Robotic Intracorporeal Urinary Diversion: Ileal Conduit

Indications and contraindications

Preoperative workup

The standard radical cystectomy/urinary diversion preoperative workup is adequate, because no specific additional evaluations are needed for robotic ileal conduit. We routinely consult an enterostomal nurse preoperatively for ostomy site planning.

Patient preoperative preparation

The preoperative preparation for a roboc-assisted ileal conduit is identical to the preparation for all radical cystectomy patients. Our practice does not include bowel preparation other than a rectal enema the evening before surgery and nothing taken by mouth after midnight the day before surgery. The patient receives another enema on arrival at the hospital on the day of surgery.

Instrumentation

Port placement

Port placement is similar in orientation to robot-assisted prostatectomy. When performing a standard robot-assisted cystectomy, we place the 12-mm camera port 24-cm cephalad from the symphysis pubis when the abdomen in deflated. With intracorporeal diversion, the ports are placed approximately 2 cm higher than this standard location. We perform robotic ileal conduits with a left-sided assistant; it is technically easier to introduce the stapler from the left side of the abdomen because this will provide the best angle. In addition, the assistant should have two assistant ports that are at least 12 mm to allow passage of the stapler from each location. If a right-side bedside assistant is preferred for the extirpative portion of the procedure, a 12-mm port can be exchanged for the 8-mm fourth arm port to allow stapler passage from the left during the urinary diversion.

Repositioning

The robot is undocked after completion of the extirpative portion of the procedure and specimen removal. The patient is taken out of the steep Trendelenburg position and placed in a neutral position to allow the small bowel to return to the lower abdomen and pelvis. This facilitates manipulation of the small bowel for subsequent ileal conduit formation. At this point, the robot is redocked.

Identification of bowel segment for diversion

With the robot redocked, attention is turned to locating the ileocecal junction. A 20-cm silk tie is used to assist with measuring the distance from the ileocecal junction. A segment of ileum at least 15 to 20 cm proximal to the ileocecal junction is selected for the diversion. A 3-0 polyglactin stitch is used to tag the segment at the proximal and distal end. Caution needs to be taken when handing the bowel with the robotic instruments because of the force that can be inadvertently applied by the surgeon, potentially resulting in a serosal injury. We recommend using only the adjacent mesenteric fat to manipulate the bowel.

Bowel resection and reapproximation

The next step is to harvest the ileal segment and restore bowel continuity. This is achieved using an endovascular stapler with a 60-mm vascular load. The bedside assistant introduces the stapler through the left lateral 12-mm assistant port while the robotic surgeon presents the bowel and mesentery to be divided. The stapler is placed in a perpendicular orientation across the bowel and mesentery, with the tips of the stapler aimed at the root of the mesentery. The endoGIA stapler is fired to divide the bowel and mesentery. The identical technique is used at the other end of the bowel segment.

To restore bowel continuity, the proximal and distal cut ends of bowel are identified and positioned in a side-to-side fashion. Three 3-0 polyglactin sutures, spaced 2-cm apart, are used to reapproximate the antimesenteric portions of the proximal and distal bowel in the proper side-to-side orientation. The anastomosis is then created by first excising a small amount of stapled bowel at each end with robotic scissors. The endoGIA stapler is reintroduced into the 12-mm left lateral port, and the jaws are inserted into the bowel segments through the enterotomies. The stapler is fired, thus creating a side-to-side, stapled anastomosis similar to that of an open procedure. If desired, a second staple load may be used to create a larger side-to-side lumen. Last, the remaining bowel opening is stapled closed using the same endoGIA stapler to complete bowel continuity. We do not close the mesenteric defect.

One of most important steps, and potential biggest pitfalls, is appropriate orientation of the mesentery at the time of bowel division. It is easy to become disoriented and skive under the bowel with the stapler, resulting in tenuous blood supply to at the site of the ileal-ileal anastomosis or to the conduit itself. The surgeon needs to take ample precaution to assure appropriate orientation. If there is difficulty obtaining the proper angle, relocate the stapler to a different port. Last, assure no adjacent structures (bowel, ureter) are incorporated in the stapler during conduit harvest, because one jaw of the device is often obscured by the bowel being divided.

Ureteroenteric anastomosis, stent placement, and completion of the ileal conduit

The ileal conduit is irrigated with a laparoscopic suction/irrigator by opening the distal suture line (ostomy side) of the bowel segment. The ureters are then identified, and the ureteroenteric anastomoses are performed. The surgeon may use a variety of approaches to the ureteroenteric anastomosis that mimic the extracorporeal technique. In our experience, we prefer the Bricker technique. Using robotic scissors, the ureter is incised and spatulated for a distance of approximately 2 cm. An incision is made at the appropriate site on the conduit for the anastomosis. The authors use two different methods for the ureteral anastomosis. We use three interrupted 4-0 poyglactin sutures on an RB-1 needle for the posterior wall. At this point, the ureteral stents are placed across the anastomosis, and the anterior wall is closed in a running fashion. This technique is then repeated with the contralateral ureter. An alternative method uses a double-armed barbed suture that is started in the apex of the spatulated ureter and closed in a runner fashion in both a clockwise and counterclockwise direction.

We use single J ureteral stents, which are individually introduced through the right-sided fourth arm robotic port with a guidewire in place. The bedside assistant controls the distal end of the stent and guidewire outside of the abdomen while the robotic surgeon grasps the tip of the stent and passes it into the ureter. When resistance is met, the bedside assistant can withdraw the guidewire. The assistant then passes the free end of the stent completely into the abdomen. The grasper is placed through the fourth arm robotic port (right-sided) and introduced into the distal/ostomy end of the ileal conduit. The assistant carefully works the grasper through the partially completed ureteroenteric anastomosis until the robotic surgeon can pass the distal end of the stent into the assistant's graspers. The stent is then drawn back through the conduit and out of the ostomy end and allowed to lay free in the abdomen. The anastomosis is completed at this time. Before undocking the robot, the ostomy side of the conduit is tagged with a 3-0 polyglactin suture and brought out through the closest port site to the ostomy site. This allows the surgeon to readily locate the conduit at the time of ostomy creation.

A major source of potential complication and morbidity can arise from inappropriate handling of the ureter during this portion of the procedure, leading to ischemic injury and stricture formation. A simple method to help avoid this issue is used by the authors. After the ureter that has been mobilized is ready for division, two Hem-o-lok clips (10 or 15 mm) are placed on the ureter above and below the site of division. Before placement of the more proximal clip, a silk tie (20 cm) is secured to the crotch of the clip. Once it is placed, this will provide a nontraumatic method to handle the ureter without increasing operative time.

Postoperative care

We use our previously reported, evidence-based, “Fast Track” program for postoperative care of all radical cystectomy patients, including those who underwent robot-assisted ileal conduit urinary diversions. ¹ This includes the immediate removal of the orogastric tube, early institution of an oral diet, nonnarcotic analgesia (eg, ketorolac), and promotility agents. We adhere to the American Urological Association guidelines regarding perioperative antibiotic duration and resuming preoperative beta-blockade and statins postoperatively.

Management of postoperative complications

Gastrointestinal-related complications (mainly ileus) are the most common complications seen after radical cystectomy and urinary diversion. The management of these complications is the same for open and extracorporeal urinary diversion and will be heavily dictated by surgeon preference and institutional experience.

Infectious complications are another leading cause of morbidity in this patient population. Again, there are no particular recommendations for the management of infectious issues that are specific to patients undergoing robotic ileal conduit. Our current practice is to use 24 hours of perioperative antibiotics per the American Urological Association guidelines. We use oral antibiotics around the time of stent removal with the choice of agent at the surgeon's discretion.

Urine leak, although rare, can be a troubling postoperative complication. We treat these patients in the same manner as those with open urinary diversion. We leave an abdominal drain in all patients in the immediate postoperative period. The daily outputs are monitored, and the fluid is sent for creatinine determination if the output is high or other clinical suspicion exists for a urine leak. A loop-o-gram may be helpful in localizing the location of the leak, and the patients have a percutaneous nephrostomy tube placed.

A more common, and potentially more troubling, long-term complication is an ureteroenteric anastomotic stricture. Once diagnosed, the management is identical to that used in patients undergoing open urinary diversions, but some focus needs to be placed on prevention in the robotic setting. First, as previously mentioned, the surgeon needs to minimize handling of the ureter. We believe an effective and efficient method involves placing a Hem-o-lok clip with a preplaced tie proximal to the site of ureteral transaction. This provides a secure stay that aids in additional ureteral dissection and ureteroenteric anastomosis. Second, care needs to be taken to preserve the vasculature traveling from the common iliac vessels to the ureter. Last, attention needs to be placed on maintaining periureteral soft tissue and minimizing tension during dissection and mobilization. Because there is no tactile feedback from the robotic system, the surgeon must rely and adjust to visual cues. A robotic ileal conduit reduces the amount of ureteral mobilization and essentially eliminates ureteral tension during the anastomosis and the technique itself, which may provide the most protection against the development of ureteral strictures.