Robot-assisted intracorporeal pyramid neobladder Wei Shen Tan, Ashwin Sridhar, Miles Goldstraw, Evangelos Zacharakis, Senthil Nathan, John Hines, Paul Cathcart, Tim Briggs and John D. Kelly Department of Urology and Division of Surgery and Interventional Science, University College London Hospital, London, UK
Objective To describe a robot-assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.
Patients and Methods In all, 20 patients (19 male and one female) with a mean (SD; range) age of 57.2 (12.4; 31.0–78.2) years underwent robotassisted radical cystectomy (RARC). Most cases were ≤pT1 (17 patients) and the remaining three patients had muscleinvasive bladder cancer (MIBC) at RARC histopathology. Although half of the patients (10) actually had MIBC at transurethral resection histopathology. All patients underwent RARC, bilateral pelvic lymphadenectomy, and intracorporeal neobladder formation using a pyramid detubularised folding pouch configuration.
Results The median estimated blood loss was 250 mL and operating time was 5.5 h. The mean (SD) number of lymph nodes removed was 16.5 (7.8) and median hospital stay was
Introduction Continent urinary diversion is an attractive option offered to patients who are suitable for bladder reconstruction after radical cystectomy (RC). Orthotopic neobladder performed using an intracorporeal approach is an evolving technique made possible by robotic surgery. Despite reports of robotassisted RC (RARC) more than a decade ago, experience of intracorporeal neobladder remains limited. Analysis of 18 centres contributing towards the International Robotic Consortium registry shows that 935 RARCs were performed between 2003 and 2011; neobladder were constructed in 198 (27.7%) and of these, 61 were intracorporeal representing 6.5% of the total cases [1]. To date, four centres have published their technique and outcomes for intracorporeal neobladder [2–5]. In all, ureteroileal anastomosis is described as refluxing, and three of four
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13189 Published by John Wiley & Sons Ltd. www.bjui.org
10 days. Early postoperative complications included urinary tract infection (UTI) (four patients), ileus (four), diarrhoea and vomiting (three), postoperative collection (two), and blocked stent (one). Late postoperative complications included UTI (seven patients), neobladder stone (two), voiding Hem-o-Loc (two), neobladder leak (two), diarrhoea and vomiting (one), uretero-ileal stricture (one), vitamin B12 deficiency (one), and port-site hernia (one). There was no evidence of hydronephrosis in 18 patients with a median follow-up of 21.5 months. At 24 months, recurrence-free survival was 86% and overall survival was 100%. In all, 19 patients and 13 patients reported 6-month day time and night time continence, respectively.
Conclusions The pyramid neobladder is technically feasible using a robotic platform and provides satisfactory functional outcomes at median of 21.5 months.
Keywords bladder cancer, cystectomy, intracorporeal, neobladder, robotassisted, urinary diversion
use an afferent limb [2–4], while one describes of a direct implant on to the neobladder [5]. The neobladder reconstruction technique is described as a detubularised cross-folded construction to form a low-pressure storage system in all [2–4], but one case uses a detubularised non-cross-folded neobladder without an afferent limb [5]. We describe the intracorporeal pyramid neobladder technique, which was adapted from Koie et al. [6], in our initial experience of 20 patients with a median follow-up of 21.5 months. The technique was developed in an effort to simplify existing intracorporeal neobladder reconstruction and uses a detubularised cross-folded 50-cm segment of terminal ileum. As with other techniques, the first step is urethro-ileal anastomosis formation following which, the patient is placed from steep Trendelenburg to a near horizontal position for completion [2]. The technique also incorporates a direct ureter to neobladder implant using a Bricker anastomosis,
BJU Int 2015; 116: 771–779 wileyonlinelibrary.com
Tan et al.
which has been described in open bladder reconstruction with good functional outcomes [6,7]. Compared with other reported intracorporeal techniques, we think the reconstruction using stay sutures to cross fold the detubularised ileal segments simplifies the technique resulting in a short completion time and a shorter learning curve, while protecting the upper tracts, although this will need to be tested in future comparative studies.
Fig. 1 Port placement.
12 mm camera port 8 mm robotic port 12 mm assistant ports 5 mm port Umbilicus
Patients and Methods Between July 2011 and March 2014, 20 patients (19 male and 1 female) underwent RARC with extended pelvic lymph node dissection and intracorporeal neobladder formation. The indication and patient selection for intracorporeal neobladder are identical to open surgery. Relative contraindication to RARC was difficult access to peritoneal cavity due to previous complex abdominal surgery. Patients with disease within the distal prostatic urethra, serum creatinine of >150 lmol/L or an estimated GFR (eGFR) of
Objective To describe a robot-assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.
Patients and Methods In all, 20 patients (19 male and one female) with a mean (SD; range) age of 57.2 (12.4; 31.0–78.2) years underwent robotassisted radical cystectomy (RARC). Most cases were ≤pT1 (17 patients) and the remaining three patients had muscleinvasive bladder cancer (MIBC) at RARC histopathology. Although half of the patients (10) actually had MIBC at transurethral resection histopathology. All patients underwent RARC, bilateral pelvic lymphadenectomy, and intracorporeal neobladder formation using a pyramid detubularised folding pouch configuration.
Results The median estimated blood loss was 250 mL and operating time was 5.5 h. The mean (SD) number of lymph nodes removed was 16.5 (7.8) and median hospital stay was
Introduction Continent urinary diversion is an attractive option offered to patients who are suitable for bladder reconstruction after radical cystectomy (RC). Orthotopic neobladder performed using an intracorporeal approach is an evolving technique made possible by robotic surgery. Despite reports of robotassisted RC (RARC) more than a decade ago, experience of intracorporeal neobladder remains limited. Analysis of 18 centres contributing towards the International Robotic Consortium registry shows that 935 RARCs were performed between 2003 and 2011; neobladder were constructed in 198 (27.7%) and of these, 61 were intracorporeal representing 6.5% of the total cases [1]. To date, four centres have published their technique and outcomes for intracorporeal neobladder [2–5]. In all, ureteroileal anastomosis is described as refluxing, and three of four
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13189 Published by John Wiley & Sons Ltd. www.bjui.org
10 days. Early postoperative complications included urinary tract infection (UTI) (four patients), ileus (four), diarrhoea and vomiting (three), postoperative collection (two), and blocked stent (one). Late postoperative complications included UTI (seven patients), neobladder stone (two), voiding Hem-o-Loc (two), neobladder leak (two), diarrhoea and vomiting (one), uretero-ileal stricture (one), vitamin B12 deficiency (one), and port-site hernia (one). There was no evidence of hydronephrosis in 18 patients with a median follow-up of 21.5 months. At 24 months, recurrence-free survival was 86% and overall survival was 100%. In all, 19 patients and 13 patients reported 6-month day time and night time continence, respectively.
Conclusions The pyramid neobladder is technically feasible using a robotic platform and provides satisfactory functional outcomes at median of 21.5 months.
Keywords bladder cancer, cystectomy, intracorporeal, neobladder, robotassisted, urinary diversion
use an afferent limb [2–4], while one describes of a direct implant on to the neobladder [5]. The neobladder reconstruction technique is described as a detubularised cross-folded construction to form a low-pressure storage system in all [2–4], but one case uses a detubularised non-cross-folded neobladder without an afferent limb [5]. We describe the intracorporeal pyramid neobladder technique, which was adapted from Koie et al. [6], in our initial experience of 20 patients with a median follow-up of 21.5 months. The technique was developed in an effort to simplify existing intracorporeal neobladder reconstruction and uses a detubularised cross-folded 50-cm segment of terminal ileum. As with other techniques, the first step is urethro-ileal anastomosis formation following which, the patient is placed from steep Trendelenburg to a near horizontal position for completion [2]. The technique also incorporates a direct ureter to neobladder implant using a Bricker anastomosis,
BJU Int 2015; 116: 771–779 wileyonlinelibrary.com
Tan et al.
which has been described in open bladder reconstruction with good functional outcomes [6,7]. Compared with other reported intracorporeal techniques, we think the reconstruction using stay sutures to cross fold the detubularised ileal segments simplifies the technique resulting in a short completion time and a shorter learning curve, while protecting the upper tracts, although this will need to be tested in future comparative studies.
Fig. 1 Port placement.
12 mm camera port 8 mm robotic port 12 mm assistant ports 5 mm port Umbilicus
Patients and Methods Between July 2011 and March 2014, 20 patients (19 male and 1 female) underwent RARC with extended pelvic lymph node dissection and intracorporeal neobladder formation. The indication and patient selection for intracorporeal neobladder are identical to open surgery. Relative contraindication to RARC was difficult access to peritoneal cavity due to previous complex abdominal surgery. Patients with disease within the distal prostatic urethra, serum creatinine of >150 lmol/L or an estimated GFR (eGFR) of
