Robot-assisted approach to 'W'-configuration urinary diversion: a step-by-step technique

Atlas of Intracorporeal Orthotopic Neobladder Techniques After Robot-assisted Radical Cystectomy and Systematic Review of Clinical Outcomes

BACKGROUND

Multiple and heterogeneous techniques have been described for orthotopic neobladder (ONB) reconstruction after robot-assisted radical cystectomy. Nonetheless, a systematic assessment of all the available options is lacking.

OBJECTIVE

To provide the first comprehensive step-by-step description of all the available techniques for robotic intracorporeal ONB together with individual intraoperative, perioperative and functional outcomes based on a systematic review of the literature.

DESIGN, SETTING, AND PARTICIPANTS

We performed a systematic review of the literature, and MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched to identify original articles describing different robotic intracorporeal ONB techniques and reporting intra- and perioperative outcomes. Studies were categorized according to ONB type, providing a synthesis of the current evidence. Video material was provided by experts in the field to illustrate the surgical technique of each intracorporeal ONB.

SURGICAL PROCEDURE

Nine different ONB types were identified: Studer, Hautmann, Y shape, U shape, Bordeaux, Pyramid, Shell, Florence Robotic Intracorporeal Neobladder, and Padua Ileal Neobladder.

MEASUREMENTS

Continuous and categorical variables are presented as mean ± standard deviation and as frequencies and proportions, respectively.

RESULTS AND LIMITATIONS

Of 2587 studies identified, 19 met our inclusion criteria. No cohort studies or randomized control trials comparing different neobladder types are available. Available techniques for intracorporeal robotic ONB reconstruction have similar operative time, estimated blood loss, intraoperative complications, and length of stay. Major variability exists concerning postoperative complications and functional outcomes, likely related to reporting bias.

CONCLUSIONS

Several techniques are described for intracorporeal ONB during robot-assisted radical cystectomy with comparable perioperative outcomes. We provide the first step-by-step surgical atlas for robot-assisted ONB reconstruction. Further comparative studies are needed to assess any advantage of one technique over others.

PATIENT SUMMARY

Patients elected for radical cystectomy should be aware that multiple techniques for robotic orthotopic neobladder are available, but that current evidence does not favor one type over the others.

Genital Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Neobladder & Paravaginal Repair

OBJECTIVE

Vaginal prolapse is a known complication after radical cystectomy, requiring additional procedures in 10% of the patients.1 This results from loss of level I and II vaginal support due to the removal of pelvic structures. In addition, a neobladder urinary diversion, with Valsalva voiding, predisposes to vaginal prolapse. A genital-sparing approach with paravaginal repair can help prevent such complications.

METHODS

The genital sparing technique preserves the uterus, fallopian tubes, ovaries, and vagina, while paravaginal repair involves suturing of the lateral vaginal wall to the arcuate fascia located on the medial aspect of the obturator internus muscle. The procedure begins by placing the patient in a lithotomy position, with a steep Trendelenburg. Standard 6 port cystectomy configuration is utilized with an additional 15 mm port for bowel anastomosis. Initially, the ureters and lateral bladder space are mobilized. Posteriorly a dissection plane is developed separating the bladder from the anterior vaginal wall. Distal dissection is carefully performed in that plane to avoid disrupting the urethral-external sphincter complex. Then the bladder is dropped from anterior attachments, the Dorsal venous complex (DVC) and bladder neck are exposed. Urethra is transected distal to the bladder neck, after circumferential mobilization, to complete the cystectomy, again avoiding disruption of the continence mechanism, and opening the endo-pelvic fascia. Cystectomy and pelvic lymph node dissection are completed in a standard fashion. The arcuate fascia is identified bilaterally for level I paravaginal repair. The lateral aspect of the paravaginal tissue is secured to this ligament, using 3 interrupted Polydioxanone (PDS) sutures, bilaterally. An ileal "Hautman's W pouch" neobladder is constructed using 50 cm of the small intestine, similar to the previously reported technique.2 Bricker-type uretero-ileal anastomosis is performed over a double J stent. Bowel continuity is restored by a side-to-side anastomosis using endo-GIA (gastrointestinal anastamosis EndoGIATM ) staplers.

RESULTS

No intra or postoperative complications were noted. Robot dock time was 8 hours and 23 minutes with an EBL of 100 mL. The patient was discharged on post operative day (POD) 6 and Foley catheter with ureteral stents was removed on POD 27 after a cystogram confirmed no leaks. At 6-month follow-up, the patient reported good continence using a single pad, voiding every 3-4 hours. Fluoro-urodynamics demonstrated 651 mL capacity, low-pressure voiding, minimal residual urine, and no reflux. No prolapse was noted on fluoroscopy and pelvic examination with the Valsalva maneuver. The patient reported a good satisfaction level, regarding her urinary symptoms.

CONCLUSION

We report satisfactory short-term outcomes of a feasible technique to prevent postcystectomy prolapse; however, long-term follow-up of a larger cohort can help establish its efficacy.

Technique and perioperative outcomes of single-port robotic surgery using the da Vinci SP platform in urology

OBJECTIVE

To describe surgical technique for single port robotic surgery using the da Vinci SP system and report the perioperative outcomes.

PATIENTS AND METHODS

Between Jan 2019 and Jan 2021, single-port robotic urologic surgeries were performed in 120 patients by a single surgeon. Clinicopathologic data and perioperative outcomes were collected. All surgical procedures were performed with a transperitoneal approach through an umbilical single port. Additional assistant port was used in complex procedures for malignant disease. Surgeries were carried out using both above and below camera position for effective retraction. For reconstructive surgery using intestine, an extra-intracorporeal hybrid method was used. Surgical procedures involving both kidney and pelvis were performed without change of patient position or trocar placement.

RESULTS

Mean age was 62.7 years and 102 patients were male. For oncologic indication, 105 patients underwent surgeries including 66 radical prostatectomy, 25 partial nephrectomy, six radical nephrectomies, five nephroureterectomy and three radical cystectomy with urinary diversion. Fifteen cases with benign indication included four ureterolithotomy, seven uretero/pyeloplasty, three ureteroneocystostomy, and one ileal ureter reconstruction. All surgeries were performed successfully without conversion to other surgical approach. Clavien-Dindo grade III complication occurred in two patients.

CONCLUSIONS

The da Vinci SP system provides a new robotic surgical platform for single port surgery while maintaining the major features of robotic surgery similar to multi-port surgery. Various single port urologic surgeries can be safely performed with this platform.

Detailed Description of the Karolinska Technique for Intracorporeal Studer Neobladder Reconstruction

In the last two decades, surgical techniques for intracorporeal urinary diversion have been developed with the aim of reducing surgical morbidity. Although increasing constantly, the numbers of urologists offering intracorporeal neobladder reconstruction remain limited due to the complex nature of the procedure. In this article, we aim to provide a detailed description of the surgical technique we currently use at our institution. This technique was initially developed and perfected at the Karolinska Institutet in Sweden starting in 2003. It is a reproducible surgical approach with standardized and well-defined surgical steps. We give a detailed description of the surgical steps and provide tips and tricks to address specific situations and to increase efficiency. We also review the indications, the preoperative considerations, equipment necessary, postoperative considerations, and clinical outcomes for this procedure. Finally, we provide an accompanying didactic surgical video. We believe that this standardized approach can be learned and reproduced safely by motivated robotic surgeons.

Robot-assisted radical cystectomy: surgical technique, perioperative and oncologic outcomes

PURPOSE OF REVIEW

Radical cystectomy is a complex procedure that encompasses surgery involving the urinary, gastrointestinal tracts and the retroperitoneum, with significant morbidity. Robot-assisted radical cystectomy (RARC) has been introduced to improve perioperative outcomes.

RECENT FINDINGS

It has been shown to provide equivalent oncologic outcomes to open radical cystectomy while providing some benefits in terms of perioperative outcomes. A complete intracorporeal approach utilizing intracorporeal urinary diversion may potentially offer additional benefits.

SUMMARY

Herein, we describe our technique for RARC and intracorporeal urinary diversion, as well as a review of oncologic and perioperative outcomes.

Ileal conduit versus neobladder: A propensity score-matched analysis of the effect on renal function

OBJECTIVES

To analyze the long-term effects of continent (neobladder) compared with incontinent (ileal conduit) urinary diversion.

METHODS

We carried out a retrospective review of our departmental database. Estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Neobladder and ileal conduit patients were matched in a 1:2 ratio and a propensity score-matched analysis was carried out. Data were summarized using descriptive analysis. Trend plots were generated using baseline and follow-up creatinine values to compare estimated glomerular filtration rate at 3 months, then annually for 5 years. Variables associated with estimated glomerular filtration rate were assessed using multivariate linear analysis.

RESULTS

Our cohort consisted of 137 patients (neobladder n = 50 and ileal conduit n = 87) with a median follow-up time of 3 years (interquartile range 1-7 years). The ileal conduit group had shorter operative times (352 vs 444 min, P < 0.01), intracorporeal diversions were more common (66% vs 44%, P = 0.01), had prior abdominal surgery (66% vs 38%, P < 0.01) and had radiation (9% vs 0%, P = 0.03). The neobladder group more commonly had recurrent urinary tract infections (22% vs 3%, P < 0.01) and a steeper decrease in estimated glomerular filtration rate in the first year. On multivariate linear analysis, age/year (-0.59), body mass index per kg/m² (-0.52), preoperative estimated glomerular filtration rate per unit (0.51), recurrent urinary tract infections (-14.03) and time versus day 90 (year 1, -7.52; year 2, -9.06; year 3, -10.78) were significantly associated with estimated glomerular filtration rate.

CONCLUSION

Ileal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. Recurrent urinary tract infections were associated with a worse estimated glomerular filtration rate.

Intracorporeal Versus Extracorporeal Neobladder After Robot-assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium

OBJECTIVE

To compare perioperative and oncologic outcomes of intracorporeal (ICNB) and extracorporeal neobladder (ECNB) following robot assisted radical cystectomy (RARC) from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of IRCC database between 2003 and 2020 (3742 patients from 33 institutions across 14 countries) was performed (I-79606). The Cochran-Armitage trend test was used to assess utilization of ICNB over time. Multivariate logistic regression models were fit to evaluate variables associated with receiving ICNB, overall complications, high-grade complications, and readmissions after RARC. Kaplan Meier curves were used to depict recurrence-free, disease-specific, and overall survival.

RESULTS

Four hundred eleven patients received neobladder, 64% underwent ICNB. ICNB utilization increased significantly over time (P <.01). Patients who received ICNB were readmitted and received neoadjuvant chemotherapy more frequently (36% vs 24%, P = .03, 35% vs 8%, P <.01, respectively). ICNB was associated with older age (OR 1.04, 95% CI 1.01-1.07, P = .001), receipt of neoadjuvant chemotherapy (OR 4.63, 95% CI 2.34-9.18, P <.01), and more recent RARC era (2016-2020) (OR 12.6, 95% CI 5.6-28.4, P <.01). On multivariate analysis, ICNB (OR 5.43, 95% CI 2.34-12.58, P <.01), positive surgical margin (OR 4.88, 95% CI 1.29-18.42, P = .019), longer operative times (OR 1.26, 95% CI 1.00-1.58, P = .048), and institutional annual RARC volume (OR 1.09, 95% CI 1.05-1.12, P <.01) were associated with readmissions.

CONCLUSION

Utilization of ICNB increased significantly over time. Patients who underwent RARC and ICNB had shorter hospital stays and fewer 30-d reoperations but were readmitted more frequently compared to those who underwent ECNB.

Robot-Assisted Intracorporeal Orthotopic Ileal Neobladder: Description of the "Shell" Technique

Background: Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder (ICNB) remains a very complicated, technically demanding and time-consuming surgical procedure. In the current study we describe our robot-assisted intracorporeal “Shell” neobladder reconstruction. Methods: From January 2017 to December 2019, we performed 30 intracorporeal ileal neobladder “Shell” reconstructions. We prospectively collected demographics and clinical and pathological data and retrospectively analysed perioperative, functional and oncological outcomes. Results: No conversion to open surgery or intraoperative blood transfusion was necessary. The median whole operative time was 493 min (IQR 433–530 min), ranging from 514 min (IQR 502–554 min) recorded during the first ten procedures to 470 min (IQR 442–503 min) of the last ten. The median estimated blood loss was 400 mL (IQR 350–700 mL). The median length of stay was 11 days (IQR 10–17). Both early and late complication rates were 46.7%. The high-grade early complication rate accounted for 20%, while the high-grade late complication rate was 30%. The daytime continence rate registered was 73.3%, while night-time continence rate was 60%. Conclusions: Our results demonstrated “Shell” neobladder reconstruction as a technically feasible procedure, with good functional outcomes in tertiary referral centre. Longer follow-up and larger populations are needed to validate these preliminary results.

Oncologic Outcomes of Intracorporeal vs Extracorporeal Urinary Diversion After Robot-Assisted Radical Cystectomy: A Multi-Institutional Korean Study

Background: We aimed to compare the oncologic outcomes of intracorporeal urinary diversion (ICUD) and extracorporeal urinary diversion (ECUD) following robot-assisted radical cystectomy (RARC) in patients diagnosed with bladder cancer. Materials and Methods: Medical records of 730 patients who underwent RARC between April 2007 and May 2019 in 11 tertiary referral centers were retrospectively reviewed. We assessed recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in the two groups using the Kaplan-Meier method. Cox regression models were used to identify factors associated with RFS, CSS, and OS. Results: Among 591 patients, neobladder diversion was performed more frequently in the ICUD group (70.8% vs 52.5%, p = 0.001). The median follow-up duration was shorter in the ICUD group than in the ECUD group (16 vs 26 months, p < 0.001). The rates of overall recurrence (36.5% vs 25.5%, p = 0.013) and pelvic recurrence (12.1% vs 5.9%, p = 0.031) were higher in the ECUD group. However, no differences in 5-year RFS (43.2% vs 58.4%, p = 0.516), CSS (79.3% vs 89.7%, p = 0.392), and OS (74.3% vs 81.4%, p = 0.411) were noted between the two groups. Multivariable analysis revealed that when compared to ICUD, ECUD was not associated with RFS (hazard ratio [HR], 0.982; p = 0.920), CSS (HR, 0.568; p = 0.126), and OS (HR, 0.642; p = 0.124). Conclusion: Although there was a difference in recurrence rate between the two groups, multivariable analysis indicated that the diversion technique after RARC did not affect the oncologic outcomes. Large prospective studies with long-term follow-up are warranted to verify the oncologic outcomes of ICUD and ECUD following RARC.

Robot-assisted versus open radical cystectomy: A cohort study on perioperative outcomes accounting for stage selection bias and surgical experience

BACKGROUND

Most comparisons of robot-assisted (RARC) versus open radical cystectomy (ORC) for urothelial carcinoma do not factor the inherent stage selection bias or surgical experience.

METHODS

We compared the perioperative outcomes of 229 RARC and 335 ORC at a single tertiary referral centre with propensity score matching and multiple regression models, when controlling for tumour and patient characteristics, surgeon's experience and type of urinary diversion.

RESULTS

RARC had less major complications (19.8% vs. 34.1%) and ICU admissions (6.6% vs. 19.8%), with lower blood loss (400 vs. 500 ml) and transfusion rates. The operating time was longer (336 vs. 286 min), but decreased with surgeon's experience. RARC had less positive surgical margins (3% vs. 8.4%) and a higher lymph node count (14 vs. 11).

CONCLUSIONS

In this large single centre series comparing RARC with ORC controlling for stage selection bias and surgical experience, RARC proved significantly better outcomes, especially with intracorporeal urinary diversion.

Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion

The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.

Genitalia Preserving Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation in the Female: Experience in 5 Cases

We present operative, postoperative, oncologic and functional outcomes of genital tract sparing robot-assisted laparoscopic radical cystectomy, bilateral extended pelvic lymph node (LN) dissection and intracorporeal Studer pouch construction on five female patients with bladder cancer. One of the cases had concomitant nephroureterectomy performed due to a non-functioning kidney. Median patient age, mean operation time, median estimated blood loss and mean duration of hospital stay were 59 (39–78), 462 ± 25, 400 (50–970), 8.8 ± 2.5, respectively. Pathologic stages were pTis (n=1), pT1 (n=1), pT3 (n=1), pT4a (n=1) and pT4b (n=1). Mean LN yield was 32.4 ± 8.9. Positive surgical margins were detected in 2 patients with pT4 diseases. Only minor complications developed that were resolved with medical treatment. Two patients had no, 1 patient had mild, and 2 patients had moderate daytime incontinence. One patient had good, 3 patients had fair, and 1 had poor night-time incontinence. This complex robotic surgery can be performed safely with acceptable short-term surgical, oncological and functional outcomes.

Urinary diversion after pelvic exenteration for gynecologic malignancies

Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B12 deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.

Robot-assisted radical cystectomy with totally intracorporeal neobladder diversion: perioperative, oncologic, and functional outcomes

Background

The use of robot-assisted radical cystectomy (RARC) has increased rapidly in the past decade. However, reports of intracorporeal neobladder diversion remain limited. This article aimed to provide the surgical steps for RARC with totally intracorporeal neobladder diversion and the present perioperative, oncologic, and functional outcomes.

Methods

Between June 2017 and January 2020, RARC with intracorporeal neobladder diversion was performed in 12 male patients. Perioperative variables, pathologic data, early and late complications, urinary continence, potency, and recurrence-free survival were evaluated as outcome measures.

Results

The surgery was successful in all cases without open conversion. The median operative time, estimated blood loss, and postoperative hospital stay were 419 min (range, 315–640 min), 400 mL (range, 250–1,200 mL), and 14.5 days (range, 9–25 days), respectively. No positive surgical margins nor lymph nodes were observed. Eleven minor (grades 1 and 2) and one major (grades 3–5) complications were found in the early (0–30 days) period and six minor and one major complications in the late (>30 days) period. The median follow-up time was 13.1 months (range, 5.4–32.0 months), and two patients died due to metastatic disease. At 6 months after surgery, the daytime continence rate was 90.0%, while the nighttime continence rate was 80.0%. Only two patients (16.7%) reported capability of potency. The study was limited by a small sample size and short follow-up.

Conclusions

RARC with intracorporeal neobladder is a complex procedure but technically feasible with acceptable oncologic and functional outcomes. Studies with long-term follow ups and increased number of cases and randomized trials are indispensable to assess the potential of this technique.

Initial Experience with Intracorporeal Laparoscopic Radical Cystectomy and Detaenial Sigmoid Neobladder Reconstruction

BACKGROUND

Intracorporeal urinary diversion is considered to be effective in improving intestinal function recovery and reducing the occurrence of early complications after radical cystectomy. Almost all neobladders constructed via intracorporeal laparoscopy have used the ileum.

OBJECTIVE

To present our intracorporeal detaenial sigmoid neobladder technique that replicates open surgery principles and to present oncological and functional outcomes and complication rates.

DESIGN, SETTING, AND PARTICIPANTS

This is a case series from a single tertiary referral hospital from September 11, 2018 to April 19, 2019, including 12 selected patients with pathologically confirmed muscle-invasive or refractory non-muscle-invasive bladder cancer.

SURGICAL PROCEDURE

Laparoscopic radical cystectomy including pelvic lymph-node dissection and intracorporeal detaenial sigmoid neobladder, which is demonstrated in the accompanying video.

MEASUREMENTS

Demographic, clinical, and pathological data were collected. Perioperative outcomes and 1-yr oncological and functional outcomes are reported.

RESULTS AND LIMITATIONS

All surgeries were successful without severe complications or conversion to open surgery. The mean operative time (± standard deviation) was 414.6 ± 52.2 min, with 33.8 ± 6.80 min for neobladder construction. Surgical margins and lymph nodes were all negative for metastasis. All patients were encouraged to do ambulation exercise 1 d after surgery, and oral liquid intake was resumed between days 2 and 4. However, because this was a retrospective study in a single centre with very few cases, it is difficult to reach a definitive conclusion.

CONCLUSIONS

Intracorporeal detaenial sigmoid neobladder is technically feasible with no need for additional medical equipment. Encouraging outcomes were observed during short-term follow-up. This approach could represent another alternative choice for patients undergoing laparoscopic radical cystectomy. Longer-term follow-up data are needed to evaluate oncological and functional outcomes.

PATIENT SUMMARY

We describe our stepwise technique for intracorporeal detaenial sigmoid neobladder while replicating established open surgery principles. In addition to retaining the advantages of a neobladder, better postoperative recovery is achieved.

Detailed Analysis of Urinary Tract Infections After Robot-Assisted Radical Cystectomy

Objective: To describe urinary tract infections (UTIs) after robot-assisted radical cystectomy (RARC) and investigate the variables associated with it. Materials and Methods: A retrospective review of 616 patients who underwent RARC between 2005 and 2019 was performed. Patients were divided into those who developed UTI and those who did not. Patients who developed UTI were further subdivided into three subgroups according to the onset, number, and severity. The Kaplan-Meier method was used to depict time to UTI. Multivariate analysis was used to investigate variables associated with UTI. Result: Two hundred forty (39%) patients were diagnosed with UTI after RARC; 48% occurred within 30 days, 17% within 30-90 days, and 35% at 90 days after RARC. Twenty-three percent of the patients presented with urosepsis. The median (interquartile ratio) time to develop UTI was 1 (0.3-7) month. On multivariate analysis, patients who received neobladders (odds ratio [OR] 2.80; 95% confidence interval [CI] 1.50-5.20; p < 0.01), prolonged hospital stay (OR 1.06; 95% CI 1.03-1.08; p < 0.01), adjuvant chemotherapy (OR 2.20; 95% CI 1.40-3.60; p < 0.01), poor renal function postoperatively (OR 2.30; 95% CI 1.30-3.80; p < 0.01), postoperative hydronephrosis (OR 2.50; 95% CI 1.40-4.50; p < 0.01), ureteroileal anastomotic stricture (OR 2.90; 95% CI 1.50-5.70; p < 0.01), and stented ureteroileal anastomosis (OR 9.35; 95% CI 1.23-71.19; p = 0.03) were associated with UTI after RARC. Conclusion: UTI is common after RARC mainly within the first month after RARC. Enterococcus faecalis was the most common causative organism.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer (part 2). Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder

Abstract

To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images.

Methods

We performed a non-systematic review of the literature with the keywords “bladder cancer”, “urinary diversion”, “radical cystectomy”, and “neobladder”.

Results

Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer “U” neobladder (70%) followed by the Hautmann “W” modified neobladder (7.5%), the “Y” neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively.

Conclusion

The most frequent types of ICONB are Studer “U” neobladder, Hautmann “W” neobladder, “Y” neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.

A comparative propensity score-matched analysis of perioperative outcomes of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium

OBJECTIVE

To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC).

PATIENTS AND METHODS

We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC.

RESULTS

Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions.

CONCLUSIONS

Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications.

Refinement Surgical Technique, and Perioperative and Functional Outcomes in Patients With Robotic Intracorporeal Hautmann Orthotopic Neobladder

OBJECTIVE

To illustrate our refinement technique for robotic intracorporeal orthotopic Hautmann neobladder with adherence to open surgical principles and evaluate perioperative and functional outcomes.

PATIENTS AND METHODS

Robot-assisted radical cystectomy with intracorporeal Hautmann orthotopic neobladder was performed by the same surgeon in 40 patients with bladder cancer from November 2017 to March 2019. Baseline demographics, pathologic data, 90-day complications, and functional outcomes at both 6 and 12 months were evaluated with questionnaire and urodynamic analysis.

RESULTS

Median follow-up was 14 months (range 4-20). Median operative time was 320 (230-500) minutes, and the estimated blood loss was 300 (100-2000) mL. No conversion to the open technique was reported. The overall 90-day complication rate was 45%, and the high-grade complication rate was only 10%. The daytime satisfactory continence rate was 90% at both 6 months (30 patients) and 12 months (20 patients), while the night-time satisfactory continence rate was 76.7% and 80.0% at 6 months and 12 months, respectively. One patient underwent clean intermittent catheterization. The cohort had minimal postvoid residual volume, normal compliance, and a mean capacity of 328.7 cm³ (range 170-500) at 6 months postoperatively.

CONCLUSION

Our preliminary data indicate that robotic intracorporeal Hautmann neobladder configuration is a feasible surgical technique and can achieve a low pressure and sufficient capacity for satisfactory early voiding patterns. Refinement of the stepwise process can effectively decrease the time of the operation. Long-term functional and oncological outcomes remain to be evaluated with longer follow-up and more cases.

Contemporary techniques and outcomes of robotic cystectomy and intracorporeal urinary diversions

PURPOSE OF REVIEW

Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is being increasingly performed worldwide. This review summarizes recent technical developments and outcome data for RARC with ICUD.

RECENT FINDINGS

With the recent description of intracorporeal continent cutaneous diversion, all classes of urinary diversion can presently be performed totally intracorporeally. The summary of our seven cases of intracorporeal continent cutaneous diversion in this article brings the number of reported cases in the literature to 17. Additional recent advancements in ICUD focus on novel technical descriptions and outcome data. Several intracorporeal orthotopic ileal neobladder techniques have been described with intermediate perioperative outcomes. There is some rationale for reduced overall, wound, gastrointestinal and genitourinary complications with ICUD.

SUMMARY

RARC with intracorporeal diversion is a feasible option for patients with bladder cancer. Prospective and randomized outcome data are needed to better characterize the benefit of ICUD in patients following radical cystectomy.

Utility of robot-assisted radical cystectomy with intracorporeal urinary diversion for muscle-invasive bladder cancer

Radical cystectomy remains the gold standard for treatment of muscle‐invasive bladder cancer. Robot‐assisted radical cystectomy has technical advantages over laparoscopic radical cystectomy and has emerged as an alternative to open radical cystectomy. Despite the advancements in robotic surgery, experience with total intracorporeal reconstruction of urinary diversion remains limited. Most surgeons have carried out the hybrid approach of robot‐assisted radical cystectomy and extracorporeal reconstruction of urinary diversion, as intracorporeal reconstruction of urinary diversion remains technically challenging. However, intracorporeal reconstruction of urinary diversion might potentially proffer additional benefits, such as decreased fluid loss, reduction in estimated blood loss and a quicker return of bowel function. The adoption of intracorporeal ileal neobladder reconstruction has hitherto been limited to high‐volume academic institutions. In the present review, we compare the totally intracorporeal robot‐assisted radical cystectomy approach with open radical cystectomy and robot‐assisted radical cystectomy + extracorporeal reconstruction of urinary diversion in muscle‐invasive bladder cancer patients.

[INITIAL EXPERIENCE WITH ROBOT-ASSISTED RADICAL CYSTECTOMY AND INTRACORPOREAL URINARY DIVERSION ~COMPARISON WITH THE CONVENTIONAL METHOD~]

(Objectives) While robot assisted radical cystectomy (RARC) has been associated with improved perioperative outcomes such as blood loss, hospital stay, and improved convalescence, much of the criticism has been attributable to the longer operative time. Opinions are divided regarding whether intracorporeal urinary diversion (ICUD) or extracorporeal urinary diversion (ECUD) should be performed. The aim of this study is to evaluate the utility of RARC and ICUD by comparing with the conventional method. (Patients and methods) From December 2014 to July 2018, 14 patients underwent laparoscopic radical cystectomy (LRC) and 16 patients underwent RARC at our institution. Among the 30 patients, 23 underwent ileal conduit or orthotopic bladder; these patients were divided into two groups: an ICUD patient group (n=10) and an ECUD patient group (n=13). Treatment outcomes were compared between groups. (Results) Compared to patients who underwent LRC those treated with RARC had older (75 vs. 67, P=0.031). There was a trend of high-risk cases (American Society of Anesthesiologists' physical status classification ≥3) more frequently (31.3% vs. 7.1%, P=0.176). Patient treated with RARC had less blood loss (150 vs. 544 ml, P=0.003). There was no significant difference in the intra- and postoperative complication rates (12.5% vs. 21.4%, P=0.642). Compared to patients who underwent ECUD, those treated with ICUD included a longer operative time for urinary diversion (222 vs. 181 minutes, P=0.007) but less maximal incision length without perineal incision (3.0 vs. 6.0 cm, P=0.002). (Conclusions) Our data suggests that RARC is a safe procedure with potential advantages in terms of reduced blood loss. ICUD has longer operative time but is a procedure with excellent cosmetic results.

Robotic cross-folded U-configuration intracorporeal ileal neobladder for muscle-invasive bladder cancer: Initial experience and functional outcomes

BACKGROUND

This study compared the surgical and urinary functional outcomes in patients with muscle-invasive bladder cancer (MIBC) who underwent robot-assisted radical cystectomy (RARC) followed by intracorporeal ileal neobladder reconstruction (ICNB) to those in patients who underwent minimum incision endoscopic radical cystectomy (MIE-RC) followed by extracorporeal ileal neobladder reconstruction (ECNB).

MATERIALS AND METHODS

This study reviewed the clinical records of 153 consecutive MIBC patients who underwent neoadjuvant chemotherapy followed by radical cystectomy and ileal neobladder reconstruction.

RESULTS

The operative time in the ICNB group was significantly longer than that in the ECNB group. The median estimated blood loss was significantly less in the ICNB group than in the ECNB group. The neobladder capacity gradually increased in both groups. The maximum neobladder pressure and urethral closure pressure gradually improved in both groups.

CONCLUSION

Our initial experience with ICNB was favourable, with acceptable surgical and urinary functional outcomes.

Use of Robotic Anastomosis Competency Evaluation (RACE) for assessment of surgical competency during urethrovesical anastomosis

INTRODUCTION

We sought to evaluate the Robotic Anastomosis Competency Evaluation (RACE), a validated tool that objectively quantifies surgical skills specifically for urethrovesical anastomosis (UVA), as a tool to track progress of trainees, and to determine the predictive value of RACE.

METHODS

UVAs performed by trainees at our institution were evaluated using RACE over a period of two years. Trainees were supervised by an experienced robotic surgeon. Outcomes included trainee-related variables (RACE score, proportion of UVA performed by trainee, and suturing speed), and clinical outcomes (total UVA duration, postoperative urinary continence, and UVA-related complications). Significance was determined using linear regression analysis.

RESULTS

A total of 51 UVAs performed by six trainees were evaluated. Trainee RACE scores (19.8 to 22.3; p=0.01) and trainee proportion of UVA (67% to 80%; p=0.003) improved significantly over time. Trainee suture speed was significantly associated with RACE score (mean speed range 0.54-0.74 sutures/minute; p=0.03). Neither urinary continence at six weeks nor six months was significantly associated with RACE score (p=0.17 and p=0.15, respectively), and only one UVA-related postoperative complication was reported.

CONCLUSIONS

Trainee RACE scores improved and proportion of UVA performed by trainees increased over time. RACE can be used as an objective measure of surgical performance during training. Strict mentor supervision allowed safe training without compromising patient outcomes.

Gynecological organ involvement at robot-assisted radical cystectomy in females: Is anterior exenteration necessary?

INTRODUCTION

We aimed to investigate patient and disease variables associated with gynecological organ invasion in females with bladder cancer at the time of robot-assisted radical cystectomy (RARC).

METHODS

We conducted a retrospective review of female patients who underwent robot-assisted anterior pelvic exenteration (RAAE) between 2005 and 2016. Patients were divided into two groups: those with gynecological organ involvement at RAAE and those without. Data were reviewed for perioperative and pathological outcomes. Kaplan-Meier method was used to depict survival outcomes. Multivariable stepwise regression analysis was performed to identify predictors of gynecological organ involvement.

RESULTS

A total of 118 female patients were identified; 17 (14%) showed evidence of gynecological organ invasion at RAAE. Patients with gynecological organ invasion had more lymphovascular invasion at transurethral resection of bladder tumour (TURBT) (82% vs. 46%; p=0.006), trigonal tumours at TURBT (59% vs. 18%; p=0.001), multifocal disease (65% vs. 33%; p=0.01), pN+ (71% vs. 22%; p<0.001), positive surgical margins (24% vs. 4%; p=0.02), and they less commonly demonstrated pure urothelial carcinoma at TURBT (18% vs. 66%; p<0.001). On multivariate analysis, significant predictors of gynecological organ invasion were pN positive disease (odds ratio [OR] 6.48; 95% confidence interval [CI] 1.64-25.51; p=0.008), trigonal tumour location (OR 5.72; 95% CI 1.39-23.61; p=0.02), and presence of variant histology (OR18.52; 95% CI 3.32-103.4; p=0.001).

CONCLUSIONS

Patients with trigonal tumours, variant histology, and nodal involvement are more likely to have gynecological organs invasion at RAAE. This information may help improve counselling of patients and better identify candidates for gynecological organ-sparing cystectomy.

Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

PURPOSE

This study aimed to provide an update and compare perioperative outcomes and complications of intracorporeal and extracorporeal urinary diversion following robot-assisted radical cystectomy using data from the multi-institutional, prospectively maintained International Robotic Cystectomy Consortium database.

MATERIALS AND METHODS

We retrospectively reviewed the records of 2,125 patients from a total of 26 institutions. Intracorporeal urinary diversion was compared with extracorporeal urinary diversion. Multivariate logistic regression models using stepwise variable selection were fit to evaluate preoperative, operative and postoperative predictors of intracorporeal urinary diversion, operative time, high grade complications and 90-day hospital readmissions after robot-assisted radical cystectomy.

RESULTS

In our cohort 1,094 patients (51%) underwent intracorporeal urinary diversion. These patients demonstrated shorter operative time (357 vs 400 minutes), less blood loss (300 vs 350 ml) and fewer blood transfusions (4% vs 19%, all p <0.001). They experienced more high grade complications (13% vs 10%, p = 0.02). Intracorporeal urinary diversion use increased from 9% of all urinary diversions in 2005 to 97% in 2015. Complications after this procedure decreased significantly with time (p <0.001). On multivariable analysis higher annual cystectomy volume (OR 1.02, 95% CI 1.01-1.03, p <0.002), year of robot-assisted radical cystectomy (2013-2016 OR 68, 95% CI 44-105, p <0.001) and American Society of Anesthesiologists® score less than 3 (OR 1.75, 95% CI 1.38-2.22, p <0.001) were associated with undergoing intracorporeal urinary diversion. The procedure was associated with a shorter operative time of 27 minutes (p = 0.001).

CONCLUSIONS

The use of intracorporeal urinary diversion has increased in the last decade. A higher annual institutional volume of robot-assisted radical cystectomy was associated with intracorporeal urinary diversion as well as with shorter operative time. Although intracorporeal urinary diversion was associated with higher grade complications than extracorporeal urinary diversion, they decreased with time.

Florence robotic intracorporeal neobladder (FloRIN): a new reconfiguration strategy developed following the IDEAL guidelines

OBJECTIVE

To describe our step-by-step technique for robotic intracorporeal neobladder configuration, including the stages of conception, development and exploration of this surgical innovation, according to the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Collaboration guidelines.

PATIENTS AND METHODS

The Florence robotic intracorporeal neobladder (FloRIN) was performed employing the following main surgical steps: isolation of 50 cm of ileum; bowel anastomosis; urethro-ileal anastomosis creating an asymmetrical 'U'-shape (30 cm distally and 20 cm proximally to anastomosis), ileum detubularisation; posterior wall reconfiguration as an 'L'; bladder neck reconstruction; anterior folding of the posterior plate to reach the 12 o'clock position; uretero-enteral 'orthotopic' bilateral anastomosis. The conception and development of the FloRIN followed the IDEAL guidelines recommended stages: Phase 1 (simulation) involved the neobladder robotic configuration using silicone models. Phase 2a (development) aimed to reproduce the configuration in an open fashion in one patient, and then in the first three robotic procedures. Phase 2b (exploration) consisted of the technique standardisation in 15 consecutive robotic approaches. Phase 2a and 2b included urodynamics and imaging assessment of the patients treated.

RESULTS

From February 2016 to September 2017 FloRIN was performed in 18 patients. Comparing the first three (Phase 2a) with the subsequent 15 patients (Phase 2b), the median (interquartile range [IQR]) reconstruction operating time was 260 (220-340) vs 160 (150-210) min, respectively. Postoperative surgical complications occurred in four of the 18 patients (22.1%), including one surgical Clavien-Dindo Grade III and three Grade I, postoperative medical Clavien-Dindo Grade II complications occurred in three (16.7%) patients. On urodynamic examination (available in nine [50%] patients) the median (IQR) reservoir cystometric capacity, compliance, and post-void residual were 240 (220-267) mL, 18 (12.5-19.8) mL/cmH₂ O, and 0 (0-50) mL, respectively. Ultrasonography showed no Grade ≥2 vesico-ureteric reflux.

CONCLUSION

We describe the FloRIN configuration, showing its technical feasibility with acceptable time efficiency. The first cases studied had good reservoir capacity, low pressure with no reflux, and complete voiding.