PROCEDURES PERFORMED:
1. Robotic-assisted laparoscopic radical cystoprostatectomy
2. Open ileal conduit urinary diversion
3. Robotic-assisted laparoscopic Bilateral Extended Pelvic lymph node dissection
4. Open Urethrectomy
PROCEDURE IN DETAIL: The patient was verified and procedure being robotic cystectomy and ileal conduit creation. Time out was performed, intravenous antibiotics were administered. General endotracheal anesthesia was introduced. The patient was placed into a low lithotomy position and her arms were tucked, shoulder bolsters were applied. A test of steep Trendelenburg position was performed. The patient was found to be stable on the operative table. Sterile field was created by prepping and draping the patient's abdomen, using chlorhexidine. Attention was directed towards robotic cystectomy. A high flow, low pressure pneumoperitoneum was quickly obtained using Veress technique in the supraumbilical midline. Next, a 12-mm camera port was inserted in the midline approximately two fingerbreadths superior to the umbilicus. Laparoscopic examination of peritoneal cavity revealed no visceral injury. Adhesions were present in the deep pelvis and were taken down sharply after placing a 15mm port superolateral to the camera port and an air seal port in the left flank. With the adhesions taken down, additional ports were then placed as follows. Flanking paramedian 8 mm robotic ports, and a far right 8 mm robotic port.
Robot was then docked and passed the electronic checks. Attention was then directed at pelvic lymphadenectomy. First on the left side, all fibrofatty tissue in the confines of the genitofemoral nerve laterally, inferior mesentearic artery superiorly, and cooper's ligament distally was harvested. Nodal packets included bilateral external iliac , bilateral internal iliac, bilateral common iliac, bilateral obturator, para aortic, interaortocaval, paracaval, and presacral nodes. Lymphostasis was achieved using Hem-o-lok clips. This fibrofatty packets was set aside for permanent pathology. The obturator nerve was carefully inspected throughout its course and no injury occurred to this.
Attention was directed at identification of the ureters. Incision was made in the left posterior peritoneum overlying the area of the iliac vessels from the area of the bifurcation towards the area of the internal ring and then superiorly towards the umbilicus. The ureter was found coursing over the common iliac vessels and dissected distally to the level of the ureterovesical junction. This was marked with a hemoloc clip. Distal end was clipped, frozen section was sent, which was negative for carcinoma. The ureter was carefully circumferentially mobilized to the area of the iliac crossing taking great care to avoid excessive skeletonization. A mirror image incision was made in the right posterior peritoneum. The right ureter was similarly encountered and circumferentially mobilized and dissected to the area of the psoas muscle again avoiding excessive skeletonization. This was marked with a hemoloc clip and divided. The ureter was also ligated distally and frozen section was negative for carcinoma on the right side. Next, the left ureter was passed underneath the posterior peritoneum to the right side in the appropriate position for later anastomosis. The posterior bladder plane between the bladder and the rectum was developd. Dissection proceeded in this plane distally, thus exposing the vesical pedicles. These were sequentially controlled using endoscopic stapler and vascular loads, which provided excellent hemostasis of the bladder pedicles. We also identified the prostatic pedicles which were also taken with a combination of lapraclips and endogia staple loads.
Next, the anterior attachments were released from the anterior abdominal wall. The space of retzius was entered and the bladder dissected down. The DVC was encoutenered and taken with an endovascular staple load. Urethra was circumferentially mobilized as distally as possible. Foley catheter was removed and the urethra clipped and cut. This freed up the cystectomy specimen. This was placed in an endocatch bag for later retreival. The robot was then undocked and we removed the specimen through an infrapubic incision
Next, attention was directed at ileal conduit formation. A segment of bowel, was identified 15 cm proximal to the ileocecal junction. The distal end of the conduit was raised to the anterior abdominal wall to assess it for adequate length and the proximal portion of bowel that was nearest the ureters was chosen for purposes of harvesting our conduit. The length of the conduit was measured at 15cm and tagged proximally and distally. This segment taken out of continuity using bowel load stapler. The conduit loop was extraperitonealized and the bowel was brought back into continuity using bowel load stapler twice within the lumen on the antimesenteric border. The bowel defect was closed with a final staple load. The defect in the mesentery was then closed with absorbable suture. The proximal end of the conduit was oversewn with a running mattress vicryl so that the staple line would not come into contact with urine.
Attention was then directed at the left ureteral anastomosis. The left ureter was suitably positioned such that it was not twisted and in close approximation to the proximal end of the conduit. An approximately 7 mm incision was made into the proximal end of the conduit such that the bowel mucosa was circumferentially seen. The ureter was trimmed to length thus performing spatulation. The posterior wall anastomosis was performed ensuring mucosa to mucosa anastomosis using interrupted 5-0 monocryl. Next, on the left side, a bander stent was placed in retrograde fashion being placed over a Glidewire. The distal limb was placed into the conduit and the anterior wall was reapproximated using interrupted with 5-0 monocryl. Similarly, the right ureteral anastomosis was performed. The anastomoses appeared tension-free and watertight.
The location of the ileal conduit marking was identified and a 1cm in diameter circle was cut in the skin and removed with a ore of underlying fat. The fascia was cut in cruciate fashion and vicryl sutures were preplaced at the corners of fascia. The muscle was divided bluntly and peritoneum cut with scissors. Two fingers were used to dilate the tract, and th distal end of the conduit was passed through the tract. The conduit was anchored to the fascia using the pre-placed fascial sutures, and no palpable defects were present following this maneuver. Great care was taken to avoid suturing directly over the bowel mesentery and the bowel appeared to be suitably pink and viable. This was matured in a standard rosebud type fashion using interrupted 4-0 Monocryl. A 15-French red rubber tube was placed in the conduit and and copious efflux of urinary fresh fluid was seen. The 12-mm12 mm airseal port site and left lateral 15 mm assist port site were closed at the level of the fascia using 0 Vicryl. The midline incision was closed using a 0 PDS suture.
We then turned our attention to the urethrectomy. We made a 5cm incision in the perineum and using electrocautery, dissected down to the bulbospongiosum muscles. The muscle was then split and the urethra was identified. We then dissected proximally with sharp dissection until the bulbar arteries were encountered. These were oversewn with 2-0 vicryl. We then dissected the proximal end free from the pelvic floor. We then dissected the urethra distally until we were able to evert the penis. Once the penis was everted the entire urethra was freed from the glans. The meatus was closed with 2-0 Vicryl. We then placed a surgicel in the perineum and closed the bulbospongiosum muscle. We then closed another 2 layers with 2-0 Vicryl. The skin was then closed with 4-0 monocryl in a running fashion
Robotic-assisted laparoscopic radical cystoprostatectomy
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