Robot assisted Radical Cystoprostatectomy with total Intracorporeal Orthotopic Ileal Neobladder Urinary Diversion: Technical considerations

Introduction: Open radical cystoprostatectomy (RC) and orthotopic neobladder (ONB), is the gold standard for treating nonmetastatic muscle invasive bladder cancer. Open approach has its associated morbidity and various technical modifications have been described to gain the advantages of minimally invasive surgery with variable outcomes. ^[1] RC is now being increasingly performed with robotic assistance due to its minimally invasive benefits. Concomitant urinary diversion either ileal conduit or orthotopic neobladder is usually performed extracorporeally primarily because intracorporeal diversion is perceived as technically complex and demanding. Established principles of neobladder creation have been replicated in robot assisted total intracorporeal orthotopic neobladder. ^[2] This is being increasingly done due to its minimally invasive benefits in addition to comparable functional and oncological outcomes.^[3] This video demonstrates step-by-step technique for robot assisted RC with total intracorporeal orthotopic ileal neobladder urinary diversion.

Material and methods: We performed robotic assisted RC, bilateral extended pelvic lymphadenectomy, and total intracorporeal orthotopic ileal neobladder urinary diversion in a 60 year old male patient with muscle invasive transitional cell carcinoma bladder (T2b N0 M0). Surgical technique is demonstrated in the video.

Results: Total console and operative times were 337 minutes and 376 minutes respectively. There were no peri-operative complications. Patient was started orally on post-operative (POD) 2 and drain was removed on POD 4. Patient was discharged with per urethral catheter and bilateral double ‘J’ stent in situ on POD 6. Histopathology revealed muscle invasive TCC, pT2 N0 M0. Bilateral stents were removed after 3 weeks after a cystogram. Patient is doing well till 12 months follow up.

Conclusion: Robot assisted RC with intracorporeal orthotopic neobladder diversion is safe and feasible with added minimal invasive benefits. Strict adherence to open surgical principles is essential to reduce the technical complexity and have comparable outcomes to open surgery. 

References:

1. Mandhani A, Dharaskar A, Kapoor R. Technical steps of open radical cystectomy and orthotopic neobladder to achieve the goals of "minimally invasive surgery"? Indian J Urol. 2010; 26: 457-60.
2. Desai MM, Gill IS, de Castro Abreu AL, Hosseini A, Nyberg T, Adding C et al. Robotic intracorporeal orthotopic neobladder during radical cystectomy in 132 patients. J Urol. 2014;192: 1734-40.​
3. Tyritzis SI, Hosseini A, Collins J, Nyberg T, Jonsson MN, Laurin O et al. Oncologic, functional, and complications outcomes of robot-assisted radical cystectomy with totally intracorporeal neobladder diversion. Eur Urol. 2013; 64:734-41.