V8-04: Robotic-Assisted Laparoscopic Partial Cystectomy with Diverticulectomy, Distal Ureterectomy with Ureteroneocystotomy, and Bilateral Pelvic Lymphadenectomy for Malignant Disease in a Bladder Diverticulum

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Introductions and Objectives
To describe a robotic surgical technique that combines diverticulectomy with partial cystectomy, pelvic lymphadenectomy, distal ureterectomy, and ureteroneocystotomy for malignant disease in a bladder diverticulum. This procedure was performed on a 65-year-old male with gross hematuria from a large bladder diverticulum containing a tumor adjacent to the right ureteral orifice. Previous robotic assisted partial cystectomy with diverticulectomy cases were reviewed for outcomes.

Methods
A transperitoneal robotic-assisted laparoscopic partial cystectomy with diverticulectomy, distal ureterectomy with ureteroneocystotomy, and bilateral pelvic lymphadenectomy was performed. Prior cases performed at our institution were reviewed for operative time, blood loss, length of stay, pathology, and clinical outcomes.

Results
The procedure described was performed without complication. Operative time was 532 minutes, estimated blood loss was 100cc. Surgical pathology was notable for high-grade urothelial carcinoma with micropapillary features and squamous differentiation. Margins were free from tumor. One of sixteen lymph nodes contained metastatic disease. Total length of stay 4 days._x000D_ A total of 11 robotic assisted partial cystectectomy with diverticulectomy were performed by a single surgeon. Only 4 including this case described were for malignant disease. Median operative time was 322.5 minutes (181-532 minutes), median blood loss was 37.5cc (20-100cc), median length of stay was 2.5 days (1-4 days). Pathology revealed grade 3 urothelial carcinoma in two patients, and grade 2 in two patients. Pathologic stage included T0, Ta, and two patients of T3, with one patient with N1 disease. One patient developed metastases at 3 months after surgery, one patient developed sporadic Ta recurrences in the bladder, and one patient was disease free at last followup. The current case is undergoing adjuvant chemotherapy for N1 disease.

Conclusions
Urothelial carcinoma confined to a bladder diverticulum can safely be removed using a robotic-assisted approach. When considering partial cystectomy the remainder of the bladder should be completely evaluated and determined to be free from malignancy. The absence of muscularis propria in a bladder diverticulum prevents the diagnosis of muscle invasive disease. However given the high risk for the development of metastatic disease from diverticular tumors we recommend a thorough associated lymphadenectomy.

Funding: None