Genital Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Neobladder & Paravaginal Repair

Abstract

Vaginal prolapse is a known complication after Radical cystectomy (RC), requiring additional procedures in 10% of patients1. This results from loss of level I and II vaginal support due to removal of pelvic structures. In addition, a neobladder urinary diversion, with Valsalva voiding, predisposes to vaginal prolapse. Genital sparing approach with paravaginal repair can help prevent such complication. Genital sparing technique preserves the uterus, fallopian tubes, ovaries, and vagina, while paravaginal repair involves suturing of the lateral vaginal wall to the arcuate fascia located on the medial aspect of the obturator internus muscle. Procedure begins by placing the patient in lithotomy position, with a steep Trendelenburg. Standard 6 port cystectomy configuration is utilized with an additional 15 mm port for bowel anastomosis. Initially the ureters and lateral bladder space is mobilized. Posteriorly a dissection plane is developed separating the bladder from the anterior vaginal wall. Distal dissection is carefully performed in that plane to avoid disrupting urethral-external sphincter complex. Then the bladder is dropped from anterior attachments, the DVC and bladder neck are exposed. Urethra is transected distal to bladder neck, after circumferential mobilization, to complete the cystectomy, again avoiding disruption of continence mechanism and opening the endo-pelvic fascia. Cystectomy and pelvic lymph node dissected are completed in standard fashion. The arcuate fascia is identified bilaterally for level I paravaginal repair. The lateral aspect of the paravaginal tissue is secured to this ligament, using 3 interrupted PDS sutures, bilaterally. An ileal "Hautman's W pouch" neobladder is constructed using 50cm of small intestine, similar to the previously reported technique2. Bricker-type uretero-ileal anastomosis is performed over a double J stent. Bowel continuity is restored by a side-to-side anastomosis using endo-GIA staplers. No intra- or post-operative complications were noted. Robot dock-time was 8 hours and 23 minutes with EBL of 100mL. Patient was discharged on POD 6 and Foley-catheter with ureteral stents were removed on POD 27 after a cystogram confirming no leaks. At 6-month follow-up, patient reported good continence using a single pad, voiding every 3-4hours. Fluoro-urodynamics demonstrated 651 mL capacity, low-pressure voiding, minimal residual urine, and no reflux. No prolapse was noted on fluoroscopy and pelvic exam with Valsalva maneuver. Patient reported good satisfaction level, regarding her urinary symptoms. We report satisfactory short-term outcomes of a feasible technique to prevent post-cystectomy prolapse, however long-term follow-up of a larger cohort, can help establish its efficacy.