Management of Challenging Urethro-ileal Anastomosis During Robotic Assisted Radical Cystectomy with Intracorporeal Neobladder Formation

Abstract

BackgroundRobotic assisted radical cystectomy (RARC) is increasingly being adopted, but intracorporeal neobladder formation remains a challenging procedure limited to selected centers. Common challenges with intracorporeal neobladder formation relate to fashioning a tension-free urethro-ileal anastomosis. In this paper, we describe a series of maneuvers to overcome these challenges that we believe will be of great utility to surgeons performing intracorporeal neobladder. ObjectiveTo describe maneuvers to overcome challenges during intracorporeal urethro-ileal anastomosis formation and to report postoperative outcomes for patients in whom these maneuvers were used. Design, setting, and participantsA retrospective review of medical records of patients who underwent RARC with intracorporeal neobladder performed by one surgeon (G.-P.H.) at our tertiary center from January 2012 to February 2015 in which at least one additional maneuver was required beyond preservation of urethral length, removal of the sigmoid colon from the pelvis, and careful ileal loop selection. The primary end point was 90-d complications. Follow-up ranged from 6 to 36 mo, and 16 patients had at least 1-yr follow-up. Surgical procedureRARC with intracorporeal neobladder formation. Outcome measurements and statistical analysesClinical and operative data collected from a prospectively maintained, institutional review board–approved database. Maneuvers used during intracorporeal urethro-ileal anastomosis were recorded. Descriptive statistics were used to evaluate postoperative outcomes. Results and limitationsNineteen patients met the inclusion criteria. Mean operative time was 486min (standard deviation: 112min) with median hospitalization of 7 d (interquartile range: 7–9 d). Seven patients (36.8%) experienced a complication, with one (5.3%) major complication thought to be unrelated to surgery. No open conversions were required. There was no 90-d mortality. ConclusionsOur stepwise approach can help overcome challenges of urethro-ileal anastomosis during intracorporeal neobladder formation. Patient summaryWhen performing intracorporeal neobladder formation, challenges are often encountered in fashioning the urethro-ileal anastomosis. We describe a series of maneuvers that, when used in a stepwise manner, help overcome these challenges.