V4-05: Robot-assisted Laparoscopic Resection of Bladder Diverticula

Video

Introductions and Objectives
Diverticulectomy (DIV) is indicated for large diverticula (DI) associated with incomplete emptying, urinary tract infection, bladder calculi, or endoscopically non-treatable tumours. With the evolution of minimally invasive (MI) technology, even complex DI can be managed with MI procedures. In this video we describe robotic (ROB) approaches to surgery of the DI with special attention paid to techniques, complications and outcomes.

Methods
We have performed, and described, a DIV procedure using the daVinci robot. The steps needed to identify, approach and resect the DI and to perform closure of the bladder are presented. A retrospective review has been carried out with 14 consecutive patients (P) who underwent ROB-DIV.

Results
The steps of the ROB-DIV are illustrated and described in our video. Prior to port placement, cystoscopy is performed for ureteral catheterization and to determine the relationship of the ureteral orifices (UO) and DI mouth. The ports are placed as for radical prostatectomy. The surgeon first incises the peritoneum medially of the obliterated medial umbilical ligament and identifies the ductus deferens and the ureter. The bladder is then filled, which permits identification of the DI. The DI neck is then identified, opened and transsected. In the case of a close proximity of the UO to the DIV mouth, a transvesical incision superior to the DI mouth or even on the contralateral side allows easier UO identification and preservation, ureteral catheterisation and ureteral reimplantation if necessary. The plane is then developed between the DI and the surrounding tissue and the DIV is completed. The bladder is closed in two layers. Between 2009 and 20013 14 consecutive patients underwent ROB-DIV with this procedure. There were no intraoperative complications. Major complications (one grade IIIa and one grade IVa according to the Clavien classification) occurred in 2 patients within 90 days of surgery. The median hospital stay after surgery was 8 days. At a median follow-up time of 20.8 months, all patients remained without signs of DI recurrence and were asymptomatic.

Conclusions
In our hands the ROB-DIV is a treatment of choice for the treatment of DI in patients who would otherwise be treated with open surgery. This video presents our technique for ROB-DIV using a trans- or extravesical approach to the DIV mouth. We feel that in cases with a close proximity of the UO to the DIV mouth, the transvesical approach allows easier UO identification and preservation, ureteral catheterisation and ureteral reimplantation if necessary.

Funding: none