Robotic - assisted radical cystectomy in a woman

Overview

Purpose: A short video is presented of robotic‑assisted radical cystectomy, hysterectomy, adnexectomy, and prophylactic appendectomy with intracorporeal Bricker diversion.

Material and methods: A patient with a BMI of 36.6 to under went the above procedure for high grade invasive urothelial carcinoma – pT2N0M0 – with squamous cell differentiation. Presurgical preparation and peri- as well as postoperative care were preformed according to the ERAS (enhancedearly recovery after surgery) protocol. During the procedure, both ureters were dissected into the pelvis where they were clipped, and, subsequently, the lateral bladder walls were released up to the endopelvic fascia. Next, the parietal peritoneum in the Pouch of Douglas was opened, the vagina was opened below the cervix, and the bladder pedicles were skeletalized and transected. The specimen was released by transecting the urethra secured with clips. Bilateral pelvic lymph node dissection was performed by removing lipolymphatic tissues around the external iliac vessels and from the obturator fossa. All the specimens were removed through the vagina which was subsequently closed with a continuous V‑Loc suture. Below the sigmoid, the left ureter was drawn to the right and a Wallace ureteral plate was created. Prophylactic appendectomy was performed, and a 15-cm preterminal ileal loop was excluded through which ureteral stent catheters were passed and the ureteral plate was anastomosed Bowel continuity was restored using two endostaplers A permanent catheter was inserted via the urethra into the pelvis as a drain The distal end of the conduit was pulled out through the assistant port incision, and urostomy was performed

Results: The surgery was carried out using the Da Vinci Xi system, with robotic 8‑mm ports placed in the transverse line approximately 3 cm above the umbilicus (see the resulting image at the end of the video) and a 12‑mm assistant port in the anticipated stoma site The duration of the procedure was 5 5 hours, with a blood loss of no more than 100 mL and an ICU stay of 4 days; bowel motility was restored on postoperative day 2; the drain was left in place for 48 hours and ureteral catheters for 14 days The postoperative course was complicated by prolonged serous secretion from the vagina that resolved spontaneously on postoperative day 18 Histologically, no viable tumour was detected in the entire bladder

Conclusion: Robotic ‑assisted radical cystectomy is a safe procedure with a number of benefits for the patient An excellent view of the confined pelvic space allows for a precise tissue dissection and blood loss reduction Specimen removal through the vagina makes it possible for the procedure to be performed without the use of minilaparotomy This effectively inhibits secondary wound healing due to increased lymphatic flow from the interrupted lymphatics after pelvic lymphadenectomy Intracorporeal construction of the diversion allows for the procedure to be done without traumatizing the bowel by opening the peritoneal cavity, thus effectively preventing the development of postoperative paralytic ileus On the contrary, a drain passed through the urethra proved to be a factor predisposing to prolonged serous secretion from the urethra

Keywords:

Robotic assisted radical cystectomy – female – intracorporeal construction of ureteroileostomy