Pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder: surgical technique

Abstract

Objective To investigate the surgical skills of pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder. Methods From October 2014 to September 2016, 37 patients with locally advanced bladder cancer(cT2-3N0-2M0)were diagnosed, including 29 males and 8 females, Their age ranged from 52 to 71 years old. According to preoperative cystoscopy, pathological diagnosis and bladder enhanced CT and other examination, 25 patients were staged as cT2, 12 cases were staged as cT3. 25 cases of them were primary tumors, who underwent pure robotic-assisted radical cystectomy and Endo-GIA assisted orthotopic U-shape ileal neobladder reconstruction. First, bilateral lymph nodes were dissected. And the ureter was explored and dissected to the outer wall of the bladder. Then, we ligated the superior artery of bladder and expose the seminal vesicle, vas deferent duct. The DV fascia was opened to expose the posterior wall of prostate. Incise was performed along the both sides of the bladder and prostate fascia to maintain the vascular nerve bundle until the tip of prostate. The urethra was cut off and then the bladder was remove. We used Endo-GIA to cut 30-35 cm ileum and construct U-shaped bladder. The anastomosis between ureter and neo-bladder and the anastomosis between urethra and neo-bladder were performed. Perioperative and follow-up data were collected. Results The surgeries were successful in all 37 cases. The operation time ranged from 245 to 335 min , mean (285±37)min. The mean intraoperative blood loss was(187±56) ml(ranging 90-300 ml). The average postoperative hospital stay was (17±2)days (ranging 15-20 days). Postoperative intestinal function recovery time ranged from 1.3 to 2.2 days, mean (1.7±0.4)days. Surgical margins were all negative. Lymph node positive rate was 21.6% (8/37). After 1 month, 22 cases achieved complete continence. After 3 months, 35 cases get fully self-control urination, 8 cases have noctual incontinence. Postoperative follow-up ranged from 6 to 24 months, no recurrence or distant metastasis was found in this study. After 6 months, cystoscopy showed no obvious formation of bladder stones. Neo-bladder capacity ranged from 270 to 350 ml. The urodynamic examination showed bladder pressure was maintained between 19 and 25cm H2O. Conclusions Pure robotic-assisted radical cystectomy can achieve better bladder resection, better remaining of urethral and neurovascular bundles and good control of urinary continence after operation. Endo-GIA assisted orthotopic U-shaped ileal bladder need shorter intestinal tract and cause less influence to the intestinal function. The neo-bladder shape is more regular, simple doing, earn shorter operation duration, less bleeding, quick recovery, which is a safe and effective surgical approach. Key words: Urinary bladder cancer; Pure robotic-assisted; Radical cystectomy; Orthotopic U-shape ileal neobladder