Intuitive Anatomical Intracorporeal Neobladder Technique After Robot-Assisted Radical Cystectomy

Abstract

Introduction: Radical cystectomy (RC) is one of the most complex urologic surgical procedures, especially in cases of orthotopic neobladder reconfiguration. Recently, robot-assisted radical cystectomy (RARC) demonstrated oncological results similar to those reported for open RC with promising outcomes and reduced procedure-related complications.1–4 Several techniques of totally intracorporeal neobladder diversion have been described, reporting satisfactory outcomes.5–11 In this video, we describe step-by-step the technique routinely employed in our Institute to perform a totally intracorporeal ileal neobladder. Patients and Methods: Between November 2013 and January 2016, 63 continent and neurologically healthy patients (54 men and 9 women) affected by muscle-invasive or high-risk bladder cancer refractory to instillation with Calmette–Guérin bacillus were recruited as candidates for RARC and orthotopic ileal neobladder. Urinary continence (UC) recovery was assessed at 30 days, 3, 6, and 12 months from catheter removal and was defined as no pad use or 1 pad per day for protection. Erectile function recovery was assessed at 6 and 12 months postoperatively and defined as an International Index Erectile Function score ≥17 and the possibility to have sexual intercourses with or without PDE5 inhibitors therapy. The intuitive anatomical intracorporeal-neobladder technique includes the following steps: (1) Identification of the optimal portion of the ileal loop to be led to the urethral stump and execution of anastomosis. (2) Defunctionalization of 60 cm of ileum and intestinal continuity restoration by laterolateral stapled anastomosis. (3) Inverted Y-shaped configuration of the neobladder. (4) Ureteral anastomosis on lateral ends of ileal loop stumps fixed to the psoas muscles bilaterally. (5) Completion of neobladder and leak test. Results: No intraoperative complications occurred. We reported early (<30 days) surgical complications in 14 (22%) patients, having Clavien grade 2 in 14 (22%) and grade 3 in 2 (3%) patients. Late complications, Clavien grade 3b, occurred in three (4%) patients. Daytime UC was preserved in 80% of male patients and sexual potency in 62% of patients receiving nerve sparing procedure. Conclusions: The goal of our technique was to offer a “user friendly” and reproducible neobladder reconfiguration. Peculiarities of our technique are the passage of two single-J stent through the catheter. This solution provides several potential advantages, such as (1) avoidance of the insertion of ureteral stents through the abdominal wall and (2) providing a single easy access to the urinary tract for irrigating procedures. Moreover, the configuration of the neobladder in an inverted Y shape, with the proximal ends fixed to the psoas muscle, allows to perform a ureteral–enteral anastomosis without the need to transpose the left ureter. Further advantage of this technique, with the two lateral stumps fixed to the psoas muscle, is to have at the end of the procedure a “pyramidal” shape of the neobladder, instead of a “cylindrical” shape, with improvement in the reservoir capacity and reducing intraluminal pressures. Overall complication rate was limited, offering a safe procedure profile. At 1 year follow-up, the majority of patients maintained daytime and nocturnal UC. No competing financial interests exist. Runtime of video: 5 min