Assessing the Learning Curve for Robotic Assisted Laparoscopic Intracorporeal Urinary Diversion- Initial Experience and Outcomes
Keith O'Brien, MD1, Ryan Dorin, MD2
1University of Connecticut, West Hartford, CT, 2The Hospital of Central Connecticut, West Hartford, CT
BACKGROUND Robotic assisted radical cystectomy with intracorporeal urinary diversion is a relatively new surgical technique for management of patients requiring bladder removal, with potential advantages relating to postoperative recovery, wound complications, and cosmesis. We sought to study the outcomes of our early experience with this procedure performed at a community medical center.
METHODS We reviewed a prospectively maintained database of a single surgeon series of 35 consecutive robotic assisted radical cystectomies with extended pelvic lymph node dissection and intracorporeal urinary diversion (RC/ICUD). Time to return of bowel function, hospital length of stay, estimated blood loss, and 90-day postoperative complications were assessed. Cases were subsequently stratified into 3 consecutive time periods to assess for change in operative time. Patients were placed on a standardized ERAS protocol.
RESULTS 29 patients underwent ileal conduit urinary diversion, while 6 underwent construction of an ileal neobladder. Average follow up interval was 12 months (1 - 42 months). Median total operative time for RC/ICUD was 459 minutes (range 266 - 665 min). Median operative time for ileal conduit patients was 430 minutes (range 266 - 635 min) and for neobladder patients was 533 minutes (range 479 - 665 min). For ileal conduit patients, the first 10 cases had a median operative time of 514 minutes. The next 10 cases had a median operative time of 456 minutes, and the most recent 9 cases had a median operative time of 331 minutes. Median EBL was 150 cc (range 25 - 800 cc). Median length of stay was 6 days (range 3 - 14 days). Median time to flatus was 3 days (range 1 - 7 days). Median time to first bowel movement was 4 days (range 2 - 7 days). 24 patients (68%) experienced a complication. 4 of the 35 patients (11%) experienced Clavien >2 complication. There were no high grade bowel complications or wound infections.
CONCLUSIONS Our initial experience with intracorporeal urinary diversion supports the feasibility of this technique as a minimally invasive option for patients undergoing cystectomy, with a similar safety profile to open urinary diversion. Median operative time improved with experience. Further study is needed to clarify the benefits of intracorporeal diversion.
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