transection of the Urethra
An anterior peritoneotomy is made just caudal to the umbilicus, and the urachus and medial umbilical ligaments are divided. The bladder is mobilized from the anterior abdominal wall, and the space of Retzius is entered and developed to expose the pubic arch down to the endopelvic fascia ( Fig. 59.11 ). The endopelvic fascia is incised, and the levator muscles are separated from the prostate. The puboprostatic ligaments are divided, and the dorsal vein complex (DVC) is suture ligated with 2-0 Vicryl on a CT-1 needle or a 3-0 V-Loc suture ( Fig. 59.12 ). The bladder is retracted using the fourth arm of the robot, and the prostate pedicle is clipped and divided and the NVB separated from the prostate down to the apex of the prostate. The DVC is now divided and the urethra is carefully dissected circumferentially ( Fig. 59.13 ). The Foley catheter is now removed, and a 15-mm Hem-o-lok clip (Teleflex Medical, Athlone, Ireland) is applied to the membranous urethra just distal to the prostate apex ( Fig. 59.14 ). Alternatively, if an orthotopic neobladder is planned and a longer length of membranous urethra is to be preserved, an anterior urethrotomy is made in the membranous urethra just distal to the prostate apex, the Foley catheter is divided between Hem-o-lok clips ( Fig. 59.15 ), and the posterior urethra is transected at the verumontanum, leaving a long urethral stump. A distal urethral margin from the apical prostatic urethra is sent for frozen section. The specimen is now free and is entrapped in a 15-mm Endo Catch (II EndoCatch bag 15 mm; Covidien, Mansfield, MA). The open end of the specimen bag is retrieved through the 15-mm port site and is separately ligated to prevent any spillage and is then returned to the abdominal cavity until final extraction.
Anterior Pelvic Exenteration in Female Patients
After ureteral division, lateral dissection of the bladder, and control of the lateral pedicles, the fourth arm retracts the uterus anteriorly, and with a sponge stick in the vagina, the posterior vaginal fornix is identified and scored ( Fig. 59.16 ). The bladder is then dissected from the anterior abdominal wall, and the DVC is suture ligated. The uterus is now retracted anteriorly with the fourth arm, and the previously scored posterior vaginal fornix is incised. The incision is carried distally and anteriorly toward the urethra ( Fig. 59.17 ). The urethra is transected just distal to the bladder neck as previously described (if an orthotopic neobladder is planned), and a central strip of the anterior vaginal wall is excised en bloc with the bladder, uterus, and adnexa. If an orthotopic diversion is not planned, complete urethrectomy can be performed along with the strip of vagina all the way down to the introitus. The specimen is entrapped in a 15-mm Endo Catch and extracted through the vagina immediately. The use of an AirSeal (Surgiquest, Milford, CT) port ( Fig. 59.18 ) is invaluable to prevent loss of pneumoperitoneum while the vagina is open. The vagina is reconstructed in a clamshell manner ( Fig. 59.19 ) with a running 2-0 V-Loc suture. If an orthotopic neobladder is planned, it is advisable to bring down a vascularized flap of omentum ( Fig. 59.20 ) and anchor it to the anterior surface of the reconstructed vagina to minimize chances of a fistula.
Extended Lymphadenectomy
After completing the radical cystectomy, the authors perform an extended LND using the classic “split-and-roll” technique. The authors’ template ( Fig. 59.21 ) for extended LND is the origin of the IMA proximally, the genitofemoral nerve laterally, the perivesical nodal tissue medially, and the node of Cloquet distally. The posterior limits are the presacral nodes, the branches of the internal iliac artery, and the presciatic fossa of Marseilles ( Fig. 59.22 ). Meticulous dissection within these boundaries is essential to maximize removal of nodal tissue. Large lymphatics at the boundaries of the dissection should be clipped to minimize the risk of lymphocele and chylous ascites. Care should be taken to avoid cutting into a node so as to minimize chances of tumor spillage.
The right-sided dissection is performed in a distal to proximal (retrograde) fashion. Thus, the procedure begins with the dissection of the right node of Cloquet and is carried proximally following the external, internal and common iliac vessels and then the aortic bifurcation up to the IMA ( Fig. 59.23 ). The sigmoid colon is retracted to the left to allow dissection of the presacral ( Fig. 59.24 ) as well as the left common iliac and paraaortic nodes. The right ureter may have to be additionally mobilized to allow the dissection of the paracaval nodes. The initial left-sided dissection is performed in an anterograde manner, from the aortic bifurcation down to the left common iliac bifurcation. At this point, the sigmoid colon and mesocolon are lifted off the psoas, and the left ureter is transposed through this window to the right ( Fig. 59.25 ). The sigmoid colon is now retracted to the right, and the left LND is now performed distal to proximal starting with the left node of Cloquet, following the external iliac vessels and up to the left common iliac vessels, which have already been dissected. To properly dissect the entire obturator fossa and the presciatic fossa of Marseilles, the node dissection should also be performed lateral to the iliac vessels, allowing direct visualization of the proximal obturator nerve and the presciatic fossa.
The individual nodal packets, from each subregion of the template, are retrieved in a reusable bag (Anchor Tissue Retrieval System; Addison, IL) to prevent any spillage in the peritoneal cavity.
Robotic Ileal Conduit Urinary Diversion
After completing the radical cystectomy and LND, Cadiere forceps are deployed in the left and fourth robotic arm, and a double-fenestrated forceps is deployed in the right robotic arm. The cecum and the terminal ileum are identified, and any interloop adhesions are carefully divided. A quarter-inch Penrose drain with 5-cm markings ( Fig. 59.26 ) is deployed into the peritoneal cavity from the 15-mm assistant port.
Distal Ileal Division
The terminal ileum is divided with a 60-mm laparoscopic stapler with a blue load (Ethicon Endo-Surgery), with care taken to place the stapler perpendicular to the bowel segment ( Fig. 59.27 ). This stapler is deployed by the assistant through the 15-mm assistant port and divides the mesentery of the small bowel as well. As soon as the bowel is transected, a dyed (blue) 2-0 Vicryl stay suture is placed in the center of the staple line in the distal end of the ileum to mark the end that will be used in the subsequent side-to-side bowel anastomosis ( Fig. 59.28 ).
If additional mesenteric division is required, an additional vascular staple load (white cartridge) can be fired to deepen the mesenteric division taking care to avoid devascularizing adjacent bowel segments. If there is any doubt, intravenous indocyanine green (ICG) and fluorescence imaging with the Firefly function of the robotic system can be used to identify the vascular arcades ( Fig. 59.29 ) and to check vascularity of bowel segments.
