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,

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.......

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

Name	Company	Catalog Number	Comments
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.