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BACKGROUND: Robotic and laparoscopic techniques continue to be applied to an increasing number of urologic procedures. We present our technique and results for robotic cystectomy and laparoscopic assisted Indiana Pouch urinary diversion.
METHODS: All patients had venodynes and subcutaneous heparin before induction. Initial ports are placed in a fashion similar to a robotic prostatectomy. The camera is just above the umbilicus with two robotic ports on the right side of the abdomen, all 6-8 cm apart. A 15 mm assistant port (to admit a large specimen bag) and robot port are similarly placed on the left side. The cystectomy is then completed robotically. For some cases, adequate laparoscopic mobilization of the terminal ileum and right colon through these ports could be performed. In other cases, two 5 mm ports are placed infraumbilically in the midline approximately 5-7 cm apart to aid in the urinary diversion. A 5-7 cm incision is made independently or by connecting these two ports. Bowel continuity is restored in a side to side fashion with staplers. The colon is opened on its anti-mesenteric border, and the detubularized pouch is created in a standard fashion. The ureters are independently implanted into the cecum over the stents, and the catheterizable stoma is matured.
RESULTS: 14 patients (7 men and 7 women) underwent robotic cystectomy and laparoscopic assisted Indiana Pouch urinary diversion. Average age was 65 years (range 50-83 years). Indications for surgery were bladder cancer (11 patients), neurogenic bladder (2 patients), and interstitial cystitis (1 patient). The mean robot time for radical cystectomy portion of the procedure was 222 minutes (range 144-300 minutes); mean laparoscopic time for terminal ileum and right colon harvesting was 56 minutes (range 23-100 minutes); mean total operating room time (skin to skin) was 458 minutes (range 298-579 minutes); mean estimated blood loss was 423 ml (range 300-500 ml). 1/11 patients with bladder cancer had a positive margin (T4N2); 3/11 had nodal metastasis; mean lymph node yield was 24 nodes (median 20 nodes, range 10-46 nodes). 3/14 patients had complications. One patient had a DVT (Clavien grade 2, treated with anticoagulation), one patient had a pulmonary embolism (Clavien grade 3a, treated with IVC filter), and 1 patient had an Iliac artery thrombosis (Clavien grade 3b, treated with thrombectomy).
CONCLUSIONS: Robotic cystectomy and laparoscopic assisted Indiana Pouch urinary diversion is a feasible technique for patients requiring concomitant cystectomy and continent diversion. Further study comparing this technique to traditional approaches is necessary.