Robotic radical cystectomy with intracorporeal orthotopic ileal neobladder: original technique.

Introduction: Open radical cystectomy is currently considered the gold standard for muscle-invasive bladder cancer. This surgical procedure is associated with a high rate of morbidity and mortality. In order to reduce the morbidity and shorten the post-operative convalescence it has been proposed the use of a laparoscopic approach which, however, presents numerous technical difficulties. The introduction of robot-assisted laparoscopic technique has overcome these limitations and has reawakened interest in the application of a minimally invasive approach. We present the case of a woman, 70 years old, suffering from muscle-invasive bladder cancer, diagnosed by bladder endoscopic resection. The CT-staging showed no significant findings. We perform in April 2012 a laparoscopic robot-assisted (4-arms Da Vinci, Intuitive Surgical, Sunnyvale, CA, USA) radical cystectomy (RALRC) with orthotopic ileal neobladder reconstruction with a Camey II technique modified to create a Y shaped reservoir. Methods: Trendelenburg position (20°). After placing the trocar, the robot is set. The ureters were identified at the crossing of the common iliac artery, clipped with Hem-o-lock and sectioned near the ureterovesical junction. The vascular pedicles were divided using Ligasure. The vagina was dissected free from the bladder and then the urethra was prepared and transected at the level of the bladder neck. To preserve sexual function, the endopelvic fascia remained intact to avoid harm to the autonomic nerves lateral to the vagina. The bladder was removed en-bloc with the anterior vaginal wall via the introitus and the vagina was closed with a running suture. At this point, to perform the reconstructive fase, we replace the fourth robotic-arm with a 12 mmtrocar, for stapler use. The ileocecal junction was identified and the terminal 15-20 cm of ileum was spared. A 45 cm long ileal segment for neobladder was isolated using the laparoscopic stapler. The stapler is used to detubularize the bowel and create the reservoir. The neobladder-urethra anastomosis was performed with two running suture along posterior and anterior lines. The continuity of the small bowel was restored by stapling the ileal antimesenteric ends side to side using the 60-mm endovascular stapler and cutter. he ureters were spatulated for a distance approximately 2 cm. The uretero-enteric anastomosis is performed with antireflux technique and a single-J stent guide. Results: The operative consolle-time was approximately 300 minutes with blood loss of 150 cc. The patient showed return to bowel activity in the second post-operative day and was discharged into 14 day, with no complications and with good urinary continence. Conclusions: Our initial experience with RALRC appears to be favorable with acceptable operative and shortterm clinical outcomes. RALRC with totally intracorporeal urinary diversion is technically feasible, with acceptable functional results. Otherwise an adequate follow-up is needed to assess oncological results.