V02-10: New technologies for old procedures when FireFly technologie improves Robotic Bladder Diverticulectomy
everal techniques have been described to aid in the intra-operative identification of the bladder diverticula. The video shows the peculiar advantage of using Firefly Fluorescence Imaging da Vinci System during bladder diverticula detection and dissection.
Patient is placed in the lithotomic position and 30° Trendelenburg. Supraumbilical camera trocar is inserted with the Hasson technique. We use a four-arm robotic approach and a 5 to 6 ports placement consisting of: one 8-mm camera port, three 8-mm robotic ports and one to two assistant ports. The robotic ports run parallel at 14 cm from the pubic bone. Pneumoperitoneum is established at 12 Hg mm. The bladder is accessed via a transperitoneal route. We perform a flexible cystoscopy with the Firefly Fluorescence Imaging System on for the diverticulum detection. The peritoneum over the bladder is then incised to expose the diverticulum. We use this near-infrared technology also as a guide in the diverticulum dissection. Using sharp and blunt dissection, the diverticulum is resected to its neck. Completion of diverticulectomy and hydraulic tightness test. Drainage placement in the Retzius space and peritoneum reconstruction.
Several approaches have been described for intra-operative diverticulum identification and its dissections: Parra used a cystoscopic transillumination of diverticulum; Das proposed the use of a Foley 50 mL balloon inserted in the diverticulum, while Nadler used a balloon catheter, made from a surgical glove, placed in the diverticulum and bloated with 180 cc saline solution. We present our technique in which transperitoneal bladder diverticulectomy is performed under the Firefly guidance that provide real-time, image-guided identification of key anatomical landmarks.
In our experience, intra-operative use of Firefly Fluorescence Imaging da Vinci System makes identification and dissection of the diverticulum rapid, safe and effective with no additional cost, even in disadvantageous anatomic conditions such as lateral-posterior diverticula.