V8-10: Robotic Anterior Pelvic Exenteration with Intracorporeal Ileal Conduit in a Patient With History of Kidney Pancreas Transplantation

Video

Introductions and Objectives
This is a case presentation of a 54 year-old woman with history of kidney pancreas transplantation in 2004 for advanced diabetes mellitus presenting with T1G3, micropapillary urothelial carcinoma. Following a multidisciplinary discussion involving transplant urology, nephrology, and medical oncology, the decision was made to proceed with early cystectomy. The patient was continued on low dose steroids, but her immunosuppression was decreased by holding mycophenolate mofetil. We aim to demonstrate the feasibility of anterior pelvic exenteration with intracoporeal ileal conduit of a renal-pancreas transplant graft. Technical considerations include avoiding injury to the transplant graft, minimizing devascularization of the transplant ureter, intracorporeal mobilization of bowel with pancreas graft, and positioning of the ileal conduit.

Methods
A Hassan technique is used to obtain intraperitoneal access, a 12-mm camera port is inserted, and pneumoperitoneum is achieved. Three 8-mm robotic ports and a 12-mm assistant port are placed in the “W” configuration under direct visualization. The patient is placed in the steep Trendelenberg position and the robot is docked. The native ureters were identified, divided and clipped, followed by dissection and division of the transplant ureter. The posterior dissection is conducted with the aid of a malleable retractor placed under the cervix. The anterior dissection of the bladder is then performed, followed by en-bloc removal of the bladder, urethra, and uterus. The vaginal cuff was then closed using V-lock stitch, and an extended lymph node dissection was performed. The intracorporeal ileal coduit is then completed.

Results
The patient’s pre-operative serum creatinine is 1.22 ng/mL. The console time is 4 hours and 21 minutes. The estimated blood loss is 30 cc, and there were no intraoperative complications. Diet was started on post-operative day 4 and she was discharged on post-operative day 6 with all transplant medications resumed. Final pathology demonstrated pT1N0 high-grade multifocal urothelial cell carcinoma with carcinoma in situ, and all surgical margins were negative. The patient’s most recent serum creatinine from a post-operative clinic visit is 1.21 ng/mL.

Conclusions
Robotic anterior pelvic exenteration with intracorporeal urinary diversion is a challenging surgical technique, which requires a multidisciplinary team and a low threshold to convert to open surgery.

Funding: None