V12-04: Robot assisted orthotopic modified Studer neobladder
Robotic intracorporeal orthotopic neobladder after radical cystectomy and extended lymphadenectomy is a technically challenging procedure. So far, only a few centers worldwide have taken this procedure into routine. After over 1000 procedures and routinely performed intracorporeal Bricker urinary deviation, the swiss team started with the intracorporeal neobladder technique carefully. The video presents our standardized technique in 10 patients after one first proctored surgery by a mentoring team (AH/PW).
A daVinci SI-system with 4 arms and 6-port access was used. The left ureter is drawn unter the mesorectum to the right side. 50cm are needed for the pouch. The urethro-ileal anastomosis with a 3-0 barbed suture is performed after an approximation of rectoprostatic fascia and the ileal sling. A 60mm/45mm stapler ileo-ileostomy is established. Two holding sutures are placed 10cm proximal from the urethroileal anastomosis, marking the deepest point of the pouch. The ileum is opened at the antimesenteric side over 40cm and the posterior wall is closed using 3-0 barbed running suture. Than, the distal ventral pouch is closed. The distal ureters were incised and a Wallace plate was formed. The ureters are stented through the abdominal wall and the chimney with Ch8 mono-J catheters. The ileo-ureteral anastomosis is performed with a 3-0 double arm running suture. The last anterior segment of the pouch is closed and than proved for water tightness.
Operative time (skin-skin) was 575(420-725) minutes, bleeding 600(200-1000)ml. 1 patient required invasive ventilaton more than 24h. Time to flatus was 2(1-5) days, to bowel movement 4(3-10) days. The in-hospital stay was 15(9-27) days. There were no reoperations within 30days and no 30d- mortality. There were no positive margins nor positive lymph nodes in 22(15-43) removed nodes. The indwelling catheters remained 26(17-40) days, all pouches voided subsequently without residual urine.
Robotic intracorporeal urinary diversion with a modified orthotopic Studer neobladder is a technically demanding procedure. With a standardized setting, the procedure is feasable in experienced robotic teams with promising intraoperativ and early postoperative results.Still, long termin pouch function, metabolism and oncological follow-up have to be observed critically.