Robotic radical cystectomy (RARC) is an established procedure for bladder cancer with oncological outcomes non-inferior to that of open radical cystectomy. Though, the first robotic intracorporeal urinary diversion (IUD) was reported as early as 2003, its outcome is still not well established. The IUD following RARC may augment the potential advantages of minimal invasive surgery in terms of a faster bowel recovery due to lesser handling of bowel, lesser blood loss due to pneumoperitoneum, lesser fluid loss by evaporation, lower incidence of uretero-ileal strictures due to lesser mobilisation of the ureters and lower postoperative pain. The adoption of enhanced recovery after surgery (ERAS) protocol aimed to reduce the surgical stress and complications may synergistically add up to the advantages of IUD.(1) A meta-analysis including 22 studies involving 7020 patients reported RARC with IUD is superior to open RC in terms of estimated blood loss, blood transfusion rate, length of hospital stay, 30 and 90 days Clavien-Dindo grades ≥III complication rate, and positive surgical margin. However, it was inferior with regard to operative time, and rates of uretero-enteric stricture.(2) However, University of South Carolina group in a RCT did not find difference between open RC and RARC with intracorporeal diversion including grade 3 or higher complications at 90 days.(3)
Our patients are prepared as per the ERAS protocol with some institutional deviations. We use 5 or 6 ports (4 robotic and one or two for assistance) for RARC with intracorporeal ileal conduit urinary diversion. After cystectomy and extended pelvic lymph node dissection, we pass left ureter over the common iliac vessels to the right side. Thereafter, we isolate 15-20 cm segment of ileum (depending on the body habitus) 20 cm proximal to ileocecal junction with the help of linear stapler followed by side-to-side antimesenteric border stapled anastomosis of ileal segments to restore the bowel continuity. Uretero-ileal anastomosis is performed by either Bricker or Wallace technique over double-J stents. Then the distal end of the conduit is taken out from the site marked for the stoma. Thereafter, the cystectomy incision is extracted by Pfannenstiel incision in male and per vagina in female. Patients are allowed to take oral clear liquids in the morning after surgery, liquid diet in the evening. Thereafter, patients are encouraged to progress to normal diet by postoperative day 3. Abdominal drain is removed once the drain output become less than 100 ml and the DJ stents are removed between post-operative day 10-14.
Table 1: Outcomes of RARC with ICIC
Parameters | RARC with Ileal conduit (n=46) |
Male/Female | 38/8 |
Total operative time | 290-450 min |
Total intracorporeal conduit reconstruction time | 80-140 min |
Time to bowel movement | 12-24 hours |
Time to soft diet | 2-3 days (n=45) |
Drain removal | 3-10 days |
Hospital stay | 4-15 days |
Complications Clavien 1-2 Clavien ≥3 | 5 2 |
Intracorporeal ileal conduit following RARC is a reproducible treatment alternative with lesser peri-operative complication and faster recovery. However, we incorporated ERAS protocol and intracorporeal ileal conduit at the same time in our practice, it may have influence in our results.
by Dr Niraj Kumar,VMMC & SJH, New Delhi
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