Intracorporeal Ileal Conduit Urinary Diversion Research Articles

Robot-assisted intracorporeal ileal conduit urinary diversion: A two-center comparative study of Bricker versus Wallace ureteroileal anastomosis.

This study was performed to evaluate the differences in the perioperative results, renal function, and incidence of hydronephrosis over time between the use of Bricker anastomosis and Wallace anastomosis for robot-assisted intracorporeal ileal conduit urinary diversion (RICIC). Fifty-five patients who underwent RICIC at two institutions were evaluated (Bricker, n = 23; Wallace, n = 32). We investigated changes in estimated glomerular filtration rate and hydronephrosis before surgery and at 3, 6, and 12 months after surgery. The patients in the Bricker group were significantly older than those in the Wallace group. The urinary diversion time was significantly longer in the Bricker group. No significant difference in postoperative renal function was observed. Additionally, no significant difference was observed in the incidence of postoperative hydronephrosis. However, the incidence of right hydronephrosis tended to be high overall, especially in the Wallace group. No patients in either group required repair surgery or ureteral stent placement. In patients undergoing RICIC, there was no difference in postoperative renal function or the incidence of hydronephrosis between Wallace and Bricker anastomosis. Symptomatic hydronephrosis was not observed in either group. The present study showed that each method was equally effective and safe.

Comparative study between the use of double J ureteric stents vs bander ureteric stents during robotic-assisted radical cystectomy with intra corporeal ileal conduit urinary diversion.

Robotic-assisted radical cystectomy (RARC) is fast becoming the standard of care with comparable oncological outcomes to open surgery for patients with muscle-invasive bladder cancer. Ileal conduit is by far the most popular means of urinary diversion following a cystectomy. Use of stents is common practice to reduce uretero-enteric anastomosis-related complications. In the current study, practice was changed from the use of Double J (DJ) stents to bander stent intraoperatively. The potential advantages of using bander stent are avoiding second surgery for stent removal and easier change under local anaesthetic in the interventional radiology department. To compare the incidence of blocked, slipped stents and rate of ureteroileal anastomotic stricture after RARC with intracorporeal ileal conduit between practices of using DJ stents and bander stents. Retrospective analysis of all the patients undergoing Robotic radical cystectomy and intracorporeal ileal conduit between June 2014 and August 2023 was done. Initially, all intracorporeal anastomosis were covered with DJ stents. The practice was changed to cover the anastomosis with bander stent in November 2020. Number of patients needing re-surgery for blocked, slipped stents and ureteroileal anastomotic stricture were analyzed and compared using Chi-square analysis and Fisher's exact test (P < 0.05). A total of 168 patients underwent RARC with intracorporeal ileal conduit between June 2014 and August 2023 of which 128 patents were diverted with DJ stents and 40 with bander stent. The mean age and the patient demographics between the two groups were comparable. Of the 128 patients who were diverted with DJ stents, 6 (4.7%) had blocked stents, 3 (2.3%) had slipped stents, and 3 (2.3%) developed ureteroileal stricture needing readmission and urgent invasive intervention to exchange the stent or nephrostomy tube, whereas only 1 (2.5%) of the 40 patients with bander stent had blocked stent which was changed under local anaesthetic in the interventional radiology suite with no slipped stents reported and 2 (5%) had ureteroileal stricture who needed nephrostomies. Intraoperative ureteric stenting using bander stent has the potential to reduce the incidence of stent-related complications, such as blockage, slippage, and ureteroileal anastomotic stricture, following RARC with intracorporeal ileal conduit urinary diversion. Additionally, managing bander stent-related complications is less invasive with lower rate of readmission postoperatively compared to managing DJ stent-related ones.

Contemporary outcomes of patients undergoing robotic-assisted radical cystectomy: A comparative analysis between intracorporeal ileal conduit and neobladder urinary diversions

ObjectiveWe aimed to compare perioperative and oncologic outcomes for patients undergoing robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IC) and neobladder (NB) urinary diversion. MethodsPatients undergoing RARC with intracorporeal urinary diversion between January 2017 and January 2022 at the Icahn School of Medicine at Mount Sinai, New York, NY, USA were indexed. Baseline demographics, clinical characteristics, perioperative, and oncologic outcomes were analyzed. Survival was estimated with Kaplan-Meier plots. ResultsOf 261 patients (206 [78.9%] male), 190 (72.8%) received IC while 71 (27.2%) received NB diversion. Median age was greater in the IC group (71 [interquartile range, IQR 65–78] years vs. 64 [IQR 59–67] years, p<0.001) and BMI was 26.6 (IQR 23.2–30.4) kg/m2. IC group was more likely to have prior abdominal or pelvic radiation (15.8% vs. 2.8%, p=0.014). American Association of Anesthesiologists scores were comparable between groups. The IC group had a higher proportion of patients with pathological tumor stage 2 (pT2) tumors (34 [17.9%] vs. 10 [14.1%], p=0.008) and pathological node stages pN2–N3 (28 [14.7%] vs. 3 [4.2%], p<0.001). The IC group had less median operative time (272 [IQR 246–306] min vs. 341 [IQR 303–378] min, p<0.001) and estimated blood loss (250 [150–500] mL vs. 325 [200–575] mL, p=0.002). Thirty- and 90-day complication rates were 44.4% and 50.2%, respectively, and comparable between groups. Clavien-Dindo grades 3–5 complications occurred in 27 (10.3%) and 34 (13.0%) patients within 30 and 90 days, respectively, with comparable rates between groups. Median follow-up was 324 (IQR 167–552) days, and comparable between groups. Kaplan-Meier estimate for overall survival at 24 months was 89% for the IC cohort and 93% for the NB cohort (hazard ratio 1.23, 95% confidence interval 1.05–2.42, p=0.02). Kaplan-Meier estimate for recurrence-free survival at 24 months was 74% for IC and 87% for NB (hazard ratio 1.81, 95% confidence interval 0.82–4.04, p=0.10). ConclusionPatients undergoing intracorporeal IC urinary diversion had higher postoperative cancer stage, increased nodal involvement, similar complications outcomes, decreased overall survival, and similar recurrence-free survival compared to patients undergoing RARC with intracorporeal NB urinary diversion.

Comparing different pneumoperitoneum (12 vs. 15 mmHg) pressures with cytokine analysis to evaluate clinical outcomes in patients undergoing robotic-assisted laparoscopic radical cystectomy and intracorporeal robotic urinary diversion.

Robotic cystectomy is the mainstay surgical intervention for treatment-refractory nonmuscle-invasive and muscle-invasive bladder cancer. However, paralytic ileus may complicate the postoperative recovery and may be a consequence of an inflammatory response associated with transient gut ischaemia. We have therefore investigated clinical, operative and inflammatory biomarker associations between paralytic ileus in the context of robotic cystectomy and intracorporeal ileal conduit urinary diversion. Prospective consective patients referred for robotic cystectomy were consented and included in the study, while patients >75 years old and converted to open procedure were excluded. The pneumoperitoneum pressure (PP) for carbon dioxide insufflation required to perform the procedure efficiently and safely was recorded (12 or 15 mmHg). We also recorded the postoperative days patients passed flatus and stools, whether they developed ileus, as well as other standard clinical and demographic data. The expression of select proinflammatory and anti-inflammatory cytokines was determined by multiplex analysis using a cytometric bead array with changes in profiles correlated with the pressures applied and with the existence of an ileus. Twenty-seven patients were recruited, but only 20 were used in the study with 10 patients in each PP group. Seven patients were excluded all of whom had an extracorporeal ileal conduit formation. There were differences in the 40-min shorter operative time and 1day shorter length of stay, as well as passing flatus 1day and stools 1.5days earlier in the 12 mmHg compared with the 15 mmHg group. More patients had ileus in the 15 mmHg group vs 12 mmHg group (30% vs. 10.0%). These were not statistically significant. Similarly, there were no statistical differences in the expression of proinflammatory cytokines at the two different pressures or between patient groups, but there were outliers, with the median indicating nonsymmetrical distribution. By comparison, anti-inflammatory cytokines showed some significant differences between groups, with IL-6 and IL-10 showing elevated levels postsurgery. No statistical difference was observed between pressures or the existence of an ileus, but the maximum levels of IL-6 and IL-10 detected in some patients reflect a pressure difference. The initial findings of this novel scientific study indicated a higher risk of paralytic ileus postrobotic cystectomy and robotic intracorporeal urinary diversion when a higher pressure of 15 mmHg is used compared with 12 mmHg. Although further studies are required to establish the linkage between cytokine profile expression, pressure and ileus, our initial data reinforces the advantages of lower pressure robotic cystectomy and intracorporeal urinary diversion in patient outcomes.

Robotic Cystectomy with Intracorporeal Urinary Diversion is Associated with Decreased Narcotic Consumption

Introduction: Improvements in robotic technology and surgeon experience have made intracorporeal ileal conduit urinary diversion (ICUD) following robot-assisted radical cystectomy (RARC) a reality. Thus, it is essential to understand the benefits and drawbacks to this technically challenging approach. This study investigates surgical and pain-related perioperative outcomes in patients who underwent ICUD compared to extracorporeal urinary diversion (ECUD) at a tertiary care center. Methods: We reviewed a prospectively maintained database of 198 patients who underwent robot-assisted radical cystectomy between January 2015 and October 2020. Surgical, functional, and pain-related perioperative outcomes were compared between 177 patients who received either ICUD or ECUD. Results and Conclusion: Among 177 patients, 107 (60.4%) patients underwent ECUD and 70 (39.6%) underwent ICUD. Patients who received ICUD had significantly lower narcotic consumption (P=.031). There were no significant differences across cohorts in operative time (P=.10), estimated blood loss (P=.958), blood transfusion rate (P=.267), overall survival (P=.485), LOS (P=.652), or 30-day readmissions (P=.080). Our study suggests that RARC with intracorporeal ileal conduit reduces post-operative narcotic use as compared to extracorporeal diversion. Further validation across multiple institutions will be required to elucidate the full advantage and/or disadvantage to this approach.

V09-04 URETERAL STRICTURE PREVENTION THROUGH A MULTI-MODAL INTERVENTION FOR ROBOTIC INTRACORPOREAL ILEAL CONDUIT URINARY DIVERSION

You have accessJournal of UrologyCME1 May 2022V09-04 URETERAL STRICTURE PREVENTION THROUGH A MULTI-MODAL INTERVENTION FOR ROBOTIC INTRACORPOREAL ILEAL CONDUIT URINARY DIVERSION Shu Wang, Ryan Russell, Michael Phelan, and M. Minhaj Siddiqui Shu WangShu Wang More articles by this author , Ryan RussellRyan Russell More articles by this author , Michael PhelanMichael Phelan More articles by this author , and M. Minhaj SiddiquiM. Minhaj Siddiqui More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002617.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An important complication of radical cystectomy and urinary diversion is benign uretero-enteric anastomosis (UEA) stricture, with reported rates of around 15-20%. In this study, we reported the impact on UEA stricture formation from the introduction of a multi-modal surgical technique combining the use of fluoroscence imaging visualization of ureteral blood flow, a wound-healing promoting wrap of decellularized umbilical tissue, and a retro-sigmoidal ileal conduit reconstruction to alleviate left ureteral tension. METHODS: We retrospectively reviewed patients with bladder cancer undergoing robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit in our center by the same urologist (MMS) from December 2015 to June 2020. Patients were divided into two groups based on the ileal conduit reconstruction (multi-modal retro-sigmoidal conduit or standard conduit with optional use of fluoroscence imaging/wound-healing promoting wrap). Patients demographics, postoperative complications and UEA status were collected and compared between groups. KM curves were used to evaluate the UEA stricture between groups. RESULTS: 52 patients received RARC and intracorporeal ileal conduit and 45 had been followed up, with 25 in the standard group and 20 in the retro-sigmoidal group. Most variables were comparable between groups. With a median follow-up time of 19 months (IQR 6-36) in standard group vs 8 months (IQR 4.75-11.5) in retro-sigmoidal group, the global UEA stricture rates were 34.8% vs 0% in the retro-sigmoidal group (p=0.009, Figure 1). The left UEA stricture rate was 24% in standard group and the right UEA stricture rate was 16% in standard. Among the 10 benign UEA strictures (per ureter), the median time of stricture formation was 6months (IQR 3-8.5). The postoperative 30-day, 90-day complication rate, and 30-day readmission rate were comparable between groups. CONCLUSIONS: The use of this multi-modal retro-sigmoidal ileal conduit technique in RARC may reduce the UEA stricture rate. Further studies with larger cohorts are needed to validate this finding as well as help elucidate if some components of the multi-modal intervention are most important. Source of Funding: None. © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e805 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shu Wang More articles by this author Ryan Russell More articles by this author Michael Phelan More articles by this author M. Minhaj Siddiqui More articles by this author Expand All Advertisement PDF DownloadLoading ...

The impact of low-pressure pneumoperitoneum on robotic-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion: a case-control study.

PurposeTo evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD).MethodsA retrospective case–control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system.ResultsDemographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar.ConclusionWith limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum.

Evaluation of Functional Outcomes and Quality of Life in Elderly Patients (>75 y.o.) Undergoing Minimally Invasive Radical Cystectomy with Single Stoma Ureterocutaneostomy vs. Bricker Intracorporeal Ileal Conduit Urinary Diversion.

Background: Diversion after radical cystectomy (RC) is crucial when considering elderly subjects. Data on the quality of life (QoL) impact with different diversions is scarce. This study aims to compare complications and QoL in patients aged > 75 y.o., who underwent minimally invasive (MI) RC with Bricker intracorporeal urinary derivation and single stoma ureterocutaneostomy. Methods: We conducted a retrospective analysis of elderly patients who underwent MIRC and intracorporeal diversion. The 78 subjects were divided into two groups: group A, ileal conduit, and group B, single stoma ureterocutaneostomy. We evaluated the bowel’s recovery time and complications rate. We investigated QoL 3 and 6 months after surgery using the Stoma-QoL questionnaire. Results: Mean age was 77.2 in group A and 82.4 in group B. The mean ASA score and Charlson Comorbidity index were comparable between the two groups. Rates of complications were 57.6% and 37.4% in groups A and B, respectively. The mean postoperative Stoma-QoL score 3 months after surgery was 52.2 and 52.4 in groups A and B, respectively. At 6 months of follow-up the Stoma QoL mean score was 63.4, showing homogeneity between the groups. Conclusion: MIRC with single stoma ureterocutaneostomy represents an alternative to ileal conduit, with comparable QoL and ostomy management 6 months after surgery, reporting fewer complications.

Management Trends and Outcomes of Patients Undergoing Radical Cystectomy for Urothelial Carcinoma of the Bladder: Evolution of the University of Southern California Experience over 3,347 Cases.

There are conflicting reports on outcome trends following radical cystectomy (RC) for bladder cancer. Evolution of modern bladder cancer management and its impact on outcomes was analyzed using a longitudinal cohort of 3,347 patients who underwent RC at an academic center between 1971 and 2018. Outcomes included recurrence-free survival (RFS) and overall survival (OS). Associations were assessed using univariable and multivariable models. In all, 70.9% of cases underwent open RC in the last decade, although trend for robot-assisted RC rose since 2009. While lymphadenectomy template remained consistent, nodal submission changed to anatomical packets in 2002 with increase in yield (p <0.001). Neoadjuvant chemotherapy (NAC) use increased with time with concomitant decrease in adjuvant chemotherapy; this was notable in the last decade (p <0.001) and coincided with improved pT0N0M0 rate (p=0.013). Median 5-year RFS and OS probabilities were 65% and 55%, respectively. Advanced stage, NAC, delay to RC, lymphovascular invasion and positive margins were associated with worse RFS (all, multivariable p <0.001). RFS remained stable over time (p=0.73) but OS improved (5-year probability, 1990-1999 51%, 2010-2018 62%; p=0.019). Among patients with extravesical and/or node-positive disease, those who received NAC had worse outcomes than those who directly underwent RC (p ≤0.001). Despite perioperative and surgical advances, and improved pT0N0M0 rates, there has been no overall change in RFS trend following RC, although OS rates have improved. While patients who are downstaged with NAC derive great benefit, our real-world experience highlights the importance of preemptively identifying NAC nonresponders who may have worse post-RC outcomes.

Simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion: step-by-step video-illustrated technique

ABSTRACTIntroduction:One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract urothelial cancer (UTUC) is exceptional. Minimally invasive approach for these synchronous tumors was just occasionally reported (1-4). The aim of this video article is to describe step-by-step the technique for simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion (ICUD). Patients and methods: A 66-year-old female presented with synchronous BCG refractory non-muscle invasive bladder cancer and a right-side UTUC. She was a former smoker and had previously been submitted to multiple transurethral resections of bladder tumor, BCG and right distal ureterectomy with ureteral reimplant. We performed a simultaneous laparoscopic right nephroureterectomy and robot-assisted anterior pelvic exenteration with totally intracorporeal ICUD. Combination of robot-assisted and pure laparoscopic approaches was proposed focusing on optimization of total operative time (TOT).Results:Surgery was uneventful. TOT was of 330 minutes. Operative time for nephroureterectomy, anterior pelvic exenteration and ICUD were 48, 135, 87 minutes, respectively. Estimated blood loss was 150mL. Postoperative course was unremarkable and patient was discharged after 7 days.Histopathological evaluation showed a pT1 high grade urothelial carcinoma plus carcinoma in situ both in proximal right ureter and bladder, with negative margins. Twelve lymph nodes were excised, all of them negative.Conclusion:In our preliminary experience, totally minimally invasive simultaneous nephroureterectomy and cystectomy with intracorporeal ICUD is feasible. Pure laparoscopic approach to upper urinary tract may be a useful tactic to reduce total operative time.

IJU this issue

In this issue, one Review Article, seven Original Articles, two Urological Notes and nine Editorial Comments (total 19 manuscripts) are published. Shigemura and Fujisawa (Hyogo, Japan) reviewed the prevention and management of infectious complications in prostate biopsy. Miyamoto et al. (Nara, Japan) reported on the clinical outcomes after intravesical bacillus Calmette–Guérin for the highest-risk non-muscle-invasive bladder cancer newly defined in the Japanese Urological Association Guidelines 2019. Tabei et al. (Kanagawa, Japan) investigated the efficacy of re-do urethroplasty for post-traumatic urethral stricture in terms of anatomical and functional outcomes to show a high success rate and beneficial effects on both anatomical and functional outcomes. Taoka et al. (Kagawa, Japan) showed the therapeutic benefits of a surgical checklist in improving the quality of resection during transurethral resection and reducing the recurrence rate in patients with non-muscle-invasive bladder cancer. Hata et al. (Fukushima, Japan) identified the preoperative low bladder contractile index as the predictor of postoperative detrusor underactivity during the early postoperative period after robot-assisted radical prostatectomy. Shin and Mimata (Oita, Japan) described the “early pull-out” technique for intracorporeal ileal conduit urinary diversion after robot-assisted radical cystectomy. Aizawa et al. (Kyoto, Japan) reported that prostate-targeted treatment plus metastasis-directed therapy through external beam radiation therapy can result in favorable long-term disease-free and survival outcomes with acceptable morbidities among synchronous oligometastatic prostate cancer patients. Iguchi et al. (Osaka, Japan) reported that enzalutamide plus androgen deprivation therapy has clinical benefit with a tolerable safety profile in Japanese men with metastatic hormone-sensitive prostate cancer, consistent with the overall population. Yamashita et al. (Wakayama, Japan) evaluated the prognostic impact of sarcopenia and myosteatosis on survival after radical cystectomy for bladder cancer. Unfortunately, the limited space does not allow me to introduce all the papers. However, all the articles in this issue are very informative and interesting, so please enjoy it by all means. None declared.

The patient-side surgeon plays a key role in facilitating robot-assisted intracorporeal ileal conduit urinary diversion in men

The influence of the console surgeon on the feasibility and outcome of various robot-assisted surgeries has been evaluated. These variables may be partially affected by the skills of the patient-side surgeon (PSS), but this has not been evaluated using objective data. This study aimed to describe the surgical techniques of the PSS in robot-assisted radical cystectomy (RARC) and intracorporeal ileal conduit (ICIC) urinary diversion and objectively examine the changes in surgical outcomes with increasing PSS experience. During a 3-year period, 28 men underwent RARC and ICIC urinary diversion. Clinical characteristics and surgical outcomes were compared between patients who underwent surgery early (first half group) or late in the study period (second half group). The pre-docking incision enabled easy specimen removal. The glove port technique widened the working space of the PSS. The stay suture allowed the PSS to control the distal portion of the conduit, facilitating the passage of the ureteral stents. During stoma creation, pneumoperitoneum pressure was lost by opening the abdominal cavity. To overcome this problem, the robotic arm was used to lift the abdominal wall to maintain the surgical field and facilitate the PSS procedure. Compared with the first half group, the second half group had significantly shorter times for urinary diversion (202 min vs 148 min, p < 0.001), ileal isolation and anastomosis (73 min vs 45 min, p < 0.001), and stenting (23.0 min vs 6.5 min, p < 0.001). As the experience of the PSS increased, the time of the PSS procedures decreased.

"Early-pull-out" technique for intracorporeal ileal conduit urinary diversion after robot-assisted radical cystectomy.

"Early-pull-out" technique for intracorporeal ileal conduit urinary diversion after robot-assisted radical cystectomy.

Robotic Radical Cystectomy, Pelvic Lymph Node Dissection, and Intracorporeal Ileal Conduit Urinary Diversion.

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower surgical blood loss, its potential association with shorter hospital stay after surgery. These factors suggest that the robotic approach to radical cystectomy may be an important component of enhanced recovery programs aimed at reducing surgical morbidity. This paper describes the importance of the cranial placement of robotic trocars, the use of Cadiere forceps for atraumatic bowel grasping, pelvic lymph node dissection (PLND), and utero-enteric anastomoses. Also discussed are steps that are critical for the successful outcome of RARC. In spite of the increased operating times and associated costs and the costs of robotic surgical platforms and equipment, adoption of the robotic technique by bladder cancer surgeons has increased. This paper describes a systematic and reproducible method that details robotic extended pelvic lymph node dissection, cystectomy/cystoprostatectomy, and intracorporeal ileal conduit urinary diversion.

Female Distal Urethral Primary Urothelial Carcinoma: Rare Entity and Management

Urethral malignancies as such are rare among urological cancers. Female distal urethral cancers are predominantly squamous cell carcinoma. Urothelial cancer mainly arises from proximal urethra and is associated with carcinoma of upper tract. A 63-year-old lady presented with hematuria and voiding lower urinary tract symptoms. On pelvic examination, ~ 3-cm hard mass was palpable in distal urethra involving anterior vaginal wall. Biopsy revealed transitional cell carcinoma. Metastatic workup was negative. Patient underwent robot-assisted laparoscopic radical cystourethrectomy (anterior exenteration) with bilateral standard pelvic LN dissection and intracorporeal ileal conduit urinary diversion. Postoperative course was uneventful. Histopathology of the specimen revealed high-grade urothelial cancer of distal urethra (pT3N0M0). At 3 months, patient presented with a solitary right inguinal lymph node, reported as malignant on fine needle aspiration cytology. Patient received 6 cycles of adjuvant chemotherapy and radiotherapy to groin and presently well at 2-year follow-up without recurrence. Distal urethral cancer is rarely of urothelial origin. These are aggressive tumors, and adequate treatment and follow-up is required for better oncological outcome.

Perioperative and oncological outcomes of laparoscopic radical cystectomy with intracorporeal versus extracorporeal ileal conduit: A matched-pair comparison in a multicenter cohort in Japan.

To compare the perioperative and oncological outcomes of pure laparoscopic intracorporeal ileal conduit urinary diversion versus extracorporeal ileal conduit urinary diversion after laparoscopic radical cystectomy for bladder cancer in a multicenter cohort in Japan. A total of 455 patients who underwent laparoscopic radical cystectomy carried out at 10 institutions were included in this retrospective study. The perioperative data of the intracorporeal ileal conduit urinary diversion and extracorporeal ileal conduit urinary diversion groups were compared using the propensity score matching method. The Kaplan-Meier curves were obtained to elucidate time to ureteroenteric stricture, reoperation, recurrence and survival. In total, 72 matched pairs were evaluated for the final analysis. The median follow-up period was 28 and 23months in the intracorporeal ileal conduit urinary diversion and extracorporeal ileal conduit urinary diversion groups, respectively. The operative time in the intracorporeal ileal conduit urinary diversion group was approximately 1h longer than that in the extracorporeal ileal conduit urinary diversion group. The early and late postoperative complication rates were similar in both groups, except for the reduced wound-related complication rates in the intracorporeal ileal conduit urinary diversion group. The median days to regular oral food intake were 4 and 5days in the intracorporeal ileal conduit urinary diversion and extracorporeal ileal conduit urinary diversion groups, respectively (P=0.014). No significant difference was noted in the occurrence of ureteroenteric strictures and reoperation rate. Furthermore, recurrence-free, cancer-specific, and overall survival rates and recurrence patterns did not significantly differ. Laparoscopic intracorporeal ileal conduit urinary diversion is a safe, feasible and reproducible procedure with similar postoperative complication rates, ureteroenteric stricture rate and oncological outcomes when compared with extracorporeal ileal conduit urinary diversion, but faster postoperative bowel recovery and decreased wound-related complication rates.

Surgical outcomes and learning curve of totally intracorporeal ileal conduit urinary diversion following laparoscopic radical cystectomy at a single institution.

Constant evaluation of the outcomes of laparoscopic intracorporeal urinary diversion is not yet established. This study aimed to describe surgical outcomes and learning curve of intracorporeal ileal conduit (ICIC) following laparoscopic radical cystectomy (LRC) at a single institution. From June 2012 to February 2018, 38 patients with bladder cancer underwent LRC with ileal conduit at our institution. Surgical outcomes were compared between ICIC (n = 30) and extracorporeal ileal conduit (ECIC) (n = 8). The learning curve during ICIC with regard to the operative time and complication rate was compared. No significant differences in patient characteristics between the ICIC and ECIC groups were found. Comparison of outcomes between the ICIC and ECIC groups were as follows: median total operative time, 688 vs 713 minutes; urinary diversion time, 213 vs 192 minutes; and estimated blood loss, 450 vs 420 mL, respectively. The median time to walking and oral intake were similar in both groups. Rates of high-grade complications associated with urinary diversion (Clavien-Dindo grade ≥ III) were 3% in ICIC and 25% in ECIC. Although 25% of ECIC patients developed wound dehiscence (Clavien-Dindo grade IIIb), no patient in the ICIC group had postoperative wound infection. For the learning curve of ICIC (n = 30), urinary diversion time decreased significantly (27 minutes decrease per 10 cases, P = .02). Clavien-Dindo grade ≥ II complication did not occur after 20 cases. LRC with ICIC could be performed safely with low incidence of severe wound infection compared with ECIC. The incidence and severity of complications also decreased with time.

Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve.

Introduction:The objective of this study was to evaluate the perioperative outcomes of patients undergoing robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IIC) urinary diversion treated in line with the enhanced recovery after surgery (ERAS) protocol.Methods:After approval from the institutional ethics committee, we conducted an analysis of a prospectively maintained database of patients undergoing RARC + IIC using ERAS protocol by a single surgical team with the da Vinci Xi® system from March 2016 till December 2018. To minimize the effect of the learning curve of this complex procedure, we excluded the first thirty patients from analysis.Results:Thirty-five consecutive patients (33 males and 2 females) with a median age of 69 years (range: 50–82) were evaluated. The median total console time and console time for diversion were 253 min (range: 191–370) and 80 min (range: 65–90), respectively. The median estimated blood loss was 300 cc (range: 50–500). The median length of stay was 8 days (range: 4–30). Per-urethral pelvic drain was removed at a median of 2 days (range: 1–17). Overall, complications occurred in 16/35 (45.7%) patients, of which major complications (≥Grade 3) were seen in 5/35 (14.3%) patients, without any 90-day mortality. The median follow-up for the cohort was 14 months (1–34).Conclusions:While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is required from multi-institutional data sets and prospective comparative studies to establish the true value of RARC + IIC and ERAS protocol for bladder cancer.

A CASE OF ILEAL CONDUIT-ENTERIC FISTULA AFTER ROBOTIC INTRACORPOREAL ILEAL CONDUIT URINARY DIVERSION

The complications of ileal conduit urinary diversion were reported to be urinary tract infections, bowel obstruction, and delayed wound healing, but ileal conduit-enteric fistula is rare. We report a case of ileal conduit-enteric fistula after robotic intracorporeal ileal conduit urinary diversion. An 81-year-old man with muscle-invasive bladder cancer underwent robot-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion. Twenty-two days after the surgery, we identified the presence of fecaluria. Loopography revealed an ileal conduit-enteric fistula. He underwent conservative treatment with fasting and intravenous hyperalimentation. Loopography was performed 48 days after the surgery. However, the fistula remained. Therefore, fistula closure surgery was performed 51 days after the surgery. Here we review the characteristics of 4 ileal conduit-enteric fistula cases reported in Japan.

Single-port Robotic Intracorporeal Ileal Conduit Urinary Diversion During Radical Cystectomy Using the SP Surgical System: Step-by-step Technique

To describe the step-by-step technique for robotic intracorporeal ileal conduit urinary diversion (ICUD) following radical cystectomy performed by using the novel da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, CA). Four consecutive patients (2 males and 2 females) were initially counseled for robotic cystectomy with ICUD performed by using the da Vinci SP surgical system. Surgeries were performed by duplicating the steps of the institutional approach for intracorporeal ICUD performed with the multiarms robotic platform. Perioperative outcomes were analyzed. Data were collected under institutional review board approval (IRB 13-780). Single-port robot-assisted radical cystectomy with ICUD was successfully completed in 3 patients (2 males and 1 female). Mean robotic operative time for ICUD was 75 minutes (range 67-90). There was no conversion to standard multiarms robotic approach. One patient needed to be converted to extracorporeal urinary diversion due to severe adhesions of small bowels. No additional ports were placed. Neither transfusions nor intraoperative complications occurred. All patients were discharged on postoperative day 5. One patient reported self-limited nausea and vomiting after discharge (Clavien grade I). In our preliminary experience, ICUD after robot-assisted radical cystectomy is feasible using the da Vinci SP surgical system. Further comparative studies with open and multiarms robotic approaches are warranted.