Robotic-assisted Radical Cystectomy and Orthotopic Ileal Neobladder Using a Modified Pfannenstiel Incision

doi:10.1016/j.urology.2010.04.053

Urology

Volume 77, Issue 2, February 2011, Pages 491-493

https://doi.org/10.1016/j.urology.2010.04.053 Get rights and content

Objectives

To report our technique of robotic-assisted laparoscopic radical cystectomy with a modified Pfannenstiel incision. Robotic-assisted laparoscopic radical cystectomy has been gaining in popularity. A completely intracorporeal procedure is a technically difficult and time-consuming procedure. Most surgeons perform the diversion using a small incision, typically midline, that is also used for specimen retrieval.

Methods

Radical cystectomy and pelvic lymph node dissection was performed using a da Vinci robotic platform in a standard fashion. The robot was undocked and an 8-10 cm modified Pfannenstiel incision made. A self-retaining retractor was used to expose the wound. The specimen was extracted, and an ileal neobladder was reconstructed using the incision.

Results

We have performed this procedure in 14 patients to date. The mean age was 58 years (range 56-61). The mean estimated blood loss was 310 ± 220 mL, and the mean operating time was 6 ± 0.8 hours. No intraoperative visceral injuries were noted. None of the patients had positive surgical margins. The mean number of lymph nodes removed was 12 ± 3. The mean hospital stay was 8.5 days.

Conclusions

Our initial experience with our technique of robotic-assisted laparoscopic radical cystectomy and neobladder construction using a modified Pfannenstiel incision has been favorable. The incision provides good exposure, facilitating neobladder reconstruction, can be used for specimen retrieval, and heals better with a cosmetic scar.

Section snippets

Step I: Patient Position and Port Placement

The patient is placed in a modified lithotomy position with mild extension at the hip and flexion at the knee. Pneumatic antiembolic stockings are applied to both lower extremities, and a urethral catheter is inserted. The pneumoperitoneum is created using a Verres needle. A transperitoneal approach is used, with 6 ports placed (Fig. 1). The patient is then placed in a steep Trendelenburg position, and the 4-arm Da Vinci robot (Intuitive Surgical, Sunnyvale, CA) is docked.

Step II: Ureteral and Posterior Dissection

The sigmoid colon is

Results

We have performed this procedure in 14 patients to date. The mean age was 58 years (range 56-61). All underwent neobladder reconstruction performed extracorporeally by way of the modified Pfannenstiel incision. The mean estimated blood loss was 310 ± 220 mL, and the mean operating time was 6 ± 0.8 hours. No intraoperative visceral injuries were noted. None of the patients had positive surgical margins. No postoperative leaks were noted. Daytime continence was achieved in 13 patients and

Comment

When RC is performed laparoscopically or robotically, the techniques duplicate the surgical principles of open surgery.11, 12 Performing RARC completely intracorporeally is a lengthy procedure, because it involves extirpation of the bladder and subsequent urinary diversion. The initial attempts at intracorporeal neobladder construction had a mean operating time of 8.5 hours.¹³ Apart from performing cystectomy, when performed laparoscopically, the placement of the urethral sutures and subsequent

Conclusions

Our initial experience with our technique of RARC and neobladder construction using a modified Pfannenstiel incision has been favorable. Our approach combines the advantages of robotic and open methods and is minimally invasive and time efficient. Additional prospective studies with larger numbers are required to evaluate the benefits of this approach.

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Cited by (13)

Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy
2015, European Urology
Citation Excerpt :
The flow of this systematic review of the literature is shown in Fig. 1. In total, 70 surgical series [8–77] and 23 comparative studies [78–100] reported perioperative outcomes and complications of RARC. Most of the surgical series were retrospective, single-center studies, with the exception of some prospective studies [8,9,29,32,33,48,62,63,67,69,71,73,77] and some multi-institutional collaboration papers [19,24,26,30,38,39,43,45,72] (LOE 4).
Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) have gained popularity.
To report a systematic literature review and cumulative analysis of perioperative outcomes and complications of RARC in comparison with ORC and LRC.
Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. Cumulative analysis was conducted.
The searches retrieved 105 papers. According to the different diversion type, overall mean operative time ranged from 360 to 420 min. Similarly, mean blood loss ranged from 260 to 480 ml. Mean in-hospital stay was about 9 d for all diversion types, with consistently high readmission rates. In series reporting on RARC with either extracorporeal or intracorporeal conduit diversion, overall 90-d complication rates were 59% (high-grade complication: 15%). In series reporting RARC with intracorporeal continent diversion, the overall 30-d complication rate was 45.7% (high-grade complication: 28%). Reported mortality rates were ≤3% for all diversion types. Comparing RARC and ORC, cumulative analyses demonstrated shorter operative time for ORC, whereas blood loss and in-hospital stay were better with RARC (all p values <0.003). Moreover, 90-d complication rates of any-grade and 90-d grade 3 complication rates were lower for RARC (all p values <0.04), whereas high-grade complication and mortality rates were similar.
RARC can be performed safely with acceptable perioperative outcome, although complications are common. Cumulative analyses demonstrated that operative time was shorter with ORC, whereas RARC may provide some advantages in terms of blood loss and transfusion rates and, more limitedly, for postoperative complication rates over ORC and LRC.
Although open radical cystectomy (RC) is still regarded as a standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RC are becoming more popular. Robotic RC can be safely performed with acceptably low risk of blood loss, transfusion, and intraoperative complications; however, as for open RC, the risk of postoperative complications is high, including a substantial risk of major complication and reoperation.
Robotic assisted laparoscopic radical cystectomy for bladder carcinoma: Early experience and oncologic outcomes
2012, Formosan Journal of Surgery
Citation Excerpt :
Three additional ports (usually two 12-mm ports and one 5-mm port) were placed on both sides of the abdomen for retraction and suction purposes by the assistant as well as for the insertion of suture materials using the technique described by Manoharan et al.8 The robot was then moved into place. The procedure also followed the technique described by Manoharan et al.8 The sigmoid colon was reflected and both ureters dissected all the way to the bladder. Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, USA) were applied to the distal ureter.
Robot-assisted radical cystectomy (RARC) has been a popular mode of therapy in the treatment of bladder carcinoma for several years, and its usage in bladder carcinoma patients is on the rise. We evaluated the usefulness of this mode of therapy by studying the clinical outcomes following RARC for the treatment of bladder carcinoma.
From 2006 to 2011, a total of eight patients in our hospital who underwent RARC for bladder carcinomas were enrolled in this study. Clinical outcomes were measured by means of preoperative status, operative strategy and initial outcomes.
Follow-up ranged from 4 to 22 months (mean 10.9 months). The mean operative time was 430.3 minutes, and the operative time decreased with the increasing experience of the surgeon and assistants. The mean estimated blood loss was 762.5 mL. The surgical approach was RARC and orthotopic ileal neobladder in five patients (62.5%), bilateral nephrectomy with RARC in two patients (25%), and RARC with ileal conduit alone in one patient (12.5%). Histological examination showed five instances of stage pT1 tumor, one pT2 tumor, and two instances of original tumor with extravesical disease (pT3b). One patient had lymph node involvement. Postoperative complications included urethral stricture in one case and vesicovaginal fistula in another. The mean hospital stay was 10.8 days (range 7–26 days). None of the patients had a positive surgical margin. There was no surgical mortality in this series.
RARC is a challenging but safe and minimally-invasive method of treating bladder carcinoma.
Intraoperative complication of radical cystectomy for muscle-invasive bladder cancer: does the surgical approach matter? A retrospective multicenter study using the EAUiaiC classification
2023, World Journal of Urology
Robot-assisted laparoscopic ileal ureter replacement with extracorporeal ileal segment preparation for long ureteral strictures: a case series
2022, BMC Surgery
Robot-assisted laparoscopic ileal ureter replacement with extracorporeal ileal segment preparation for long ureteral strictures: a case series
2022, Research Square
Intracorporeal versus extracorporeal urinary diversion following robot-assisted radical cystectomy: a meta-analysis, cumulative analysis, and systematic review
2021, Journal of Robotic Surgery

View all citing articles on Scopus

: This study was supported by “CURED” and Vincent A. Rodriguez.

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Surgical Techniques in UrologyRobotic-assisted Radical Cystectomy and Orthotopic Ileal Neobladder Using a Modified Pfannenstiel Incision

Objectives

Methods

Results

Conclusions

Section snippets

Step I: Patient Position and Port Placement

Step II: Ureteral and Posterior Dissection

Results

Comment

Conclusions

J Am Coll Surg

Eur Urol

Urology

Eur Urol

Urology

J Urol

Eur Urol

Surgical Techniques in Urology
Robotic-assisted Radical Cystectomy and Orthotopic Ileal Neobladder Using a Modified Pfannenstiel Incision