V4-04: Surgical Technique of Staplerless Total Intracorporeal Robot assisted Laparoscopic Ileal Conduit for Transitional Cell Carcinoma of bladder

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Introductions and Objectives
The introduction of Robot-assisted laparoscopic radical cystectomy has emerged as an alternative to the open procedure. Most centres still advocate a combination of robot-assisted laparoscopy and open surgery, performing the cystectomy and lymphadenectomy with the robot, and using an extracorporeal approach for the construction of the conduit or neobladder. We present our surgical technique of Staplerless Total Intracorporeal Robot assisted Laparoscopic Ileal Conduit (TIRLIC) for transitional cell carcinoma of bladder.

Methods
From February 2011 to August 2013, Robotic Radical Cystectomy was done in 101 patients. Ileal Conduit urinary diversion were done extracorporeally in 44 patients and orthotopic neobladder were done extracorporeally in 50 patients. TIRLIC without using Gastro-intestinal anastomosis stapler was performed in 4 patients and Total Intracorporeal Robotic orthotopic neobladder were done in 3 patients. Patients underwent robot assisted laparoscopic radical cystectomy, extended pelvic lymph node dissection, retroperitoneal transfer of left ureter to the right side, ileal conduit urinary diversion including isolation of 15 cm of ileal loop and bilateral stented uretero-ileal anastomosis in end to side fashion and restoration of bowel continuity,done without the use of stapler, intracorporeally and finally specimen was retrieved and conduit stoma was fashioned. We demonstrate our technique of Staplerless TIRLIC with da Vinci Robotic system.

Results
Staplerless TIRLIC was technically successful in 4 patients. Median patient age, body mass index, estimated blood loss were 67 years(range 65-79), 29( 24-30), 300 ml(290-320ml), respectively. Average operative time was 335 min(260-500min) . Average time for the cystectomy was 135 minutes. Mean time to liquid diet was 3.2 days and stents were removed on seventh day. Median post operative hospital stay 7 days (6- 16 days). 30-day and 90-day complications were Clavien grade 1-2 (n= 4 and 2), clavien grade 3-5 (n= 0 and 0). One ileal conduit patient developed Right lower limb deep vein thrombosis(DVT) on first postoperative day and 1 patient had prolonged ileus.

Conclusions
Robot assisted Laparoscopic cystectomy with TIRLIC for the treatment of transitional cell carcinoma of bladder is technically feasible. The robotic system aids in replicating open procedure precisely while following the oncological principles of open cystectomy with reduced perioperative morbidity, speedy functional recovery, minimal blood loss and good cosmetic results.

Funding: None