Robotic Radical Cystectomy, Pelvic Lymph Node Dissection, and Intracorporeal Ileal Conduit Urinary Diversion

Summary

This paper describes robotic radical cystectomy, pelvic lymph node dissection, and intracorporeal ileal conduit urinary diversion.

Abstract

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower surgical blood loss, its potential association with shorter hospital stay after surgery. These factors suggest that the robotic approach to radical cystectomy may be an important component of enhanced recovery programs aimed at reducing surgical morbidity. This paper describes the importance of the cranial placement of robotic trocars, the use of Cadiere forceps for atraumatic bowel grasping, pelvic lymph node dissection (PLND), and utero-enteric anastomoses. Also discussed are steps that are critical for the successful outcome of RARC. In spite of the increased operating times and associated costs and the costs of robotic surgical platforms and equipment, adoption of the robotic technique by bladder cancer surgeons has increased. This paper describes a systematic and reproducible method that details robotic extended pelvic lymph node dissection, cystectomy/cystoprostatectomy, and intracorporeal ileal conduit urinary diversion.

Introduction

Since the advent of robotic surgery in the USA in 2000, the Da Vinci robot has become increasingly utilized across surgical specialties¹. The reasons for this trend are multiple and may include ease of instrumentation with wristed instruments (particularly in small or narrow body cavities), the desire to adopt new technology, and the potential for decreased perioperative morbidity as measured by intraoperative blood loss, post-operative pain, and/or length of inpatient stay after surgery^2,3,4,5,6. Radical cystectomy is the standard of care for surgical management of localized muscle invasive bladder cancer (clinical stages cT2-4a, N0, M0)^7,8,9. Clinical evidence strongly suggests that oncologic outcomes of open and robotic radical cystectomy are similar¹⁰. The impetus to adopt a robotic approach for radical cystectomy is the possibility that a minimally invasive approach may reduce complication rates.

As the morbidity of radical cystectomy is high (90-day overall complication rate of 64% and a 1.5% 30-day mortality rate), reducing cystectomy-associated complications is an urgent clinical need^11,12. In fact, the robot-assisted radical cystectomy (RARC) versus ORC in patients with bladder cancer (RAZOR) trial demonstrated that a robotic approach to cystectomy is associated with much lower intraoperative blood loss, lower transfusion rates, and a slightly shorter postoperative length of stay¹⁰. It should be noted that RARC with intracorporeal urinary diversion (RARC with ICUD) is a complex procedure with a steep learning curve^13,14,15. Accordingly, the objective of this paper is to explicitly detail the smaller component steps to one approach, which when considered individually, are simple and reproducible.

Herein, a systematic approach to robotic radical cystectomy, pelvic lymph node dissection (PLND), and intracorporeal ileal conduit urinary diversion has been described. Institutionally, the decision to perform an extracorporeal versus intracorporeal ileal conduit is surgeon- and patient-dependent. Although not necessary, it is preferable to perform bilateral extended pelvic lymph node dissection (PLND) prior to cystectomy for complete visualization of the external and internal iliac vessels and obturator nerve and vessels during division of the bladder pedicles to prevent inadvertent ligation/division of specific obturator and internal iliac structures. This may help in cases of bulky bladder tumors. Outcomes in three patients have been provided for illustrative purposes.

Protocol

This protocol and description of representative results abide by the guidelines of the Ohio State University human research ethics committee, and the approval to provide these representative results was obtained from each patient in compliance with the institution's guidelines. The inclusion criteria were patients recommended to undergo surgical management of their bladder cancer. Patients with metastatic disease, comorbidities prohibiting surgical management of their cancer, or cancer determined to be unresectable w…

Representative Results

Representative results of the described approach to robotic radical cystectomy, pelvic lymph node dissection, and intracorporeal ileal conduit urinary diversion are presented in Table 1. The three selected patients underwent the procedure by a single surgeon (DS) between December 2019 and June 2020. All procedures were completed on the Da Vinci Xi Robot using the port placement as illustrated in Figure 1. Blood loss was minimal (125 mL or les…

Discussion

Robotic radical cystectomy was first described in 2003^17,18. Unlike the widespread adoption of the robotic approach for radical prostatectomy for prostate cancer, less than 20% of radical cystectomies are performed robotically in the USA¹⁸. However, as adoption of RARC grows over time, the overwhelming majority of cystectomy cases are performed with a robotic approach at certain centers²¹. Although intraoperative bl…

Materials

19 Fr drain	N/A	N/A	Pelvic drain
AirSeal Port	ConMed	IASB12-120	12 mm assistant port that keeps stable pneumoperitoneum despite sunctioning
Anchor Endo Catch Specimen Bags	ConMed	TRS100SB2	10 mm reusable specimen bag for lymph node packets; 12 mm bag for bladder specimen
Babcock clamp	N/A	N/A	Used to externalize the ileal conduit
Biosyn suture	N/A	N/A	4-0 suture used to close skin incisions
Carter Thomason Needle Device	Cooper Surgical	CTI-1015N	Used for fascial closure and to suspend the ileal conduit to the abdominal wall
Da Vinci Xi or Si Robot	Da Vinci	N/A
Endo-GIA Stapler	Medtronic	EGIA30AMT	80 mm (purple) loads for division of bowel to create ileal conduit
Guidewire	N/A	N/A	Used to load the ureteral stents
Hem-o-Lok Clip Applier and Clips	Weck	544995	Ligation of prostatic pedicle
Laparoscopic Suction Tip	N/A	N/A	Used to preload the ureteral stents
Luer lock syringe, 10 mL	N/A	N/A	Used to perform saline drop test and to inflate foley balloon.
LigaSure Vessel Sealer	Medtronic		Robotic vessel sealer
Monocryl suture	N/A	N/A	4-0 suture on a PS-2 reverse cutting needle
Nylon sutures	N/A	N/A	2-0, used to secure the drain and ureteral stents to the abdominal wall
Robotic cadiere grasping forceps	Da Vinci	470049
Robotic maryland bipolar forceps	Da Vinci	470172
Robotic monopolar scissors	Da Vinci	470179
Silk suture	N/A	N/A	3-0 silk suture for marking the bowel segment for ileal conduit creation
Single J Ureteral stent	N/A	N/A	6 Fr
Symmetric Stratafix Suture	Ethicon	SXPP1A406	0 barbed suture
Tonsil clamp	N/A	N/A	Used when maturing the stoma
Vicryl suture	N/A	N/A	3-0 vicryl suture cut to 20 cm to be used as a suspending suture for the ileal conduit
V-Loc Suture	Covidien	KENDVLOCL0315	2-0 on CT-1 needle. Barbed absorbable suture.