Safe transition from extracorporeal to intracorporeal urinary diversion following robot-assisted cystectomy: a recipe for reducing operative time, blood loss and complication rates

Rajesh Nair,Teck Wei Tan,Ramesh Thurairaja,Sanad Saad,Muhammad Shamim Khan

doi:10.1007/s00345-018-2386-4

Abstract

PurposeWe report the perioperative outcomes and complications after transition from extracorporeal urinary diversion (ECUD) to intracorporeal urinary diversion (ICUD) following robot-assisted radical cystectomy (RARC).MethodsAnalysis of data from a prospectively maintained institutional review board-approved database of 180 patients treated with cystectomy at our institution from April 2015 to October 2017 was performed. 127 patients underwent RARC and received an ileal conduit. Only five patients received a neobladder after RARC and were excluded from analysis.Results68 patients had extracorporeal and 59 intracorporeal ileal conduit after RARC. There were no significant differences in patient demographics and oncological characteristics between the two groups. Of note, intracorporeal ileal conduit was associated with significantly reduced median total operative times (330 vs 375 min, p = 0.019), reduced median estimated blood loss (300 vs 425 ml, p < 0.035) and lower 30-day overall complication rates (48.4 vs 71.4%, p = 0.008) when compared to extracorporeal diversion. However, the median length of stay, 30–90-day complication rates, mortality rates and ureteroileal anastomotic stricture rates were similar in both groups. The median operative time for RARC and intracorporeal ileal conduit was significantly shorter in the second cohort of 29 cases compared to the first 30 cases (300 vs 360 min, p = 0.004). Other outcomes were similar in both cohorts.ConclusionIn our experience, transition from extracorporeal to intracorporeal diversion after RARC is safe, technically feasible and benefits from shorter operative times, reduced estimated blood loss, and lower 30-day overall complication rates.

Highlights

Radical cystectomy with extended pelvic lymph node dissection is the standard treatment for muscle-invasive and highrisk non-muscle-invasive carcinoma of the bladder [1]
There were no significant differences between the extracorporeal urinary diversion (ECUD) and intracorporeal urinary diversion (ICUD) groups with respect to median age (71 vs 69 years, p = 0.059), gender (85.7% male vs 79.0% male, p = 0.323), median BMI (27.0 vs 26.5, p = 0.885), median American Society of Anesthesiologists (ASA) score (2 vs 2, p = 0.803), receipt of neoadjuvant chemotherapy (13.2 vs 22.0%, p = 0.193) and history of prior pelvic external beam radiotherapy (16.2 vs 6.8%, p = 0.103)
robot-assisted radical cystectomy (RARC) is a technically complex procedure consisting of three parts: extirpation of the bladder, pelvic lymph node dissection, and urinary diversion

Summary

Introduction

Radical cystectomy with extended pelvic lymph node dissection is the standard treatment for muscle-invasive and highrisk non-muscle-invasive carcinoma of the bladder [1]. Robot-assisted radical cystectomy (RARC) is increasingly being utilized in a number of institutions to reap the benefits of minimally invasive surgery [2,3,4,5] while replicating principles of open surgery and maintaining oncological equivalence [6]. There are limited studies comparing perioperative outcomes of ICUD and ECUD [12,13,14].

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Conclusion