Single-port robotic radical cystectomy with ileal conduit urinary diversion: technique and review of the early outcomes in literature

Patient positioning and port placement

After induction of general anesthesia, the patient is positioned in the standard positioning for robotic pelvic surgery, specifically the dorsal lithotomy position with arms tucked, extremities padded and secured, and the bed in steep Trendelenburg. After the patient is prepped and draped in the normal sterile fashion, a Foley catheter is placed. A 2.5 cm incision is then made inferolateral to the umbilicus, approximately ⅓ of the distance between the umbilicus and iliac crest, and the Hasson technique is used to dissect through layers of fascia to access the abdominal cavity. Of note, this incision is later used as our stoma site for ileal conduit creation. We then insert an Alexis retractor into this incision site and attach the GelPOINT advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) with the SP Cannula to the Alexis. The abdomen is then insufflated to 15 mmHg, and carefully surveyed to identify any abdominal adhesions. We then place 2 additional trocars under direct vision, specifically a 12 mm port (to which an AirSeal is attached) approximately ⅔ of the distance between the umbilicus and left iliac crest and a 5 mm assistant port halfway between the umbilicus and the 12 port. The SP robot is then side-docked.

General considerations

The SP RARC technique largely follows the standard multiport technique with RARC, with several key adjustments, notably the positioning of the robotic instruments. We begin with the monopolar scissors at the 3 o’clock position, Cardiere forceps at the 6 o’clock position, bipolar forceps at the 9 o’clock position, and the camera at the 12 o’clock position. Instruments are switched periodically to allow for optimal retraction depending on the specific step of the procedure performed.

Identification of the ureters

We locate the ureters bilaterally by incising the overlying peritoneum just lateral to the medial umbilical ligament and dissecting down to the level of the common iliac artery. The Cadiere forceps at 6 o’clock are useful for holding traction on the ureters and pushing the bowel medially during this dissection, which can be completed without the bedside assistant. Once the ureters are identified, they are placed on vessel loops and dissected down to the ureteropelvic junction, at which time they are clipped with two Hem-o-lock clips (Weck Closure Systems, Research Triangle Park, NC, USA) and divided.

Anterior and posterior bladder dissection

The LigaSure device is then used to divide the obliterated umbilical arteries bilaterally and the tissue lateral to the ureters. The bipolar forceps at 9 o’clock are used to lift the bladder, the Cardiere at 6 o’clock is used to provide downward traction on the bladder, and the monopolar scissors at 3 o’clock are used to open up the endopelvic fascia. The posterior peritoneum is then incised over the rectum, connecting the two entry points into the endopelvic fascia. The seminal vesicles are then identified and elevated, and the posterior plane between the rectum and bladder is bluntly dissected out. The LigaSure device is used to divide the superior vesical arteries bilaterally, taking care to stay below the seminal vesicles and ureteral stumps bilaterally. This dissection plane is taken all the way down to the prostate apex. We then divide the median and medial umbilical ligaments using the LigaSure device and drop the bladder into the pelvis. After the apex of the prostate is dissected, we switch our 3 o’clock and 9 o’clock instruments out for robotic needle drivers and oversew Santorini’s plexus using 2-0 V-Loc suture in a figure-of-eight fashion. We then replace our monopolar scissors at 3 o’clock and bipolar forceps at 9 o’clock and divide Santorini’s plexus. Next, we dissect out and free the urethra. The Foley catheter is clipped with a Weck clip to keep the balloon inflated to avoid spillage of bladder contents. The remaining lateral attachments of the prostate are then divided in a modified nerve-sparing fashion with bipolar cautery. Once the specimen is completely freed, it is placed in a 15 mm entrapment sac and set aside.

Pelvic lymphadenectomy

We then perform our bilateral pelvic lymphadenectomy, removing the external, obturator, internal, and common iliac lymph nodes bilaterally using Weck clips and bipolar cautery for lymphostasis. We periodically switch the positions of the Cadiere and bipolar forceps between the 6 o’clock and 9 o’clock positions as needed for better retraction of the lymph nodes, as the Cardiere provides a better medial retraction. The specimens are sent to pathology as right and left pelvic lymph nodes. The presacral space is then divided to allow for the passage of the left ureter under the mesorectum at the level of the sacral promontory. This dissection is performed with the Cardiere forceps at the 9 o’clock position to hold traction on the sigmoid colon.

Intracorporeal ileal conduit creation

We begin the intracorporeal reconstruction portion of the case with the bipolar forceps at the 6 o’clock position, needle driver at 9 o’clock, and Cadiere forceps at 3 o’clock. The left ureter is tunneled under the presacral space and sigmoid colon, with the Cadiere forceps pulling the ureter through into the right retroperitoneum. The ileocecal valve is then identified, and a 3-0 Vicryl stay stitch is placed 30 cm from the valve, with a 15 cm segment of ileum marked out for the conduit. At this time, we switch the needle driver to the 3 o’clock position and Cadiere to 9 o’clock, and monopolar scissors at 6 o’clock. Ligasure is used to take down the mesentery. The monopolar scissors are used to open up the bowel at both ends. The Endo-GIA stapler is advanced through the 12 trocar assistant port, and a stapled side-to-side small bowel anastomosis is performed at the first and second corners of each end of the bowel. This is first stapled across longitudinally, and then stapled again to seal the edge of the side-to-side anastomosis. Additional 3-0 Vicryl is used to buttress the staple line. We then orient the proximal segment of the ileal conduit towards the pelvis and the distal end towards the skin.

The right ureter is trimmed, with the distal ureter sent for frozen pathology. The ureter is then spatulated and anastomosed to the conduit in an end-to-side fashion with a running 4-0 Vicryl in a Bricker style. This is done with the Cadiere at the 6 o’clock position to hold the conduit down and the bipolar forceps holding the ureter up - it must be noted that no assistant is needed for the anastomosis. We similarly prepare, spatulate, and anastomose the left ureter to the proximal end of the ileal conduit in an end-to-side fashion in the Bricker style.

Before each anastomosis is closed, we place single-J ureteral stents inside each ureter in the following fashion. Through the gel point, we insert a laparoscopic right angle holding a Motion wire inside the 2.5 cm right lower quadrant incision beside the robotic instruments. The wire is then passed from the distal to the proximal end of the conduit using the laparoscopic right angle, and pulled through with the Cadiere forceps. The wire is then advanced into the ureter, and the single-J stent is advanced over the wire up the ureter until resistance is felt. The same step is used to place a stent up the ureter. After the conclusion of the ureteral-ileal anastomoses, the single j is secured to the distal part of the conduit with a long 0 Vicryl suture, the tail of which can be followed through the gel point. Eventually, a 15 round JP drain is inserted into the pelvis via the 5 mm port, which we suture to the skin with a 2-0 nylon. The robot is then undocked, the pneumo removed, and the specimen is removed through the SP incision. If needed, the incision is lengthened slightly to accommodate the sample. At this point, pulling gently on the 0 Vicryl previously placed, we can recover the distal part of the conduit, grab it with a ring forceps and bring it out through the SP incision. The stoma is then secured with 3-0 Vicryl to the fascia with seromuscular bites, and then the end of the stoma is matured, securing it to the dermis with seromuscular to mucosa to dermal sutures circumferentially, taking care not to suture the mesentery of the ileum. The stents are then trimmed and brought into a urostomy bag.