V1-01: Robotic Intracorporeal Indiana Pouch: replicating open surgery
Continent cutaneous diversion is an option for patients undergoing cystectomy. Herein we report our experience of 10 consecutive patients who underwent completely intracorporeal robotic Indiana Pouch construction following robotic cystectomy.
Surgical steps: Robotic cystectomy and pelvic lymph node dissection (PLND) are performed with a 6-trocar access. Robot is undocked and specimen extracted from the left lateral port. Both left side ports are closed and three additional ports are placed. Table is rotated 45 degree to left and the robot is re-docked on right side. Replicating open techniques: 12 cm of distal ileum and 30cm of right colon are isolated; side to side stapled ileocolonic anastomosis is performed; colonic segment is detubularized along the antimesenteric tenia up to 3cm distal to the ileocecal valve and U folded. The medial aspect of the folded colon is sewn. Ureterocolonic anastomoses are performed on the posterior aspect of the pouch. Bilateral J stents are placed in ureters and secured to a 24-Fr hematuria catheter inserted via the appendiceal orifice. After closing the lateral aspect of the pouch, a Foley catheter is inserted via the umbilical port and through efferent ileal limb and placed into the colonic pouch. The efferent limb is tapered with a 60mm stapler on the antimesenteric aspect. The ileocecal valve and the efferent limb are plicated to increase the outflow resistance. The efferent limb is now extracted and the stoma created at the umbilical site.
There were no intraoperative complications and all procedures (n=10) were successfully completed robotically. Median operative times were 60 min for cystectomy, 65 min for PLND, 45 min for repositioning/re-docking and 210 min for pouch construction. The median overall operative time was 365 (295-540) min. No patients were transfused. Median hospital stay was 9 days. 30-day complication rate was 40%. There were no grade 3 or 4 complications. At 3-month follow-up urodynamics demonstrated a mean maximum capacity of 270mL without ureteral reflux and minimal urine residual; 9 patients (90%) reported full continence. No patient died.
Robotic Indiana pouch can be safely performed, completely intracorporeally. This technique provides a minimally-invasive, time efficient approach with acceptable complication rates. Patients undergoing radical cystectomy can now be offered all types of urinary diversions robotically.