Download possible complications during robotic cystectomy and how to avoid

THE JOURNAL OF UROLOGYâ
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post-operative course was complicated by a UTI. At 3 months, a renal
ultrasound revealed mild bilateral hydronephrosis that resolves
with voiding.
CONCLUSIONS: The accompanying teaching video demonstrates positioning and operative technique for a robotic-assisted
laparoscopic TUU. This innovative and minimally invasive technique is
a safe and feasible approach to manage ureteral reflux and persistent
hydronephrosis in a collecting system that is not amenable to
ureteroneocystotomy.
Source of Funding: none
V10-06
A NOVEL TECHNIQUE FOR PREVENTION OF LYMPHOCELES
DURING TRANSPERITONEAL ROBOTIC ASSISTED PELVIC
LYMPH NODE DISSECTION
Christopher Lebeis*, David Canes, Jason Gee, Andrea Sorcini,
Alireza Moinzadeh, Burlington, MA
INTRODUCTION AND OBJECTIVES: Lymphocele formation is
a known complication of pelvic lymph node dissection (PLND) after
robotic-assisted radical prostatectomy (RARP). We developed a novel
technique to prevent lymphocele formation, utilizing the existing peritoneum of the bladder.
METHODS: We evaluated 155 consecutive patients undergoing RARP with PLND over 24 months. Group A included the first 77
patients with PLND using standard technique (no peritoneal flap).
Group B included the subsequent 78 patients with PLND and peritoneal
interposition flap. The peritoneal interposition flap is developed from the
redundant peritoneal surface after dropping down the bladder and using
the tissue lateral to the obliterated ligament. At the end of the case after
the vescico-urethral anastomosis is completed, the flap is brought to the
most dependent portion of the pelvis (posterior and caudal) by rotating
and advancing the peritoneal flap around the lateral surface of the
ipsilateral bladder. The flap is fixed to the bladder using at least two
interrupted Vicryl sutures. This prevents the bladder adipose tissue from
contacting the lymph node dissection bed and scaring down. The window that is created allows the continuous egress of lymphatic fluid into
the peritoneal cavity to be reabsorbed. A cystogram was performed in
91% of the patients 7-14 days after the surgery. Lymphocele formation
rates were compared (based on symptoms, cystogram findings, and
radiographic confirmation).
RESULTS: The two groups were statistically equivalent in
terms of PSA, age, blood loss, body mass index, Gleason score,
prostate size, pathology, and heparin administration. Symptomatic
lymphocele formation occurred in 9/77 (11.6%) Group A patients and in
0/77 Group B patients (p ¼ 0.003). Mean time to lymphocele detection
in Group A was 30.4 days. Mean follow up in Groups A and B were
374.3 and 113.8 days respectively (p <0.001).
CONCLUSIONS: Strategic rotation and fixation of a peritoneal
flap around the lateral aspect of the bladder during transperitoneal
RARP with PLND is a novel technique to prevent symptomatic lymphocele formation. Given the sample size and single institutional study,
a prospective randomized, multi-institutional trial is planned.
Source of Funding: none
V10-07
DA VINCI ROBOT ASSISTED VIDEO ENDOSCOPIC INGUINAL
LYMPHADENECTOMY : VIDEO DEMONSTRATION OF THE
TECHNIQUE
Yuvaraja Thyavihally*, Amit Patil, Harsha Vardhan, Nikhil Gulavani,
Harshvardhan Pokharkar, Abhinav Pednekar, Mumbai, India
INTRODUCTION AND OBJECTIVES: Inguinal lymphadenectomy is a well-established therapeutic option for patients with invasive
penile squamous cell carcinoma who are at risk of regional metastases
Vol. 191, No. 4S, Supplement, Tuesday, May 20, 2014
but with high incidence of wound related morbidity. The objective is to
report the use of endoscopic robotic-assisted Video Endoscopic
Inguinal Lymphadenectomy (R-VEIL) in managing the groin of these
patients highlighting the steps in the video segments.
METHODS: We have performed 9 R-VEIL for 7 cancer penis
patients in last 14 months. Two patients underwent bilateral and five
had unilateral R-VEIL. All had high grade primary tumor with clinically
negative groin and in five groins, frozen section was positive for lymph
node metastasis who had robotic pelvic dissection as well in the same
sitting. Technique of R-VEIL involves a 2-cm mid-thigh incision and
developing a plane just deep to Camper’s (fatty) fascia by using finger
dissection. After creating sufficient working space 3 robotic ports and 1
assistant port are placed, and the robotic device (Da Vinci Si HD) was
docked. Inguinal triangle was dissected to include both superficial and
deep lymph nodes in the dissection template.
RESULTS: Mean age of the patients was 58 years (Range
50-66). Mean console time was 130 mts (Range 110-190) for each
groin, blood loss 70 ml (Range 30-100ml). There were no intraoperative complications. None of the patient had wound related
complications like necrosis, infection. Average time for lymphorrheoa
to stop was 14 days. Two patients had lymph drainage for 20 and 23
days. With mean follow up of 9 months none of the patient had local
recurrence. One developed para-aortic lymph node metastasis and
died of disease.
CONCLUSIONS: With our initial experience with R-VEIL in
selected patients, a minimally invasive approach circumventing the
need for thick skin flaps, the improved flexibility afforded by robotic instruments, and the improved magnification could decrease the
morbidity associated with inguinal lymphadenectomy while maintaining
oncologic principles. However long term follow up with more number are
needed to draw conclusions on oncological safety.
Source of Funding: None
V10-08
POSSIBLE COMPLICATIONS DURING ROBOTIC CYSTECTOMY
AND HOW TO AVOID THEM
~o, Homayoun Zargar,
Humberto Laydner*, Luis Felipe Branda
Oktay Akça, Jayram Krishnan, Dinesh Samarasekera,
Riccardo Autorino, Robert Stein, Jihad Kaouk, Cleveland, OH
INTRODUCTION AND OBJECTIVES: Bladder cancer is the
fourth most common tumor in men in the United States. Radical
cystectomy is a complex procedure with a high complication rate.
Ninety-day complication rate of robotic radical cystectomy was similar
to open radical cystectomy in a recent randomized trial however robotic radical cystectomy is technically demanding and the anticipation
of possible complications is crucial to prevent their occurrence.
Herein, we discuss possible complications in each step of robotic
radical cystectomy.
METHODS: The present study is an analysis of recorded
videos from robotic radical cystectomies with focus on possible complications and tips to avoid them. Surgical steps are divided into patient
positioning and port placement, docking of robot, ureteral dissection,
posterior dissection, apical dissection, lymphadenectomy and urinary
diversion. In each step, anatomical landmarks are examined and potential complications are noted. Various options of instruments used
during surgery are noted.
RESULTS: We show strategies to prevent possible intraoperative complications that can occur in each step of robotic radical
cystectomy, including nerve, vascular and visceral injuries. We also
present some key technical points that can be helpful to avoid postoperative complications. Results obtained with the application of these
lessons have led to continuous improvement of operative outcomes in
our center.
CONCLUSIONS: Robot-assisted radical cystectomy and urinary diversion has numerous surgical steps with potentially high risk for
complications. Due to the technically complex nature of this procedure,
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Tuesday, May 20, 2014
the awareness of potential complications during each step is extremely
important to prevent their occurrence.
Source of Funding: none
V10-09
SURGICAL TECHNIQUE OF TOTAL INTRACORPOREAL ROBOT
ASSISTED LAPAROSCOPIC PITCHER POT ILEAL NEOBLADDER
FOR MUSCLE INVASIVE TRANSITIONAL CELL CARCINOMA OF
BLADDER
Sudhir Rawal*, Amit Goel, Anish Gupta, Samir Khanna,
Saurabh Vashishtha, Delhi, India
INTRODUCTION AND OBJECTIVES: To present our surgical
technique in patients who underwent Total Intracorporeal Robot assisted Laparoscopic Pitcher Pot Ileal Neobladder (TIRLPIN) for muscle
invasive transitional cell carcinoma of bladder.
METHODS: 101 patients underwent Robotic Radical Cystectomies from February 2011 to August 2013. Ileal Conduit urinary
diversion were done extracorporeally in 44 patients and Neobladders
were done extracorporeally in 50 patients. Total Intracorporeal Robot
assisted Laparoscopic Ileal conduit was performed in 4 patients and
Total Intracorporeal Robot assisted Laparoscopic Pitcher pot Ileal
Neobladder(TIRLPIN) were done in 3 patients. [Pitcher pot Ileal Neobladder is a modification of Studer Neobladder which is ileal neobladder
in spherical configuration with ileal neourethra (giving the shape of an
inverted Indian earthenware container called a ‘pitcher pot’) to circumvent the problem of short mesentery and construct a low-pressure
spherical ileal neobladder].
Three patients who underwent robot assisted laparoscopic radical
cystectomy extended pelvic lymph node dissection, transposition of
left ureter to the right, Pitcher pot ileal neobladder including isolation
of 55 cm of ileal loop and bilateral stented uretero-ileal anastomosis
in end to side fashion were all performed intracorporeally using
the da Vinci Surgical Robot and finally specimen was retrieved.
We demonstrate our technique of TIRLPIN with da Vinci Robotic system.
RESULTS: TIRLPIN technically successful in all the 3 patients.
Median patient age, body mass index, estimated blood loss were 65
years(range 56-67), 26.2(23.5-27), 300 ml(280-320ml, respectively.
Average operative time was 600 minutes (540-720 min). Average time
for the cystectomy was 135 minutes. Mean time to liquid diet was 3.3
days and the stents were removed on seventh day. Perurethral catheter
was removed on tenth day in neobladder patients. Median post operative hospital stay was 16 days(12-18 days). 30-day and 90-day complications were Clavien grade 1-2 (n¼ 3 and 2), clavien grade 3-5 (n¼
0 and 0). All patients received Total parental nutrition. One patient had
high persistent drain output which resolved after keeping perurethral
catheter for extra 1 week. All patients have completed 3 months of
follow up.
CONCLUSIONS: TIRLPIN for neobladder formation is technically feasible. The robotic system aids in replicating open procedure of
reservoir configuration precisely, with reduced perioperative morbidity,
minimal blood loss and good cosmetic results.
Source of Funding: None
V10-10
THE ROLE OF ROBOTIC CYSTO-PROSTATECTOMY WITH
BILATERAL NERVE AND APEX PRESERVATION IN YOUNG
PATIENTS WITH BLADDER CANCER
Jayram Krishnan*, Vishnu Ganeshan, Riccardo Autorino, Yaw Nyame,
Idir Ouzaid, Robert Stein, Georges-Pascal Haber, Cleveland, OH
INTRODUCTION AND OBJECTIVES: Young males (<40
years of age) with bladder cancer requiring cystectomy have concerns
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regarding their potency and continence if neobladder is performed. As
an alternative to previously described techniques of total prostate
sparing cystectomy, we demonstrate the surgical feasibility of bilateral
nerve sparing with apical prostate preservation in select young patients.
We use the principles of the intra-fascial nerve sparing technique
described for radical prostatectomy.
METHODS: Ports are placed in the standard cystectomy
fashion as previously described in the “W” configuration with a 12 mm
assistant port on the right side of the patient. The patient is placed in the
steep trendelenberg position and the robot is docked. The ureters are
dissected followed by posterior rectal dissection. The pedicles are then
carefully dissection with Hem-o-lock (Weck) clips with minimal electrocautery in the vicinity of the neurovascular bundles. Bilateral intrafascial nerve dissection is performed followed by close apical dissection
of the prostate. The dorsal venous complex is preserved followed by
division of the urethra, creating a robust, long stump. Urinary diversion
is performed at surgeon preference.
RESULTS: We have performed three robotic cystectomies with
apex preservation followed by totally intra-corporeal neobladders. All
patients did not have evidence of prostatic urethral or intraductal
involvement of their bladder cancer and their preoperative PSA values
were normal. All patients reported preoperative SHIM scores above 23
and experienced rapid recovery of erectile function post-operatively with
full daytime continence. All patients had negative margins with longterm data pending.
CONCLUSIONS: Robotic cysto-prostatectomy with bilateral
nerve and apical preservation can be performed safely in the properly
selected young patient with excellent results. A larger series with prospective randomized trials will be needed to assess the long-term implications and benefits.
Source of Funding: None
V10-11
ROBOTIC CYSTECTOMY WITH ANTERIOR PELVIC
EXENTERATION: A SIMPLIFIED STEP-BY-STEP APPROACH
Idir Ouzaid, Jayram Krishnan*, Vishnu Ganeshan, Riccardo Autorino,
Nima Almassi, Iryna Makovey, Robert Stein, Jihad Kaouk,
Georges-Pascal Haber, Cleveland, OH
INTRODUCTION AND OBJECTIVES: Robotic cystectomy with
anterior pelvic exenteration (RCAPE) is feasible and is a minimally
invasive approach for managing bladder cancer in females requiring
cystectomy. We describe a simplified, standardized technique that
removes many technical limitations while adhering to all oncologic
principles.
METHODS: Ports are placed in the standard cystectomy
fashion as previously described in the “W” configuration with a 12 mm
assistant port on the right side of the patient. The patient is placed in the
steep Trendelenberg position and the robot is docked. The ureters are
dissected followed by posterior dissection with assistance of a
malleable retractor in the vagina. Lateral dissection is performed to
develop the pedicles and vaginal walls which are then secured using
the CaimanÓ Tissue Sealing Device (Aesculap, Center Valley PA).
Finally, the dorsal venous complex and urethra are divided. We
routinely perform intracorporeal ileal conduit urinary diversion according
to our described technique.
RESULTS: Between August 2011 and October 2013 we have
performed 25 RCAPE using this standardized technique. Operative
time including pelvic exenteration, vaginal closure, bilateral extended
pelvic node dissection and intracorporeal ileal conduit urinary
diversion was an average of 355 minutes and estimated blood loss
was an average of 347 mL. One patient required a blood transfusion
and length of hospital stay was an average of 6 days. Finally,
complications were assessed according to the Memorial-Sloan
Kettering Grading System and 3 patients had minor (grades 1-2)
complications and 2 patients experienced major (grades 3-5)
complications.