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The First 100 Consecutive, Robot-assisted, Intracorporeal Ileal Conduits: Evolution of Technique and 90-day Outcomes

European Urology

Abstract

Background

Robot-assisted radical cystectomy (RARC) has evolved over the last few years to become an acceptable alternative option to open radical cystectomy. Most series of RARC used an open approach to urinary diversion. Even though robot-assisted intracorporeal urinary diversion (RICUD) is the natural extension of RARC, few centers have reported their experiences with RICUD in general, and in particular, of robot-assisted intracorporeal ileal conduits (RICIC).

Objective

To report our experience with RICIC using the Marionette technique.

Design, setting, and participants

The first 100 consecutive patients who underwent RARC and RICIC, and had ≥3 mo of postoperative follow-up were included in this study. Patients were divided into four groups of 25 patients each to study the evolution of our surgical technique.

Intervention

RICIC.

Outcome measurements and statistical analysis

Intraoperative, pathologic, and 90-d postoperative outcomes for the four groups and the overall cohort were compared using the Fisher exact test (categorical variables) and the Kruskal-Wallis test (continuous variables). Continuous variables were reported as median (range) and categorical variables were specified as frequency (percentage).

Results and limitations

Overall operative and specific diversion times were 352 and 123 min, respectively. Estimated blood loss was 300 ml, lymph node yield was 24, and positive surgical margin rate was 4%. Length of hospital stay increased from 7 d for group 1 to 9 d for group 4. The overall 90-d complication rate was 81%; 19% of complications were high grade. Infections were the most common complications, representing 31% of all complications. There were no statistically significant intergroup differences except in diversion time, intraoperative transfusions, and length of stay.

Conclusions

RICIC diversion is safe, feasible, and reproducible. Larger series with longer follow-up are needed to validate the procedure and define its place in the minimally invasive urologic armamentarium. Quality of life studies need to be conducted to compare benefits of intracorporeal urinary diversion.

Take Home Message

Robot-assisted intracorporeal ileal conduit urinary diversion is safe, feasible, and reproducible. Larger series with longer follow-up are needed to validate the procedure and define its place in the urologic armamentarium and to study its impact on quality of life.

Keywords: Robotic, Robot-assisted, Radical cystectomy, Intracorporeal, Ileal conduit, Marionette, Urinary diversion.

1. Introduction

Robot-assisted radical cystectomy (RARC) has evolved over the last few years to become an acceptable alternative option to open radical cystectomy (ORC) with similar short-term and intermediate-term oncologic outcomes [1], [2], [3], and [4]. After establishment of the robot-assisted surgery program at Roswell Park Cancer Institute in 2004, RARC was incorporated into the program in 2005. Our original technique and initial experience with the Marionette robot-assisted intracorporeal ileal conduit (RICIC) diversion were previously reported [5] . In this series, we describe modifications to the original technique and outcomes of our first 100 consecutive patients who underwent RARC and RICIC diversion with a minimum of 90-d postoperative follow-up.

2. Materials and methods

From May 2009 to February 2012, the Marionette technique of RICIC diversion was performed on 121 consecutive patients with bladder cancer who underwent RARC by a single surgeon (KG). Clinical and pathologic information for these patients was retrieved from our institutional review board–approved, prospectively maintained, quality assurance bladder cancer database. The first 100 consecutive patients who had a minimum of 90-d postoperative follow-up were included in this study. This cohort was divided into four groups (25 patients each) to facilitate comparison in terms of demographics, and pathologic, perioperative, and 90-d postoperative outcomes. Postoperative complications were divided into early (≤30 d) and late (≤90 d) and categorized using the modified Clavien system [6] . Minor complications were placed in Clavien category 1–2 and major complications were placed in category 3–5. Two patients were lost to follow-up within 90 d postoperatively and were excluded from analysis.

Statistical analysis for comparing groups in regard to categorical variables was performed using the Fisher exact test. Similar comparisons for continuous variables were done using the Kruskal-Wallis test. Values for continuous variables are given as median (range). Values for categorical data are specified as frequency (percentage). Statistical analysis was performed using SAS v.9.3 (SAS Institute Inc., Cary, NC, USA).

2.1. Overview of the Marionette technique

A detailed description of the initial Marionette technique was published previously [7] . A standard, six-port, transperitoneal approach in steep Trendelenburg position, similar to robot-assisted radical prostatectomy, is used. An additional 12-mm, short (75 mm long) suprapubic port is placed for bowel reanastomosis toward the end of surgery. Port placement is modified by moving the ports more cephalad for ease in performing the intracorporeal urinary diversion (ICUD). RARC and extended pelvic lymphadenectomy are performed in a standard fashion.

The specimens from RARC and extended pelvic lymphadenectomy are placed in Endo Catch bags (Covidien plc, Dublin, Ireland), and positioned in the pelvis to allow room for conduit creation. The specimen is removed through the vagina in females, and through a transverse extension of the suprapubic port site (Pfannenstiel) at the end of the procedure in male patients. The left ureter is delivered under the sigmoid mesocolon to the right side.

A 60-in 1-silk suture on a Keith needle is introduced through the abdominal wall, passed through the distal end of the future conduit, and brought back outside. This stitch is not tied but controlled with an instrument to allow the distal end of the conduit to be raised and lowered, like a marionette. The marionette suture is placed lower than the actual stoma site for ease of robotic arm manipulation. A 12- to 15-cm ileal segment is harvested approximately 15 cm away from the ileocecal valve. The hook cautery is used to divide the peritoneum of the bowel mesentery, and two mesenteric windows are created. Bowel mesentery is controlled with electrocautery, Ligasure (Covidien plc, Dublin, Ireland), or the vascular stapler. The 45-mm Endo GIA stapler (Covidien plc, Dublin, Ireland) is passed through the 15-mm assistant port to divide the bowel proximally and distally. Bowel continuity (BC) is not reestablished at this point; instead, a single 0-silk suture is used to bring the two ends of ileum together, preventing malrotation and ensuring proper orientation.

The proximal staple line is not isolated from the remainder of the conduit. The marionette suture is lowered to gain access to the proximal end of the conduit to facilitate ureteroileal anastomosis (UIA). The distal end of the ureter is held in position using the fourth robotic arm to allow for UIA. Scissors or an electrocautery hook is used to make two small enterotomies in the proximal conduit on two opposite sides. The ureter is partially transected and spatulated using robotic scissors so the distal end can be used as a handle to facilitate the anastomosis. A Van Velthoven-type, double-armed, 4-0 Vicryl suture (5 cm long) is inserted at the angle of the ureteric spatulation and run along both sides. Once the posterior wall is anastomosed, ureteral stents are passed into the upper tracts. An opening is made in the distal conduit using the hook, and a metal laparoscopic suction tip is passed through the 15-mm assistant port into the distal conduit. The suction tip is gently advanced through the entire conduit and across the ureteral opening. A 90-cm, 8.5F, single-J ureteral stent with a guidewire is passed through the suction tip and fed gently into the ureteral opening. Once the single J stent is seen to pass into the upper ureter, the suction tip is withdrawn while the console surgeon controls the stent. The guidewire is left in the stent to allow easy identification of the stent inside the conduit. A 3-0 chromic suture is used to secure the stent to the conduit to prevent accidental dislodgement and the guidewire is removed.

The distal ureter is completely transected and sent for permanent pathologic examination. The UIA is then completed. The distal ends of the two stents are left in the 15-mm side port; the ex vivo portions of these stents should not be clamped to prevent accidental dislodgement while maneuvering the conduit inside the abdominal cavity. Subsequently, BC is reestablished. This is facilitated by insertion of the seventh, short, suprapubic port and by using the fourth arm to hold the silk suture in the two stapled ends of ileum. A 60-mm Endo GIA stapler is passed through the newly placed port straight into two enterotomies made in the two stapled ileal ends. After ensuring that the antimesenteric sides of the bowel are properly opposed, BC is reestablished. A second firing of the Endo GIA stapler, this time through the 15-mm assistant port, is used to close the enterotomy. The mesenteric window is closed using 3-0 silk sutures; reinforcement sutures can be placed if desired.

Finally, the marked stoma site is opened. A Babcock forceps is passed into the peritoneal cavity and used to grasp the marionette stitch and the ureteral stents and bring them out through the stoma site. Subsequently, the distal end of the conduit is gently externalized through the stoma site. The stoma is fashioned in the standard way.

3. Results

Patient demographics were similar across the four groups ( Table 1 ). While overall operative time (OOT) remained unchanged, diversion time significantly improved from a median of 140 min in group 1 to 103 min in group 4 ( Table 2 ). More intraoperative transfusions were noted in group 4 compared to the other three groups despite the median estimated blood loss being the lowest in group 4. Hospital length of stay (LOS) significantly increased from a median 7 d in group 1 to 9–10 d in the remaining groups. Twenty patients (20%) in this study received neoadjuvant chemotherapy and 4% received adjuvant chemotherapy. Lymph node yield and positivity, pathologic T stage, and margin status were similar across all groups (Table 2 and Table 3).

Table 1 Patient demographics

Patients 1–25 Patients 26–50 Patients 51–75 Patients 76–100 All patients p value
Age, yr, median 72 72 69 70 71 0.86
BMI, kg/m2, median 27.3 27.9 29.5 29.2 28.5 0.86
Male patients, no. (%) 23 (92) 17 (68) 14 (56) 19 (76) 73 (73) 0.026
ASA score ≥3, no. (%) 13 (52) 11 (44) 12 (48) 16 (64) 52 (52) 0.532
Previous surgery, no. (%) 10 (40) 19 (76) 15 (60) 13 (52) 57 (57) 0.06
Clinical stage <cT2, no. (%) 10 (40) 8 (32) 11 (44) 11 (44) 40 (40) 0.43
Clinical stage ≥cT2, no. (%) 15 (60) 17 (68) 14 (56) 14 (56) 60 (60)  

BMI = body mass index; ASA = American Society of Anesthesia.

Table 2 Intraoperative and pathologic parameters

Patients 1–25 Patients 26–50 Patients 51–75 Patients 76–100 All patients p value
OOT, min, median 366 349 373 344 352 0.802
DT, min, median 140 120 130 103 123 0.002
EBL, ml, median 400 350 300 200 300 0.5
Intraoperative transfusions, no. (%) 0 3 (12) 1 (4) 6 (24) 10 (10) 0.025
LNY, median no. 23 24 26 24 24 0.615
pN+, no. (%) 4 (16) 5 (20) 5 (20) 3 (12) 17 (17) 0.935
Clinical stage <pT2, no. (%) 9 (36) 10 (40) 11 (44) 5 (20) 35 (35) 0.318
Clinical stage ≥pT2, no. (%) 16 (64) 15 (60) 14 (56) 20 (80) 65 (65) 1.00
PSM, no. (%) 1 (4) 1 (4) 1 (4) 1 (4) 4 (4)  

OOT = overall operative time; DT = diversion time; EBL = estimated blood loss; LNY = lymph node yield; PSM = positive surgical margin.

Table 3 Complications

Patients 1–25 Patients 26–50 Patients 51–75 Patients 76–100 All patients p value
Follow-up, mo, median 26.5 21 12.5 5.3 12.3 <0.001
LOS, d, median 7 9 10 9 9 0.014
30-d readmissions, no. (%) 3 (12) 3 (12) 5 (20) 5 (20) 16 (16) 0.807
90-d readmissions, no. (%) 0 1 (4) 2 (8) 1 (4) 4 (4) 0.9
30-d complications *           0.068
Clavien 0, no. (%) 12 (48) 11 (44) 6 (24) 8 (32) 37 (37)  
Clavien 1–2, no. (%) 8 (32) 9 (36) 17 (68) 16 (64) 50 (50)  
Clavien 3–5, no. (%) 5 (20) 5 (20) 2 (8) 1 (4) 13 (13)  
90-d complications *           0.174
Clavien 0, no. (%) 7 (28) 6 (24) 3 (12) 3 (12) 19 (19)  
Clavien 1–2, no. (%) 12 (48) 14 (56) 20 (80) 20 (80) 66 (66)  
Clavien 3–5, no. (%) 6 (24) 5 (20) 2 (8) 2 (8) 15 (15)  

* Number of patients with the complication category of interest divided by number of patients in the group.

LOS = length of stay.

The 30-d readmissions rate ranged from 12% to 20%, with an increasing trend that was not statistically significant. Reasons for 30-d readmissions included febrile urinary tract infections (n = 7), dehydration manifesting as prerenal azotemia (n = 4), partial small bowel obstruction (n = 3), pelvic abscess (n = 1), and atrial fibrillation (n = 1).

No statistically significant differences were noted in early and late complication rates; however, reciprocal trends in overall and major complications were noted ( Table 3 ). Eighty-one patients had a postoperative complication in the first 90 d (overall complication rate: 81%), of whom 15 patients had a high-grade complication (high-grade complication rate: 15%).

A total of 164 complications were recorded within the first 90 d postoperatively ( Table 4 ). The most common complications were due to infection; this category represented 31% of overall complications. Urinary tract infections were the most common single complication and composed 13% of overall complications. Two ureterointestinal anastomotic leaks were observed. One required a percutaneous nephrostomy tube due to postoperative ileus, which was attributed to the urine leak. The other was asymptomatic and resolved spontaneously. Ninety-day mortality was 1% (one death) due to myocardial infarction ( Table 5 ).

Table 4 Complication categories

Category, no. (% of total complications) Complication Treatment of complication Frequency
Infectious, 51 (31) Urinary tract infection Antibiotics (n = 21) 21
  Fungal infection Antifungals (n = 5) 5
  Sepsis Supportive (n = 9) 9
  Fever Antipyretics plus antimicrobials (n = 16) 16
Gastrointestinal, 36 (22) Ileus Conservative (n = 16) 16
  Large bowel obstruction Conservative (n = 1) 1
  Small bowel obstruction Conservative (n = 7) 8
    Exploration (n = 1)  
  Clostridium difficile colitis Antibiotics (n = 2) 2
  Intestinal fistula Exploration (n = 1) 1
  Liver dysfunction Conservative (n = 1) 1
  Constipation Conservative (n = 5) 5
  Diarrhea Conservative (n = 1) 1
  Gastrointestinal bleeding Endoscopy (n = 1) 1
Hematologic, 18 (11) Pulmonary embolism Anticoagulation (n = 3) 3
  Deep venous thrombosis Anticoagulation (n = 1) 2
    IVC filter (n = 1)  
  Bleeding/hemorrhage Conservative (n = 1) 1
  Thrombocytopenia Conservative (n = 3) 3
  Neutropenia Observation (n = 1) 1
  Hematoma Observation (n = 1) 1
  Anemia Observation (n = 4) 5
    Transfusion (n = 1)  
  Hematuria Observation (n = 2) 2
Wound, 4 (2) Wound infection Debridement, antibiotics (n = 2) 2
  Fascial dehiscence Exploration (n = 1) 1
  Seroma Conservative (n = 1) 1
Genitourinary, 18 (11) Hydronephrosis Conservative (n = 5) 9 renal units
    Percutaneous nephrostomy (n = 4)  
  Renal failure Conservative (n = 4) 4
  Anastomotic leak, urinary Percutaneous nephrostomy (n = 1) 2
    Conservative (n = 1)  
  Epididymitis Antibiotics, NSAIDs (n = 1) 1
  Lymphocele Conservative (n = 3) 3
  Stoma dysfunction Conservative (n = 2) 2
Cardiac, 8 (5) Myocardial infarction Conservative (n = 1) 3
    Cardiac catheterization (n = 2)  
  Supraventricular arrhythmia   1
  Hypotension/shock Conservative (n = 1) 4
    Supportive (n = 3)  
  Pericardial effusion/pericarditis NSAIDs (n = 1) 1
Pulmonary, 6 (4) Apnea/hypoxia Bronchoscopy (n = 1) 1
  Pneumonitis Conservative (n = 3) 3
  Acute respiratory distress syndrome Intubation (n = 1) 1
  Vocal cord paralysis Conservative (n = 1) 1
Other, 23 (14) Pain syndrome(acute) Analgesics (n = 3) 3
  Pain syndrome(chronic) Analgesics (n = 4) 4
  Intraabdominal/thoracic collection Drainage (n = 1) 1
  Dehydration Hydration (n = 9) 9
  Neuropathy (motor) Conservative (n = 1) 1
  Psychosis, confusion, or depression Anxiolytics (n = 2) 2
  Hyperkalemia Conservative medical

Management (n = 2)
2
  Acidosis Conservative medical

Management (n = 1)
1

IVC = inferior vena cava; NSAID = nonsteroidal antiinflammatory drug.

Table 5 Early and late complications by Clavien grade

Group Clavien grade Within 30 d Within 30–90 d
Complication (no.) Complication (no.)
I 1 UTI (2), fever (1), DVT (1), hematuria (1), ileus (2), sepsis (1) Thrombocytopenia (1), fungal infection (1)
  2 Fever (1), ileus (1) UTI (2), SBO (1), vocal cord paralysis (1)
  3 Ileus (1), SBO (1), Clostridium difficile colitis (1), bleeding (1), apnea/hypoxia (1), lymphocele (1), anastomotic leak-urinary (1)
II 1 Constipation (1), dehydration (2), fever (1), chronic pain syndrome (1), wound infection (2) Epididymitis (1), anemia (1), fungal infection (1), pulmonary embolism (1),UTI (1), acute pain syndrome (1), thrombocytopenia (1)
  2 Ileus (5), fever (1), pulmonary embolism (1), SVT (1), sepsis (1), SBO (1), pneumonitis (1), dehydration (1), myocardial infarction (1) Acute pain syndrome (1), C. difficile colitis (1), sepsis (1), dehydration (1), UTI (1)
  3 Hydronephrosis (2), fistula-intestinal (1), fascial dehiscence/evisceration (1), noninfected intraabdominal/intrathoracic collection (1), hematoma (1), lymphocele (1) Lymphocele (1)
III 1 Constipation (3), UTI (3), SBO (1), dehydration (1), pneumonitis (1), chronic pain syndrome (1), anemia (2), fever (1), diarrhea (1), ileus (3), liver dysfunction (1) Anemia (1), UTI (1), hyperkalemia (1), fever (1), SBO (1), hematuria (1), neutropenia (1), thrombocytopenia (1), chronic pain syndrome (1)
  2 Ileus (4), sepsis (4), UTI (4), renal failure (1), hypotension/shock (2), pericardial effusion/pericarditis (1), fungal infection (2), pulmonary embolism (1), anemia (1), hyperkalemia (1), SBO (2), fever (1), psychosis, confusion, or depression (1), Dehydration (1), UTI (1)
  3 Myocardial infarction (1), hydronephrosis (1)  
  5   Myocardial infarction (1)
IV 1 Hydronephrosis (2), Constipation (1), Stoma

Dysfunction (1), Anastomotic leak-urinary (1), Fever (2), UTI (2),

Pain Syndrome-chronic (1), Pneumonitis (1),

Seroma (1), Neuropathy, Motor (1),

Psychosis, Confusion, or Depression (1),
SBO (1), LBO (1), UTI (2)

Hydronephrosis (1),

Fever (2), Fungal Infection (1)
  2 GI bleeding (1), Dehydration (3), Sepsis (2), Fever (4), UTI (1), Renal failure (2), Acidosis (1),

Acute Respiratory Distress Syndrome (1)
Hypotension/Shock (1),



Renal Failure (1),

Fever (1), UTI (1)
  3 DVT (1) Pain syndrome-acute (1)

UTI = urinary tract infection; DVT = deep vein thrombosis; LBO = large bowel obstruction; SBO = small bowel obstruction; SVT = supraventricular tachycardia.

4. Discussion

Minimally invasive surgical approaches to radical cystectomy and urinary diversion were introduced in an attempt to decrease postoperative complications and quicken recovery, which theoretically would allow more timely administration of adjuvant chemotherapy if needed. Other potential benefits of minimally invasive surgical approaches include smaller incisions, reduced intraoperative blood loss, less postoperative pain, minimal bowel manipulation, earlier return of bowel function, and improved quality of life [8] and [9]. Gill et al., in 2000, were the first to perform a complete laparoscopic ileal conduit after laparoscopic radical cystectomy (LRC) [10] .

LRC and laparoscopic intracorporeal urinary diversion (LICUD) are technically challenging procedures that require extensive operative experience. Laparoscopic creation of the urinary diversion has posed problems, such as difficulties with bowel reconstruction and UIA. The largest experience with LRC and LICUD came from the Cleveland Clinic [11] . Haber et al. retrospectively evaluated outcomes of LRC with LICUD versus LRC and extracorporeal diversion (ECUD). BC was restored early in the complete laparoscopic procedure, followed by stoma fashioning, and then by UIA. The complete laparoscopic approach was associated with a major complication rate of 30%. The authors reported difficulty with the intracorporeal approach in achieving proper bowel alignment, internal soiling with bowel contents during irrigation of the conduit limb, and prolonged OOT. As a result, LICUD was abandoned and all subsequent urinary diversions were performed extracorporeally [11] .

Robotic technology, with its enhanced ergonomics, represents an innovative method of simplifying ICUD and flattening the learning curve [12] and [13]. Indeed, several centers have reported their preliminary outcomes with robot-assisted intracorporeal urinary diversion (RICUD) with acceptable results [5], [14], [15], [16], [17], [18], and [19].

Schumacher et al. reported perioperative outcomes on 45 patients, divided into three groups of 15, who underwent RARC and RICUD [14] . Nine patients had RICIC (20%) and the remainder had an intracorporeal orthotopic neobladder (ONB). Mean OOT was 476 min and mean estimated blood loss was 677 ml. Median LOS was 9 d. Early (≤30 d) and late overall complications occurred in 40% and 31% of patients, respectively, with major (Clavien 3–5) complications representing half of early and late complications. Intraoperative, pathologic, and surgical complications, stratified by urinary diversion type, were recently reported [15] . The RICIC cohort was significantly older (73 vs 60 yr), had longer LOS (17 vs 9 d; p = 0.013), and higher rate of pN+ disease (33% vs 17%). No difference in complications was noted between the RICIC and ONB groups. Median overall recurrence-free survival was 84% and overall 3-yr cancer-specific survival was 86%.

We have previously published our initial experience with the first 13 consecutive RICIC and compared it to another cohort of 13 patients who underwent RARC and extracorporeal ileal conduits [5] . No differences were noted between the two groups in any of the demographic, perioperative, pathologic, and 3-mo postoperative outcomes.

Pruthi et al. published their initial results of RARC and RICUD, where 9 of 12 patients received RICIC [16] . The RICUD cohort was compared with another group of 20 patients who underwent RARC and ECUD. No significant differences in perioperative outcomes were noted except for mean OOT, which was shorter for the ECUD cohort (5.3 vs 4.2 h; p < 0.001). In the RICUD group, there was no stratification of patients according to type of diversion, probably due to small sample size. Table 6 compares all series of RICUD.

Table 6 Series of robot-assisted intracorporeal urinary diversions

Series Year Patients, no. (no. ileal conduits) BMI, kg/m2 LOS, d OOT, min DT, min Complications: early/late, %
Jonsson [15] 2011 45 (9) 24 (md) 17 (md) 460 (md) 44/33
Pruthi [16] 2010 12 (9) 28 (mn) 4.5 (mn) 320 (mn) 180 (mn) 50/67
Rehman [17] 2011 9 (9) 14 (md) 346 (mn) 72 (mn) 11
Canda [18] 2011 27 (2) 26 (mn) 11 (md) 600 (console) (mn) 48/26
Goh [19] 2012 15 (7) 27 (md) 9 (md) 450 (md) 100/14
Guru [5] 2010 13 (13) 9 (mn) 375 (md) 170 (md) 31 (late)
Present series 2012 100 (100) 29 (md) 9 (md) 352 (md) 123 (md) 63/81

BMI = body mass index; LOS = length of stay; OOT = overall operative time; DT = diversion time; md = median; mn = mean.

The current series differs from the other series of RICUD by being the largest series of RICUD, and specifically of RICIC. In addition, patients included in this study were the first 100 consecutive patients to undergo RARC and RICIC at our institution, which minimizes selection bias. No patient required conversion to ORC and all patients who demanded an ONB underwent an extracorporeal ONB procedure.

Our median OOT was 352 min, which is not markedly different from the mean OOT reported in literature for RARC and ECUD [20], [21], and [22]. It is significantly shorter than early series of ICUD [23], [24], and [25], and slightly better than our earlier reported OOT of 375 min [5] . Median diversion time was 123 min, which represents an improvement from our earlier reported time of 170 min. The continuous improvement in our OOT and diversion time reflects increasing familiarity and experience with RARC and RICUD, and flattening of the learning curve. Median LOS increased from group1 to groups 2–4, most likely due to an increasing trend in overall 30-d complications. Despite the higher overall complication rate in groups 3 and 4 compared to groups 1 and 2, most of these complications were minor and were responsible for longer LOS. In fact, early and late major complications decreased by >50% in groups 3 and 4 compared to groups 1 and 2.

Several modifications were introduced to our original technique of RICIC [5] . We abandoned isolating the proximal staple line and irrigating the conduit after the first 25–30 cases, which partly explains the improvement in our diversion time. No patient developed a conduit stone in the entire cohort. Stratifying infectious complications (overall and categorized) between the first 30 and the last 70 patients did not reveal any significant differences (data not shown). The UIA was initially performed using simple interrupted stitches. Over time, we transitioned to anastomosing the ureters to the conduit using a running (Van Velthoven) technique. Previously, the laparoscopic stapler was introduced through the 15-mm assistant port to reestablish BC. This posed a difficulty in aligning the stapler jaws parallel to the antimesenteric borders of the bowel segments to be anastomosed. After approximately the first 30 cases, we started placing a separate (seventh) port, just before reestablishing BC, to introduce the laparoscopic stapler. This port provides direct passage to bowel segments and helps avoid bowel malrotation. This port is placed in the suprapubic area and is finally extended as a Pfannenstiel incision to remove the specimen in men. We continue to mature the stoma at the end to permit flexibility with the marionette. Hence, UIA is performed first, followed by reestablishment of BC and lastly, stoma maturation.

Our overall complication rates of 63% within 30 d and 81% within 90 d postoperatively are comparable to other open series [26] and [27]. Shabsigh et al. reported all complications that occurred in 1142 ORC patients who had ≥3 mo of postoperative follow-up [26] . Ileal conduits were performed in 63% of patients. Overall, 90-d complications occurred in 64% of all patients, of which low-grade complications (Clavien 1–2) were the most common (79% of all complications). Madersbacher et al. reported complications in 131 patients who underwent open ileal conduits with median follow-up of 8 yr [27] . The overall complication rate was 66%, and 94% of patients who survived >15 yr had at least one complication.

The current study has several limitations. It is retrospective and therefore subject to selection bias. It is not a randomized study of RICUD versus ECUD. Follow-up was short and the number of patients included in the study may not be adequate to reveal any other significant statistical differences.

5. Conclusions

RICIC diversion is safe, feasible, and reproducible. Larger series with longer follow-up are needed to validate the procedure and define its place in the minimally invasive urologic armamentarium. Quality of life studies are needed to compare benefits of the total intracorporeal approach to urinary diversion.


Author contributions: Khurshid A. Guru had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Guru.

Acquisition of data: Rehman, Stegemann, Sharif, Din, Khan.

Analysis and interpretation of data: Azzouni, Rehman.

Drafting of the manuscript: Azzouni, Rehman.

Critical revision of the manuscript for important intellectual content: Guru.

Statistical analysis: Shi, Wilding.

Obtaining funding: None.

Administrative, technical, or material support: None.

Supervision: Guru.

Other (specify): None.

Financial disclosures: Khurshid A. Guru certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Khurshid Guru is a board member for Simulated Surgical Systems LLC.

Funding/Support and role of the sponsor: None.

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Footnotes

a Department of Urology, Roswell Park Cancer Institute, Buffalo, NY, USA

b Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, NY, USA

lowast Corresponding author. Department of Urology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA. Tel. +1 716 845 3389; Fax: +1 716 845 3300.