Intracorporeal Urinary Diversion Research Articles

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

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.

Robotic radical cystectomy for the management of bladder cancer: Analysis of operative and pathological outcomes of eighteen patient.

To present the surgical and pathological results of robotic radical cystectomy (RRC) operations performed in our clinic. A total of 18 patients, who underwent RRC and intracorporeal urinary diversion between October 2016 and September 2017 for clinically localized bladder cancer in our clinic, were included in the study. The results were evaluated under three headings. 1. operative outcomes (total operation time, perioperative blood loss, postoperative hematocrit decrease) 2. recovery period (pull-off drain day, hospitalization time) 3. oncological results (pathologic stage, surgical margin, number, and characteristics of lymph nodes removed). Complications within the postoperative 30-day period, were evaluated and the Clavien classification system was used to classify the complications. The mean age of the patients was 64.4 (52-80) years. Seventeen male patients and one female patient underwent robotic cystectomy. At the operative outcomes, the mean blood loss was 325 mL, and the mean hematocrit decrease was 3.15%. The mean duration of the surgery was 471 minutes (330-630), while the median operative time was 450 minutes. Complications occured in 6 patients during the early postoperative period. Six of them (75%) had minor complications (Clavien grade 1), two patients (25%) had major complications (Clavien grade 4). Our initial experience with RRC is that, this surgical technique has acceptable operative, oncological and short-term clinical outcomes. However, prospective randomized studies are needed to assess whether there is a clear advantage compared to open surgery.

Updates on Robotic Intracorporeal Urinary Diversions.

More than a century of development has led to contemporary urinary diversion. It is paramount that robotic intracorporeal diversions uphold the principles defined by open surgery. In this review, we discuss the fundamental open surgical principles that have led to contemporary techniques of urinary diversion. We then outline the technical aspects of several recently described robotic intracorporeal urinary diversions in the context of these surgical principles. Several potential benefits of intracorporeal urinary diversion are being investigated-such as a reduction in gastrointestinal complications, ureteral strictures, and wound complications. Finally, we highlight the important aspects of establishing an intracorporeal urinary diversion program integrated with an Enhanced Recovery after Surgery (ERAS) program. We have included the perioperative outcomes of 100 consecutive cases of intracorporeal urinary diversion with an Enhanced Recovery after Surgery (ERAS) protocol. In this series, 49% were continent diversions. Patients had a median length of stay of 5days, with 37% staying 4days or less. High-grade complications and readmissions were noted in 22 and 20% of patients, respectively. The benefits of intracorporeal urinary diversion appear promising, and there is continued need for high-quality randomized controlled trials to define its role in patients undergoing radical cystectomy.

Robot-sewn ileoileal anastomosis during robot-assisted cystectomy.

To analyze the feasibility and perioperative results of patients undergoing robot-assisted cystectomy with intracorporeal urinary diversion and robot-sewn ileoileal anastomosis. This is a mono-centric analysis of perioperative data from 48 consecutive patients undergoing robot-assisted cystectomy with intracorporeal urinary diversion and robot-sewn ileoileal anastomosis. Data include the preoperative variables, operative and postoperative course and complication rates related to bowel anastomosis. End points were time spent for anastomosis and intra- and postoperative complication rates. Median operating time was 23.0 (13-60)min for the ileoileal anastomosis. Median overall operating time was 295 (200-780)min, with a median of 282 (200-418)min and 414.0 (225-780)min for the ileum conduit (N=35) and ileal neobladder (N=13). Two patients developed paralytic ileus; in another patient acute peritonitis occurred, but was caused by urinary leakage and therefore unrelated to the bowel anastomosis. No anastomotic leakage was noticed. Costs for the robot-sewn anastomosis was 8€ compared to 1250€ for a stapled anastomosis which was performed in previous cases. Limitations are the non-comparative nature of the analysis and the limited number of patients. Robot-sewn ileoileal anastomosis is feasible with low complication rates. Compared to the stapled anastomosis, a robot-sewn ileoileal anastomosis may serve as an alternative and cost-saving approach.

Contemporary techniques and outcomes of robotic cystectomy and intracorporeal urinary diversions.

Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is being increasingly performed worldwide. This review summarizes recent technical developments and outcome data for RARC with ICUD. With the recent description of intracorporeal continent cutaneous diversion, all classes of urinary diversion can presently be performed totally intracorporeally. The summary of our seven cases of intracorporeal continent cutaneous diversion in this article brings the number of reported cases in the literature to 17. Additional recent advancements in ICUD focus on novel technical descriptions and outcome data. Several intracorporeal orthotopic ileal neobladder techniques have been described with intermediate perioperative outcomes. There is some rationale for reduced overall, wound, gastrointestinal and genitourinary complications with ICUD. RARC with intracorporeal diversion is a feasible option for patients with bladder cancer. Prospective and randomized outcome data are needed to better characterize the benefit of ICUD in patients following radical cystectomy.

Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

This study aimed to provide an update and compare perioperative outcomes and complications of intracorporeal and extracorporeal urinary diversion following robot-assisted radical cystectomy using data from the multi-institutional, prospectively maintained International Robotic Cystectomy Consortium database. We retrospectively reviewed the records of 2,125 patients from a total of 26 institutions. Intracorporeal urinary diversion was compared with extracorporeal urinary diversion. Multivariate logistic regression models using stepwise variable selection were fit to evaluate preoperative, operative and postoperative predictors of intracorporeal urinary diversion, operative time, high grade complications and 90-day hospital readmissions after robot-assisted radical cystectomy. In our cohort 1,094 patients (51%) underwent intracorporeal urinary diversion. These patients demonstrated shorter operative time (357 vs 400 minutes), less blood loss (300 vs 350 ml) and fewer blood transfusions (4% vs 19%, all p <0.001). They experienced more high grade complications (13% vs 10%, p = 0.02). Intracorporeal urinary diversion use increased from 9% of all urinary diversions in 2005 to 97% in 2015. Complications after this procedure decreased significantly with time (p <0.001). On multivariable analysis higher annual cystectomy volume (OR 1.02, 95% CI 1.01-1.03, p <0.002), year of robot-assisted radical cystectomy (2013-2016 OR 68, 95% CI 44-105, p <0.001) and American Society of Anesthesiologists® score less than 3 (OR 1.75, 95% CI 1.38-2.22, p <0.001) were associated with undergoing intracorporeal urinary diversion. The procedure was associated with a shorter operative time of 27 minutes (p = 0.001). The use of intracorporeal urinary diversion has increased in the last decade. A higher annual institutional volume of robot-assisted radical cystectomy was associated with intracorporeal urinary diversion as well as with shorter operative time. Although intracorporeal urinary diversion was associated with higher grade complications than extracorporeal urinary diversion, they decreased with time.

Intracorporeal robot-assisted radical cystectomy, together with an enhanced recovery programme, improves postoperative outcomes by aggregating marginal gains.

To assess the cumulative effect of an enhanced recovery after surgery (ERAS) pathway and minimally invasive robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) in comparison with open radical cystectomy (ORC) on length of hospital stay (LOS) and peri-operative outcomes. Between February 2009 and October 2017, 304 radical cystectomy cases were performed at a single institution (ORC, n = 54; robot-assisted radical cystectomy [RARC], n = 250). Data were prospectively collected. We identified 45 consecutive ORC cases performed without ERAS before the commencement of the RARC programme (Cohort A), 50 consecutive iRARC cases performed without ERAS (Cohort B) and 40 iRARC cases with ERAS (Cohort C). The primary outcome measure was LOS, while secondary outcome measures included peri-operative 90-day complications and readmission rate. Complications were accessed using the Clavien-Dindo system. Patients in all cohorts were evenly matched with regard to age, sex, body mass index, neoadjuvant treatment, tumour stage, lymph node yield, previous pelvic radiotherapy and surgery, peri-operative anaemia, as well as physiological state. Patients who underwent iRARC with ERAS had a significantly higher American Society of Anesthesiologists score (III-IV) and were more likely to receive neobladder reconstruction. The median (interquartile range) LOS was shorter in the iRARC with ERAS group (7 [6-10]) days than in the iRARC without ERAS group (11 [8-15]) days and the ORC group (17 [14-21] days). In a propensity score-matched cohort of patients who underwent iRARC, patients who followed the ERAS pathway had significantly lower 90-day readmission rates. Additionally, implementing ERAS in an iRARC cohort resulted in a significantly lower 90-day all (P < 0.001) and gastrointestinal-related complications (P = 0.001). The ERAS pathway and younger patients were independently associated with an LOS of ≤10days on multinomial logistic regression. A comprehensive ERAS programme can significantly reduce LOS in patients undergoing iRARC without increasing 90-day readmission rates. An ERAS programme can augment the benefits of iRARC in improving peri-operative outcomes. In studies comparing ORC and RARC, the presence or absence of an ERAS programme will be a confounding factor and only level 1 evidence can be interpreted reliably.

Robot assisted radical cystectomy with totally intracorporeal urinary diversion: initial, single-surgeon's experience after a modified modular training.

To report the perioperative and early functional outcomes of patients undergoing Robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion performed by a single surgeon after a modified modular training. The surgeon (A.P.) attained a 30-days modified modular training at a referring Center mentored by a worldwide-recognized robotic surgeon (P.W.). The training program consisted of: 1) e-learning based on 10 hours of theoretical lessons made by the mentor; 2) video-session concerning the different steps of the procedure, 3) step-by-step in vivo modular training. Demographics, intraoperative data and post-operative complications were recorded for each patient. Twenty-four consecutive patients were prospectively evaluated. Median age was 68.5 years (IQR 59-75). Thirteen (54.2%) and 11 (45.8%) patients received RARC with orthotopic neobladder (ONB) and ileal conduit (IC), respectively. Overall mean (±SD) operative time was 392 (± 34.8) minutes. The median number of lymph node retrieved was 30 (IQR 24-42), the mean intraoperative estimated blood loss (EBL) was 403 mL (±60) with average hospitalization of 7.8 days (±2.2). All procedures were completed successfully without open conversion. A statistically significant difference in terms of overall operative time (OT) and urinary diversion operative time (UDOT) was found in favor of IC group compared to ONB group (P=0.002). Overall complication rate was 33%, 7 out of 9 (88%) were graded as minor (Clavien 1-2). Two (22%) major complications (Clavien 3-5) occurred solely on ONB group. Robot-assisted radical cystectomy with totally intracorporeal urinary diversion is a challenging procedure with a steep learning curve. An adequate modular training with an experienced mentor and a skilled robotic team could be essential to reach these optimal results. Further studies investigating the impact of modular learning curve and a dedicated menthorship on operative and functional outcomes after RARC are needed.

Feasibility of expert and crowd-sourced review of intraoperative video for quality improvement of intracorporeal urinary diversion during robotic radical cystectomy.

Development of uretero-ileal stricture (UIS) after robotic-assisted radical cystectomy (RARC) may be dependent on surgical technique. Video review of intraoperative technique is an emerging paradigm for surgical quality improvement. We examined whether surgeon-perceived risk of UIS or crowd-sourced assessment of robotic skill are associated with the development of UIS. We conducted a case-control study comparing the operative technique of uretero-ileal anastomoses resulting in clinically significant UIS with the contralateral anastomosis for the same patient. De-identified videos were analyzed by 1) five high-volume surgeons; and 2) crowd workers (Crowd-Sourced Assessment of Technical Skill, C-SATS) to determine Global Evaluative Assessment of Robotic Skill (GEARS) score. Mantel-Haenszel common odds ratio (OR) estimates were calculated to assess the association between surgeon performance and the development of UIS. Logistic regression models were used to examine the association between GEARS scores and the development of UIS. A total of 10 UIS videos were compared to eight control videos by five surgeons and 2142 crowd workers. Expert surgeons systematically evaluated intraoperative footage, however, no association between the expert mode response and UIS (OR 0.42; 95% confidence interval [CI] 0.05-3.45; p=0.91) was identified. Crowd-sourced assessment was not predictive of UIS (p=0.62). We used video review to systematically analyze procedure-specific content and technique. The inability of surgeons to predict UIS may reflect the questionnaire, uncontrolled patient factors, or a lack of power. Crowd-sourced GEARS score was unsuccessful in predicting UIS after RARC.

PE72 - Robot-sewn ileoileal anastomosis during robot-assisted cystectomy

To analyze the feasibility and perioperative results of patients undergoing robot-assisted cystectomy with intracorporeal urinary diversion and robot-sewn ileoileal anastomosis. This is a mono-centric analysis of perioperative data from 48 consecutive patients undergoing robot-assisted cystectomy with intracorporeal urinary diversion and robot-sewn ileoileal anastomosis. Data include the preoperative variables, operative and postoperative course and complication rates related to bowel anastomosis. End points were time spent for anastomosis and intra- and postoperative complication rates. Median operating time was 23.0 (13–60) min for the ileoileal anastomosis. Median overall operating time was 295 (200–780) min, with a median of 282 (200–418) min and 414.0 (225–780) min for the ileum conduit (N = 35) and ileal neobladder (N = 13). Two patients developed paralytic ileus; in another patient acute peritonitis occurred, but was caused by urinary leakage and therefore unrelated to the bowel anastomosis. No anastomotic leakage was noticed. Costs for the robot-sewn anastomosis was 8€ compared to 1250€ for a stapled anastomosis which was performed in previous cases. Limitations are the non-comparative nature of the analysis and the limited number of patients. Robot-sewn ileoileal anastomosis is feasible with low complication rates. Compared to the stapled anastomosis, a robot-sewn ileoileal anastomosis may serve as an alternative and cost-saving approach.

VE45 - Implementation of EndoWrist ® stapler for da Vinci Xi system and Alexis® device during robot-assisted radical cystectomy with intracorporeal urinary diversion

VE45 - Implementation of EndoWrist ® stapler for da Vinci Xi system and Alexis® device during robot-assisted radical cystectomy with intracorporeal urinary diversion

PE81 - Comparison of complication rates and perioperative results of radical cystectomy in a single academic centre after introduction of robot-assisted radical cystectomy with intracorporeal urinary diversion

PE81 - Comparison of complication rates and perioperative results of radical cystectomy in a single academic centre after introduction of robot-assisted radical cystectomy with intracorporeal urinary diversion

Impact of body mass index on robot-assisted radical cystectomy with intracorporeal urinary diversion.

To determine the impact of body mass index (BMI) on peri-operative and oncological outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion. A total of 216 patients undergoing RARC, extended lymphadenectomy and intracorporeal urinary diversion, between July 2010 and December 2015, were categorized into four BMI groups according to the 2004 World Health Organization obesity classification groups: <25 kg/m2 (normal); 25-29.9 kg/m2 (pre-obese); 30-34.9 kg/m2 (obese class I); and ≥35 kg/m2 (obese class II). Pre-, intra- and postoperative characteristics, oncological outcomes, and 90-day complications were compared using sas statistical software. All 216 patients underwent intracorporeal urinary diversion, with 68 (32%) undergoing orthotopic neobladder construction. Demographics were similar among the BMI groups with regard to median (range) age (71.8 [35- 95] years), gender (80.6% men), Charlson comorbidity index (CCI) score (66.2% with CCI score 0-1), pathological stage (carcinoma in situ to T2: 55.1%, T3-T4/N0: 18.5%, Tx/N+: 26.4%), median (interquartile range) node count [41 (28, 53)] and positive soft tissue margin rate (4.2%). Obese patients had greater blood loss and longer operating time (P = 0.02 and P = 0.04, respectively). There were no significant differences in length of hospital stay, transfusion rates, readmission or 90-day overall and high-grade complication rates (P = 0.16, P = 0.96, P = 0.89, P = 0.22 and P = 0.51, respectively). At a median (range) follow-up of 13 months (15 days to 4.8 years), recurrence-free survival (P = 0.92) and overall survival (P = 0.68) were similar among the groups. The results of the present study show that RARC with intracorporeal urinary diversion is safe and feasible in obese patients with bladder cancer. BMI was not associated with significant differences in peri-operative, pathological or early oncological outcomes.

Postoperative C-reactive protein concentration and clinical outcome: comparison of open cystectomy to robot-assisted laparoscopic cystectomy with extracorporeal or intracorporeal urinary diversion in a prospective study

Objective: This study aimed to compare clinical outcome and postoperative systemic inflammatory response using C-reactive protein (CRP) levels, to quantify the degree of tissue injury in open mini-laparotomy cystectomy (OMC) versus robot-assisted laparoscopic cystectomy with extracorporeal (RALC-EUD) or intracorporeal urinary diversion (RALC-IUD).Materials and methods: From September 2012 to September 2015, 309 patients diagnosed with bladder cancer underwent radical cystectomy with urinary diversion. Of these, 175 patients were eligible for the study and underwent OMC (n = 125), RALC-EUD (n = 12) or RALC-IUD (n = 38). Blood samples were obtained preoperatively and postoperatively on days 1–7. Clinical and perioperative parameters, including demographics, comorbidity, tumour stage and postoperative outcomes, were collected from medical records.Results: Age, American Society of Anesthesiologists score and Charlson score were significantly higher in OMC than in the robotic groups (p = 0.020, 0.012 and 0.008, respectively). Other demographic data showed no significant group differences. Estimated blood loss and blood transfusion volume were higher in OMC (p < 0.001) and operative time was longer in the robotic groups (p < 0.001); no difference was found between RALC groups. Postoperative CRP levels changed over time (p < 0.001) and RALC-IUD appeared to have significantly higher CRP levels on postoperative days 3–7 compared to OMC and RALC-EUD (p < 0.031), but OMC CRP levels were higher than RALC-EUD.Conclusions: In this study, robotic techniques seem less traumatic overall than open surgery, as OMC had higher postoperative CRP levels than RALC-EUD. The higher CRP levels in RALC-IUD may be more reflective of the urinary diversion technique than the true tissue trauma.

Perioperative Systemic Inflammatory Response following Robot-Assisted Laparoscopic Cystectomy vs. Open Mini-Laparotomy Cystectomy: A Prospective Study

Introduction: Surgeries, such as radical cystectomy (RC), induce a systemic inflammatory response (SIR). SIR plays an important role in controlling the human immune system. This study aims at comparing the SIR in robot-assisted laparoscopic cystectomy (RALC) to open mini-laparotomy cystectomy (OMC) with a urinary diversion (UD). Comparison was based on immunologic markers of SIR, thus quantifying the degree of tissue trauma. Materials and Methods: Forty-two male patients underwent RC with an ileal conduit. Either OMC RC (OMC; n = 20), RALC with extracorporeal UD (RALC-EUD; n = 13), or RALC with intracorporeal UD (RALC-IUD; n = 9) was performed. Blood samples were obtained preoperatively (PREOP), immediately after surgery (POD0), 24 (POD1) and 48 h (POD2) postoperatively. Clinical parameters were collected from medical records. Results: Estimated blood loss and blood transfusion volume was higher in OMC (p's < 0.001). The operative time was longer in RALC groups (p < 0.001). On POD0, interleukin (IL)-6 showed significant lower level in RALC-IUD compared to OMC (p = 0.016). IL-10 level was higher at POD0 (p = 0.029) and POD1 (p = 0.038) in OMC vs. RALC-EUD. MCP-1 levels for RALC-IUD were significantly lower compared to RALC-EUD (p = 0.027). Conclusions: This study found that postoperative SIR was overall less pronounced in RALC, thus depicting reduced tissue trauma. No major clinical differences between RALC-IUD and -EUD were found.

PD38-07 ROBOT-ASSISTED INTRACORPOREAL RIGHT COLON CONTINENT CUTANEOUS URINARY DIVERSION AND AUGMENTATION CYSTOPLASTY: A SINGLE INSTITUTION EXPERIENCE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II1 Apr 2017PD38-07 ROBOT-ASSISTED INTRACORPOREAL RIGHT COLON CONTINENT CUTANEOUS URINARY DIVERSION AND AUGMENTATION CYSTOPLASTY: A SINGLE INSTITUTION EXPERIENCE Spencer Craven, John Sigalos, Rose Khavari, and Alvin Goh Spencer CravenSpencer Craven More articles by this author , John SigalosJohn Sigalos More articles by this author , Rose KhavariRose Khavari More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1721AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Continent cutaneous diversion (CCD) is a less commonly utilized diversion choice following open or robotic cystectomy. We have previously described a novel technique for robotic intracorporeal CCD. Meanwhile, continent cutaneous augmentation cystoplasty (CCAC) is a viable option for patients with neurogenic bladder. There is limited worldwide experience performing intracorporeal CCD and no studies describing intracorporeal CCAC. Principles developed in robotic CCD can be readily applied to robotic CCAC. We share our experience with these novel robotic procedures. METHODS Robotic cystectomy was performed in patients undergoing CCD using a standard 6-port technique. The patient and robot were then repositioned for intracorporeal bowel mobilization and segmentation, ileocolonic anastomosis, uretero-colonic anastomoses, pouch construction, tapering of catheterization channel, reinforcement of ileocecal valve, and stoma creation. All patients were placed on an evidence-based Enhanced Recovery after Surgery protocol postoperatively. Operative times, intraoperative blood loss (EBL), length of stay (LOS), and complications occurring within 90 days of surgery were reviewed. RESULTS Ten robotic intracorporeal right colon urinary diversions, including four robotic intracorporeal CCAC and six robotic intracorporeal CCD, were performed. Mean total operative times for cystectomy and intracorporeal urinary diversion were 7.8 and 10 hours for CCAC or CCD respectively (5.4-9.5; 7.9-12.9). Mean EBL was 181ml (75-300) for CCAC and 250ml (100-500) for CCD. Mean LOS for CCAC and CCD groups was 10 and 8.8 days respectively (5-18, 4-18). A single CCAC patient required transfusion postoperatively. Two high grade complications (Clavien III or greater) were reported in the CCAC group (50%). One high grade complication was reported in the CCD group (17%). Within 30 days of surgery, no CCAC and two CCD patients required readmission (0%, 33%). With a median follow up of 17 months, no incontinence was reported and all patients were able to catheterize without difficulty. CONCLUSIONS We demonstrate that robotic intracorporeal CCD and CCAC are technically feasible and safe with good functional outcomes. Further evaluation of these novel surgical techniques along with comparative studies are needed. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e742 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Spencer Craven More articles by this author John Sigalos More articles by this author Rose Khavari More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD38-02 UTILIZATION OF INDOCYANINE GREEN FLUORESCENCE ANGIOGRAPHY PRIOR TO INTRACORPOREAL URETEROILEAL ANASTOMOSIS FOLLOWING ROBOTIC RADICAL CYSTECTOMY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II1 Apr 2017PD38-02 UTILIZATION OF INDOCYANINE GREEN FLUORESCENCE ANGIOGRAPHY PRIOR TO INTRACORPOREAL URETEROILEAL ANASTOMOSIS FOLLOWING ROBOTIC RADICAL CYSTECTOMY Daniel MO Freitas, Toshitaka Shin, Nariman Ahmadi, Carlos Fay, Andre Luis Abreu, Masakatsu Oishi, Giovanni Cacciamani, Mihir Desai, Inderbir Gill, Andre Berger, and Monish Aron Daniel MO FreitasDaniel MO Freitas More articles by this author , Toshitaka ShinToshitaka Shin More articles by this author , Nariman AhmadiNariman Ahmadi More articles by this author , Carlos FayCarlos Fay More articles by this author , Andre Luis AbreuAndre Luis Abreu More articles by this author , Masakatsu OishiMasakatsu Oishi More articles by this author , Giovanni CacciamaniGiovanni Cacciamani More articles by this author , Mihir DesaiMihir Desai More articles by this author , Inderbir GillInderbir Gill More articles by this author , Andre BergerAndre Berger More articles by this author , and Monish AronMonish Aron More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1716AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteroileal strictures are diagnosed in 2-10% of patients following radical cystectomy and urinary diversion. Poor vascularity of the distal ureteric stumps is a well-known cause factor. Indocyanine-green (ICG) is an exogenous tracer that helps in assessing the vascularity of tissues. Herein, we report a proof-of-concept and our initial experience in using ICG prior performing intracorporeal ureteroileal anastomosis following robotic radical cystectomy (RRC). METHODS From April to November 2016, the use of ICG was analyzed in 10 patients who underwent RRC with intracorporeal urinary diversion (IUD). Intravenous ICG (25mg) was administered prior to ureteroileal anastomosis and the non-enhanced distal ureters were excised prior to ureteric spatulation. Anastomosis was performed in routine manner with 4-0 vicryl sutures over ureteric stents. RESULTS Among 10 patients who underwent to RRC-IUD (5 neobladders and 5 ileal conduits), ICG revealed poor distal ureteric enhancement in 7 patients (70%). Three (30%) patients required bilateral distal ureteral resection, three (20%) patients required left distal ureteral resection and one (10%) patient required right distal ureteral resection. Median resected ureteral length was 2 cm (1-4). Median operative time was 480 minutes (410-620), median EBL was 200 ml (100-650) and median hospital of stay was 5.5 days (3-9). Three patients experienced Clavien 2 complications (fever, n=2 and ileus, n=1). At a median follow-up of 81 days (7-198), no anastomotic strictures were identified. CONCLUSIONS Intravenous injection of ICG prior to ureteroileal anastomosis is a useful tool to evaluate distal ureter vascularity and to identify and excise the transition point of the non-vascularized ureteral segment. Longer follow-up is required to evaluate rates of anastomotic strictures. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e739 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Daniel MO Freitas More articles by this author Toshitaka Shin More articles by this author Nariman Ahmadi More articles by this author Carlos Fay More articles by this author Andre Luis Abreu More articles by this author Masakatsu Oishi More articles by this author Giovanni Cacciamani More articles by this author Mihir Desai More articles by this author Inderbir Gill More articles by this author Andre Berger More articles by this author Monish Aron More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V12-04 ROBOT ASSISTED ORTHOTOPIC MODIFIED STUDER NEOBLADDER

You have accessJournal of UrologyBladder Oncology and Diversion1 Apr 2017V12-04 ROBOT ASSISTED ORTHOTOPIC MODIFIED STUDER NEOBLADDER Hubert John, Christian Padevit, Kevin Horton, Abolfazl Hosseini, and Peter Wiklund Hubert JohnHubert John More articles by this author , Christian PadevitChristian Padevit More articles by this author , Kevin HortonKevin Horton More articles by this author , Abolfazl HosseiniAbolfazl Hosseini More articles by this author , and Peter WiklundPeter Wiklund More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3210AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic intracorporeal orthotopic neobladder after radical cystectomy and extended lymphadenectomy is a technically challenging procedure. So far, only a few centers worldwide have taken this procedure into routine. After over 1000 procedures and routinely performed intracorporeal Bricker urinary deviation, the swiss team started with the intracorporeal neobladder technique carefully. The video presents our standardized technique in 10 patients after one first proctored surgery by a mentoring team (AH/PW). METHODS A daVinci SI-system with 4 arms and 6-port access was used. The left ureter is drawn unter the mesorectum to the right side. 50cm are needed for the pouch. The urethro-ileal anastomosis with a 3-0 barbed suture is performed after an approximation of rectoprostatic fascia and the ileal sling. A 60mm/45mm stapler ileo-ileostomy is established. Two holding sutures are placed 10cm proximal from the urethroileal anastomosis, marking the deepest point of the pouch. The ileum is opened at the antimesenteric side over 40cm and the posterior wall is closed using 3-0 barbed running suture. Than, the distal ventral pouch is closed. The distal ureters were incised and a Wallace plate was formed. The ureters are stented through the abdominal wall and the chimney with Ch8 mono-J catheters. The ileo-ureteral anastomosis is performed with a 3-0 double arm running suture. The last anterior segment of the pouch is closed and than proved for water tightness. RESULTS Operative time (skin-skin) was 575(420-725) minutes, bleeding 600(200-1000)ml. 1 patient required invasive ventilaton more than 24h. Time to flatus was 2(1-5) days, to bowel movement 4(3-10) days. The in-hospital stay was 15(9-27) days. There were no reoperations within 30days and no 30d- mortality. There were no positive margins nor positive lymph nodes in 22(15-43) removed nodes. The indwelling catheters remained 26(17-40) days, all pouches voided subsequently without residual urine. CONCLUSIONS Robotic intracorporeal urinary diversion with a modified orthotopic Studer neobladder is a technically demanding procedure. With a standardized setting, the procedure is feasable in experienced robotic teams with promising intraoperativ and early postoperative results. Still, long termin pouch function, metabolism and oncological follow-up have to be observed critically. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1373 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Hubert John More articles by this author Christian Padevit More articles by this author Kevin Horton More articles by this author Abolfazl Hosseini More articles by this author Peter Wiklund More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Intracorporeal Continent Cutaneous Diversion

Robotic intracorporeal urinary diversion has mostly been done for ileal conduit or orthotopic neobladder diversion. We present what is to our knowledge the initial series, detailed technique and outcomes of the robotic intracorporeal Indiana pouch with a minimum 1-year followup. Ten patients underwent robotic radical cystectomy, pelvic lymphadenectomy and intracorporeal Indiana pouch urinary diversion for cancer in 9 and benign disease in 1. Data were collected prospectively. Baseline demographics, pathology data, and 1-year complication rates and functional outcomes were assessed. All 10 cases were successfully completed intracorporeally without open conversion. Median total operative time was 6 hours, including 3.5 hours for pouch creation. Median blood loss was 200 cc and median hospital stay was 10 days. Four Clavien grade 1-2 and 3 Clavien 3-5 complications occurred. None of the patients had a bowel leak. One noncompliant patient requested undiversion to an ileal conduit. The remaining 9 patients successfully catheterized the ileal channel and were completely continent at the last followup at a median of 13.7 months (range 12.3 to 15.2). Study limitations include small sample size and short followup. We present what is to our knowledge the initial series of robotic completely intracorporeal Indiana pouch diversion. Early perioperative data indicate acceptable operative efficiency and complication rates. Longer followup is required to assess the functional outcomes of this less commonly performed diversion.

Natural History, Predictors and Management of Ureteroenteric Strictures after Robot Assisted Radical Cystectomy

Ureteroenteric strictures represent the most common complication requiring reoperation after radical cystectomy. We investigated the prevalence, outcomes, predictors and management of ureteroenteric strictures. We retrospectively reviewed our quality assurance, robot assisted radical cystectomy database to identify patients in whom ureteroenteric strictures developed. Data were reviewed for demographics, perioperative outcomes and ureteroenteric stricture characteristics. The Kaplan-Meier method was used to calculate time to ureteroenteric stricture and multivariable stepwise regression was done to evaluate predictors of ureteroenteric strictures. Ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1,3 and 5 years after robot assisted radical cystectomy, respectively. All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in 6 and robot assisted repair in 16. At a median followup of 23 months 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and 5 after open revision. Open and robot assisted revisions showed comparable perioperative outcomes. On multivariable analysis the predictors of ureteroenteric anastomotic strictures were body mass index (OR 1.07, 95% CI 1.01-1.13, p = 0.02), intracorporeal urinary diversion (OR 3.28, 95% CI1.41-7.61, p = 0.006), length of the right resected ureter (OR 0.66, 95% CI 0.50-0.88, p = 0.004), estimated glomerular filtration rate 30 days after assisted radical cystectomy (OR 0.85, 95% CI 0.74-0.98, p = 0.03), urinary tract infection (OR 2.68, 95% CI 1.31-5.49, p = 0.007) and leakage (OR 3.85, 95% CI 1.05-14.1, p = 0.04). Male gender (OR 0.19, 95% CI 0.04-0.96, p = 0.04) and higher body mass index (OR 0.85, 95% CI 0.72-0.996, p = 0.05) were associated with lower odds of successful endoscopic management. Multiple modifiable factors were associated with ureteroenteric anastomotic strictures following robot assisted radical cystectomy. Surgical revision can provide a definitive management with comparable outcomes for open and robotic repairs.