Robot-Assisted Laparoscopic Bilateral Nerve-Sparing Radical Cystoprostatectomy for Bladder Cancer

Abstract

Introduction: We present an 8-minute video of bilateral nerve-sparing (NS) robot-assisted laparoscopic radical cystoprostatectomy (RALC) performed for invasive bladder cancer. Materials and Methods: Between December 2009 and April 2010, we performed 12 NS-RALC procedures with intracorporeal Studer pouch formation and bilateral extended pelvic lymph node dissection for muscle invasive bladder cancer.1,2 Trocars: six ports were used (a 12-mm camera, three 8-mm robotic, 12- and 15-mm assistant ports). NS radical cystoprostatectomy: a zero-degree lens is used. Patient position: maximum trendelenburg (30°). Peritoneum overlying the ureters is incised. Ureters are dissected off until entering the bladder, clipped from their most distal part. Distal ends are sent for frozen analysis. Peritoneum overlying the anterior wall of the Douglas' pouch is incised; vasa and seminal vesicles (SV) are exposed. Fascial leaflet of Denonvilliers' fascia is opened over the SV and dissected off until membraneous urethra is reached. Neurovascular bundles (NVB) are dissected laterally from prostatic base to apex with blunt dissection on each side. Extensions from NVB at the level of the tips of SV is clipped with hem-o-lock and used as a landmark for the future part of NVB dissection. Peritoneum lateral to the medial umblical ligaments is incised; pubic bones are exposed. Endopelvic fascia is opened after removal of overlying fatty tissue. The levator ani muscle fibers are dissected off. Prostatic fascia is released bilaterally to make a high anterior release and NVB dissection continued. Ligation of the lateral bladder pedicle is accomplished with the use of Ligasure® starting from medial to external iliac artery until the hem-o-lock clip at the level of ipsilateral SV tip is reached. Distal to this level, NVB is dissected off of the SV wall and posterolateral prostate with sharp and blunt dissection and hem-o-lock clips when necessary. No energy is used around NVB. Transection of the urachus at the level of umblicus and attacments between anterior bladder wall with the abdomen completes bladder dissection. Puboprostatic ligaments are cut and dorsal venous complex is suture tied with 2/0-vicryl and severed with bipolar and monopolar scissors. Urethral catheter is withdrawn, and a 0/0-vicrly suture is passed across urethra at the level of prostatic apex. Free end of this suture is then passed underneath the urethra, and tied on the apex. Urethra is cut flush with the apex and specimen is placed in an endobag. A 12-mm rim from the most proximal urethral remnant is sent for frozen analysis. Results and Conclusions: Mean console time (whole procedure) was 10 hours (8.1–11.5); mean intraoperative blood loss was 455 mL (100–700); mean lymph node yield was 21.3 (8–38). Surgical margins were negative in all patients. Perioperative death rate was zero. Right external iliac vein injury occurred in one patient during performing lymph node dissection whom we converted to open surgery and repaired. RALC is a safe procedure and can be learned and performed with excellent short-term surgical results and satisfactory pathological outcomes. No competing financial interests exist. Presented during the 28th World Congress of Endourology and SWL, September 1–4, 2010, Chicago, IIlinois. Runtime of video: 8 mins