Keywords

Introduction

The creation of the urinary diversion is a challenging surgical part after radical cystectomy and holds a special place in the development of urological practice. Following cystectomy, urine can be diverted either into an incontinent stoma, into a continent urinary reservoir catheterized by the patient or controlled by the anal sphincter, or into an orthotopic bladder substitute so that the patient voids per urethra.

The history of urinary diversion is almost more than one and half centuries old. Simon was the first to describe a urinary diversion, using intestinal segments in 1852 [1]. Ureterocutaneostomy or transuretero-ureterocutaneostomy, the simplest form of urinary diversion, was the first diversion which has been tried initially. Strictures and scarring of the ureters were common problems, which later led to the use of intestinal segments of ileum or colon to create conduits.

In the late nineteenth and early twentieth centuries, in the absence of prophylactic antibiotic treatment, urinary diversion using bowel segments carried a high risk for peritonitis. When Coffey in 1911 [2] introduced a new method for ureteric implantation, ureterosigmoidostomy became the most frequently used technique. With increasing concern over secondary colonic malignancy, fewer ureterosigmoidostomies were performed, as it became unpopular because of the high incidence of tumor occurrence at the anastomosis between the ureters and the colon [3].

The ileal conduit, first described by Zaayer in 1911, was established as a standard technique by Bricker in 1950 [4]. At the same time, Ferris and Oedel demonstrated that hyperchloremic metabolic acidosis was common in 80% of the patients treated with ureterosigmoidostomy [5]. Thus the ileal conduit became the preferred form of urinary diversion. Longer follow-up has shown that ileal conduits do have significant physical and psychological morbidity, and this has stimulated the increasing use of continent urinary diversion and orthotopic bladder substitutes.

The first attempts to create a continent urinary diversion were undertaken by Tizzoni and Foggi in 1888 [6]. They replaced the bladder in a female dog by an isoperistaltic ileal segment. Mauclaire, in 1895, used the isolated rectum as a urinary reservoir [7]. Sinaiko was the first to use the stomach for the creation of a urinary reservoir in 1956 [8]. Two findings were essential for the development of modern continent urinary diversion: Kock established the principle of bowel detubularization to create a low-pressure reservoir, and Lapides popularized the use of clean intermittent catheterization [9]. In 1969, Kock published his first results obtained with an ileal continent fecal reservoir in patients after total proctocolectomy [10] and in 1975 he transferred the principle of this technique to urinary diversion [11]. In the 1980s as surgical outcomes of cystectomy continued to improve, emphasis was directed toward improving long-term quality of life. The pioneering work of Nils Kock and Maurice Camey [12] led to a variety of continent urinary reservoirs. The majority of these used either ileal segments, like the Hautmann and Studer neobladder [13, 14], or ileocecal segments, like ‘Le Bag’ MAINZ II pouch [15] and the modified rectal bladder of Ghoneim [16]. These are only a few examples of continence reservoirs which are still commonly used.

In the 1990s with development of minimally invasive techniques and advances in instrumentation design the interest in laparoscopic urinary diversion following cystectomy increased dramatically. The first simple laparoscopic cystectomy for pyocystis was performed by Parra et al. in 1992 [17]. In 1993 de Badajoz et al. published the first study on laparoscopic radical cystectomy (LRC) for muscle-invasive bladder cancer, wherein the ileal conduit urinary diversion was performed extracorporeally [18].

In 1995 Puppo et al. [19] described five cases of a combined laparoscopic and transvaginal anterior pelvic exenteration for bladder cancer. In 2001 Turk et al. described a completely intracorporeal LRC with a continent urinary diversion (rectal sigmoid pouch) [20]. A completely intracorporeal reconstruction of the entire LRC and urinary diversion procedure was reported by Gill et al., who also performed the first purely laparoscopic ileal conduit urinary diversion and laparoscopic orthotopic Studer neobladder in 2000 and 2002, respectively [21, 22].

During the last 15 years, urologists worldwide have witnessed a tremendous uptake of minimally invasive surgery due to the development of robotassisted surgery in many urological diseases. In parallel the interest in expanding the role of robot-assisted radical cystectomy (RARC) for the management of urinary bladder cancer has risen during the last years and continues to grow. Robotic-assisted laparoscopic techniques have emerged allowing surgeons to more readily overcome the difficult learning curve and shorten operative times in minimally invasive abdominal and pelvic operations [23, 24].

The da Vinci Surgical System® (Intuitive Surgical, Inc., Sunnyvale, CA) was first introduced in 2000 [25]. After the initial report of robot-assisted radical cystectomy [26], several investigators have described the feasibility of RARC in the management of urinary bladder cancer [27,28,29,30].

RARC has been grown steadily during the last decade and has replaced LRC in centers where the robot is available. The neobladder can be formed intracorporeally [26, 31, 32] but operative time may be reduced early in the learning curve if this is done extracorporeally through the same incision used to deliver the cystectomy specimen. It has been shown that operation time is related to surgical experience and can be reduced using a standardized approach to RARC [24].

Raza et al. [33] reported that RARC is a minimally invasive procedure with long-term follow-up which is oncologically equivalent to open radical cystectomy. Novara et al. [34] reported in a review article that minimally invasive techniques, LRC and RARC, were associated with significantly reduced blood loss, hospital stay, marginally higher operative time and similar postoperative complication rates when compared to open radical cystectomy. Yuh et al. [35] reported in a review article that RARC oncological and functional outcomes with early and intermediate follow-up analysis were equivalent to reported outcomes from open surgery. Herein we describe step by step the method used at Karolinska University Hospital for robot-assisted urinary diversion with ileal conduit and orthotopic neobladder by intra- and extracorporeal technique.

Patient Selection

Selecting the correct patient for totally intracorporeal RARC and optimising their peri-operative care is crucial to optimising outcomes. The selection process includes preoperative investigation to ensure fitness for surgery as well as specific counselling about robotic technology. Patients with decreased pulmonary compliance who cannot tolerate prolonged Trendelenburg positioning are not candidates for the robotic-assisted technique. Furthermore, if the patient has a history of previous extensive abdominal surgery, RARC may be contraindicated. Relative contra-indications include patients aged >80 years, body mass index (BMI) >30 and those with bulky disease and such cases should be avoided early in the operative learning curve.

Options for urinary diversion (UD) are discussed with the patient. Inclusion criteria for robot-assisted formation of an orthotopic ileal neobladder are the same as for open surgery, with all suitable patients primarily considered for orthotoptic neobladder. If a neobladder is contraindicated or if patients prefer, they will then receive an ileal conduit. The absolute contraindications for neobladder formation are: disease infiltration of the urethra distal to the prostate, impaired renal (serum creatinine >2 mg/dL) and hepatic function, and decreased mental capability and hand dexterity. The relative contraindications include: inflammatory bowel disease (Crohn’s disease), non-competent external sphincter with associated urinary incontinence, history of recurrent urethral strictures, previous abdominal or pelvic irradiation and history of severe comorbidities, elderly patients (octogenarians), or morbid obesity (BMI > 30).

Preoperative Preparation

Standard preoperative evaluation includes computed tomography (CT) of the chest, abdomen and pelvis, routine blood tests and anaesthetic review incorporating evaluation of cardiopulmonary reserve. Patients with pT2 + tumours receive preoperative neoadjuvant platinum-based chemotherapy. In RARC with intracorporeal urinary reconstruction, bowel preparation can be avoided [36]. However, irrigation of the bowel segment may be tricky and non-digestible vegetables can be seeded into the peritoneum when the small bowel segment is opened. Thus, vegetables should not be part of the diet the day before surgery. A stoma site is marked the day prior to surgery in all patients and broad spectrum intravenous antibiotics are administrated at the start of the procedure. All patients should follow an enhanced recovery after surgery protocol for their peri-operative care planning [37].

Operative Setup

Patient Position

After induction of general endotracheal anesthesia a naso-gastric tube and an 18 Ch Foley urinary catheter are inserted. The patient is placed in lithotomy position with arms adducted and padded. The legs are also abducted and slightly lowered on spreader bars. The table is placed in 25° Trendelenburg position during the cystectomy and lymph node dissection. For the urinary diversion the Trendelenburg position is decreased to 10–15°.

Equipment

The technique is challenging, requiring conventional laparoscopic infrastructure as well as an assistant with high skills in conventional laparoscopy. Standard laparoscopic surgical equipment with some extra instruments is required (Ligasure® Covidien, surgical endoscopy clip applicators, laparoscopic endo-catch bags, and laparoscopic stapler for intestinal stapling).

Surgical Steps (Table 56.1)

Trocar Configuration

Port placement is critical for successful robotic surgery (Fig. 56.1). A six-port technique is used with the camera port placed 5 cm above the umbilicus in the midline. The camera port is placed by a small mini laparotomy as described by Hasson [38] and the other ports are placed in view of the camera. A pneumoperitoneum pressure of 18 mmHg during the port placement can be helpful in creating additional tension on the abdominal wall. Two robotic ports are placed symmetrically and level with the umbilicus on the left and right side, lateral to the rectus sheath. A third robotic instrument port is placed just above and medial to the left anterior superior iliac spine through a 15-mm port thereby enabling laparoscopic stapling by the assistant when the third robotic port is temporarily disconnected. The fourth port (5 mm right assistance port) is placed approximately 5 cm above the right anterior superior iliac spine in the mid-axillary line. The fifth (15 mm) port is positioned approximately 5 cm above the left anterior superior iliac spine for the insertion of the fourth robotic arm instrument. During the intracorporeal construction of the urinary diversion the fourth arm port will be removed from the 15-mm port above the left anterior superior iliac spine allowing intestinal stapling through this port. The sixth (12 mm) assistant port is placed midway between the right robotic arm port and the camera port approximately 2 cm above the camera port. The pneumopertioneum can then be reduced to 10–12 mmHg.

Table 56.1 Surgical steps
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Fig. 56.1
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Trocar placement for standard da Vinci system. (A) 5 mm trocar. (B) 8 mm trocar, right robot instrument. (C) 12 mm trocar, suction, bowel grasping, LigaSure. (D) camera trocar. (E) 8 mm trocar, left robot instrument. (F) 15 mm four robotic arm, specimen retrieval and stapling

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Urinary Diversion

Orthotopic Neobladder, Intracorporeal Technique

Anastomosis Between the Urethra and Ileum

After completing the radical cycstectomy and the ePLND the urinary diversion is performed. For the urinary diversion the robot is undocked and the Trendelenburg position is decreased to 10–15° before re-docking, so as to facilitate the bowel dropping into the pelvis.

The first step is to perform an anastomosis between the ileum and the urethra. The 0° lens is used for this initial step. The ileum is sufficiently mobilized in order to reach down to the urethra. This is important for two reasons, first the anastomosis between the neobladder and urethra can be performed without tension, and second the neobladder will be placed correctly in the small pelvis during the whole procedure. This will help during construction of the neobladder by running suture. A 20 Ch opening (Fig. 56.2) is made in the antimesentric site of ileum, using robotic scissor. The anastomosis is performed according to the Van Velthoven technique with a two times 16 cm 2–0 Quill® suture, allowing for 10–12 suture passes (Fig. 56.3). A needle driver and a cadiere are used to establish the anastomosis.

Fig. 56.2
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An opening (B) in ileum (A) is performed to allow the passing of a 20 Ch catheter

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Fig. 56.3
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Anastomosis between urethra (A) and ileum (B)

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Isolation of 50 cm Ileum

The orthotopic neobladder is fashioned from a 50 cm segment of terminal ileum. The intestine is isolated using laparoscopic Endo-GIA with a 60 mm intestinal stapler (Fig. 56.4). The staple is inserted by the assisting surgeon, using the 15 mm port on the left side. The ileum is stapled 40 cm proximal to the urethral– ileal anastomosis. The continuity of the small bowel is restored by using Endo-GIA with a 60 mm intestinal stapler, positioning the distal and proximal end of the ileum side to side with the anti-mesentery part facing each other (Fig. 56.5). An additional transverse firing of the Endo-GIA staple is used to close the open ends of the ileal limbs (Fig. 56.6). Stay sutures may be used to attach the intestines before stapling them together.

Fig. 56.4
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Stapling of ileum using Endo-GIA 60 mm

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Fig. 56.5
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Side-to-side anastomosis of ileum by Endo-GIA 60 mm

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Fig. 56.6
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Closing of the open end of ileal limbs using the Endo-GIA staple

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Detubularization

The distal 40 cm of the isolated ileal segment is detubularized along its antimesenteric border with cold scissors (Fig. 56.7), leaving a 10 cm intact proximal isoperistaltic afferent limb. Care is taken not to interfere with the sutures used for the anastomosis to the urethra (Fig. 56.8).

Fig. 56.7
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Detubularization of ileum, antimesentricaly (A) in order to create the neobladder

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Fig. 56.8
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Detubularization close to the ileourethral anastomosis (A), special care is taken not to interfere with the anastomotic suture

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Formation of Studer Neobladder

After detubularization, the posterior part of the Studer reservoir is closed using multiple running sutures (15 cm 3–0 V-Loc®) in a seromuscular fashion, avoiding suturing the mucosa. After the posterior part is sutured, the distal half of the anterior part of the reservoir is sutured, using the same suture. The 0° or 30° lens can be useful for this part of procedure. The proximal half of the anterior part of the reservoir is left open and is closed in the last part of the procedure.

Ureteric Entero-Anastomosis

The anastomosis between the ureters and the afferent limb is performed using the Wallace technique [39]. Using the fourth arm the ureters are aligned holding the ties attached to the Hem-o-lok clips. The ureters are then incised and spatulated for 2 cm (Fig. 56.9). The posterior walls of the ureters are sutured side-to-side, using a 15 cm running 4–0 Biosyn suture (Fig. 56.10). Before the anastomosis between the ureters and the intestinal loop is made, two single-J 40 cm ureteric stents are introduced with the Seldinger technique [40] through two separate 4-mm incisions at the lower part of abdominal wall (Fig. 56.11). Using the Cadiere forceps the stents are pulled through the afferent limb and pushed up into the ureters on each side (Fig. 56.12). The ureters are then sutured to the afferent limb of the Studer pouch, using a two-times 16 cm 3–0 Quill suture with a needle on each end (Fig. 56.13). After the entero-ureteric anastomoses are completed the stents are sutured and fixed to the skin.

Fig. 56.9
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Spatulation of the right ureter (A)

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Fig. 56.10
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Suture of left (A) and right (B) ureter side to side, according to the Wallace technique

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Fig. 56.11
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Placement of uretric stent through a 3 mm port (A). Right robotic instrument (B) grasps the tip of the stent (C) and pulls in upward through the afferent limb of Studer reservoir (D)

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Fig. 56.12
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Placement of stent up through the right ureter (A). The left uretric stent is already in place (B)

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Fig. 56.13
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Anastomosis between Wallace plate (A) and afferent limb (B) of the Studer reservoir, using seromucosal suturing technique

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Closure of the Studer Reservoir

The remaining part of the neobladder is then closed with a running 3–0 V-Loc suture. The balloon of the indwelling catheter is filled with 10 mL sterile water. The neobladder is then filled with 50 mL of saline to check for leakage (Fig. 56.14). Extra suturing to secure a watertight reservoir and anastomosis is fundamental to decreasing post-operative complications. A 21F passive drain is introduced and placed in the small pelvis. Drain fluid is sent for biochemical analysis the morning after surgery and if there is no indication of urine leakage the drain is removed on day 1 post-operatively [36]. The urethral catheter is removed after 21 days. We do not place a suprapubic catheter.

Fig. 56.14
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After the neobladder (A) is completed it is filled with 50 cc saline to check for leakage. The anastomosis between ureters and afferent limb (B) is also checked for leakage. The uretric stents (C) are placed separately in the Studer reservoir

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Ileal Conduit, Intracorporeal Technique

Twenty centimeter intestine is isolated from the terminal ileum, using Endo-GIA with a 60 mm intestinal stapler. The continuity of the small bowel is restored as described above. The distal end of the conduit is fashioned as a stoma by surgical assistant at a previously marked site on the abdominal wall. The left ureter is tunneled under the sigmoid mesentery to the right side. The ureters are then incised and spatulated 2 cm. The Wallace technique is used here as described above. Single-J 40 cm ureteric stents are then introduced through the isolated ileal segment (ileal conduit), using a suction tube for a protective channel avoiding intestinal perforation. The stents are then pushed up into the ureters on each side and the ureteroenteric anastomosis is completed, using a two-times 16 cm 3–0 Quill® suture which has a needle on each end.

Special Consideration

Patient Position

Care should be taken for using a pneumatic leg compression system due to risk of decreased vascular perfusion during the procedure [37]. To avoid cardiovascular complications the patient is started on anticoagulant treatment with low molecular weight heparin according to his body weight the evening before surgery until the patient is fully mobilized. It is feasible to perform the urinary diversion with 10–15° Trendelenburg, since higher degree of Trendelenburg is to be avoided in order to minimize the risk for cardiopulmonary complications.

Port Position

It is always important to make sure that the fourth arm port and the left robotic arm port are not in a same superior-inferior alignment to avoid clashing of robotic arms.

Urethral-Neobladder Anastomosis

The anastomosis between the urethra and the ileum (see Fig. 56.2) should be the first step in the formation of an intracorporeal orthotopic neobladder. This is a critical step because the anastomosis can be performed without tension, and the neobladder will be placed correctly in the small pelvis during the whole procedure.

Steps to Avoid Complication

Shoulder pads should be avoided due to the high risk of plexus damage. Care should be taken during the tunnelling of the left ureter behind the colon sigmoid and during the extended lymph node dissection to avoid damaging any vascular structures. It is important to check for leakage after the neobladder has been created. Extra suturing to secure a watertight reservoir and anastomosis is fundamental to decrease postoperative complications.

Current Status and Outcomes

Construction of the urinary diversion after RARC is probably the most challenging part of the procedure, especially if using a totally intracorporeal approach. Since the first robot-assisted radical cystectomy (RARC) by Beecken et al. in 2003 [26] RARC has been gradually adopted as a surgical alternative to open cystectomy. As recently as 2010 the number of centres performing this surgery appeared limited, with only ∼500 cases being reported in the worldwide literature [41], but by 2012 this had increased to ∼1000 cases [42]. Results from more than 2000 RARC cases worldwide have now been published [34]. The first papers publishing long-term oncological outcomes show results that are comparable to published open series [33] and reviews have concluded that functional outcomes and complication rates are also comparable [34, 35]. The operative time used for the reconstruction, early in the surgeons learning curve, is one of the important factors in the decision between performing the diversion extra- or intracorporeally. Currently the vast majority of RARC in the United States are completed with an extracorporeal approach to the urinary diversion by extending the mini-incision used for removal of the specimen [26, 43,44,45]. In a recent multi-institutional report from the USA only 3% of patients had a totally intracorporeal approach [46]. Robot-assisted intracorporeal ileal conduit and orthotopic neobladder have been described in the literature [26, 47,48,49]. There is a growing body of evidence that intracorporeal urinary diversion is becoming increasingly utilised and that there are potential advantages to the patient if they undergo a totally intracorporeal approach to RARC [50].

Table 56.2 presents data from case series of intracorporeally performed urinary diversions performed at single institutions.

Table 56.2 Robotic-assisted radical cystectomy with intracorporeal urinary diversion
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Currently, there is a limited amount of data on functional outcomes. Whereas in robot-assisted radical prostatectomy (RARP) surgery there is a potential trade-off between oncological and functional outcomes, in RARC functional outcomes are dependent on various factors and surgical choices, e.g., continent vs non-continent diversion, with additional variables such as natural voiding vs required intermittent self-catheterization. Although continence rates after RARC are directly related to the surgical approach, they are influenced by multiple factors including patient age and mental status, an intact and innervated urethral sphincter, urethral length, low-pressure/large-capacity reservoir (>300 mL), absence of bacteriuria, and completeness of voiding. Continence after orthotopic bladder substitution continues to improve up to 12 months after surgery. It is therefore preferable to assess continence stratified by daytime and night-time continence and by gender [51, 54]. Similar conclusions were reached in the 2012 EAU International Consultation on Bladder Cancer [55] which reviewed the data published on urinary diversion between 1970 and 2012 and found that in patients with open radical cystectomy and orthotopic bladder substitution, day- and night-time continence is achieved in 85–90% and 60–80%, respectively. If we consider totally intracorporeal continent urinary diversion, in most published series a Studer neobladder has been created [31, 48, 49, 51] and, although current cohorts are small, functional outcomes reported are encouraging. Tyritzis et al. [51], in a series of 70 patients, reported daytime continence of 88.2% in male patients who had undergone nerve-sparing surgery, whilst night-time continence reached 73.5% at 12 months. Similar rates were achieved for males who had undergone non-nerve-sparing surgery at 12 months (83.3% and 88.9%, respectively). Of female patients, 66.7% were found to be continent during the day and 66.7% at night at 12 months. All continence rates showed significant improvement at 12 months compared with the 6-month follow-up. A total of 81.2% of male patients were potent with or without phosphodiesterase type 5 inhibitor medication at 12 months. In that series, all eight female patients received a nerve-sparing procedure by preserving the autonomic nerves on the anterior vaginal wall. Of the evaluated male nerve-sparing, male non-nerving-sparing and female patient groups 84.4, 23.8% and 66.7% of patients, respectively, were sexually active postoperatively. Goh et al. [48] reported daytime continence in six out of eight patients at a mean (range) follow-up of 3.1 (3–21) months. Canda et al. [49] reported daytime continence in 11 out of 17 patients at a mean (range) follow-up of 6.4 (2–12) months, four had mild and two had severe daytime incontinence. In sexual functionality in females, important outcome measures after the reconstruction of the vagina include both the ability to have sexual intercourse and the absence of dyspareunia (see Table 56.2).

RARC surgery is complex surgery with several important outcome measures. It is crucial to optimize both oncological and functional outcomes whilst minimizing complications. With time and increased experience, operative times, functional and oncological outcomes will continue to improve [24]. Totally intracorporeal RARC has potential advantages with the literature showing consistent advantages, such as blood loss and length of stay, compared with open radical cystectomy [34]. However, the outcomes of prospective randomized controlled trials comparing RARC with intracorporeal and extracorporeal urinary diversion and/or standard open radical cycsteectomy are awaited to confirm the current findings. Measures of optimum outcome should include, negative surgical margins, cancer specific survival at 3 and 5 years, absence of major complications in the 30- and 31–90-day periods, daytime and night-time continence at 12 months, sexual activity, plus measures of length of hospital stay and time to return to normal activities. Comparative studies should also include quality-of-life or overall satisfaction scores [50].