V874: Incisionless Dual Diversions: Creation of Urostomy and Colostomy using the da Vinci Robot

Video

Introduction and Objectives
With the introduction of the Da Vinci robotic system (Intuitive Surgical Inc), many urological reconstructive procedures have been performed through this minimally invasive approach. Recent studies have suggested that robotic surgeries may reduce peri-operative morbidity and hospital stay. This technique may be useful in patients who are chronically debilitated secondary to advanced neurological disease, such as multiple sclerosis. In this video, we demonstrate an incisionless approach to create dual urinary and intestinal diversions using the da Vinci robotic system.

Methods
The patient is a 53 year old female with progressive multiple sclerosis and refractory urinary symptoms despite chronic catheter treatment. She also had significant fecal difficulty. The decision was made to proceed with robotic-assisted dual urinary and intestinal diversions at Indiana University. The procedure began with placement of bilateral lighted ureteral stents to facilitate identification of both ureters. The ureters were mobilized and divided as distal to the bladder as possible. A sigmoid colon conduit of 15cm in length was isolated by dividing both ends with an endoscopic GIA (gastrointestinal anastomosis) stapler. The proximal and distal staple lines became the end colostomy and the Hartmann’s pouch, respectively. Uretero-intestinal anastomoses were accomplished intracorporeally using a modified Wallace technique. The right robotic arm port became the urostomy and the left robotic arm port became the colostomy.

Results
Total operative time was 6 hours and total robotic time was 4 hours. Total estimated blood loss was less than 50ml. The post-operative course was uneventful. Patient had significantly reduced post-operative pain and narcotic requirement. She demonstrated normal colostomy function by post-operative day 2.

Conclusions
Dual urinary and intestinal diversions can be achieved intracorporeally using the da Vinci robotic system. This minimally-invasive approach offers less post-surgical pain leading to less narcotic requirement in the post-operative setting. The lack of small bowel anastomosis provides early return of bowel function. This approach may be advantageous in select patients who are chronically immobilized secondary to advanced neurological disease and subsequently at increased risk for post-operative complications.

Funding: None