V2-11: Technique for Robotic Intracorporeal Continent Cutaneous Urinary Diversion

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Introductions and Objectives
Although robot-assisted radical cystectomy continues to gain wider acceptance, the concomitant urinary diversion is typically performed extracorporeally. Recently, we have described our experience with intracorporeal urinary diversions, including orthotopic ileal neobladder and ileal conduit. Intracorporeal urinary diversion remains an advanced technique focused in centers of excellence. To our knowledge, there have been no previous reports of robotic intracorporeal continent cutaneous diversion. Herein, we provide the first description of our technique of robotic intracorporeal continent cutaneous urinary diversion (Indiana pouch) following robotic cystectomy, including the results of our initial experience.

Methods
We perform a robotic cystoprostatectomy using a standard 6-port transperitoneal technique, as previously described. We provide a step-by-step illustration of our intracorporeal approach to right colonic mobilization, bowel segmentation, ileocolonic anastomosis, ureterocolonic anastomoses, and creation of a hand-sewn Indiana pouch continent cutaneous urinary diversion. We describe optimization of port utilization and technique for robot positioning. Tapering of the catheterization channel and reinforcement of ileocecal valve are performed via the standard extraction incision.

Results
Robotic intracorporeal Indiana pouch was successfully performed following robotic cystoprostatectomy. Only 2 additional port incisions were necessary to complete the diversion. Operative time for intracorporeal diversion was 180 minutes, with negligible blood loss, and without any intra-operative complications. Post-operative care followed a standardized clinical care pathway. Length of stay was 7 days. There were no major (Clavien 3-5) 90-day complications observed. Externalized ureteral stents are removed at 2 weeks. At 3 weeks post-operatively, a pouchgram is performed. The malecot drain is capped, and the patient begins catheterizing via the cutaneous stoma. The malecot is subsequently removed.

Conclusions
We demonstrate robotic intracorporeal continent cutaneous urinary diversion following robotic cystectomy is technically feasible and safe. Early functional results are promising. To our knowledge, this is the first description of completely intracorporeal continent cutaneous diversion.

Funding: none