Robotic-Assisted Laparoscopic Radical Cystoprostatectomy and Intracorporeal Urinary Diversion (Studer Pouch or Ileal Conduit) for Bladder Cancer

Bladder cancer is the fourth most common malignancy in American men and almost 25% is muscle invasive at the time of diagnosis (Cancer Facts and Figures, 2009; Nieder et al., 2008). Currently, most effective local treatment of muscle invasive bladder cancer and noninvasive, high-grade bladder tumors that recur or progress despite intravesical therapies is open radical cystoprostatectomy with urinary diversion (Clinical Practice Guidelines in Oncology, 2010; Huang et al., 2007). With the advancement of technology, minimally invasive surgical approaches including laparoscopic (Huang et al., 2010; Guazzoni et al., 2003) or robotic-assisted laparoscopic (Akbulut et al., 2011; Rehman et al., 2011; Kauffman et al., 2011; Hellenthal et al., 2010; Kasraeian et al., 2010; Pruthi et al., 2010; Schumacher et al., 2009) cystectomies are increasingly being performed. This chapter summarizes the current state of the use of the surgical robot in performing radical cystoprostatectomy with urinary diversion in patients with bladder cancer.


Introduction
Bladder cancer is the fourth most common malignancy in American men and almost 25% is muscle invasive at the time of diagnosis (Cancer Facts and Figures, 2009;Nieder et al., 2008).Currently, most effective local treatment of muscle invasive bladder cancer and noninvasive, high-grade bladder tumors that recur or progress despite intravesical therapies is open radical cystoprostatectomy with urinary diversion (Clinical Practice Guidelines in Oncology, 2010; Huang et al., 2007).With the advancement of technology, minimally invasive surgical approaches including laparoscopic (Huang et al., 2010;Guazzoni et al., 2003) or robotic-assisted laparoscopic (Akbulut et al., 2011;Rehman et al., 2011;Kauffman et al., 2011;Hellenthal et al., 2010;Kasraeian et al., 2010;Pruthi et al., 2010;Schumacher et al., 2009) cystectomies are increasingly being performed.This chapter summarizes the current state of the use of the surgical robot in performing radical cystoprostatectomy with urinary diversion in patients with bladder cancer.

Why to use a surgical robot?
Radical cystoprostatectomy with bilateral extended lymph node dissection and urinary diversion (Studer pouch reconstruction or ileal conduit formation) are complex and time consuming surgical procedures.Performing these complex procedures in an open surgical approach is well established.To perform these complex procedures pure laparoscopically is extremely difficult.However, the use of a surgical robot enables the operating surgeon to perform these procedures much more easily because it has the advantages of the 3dimensional and magnified image capability, higher grades of wristed hand movements, decreased hand tremor leading to a shorter learning curve.Besides, having the 4 th -robotic arm gives the advantage of additional assistance and tissue retraction and letting the console surgeon to operate in a comfortable sitting position rather than standing position for long hours.Menon et al suggested that robotic approach combines the oncological principles of

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A recent review from the Memorial Sloan-Kettering Cancer Center has recently evaluated the oncological outcomes after radical cystectomy for bladder cancer comparing open versus minimally invasive approaches (Chade et al., 2010).Although the follow-up is limited in robotic series compared to open surgical approach, robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years and 90% to 96% overall survival in 1 to 2 years of follow-up.On the other hand, large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years.With these limited current data, robotic approach seems to provide sufficient short-term surgical oncologic efficacy in patients with bladder cancer.

Comparison of cost
Controversial reports exist regarding the cost analysis of open versus robotic approaches.One study revealed that robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost than the open approach in the perioperative setting (Smith et al., 2010).Whereas, another study suggested that although robotic approach is more expensive in terms of operative costs and robotic supplies, due to decreased hospital stay in robotic approach and higher complication rates with open surgical approach make total actual costs much higher than robotic approach (Martin et al., 2011).

Surgical oncologic safety of robotic approach (lymph node yield and surgical margins)
Regarding open radical cystectomy, lymph node yield and positive surgical margin rates are considered as the significant factors related to surgical quality (Herr et al., 2004;Skinner et al., 2007;Stein et al., 2003).Herr et al and Skinner et al suggested a lymph node yield of greater than 10 and a positive surgical margin rate of less than 10% in surgical oncologic adequacy (Herr et al., 2004;Skinner et al., 2007).Stein et al suggested a lymph node yield of greater than 15 obtained during open radical cystectomy in order to be oncologically acceptable and sufficient (Stein et al., 2003).Guru et al evaluated whether robot assistance allows adequate pelvic lymph node dissection particularly during the initial experience (Guru et al., 2008).In a series of 67 patients, mean number of lymph nodes retrieved was 18 (6-43) (Guru et al., 2008).Mean lymph node yield was 41.8 (18-67) in another series of 15 consecutive patients who underwent robotic radical cystectomy for bladder cancer (Lavery et al., 2010).Recently, International Robotic Cystectomy Consortium (IRCC) evaluated 527 patients who underwent robotic cystectomy for bladder cancer and mean lymph node yield was 17.8 (range 0-68) (Hellenthal et al., 2011).Mean lymph node yield was 21.3 (range, 8-38) and 24.8.9.2 in our initial series of 12 (Akbulut et al., 2011) and 27 cases (unpublihsed data), respectively.Positive surgical margin rates were reported as 6.8%, 0%, 7.2% and 2% in 513, 83, 100 and 50 robotic cystectomy patients (Hellenthal et al., 2010;Pruthi et al., 2010;Ng et al., 2010;Shamim Khan et al., 2010).In our initial series of 12 patients, positive surgical margin rate was 0% (Akbulut et al., 2011).We had only one patient with positive surgical margin (3.7%) who had pT4b disease in the total of 27 patients underwent totally intracorporeal robotic cystectomy (unpublihsed data). www.intechopen.com

Learning curve of robotic approach
Robotic-assisted laparoscopic radical cystectomy with bilateral extended lymph node dissection and particularly intracorporeal urinary diversion (Studer or ileal conduit) are complex procedures.Therefore, a learning curve is required in order to perform these procedures successfully.Regarding the completion of the learning curve of robotic cystectomy, some authors have suggested to perform a certain number of cases in the literature.International Robotic Cystectomy Consortium (IRCC) suggested that 21 cases were needed to be performed for operative time to reach 6.5 hours and 8, 20 and 30 patients were required to reach a lymph node yield of 12, 16 and 20, respectively (Hayn et al., 2010).On the other hand, others reported that after the first 20 cases of robotic cystectomy, no further significant improvement was detected in terms of intraoperative parameters, pathologic outcomes and complication rates (Pruthi et al., 2008).Following evaluation of 100 cases of robotic cystectomy, Guru et al stated that operative results and oncologic outcomes for roboticassisted radical cystectomy constantly improve as the technique evolves (Guru et al., 2009).We have started performing robotic urological procedures at our institution in February 2009, following initially performing more than 50 cases of robot assisted laparoscopic radical prostatectomy cases some of which also included pelvic lymph node dissection.We recommend to start performing robotic cystectomy cases after a certain experience gained particularly on robotic radical prostatectomy.Additionally, a good knowledge of the pelvic anatomy and adequate open surgical experience are essential.

Surgical technique 6.1 Patient position
Patient is placed in deep (30°) Trendelenburg position at the beginning of the procedure until the completion of robotic cystectomy, bilateral extended lymph node dissection and transposition of the left ureter under the mobilized sigmoid colon.During performing intracorporeal Studer pouch reconstruction or ileal conduit formation, patient position is adjusted to mild (5°) Trendelenburg position.A Veress needle is introduced into the abdominal cavity about 2 cm above the umbilicus.Intra-abdominal pressure is set to 10-12 mmHg during performing bilateral extended lymph node dissection.Regarding rest of the surgery, intra-abdominal pressure is set to 16-18 mmHg.

Abdominal port locations
Overall, we use 6 trocars with the 4 th -arm of the surgical robot placed on the patient's right which provides easy control to the right-handed console surgeon (Figure 1).Camera port (12-mm) is placed 2 cm above the umblicus.Two robotic trocars (8-mm) are placed 8 cm apart from the camera port at the level of the umblicus.An 8-mm sized robotic trocar is placed 3 cm vertically above from the right iliac crest for the 4 th -arm.We use 2 assistant trocars on the left abdomen for the assistant surgeon: A 15-mm trocar for introducing for tissue staplers for bowels and endobags for specimens is placed 3 cm vertically above from the left iliac crest and a 12-mm trocar is placed between the camera port and the 2 nd -robotic arm.Peritoneum on the anterior wall of the Douglas' pouch is incised and posterior dissection of the prostate is carried out (Figure 3).Following the identification of seminal vesicles, Denonvilliers' fascia is opened (Figure 4).Tissue lateral to the tip of the seminal vesicles corresponding to the mid point of the pararectal plexus is marked with Hem-o-lok® clips on both sides (Figure 5).Prostate is dissected off of the rectum.Lateral bladder pedicles are severed with vessel sealing system (Ligasure®) until the Hem-o-lok® clips placed at the tips of the seminal vesicles to mark pararectal plexus of which the neurovascular bundles originate (Figure 6).Then, endopelvic fascia is opened on both sides.Dorsal venous complex is ligated by 0/0 vicryl (40 mm ½ RB needle).High anterior release (intra-fascial) neurovascular bundle preservation is performed on both sides by dissecting the periprostatic fascia over the prostatic capsule alongside the prostate down until the dorsal venous complex suture and bilateral neurovascular bundle dissections are completed (Figure 7).Starting from the umblical level, urachus is dissected by incising lateral to the medial umblical ligaments on the anterior abdominal wall.Puboprostatic ligaments are cut.Ligated dorsal venous complex (Figure 8) and ligated membraneous urethra (Figure 9) with 0/0 vicryl (40 mm ½ RB needle) to prevent tumor spillage are cut.Cystoprostatectomy is completed (Figure 10) and specimen is put into the endobag.Urethral stump is sampled for frozen section analysis.Then, bifurcation of common iliac artery are identified and lymphatic tissues located below the obturator nerve and surrounding the internal iliac artery are removed.Later, lymphatic tissues medial to the genitofemoral nerve and around the common iliac artery are dissected until the aortic bifurcation.Same lymphatic dissection is performed on the other side.Then, lymphatic tissues which are located distal to the aortic bifurcation, overlying and distally located to the vena caval bifurcation and common iliac arteries and veins are removed followed by presacral lymph nodes anterior to the sacrum.Lastly, preaortic and paracaval lymphatic dissections are performed.Inferior mesenteric artery on the aorta makes the most proximal end of the extended lymphatic dissection (Figure 12).Hem-o-lok® clips are used in order to tie off the most distal parts of the lymphatic vessels draining the limbs to prevent or reduce lymphatic leakage and lymphocele formation.Having completed the extended lymph node dissection, sigmoid colon is mobilized and left ureter is transposed to the right gutter underneath the sigmoid colon above the vasculature.

Robot assisted laparoscopic intracorporeal Studer pouch reconstruction (Canda et al., 2011; Akbulut et al., 2010; Akbulut et al., 2011)
Using a double armed 3/0 monocryl (17 mm ½c RB needle) urethral remnant is anostomosed to the assigned 1 cm opening on the antimesenteric wall of the most dependent part of the segregated ileum, initially (Figures 13,14).A 10 cm ileal segment on the right and a 40 cm ileal segment on the left side of urethroileal anastomosis are assigned for the pouch sparing the distal 20 cm ileal segment adjacent to the ceacum.Laparoscopic intestinal staplers are introduced through the 15 mm assistant port on the left side and placed perpendicular across the ileum and adjacent mesointestinum of approximately 2 cm (Figure 15).Side-to-side ileoileostomy is performed using two additional laparoscopic intestinal staplers between proximal and distal ends of the ileum (Figure 16).Proximal 10 cm segment of the segregated ileum is spared as afferent loop.Then, a 60 cm feeding tube is inserted through the urethra and advanced within the lumen of the ileal segment until the proximal end of the afferent loop.Next, sparing the afferent loop, antimesenteric border of the remaining ileal segment is incised.Asymmetric closure of the posterior wall is accomplished with interrupted 2/0 vicryl (30 mm ½c RB needle) sutures f o l l o w e d b y a r u n n i n g s u t u r e o f 3 / 0 m o n o c r y l ( 2 6 m m ½ c R B n e e d l e ) .A n t e r i o r w a l l anastomosis is accomplished using a running 3/0 monocryl (26 mm ½c RB needle) (Figure 17).Distal ureteric ends are spatulated and anastomosed to each other at their medial edges in order to develop a common ureteral duct (Figure 18).Double J stents with long strings at their distal ends are passed through inside the feeding tube over a guide wire to the uretero-intestinal anostomosis site and fed up to the ureters and renal pelves (Figure 19).Distal tips of the stents are tied to the tip of a 22F urethral catheter outside the body, which will then be passed through the urethra into the completed Studer pouch over a guide-wire.A Wallace type uretero-intestinal anostomosis is performed between common ureteral duct and proximal end of the afferent loop.To do this anostomosis, medial edge of the ureteral duct is sutured to the medial edge of the ileal wall with a double armed 4/0 monocryl (22 mm ½c RB needle) running suture.After internalization of the double-J stents, rest of the ureteroileal anastomosis is completed (Figure 20).Ureteroileal anastomosis is retroperitonealized by using several interrupted sutures in the right gutter laterally.Patients are discharged after tolerating an oral diet and sufficient ambulation following removal of the lodge drain.A cystography is done by filling the bladder with 200 cc of diluted contrast material on the postoperative 21 st -day.When no leakage is seen, urethral catheter is removed.If leakage is detected, urethral catheter is kept for one more week and removed after another cystography.

Robotic-assisted laparoscopic intracorporeal ileal conduit formation (Canda et al., 2011)
Initially, sigmoid colon is mobilized and left ureter is transposed to the right gutter underneath the sigmoid colon above the vasculature.20 cm ileal segment including the terminal ileum adjacent to the ceacum is spared and a 15-20 cm of ileal segment is segregated by using tissue staplers.A Wallace type uretero-ureteric anastomosis is performed as explained above.For inserting the JJ stents into the renal pelves, a feeding tube is passed through the urethra and advanced within the lumen of the ileal segment.Its tip is held close to anastomozed ureteral lumens and JJ stents are passed over a guide wire up to the renal pelves.Then, uretero-ileal anostomosis is performed by using a double armed running 3/0 monocryl suture (Figure 23).Ureteroileal anastomosis is retroperitonealized by using several interrupted sutures in the right gutter laterally.

Fig. 2 .
Fig. 2. Ureters are dissected, double clipped and cut where they enter the bladder (left side).Arrow: left ureter, arrowhead: incised and opened peritoneum on the left side.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)

Fig. 5 .
Fig. 5. Tip of the seminal vesicle is marked with a Hem-o-lok® clip and cut (arrow).(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)

Fig. 12 .
Fig. 12. Completed bilateral extended lymph node dissection and appearance of the major abdominal vasculature that are skeletonized.A: abdominal aorta, VCI: vena cava inferior, Arrows: right and left common iliac arteries, Arrowhead: right external iliac artery.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)

Fig. 18 .
Fig. 18.Distal ureteric ends are spatulated and anastomosed to each other at their medial edges in order to develop a common ureteral duct before reconstruciton of a Wallace type uretero-ureteral and intestinal anastomosis.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)

Fig. 19 .
Fig. 19.Use of a feeding tube for inserting the double J catheters through the urethra, within the lumen of the ileum and into the ureters up to the renal pelves.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey) Fig. 20.Stapler line is excised at the proximal end of the afferent loop and posterior wall is anastomosed halfway between the ileal wall and medial edge of the uretero-ureteric anastomosis with a double armed 4/0 monocryl (22 mm ½c RB needle) running suture.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)Watertightness of the created Studer pouch is tested filling it with 150 cc of saline (Figure21).
Fig. 21.Completed intracorporeal Studer pouch.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)Robotic-assisted laparoscopic radical cystoprostatectomy with intracorporeal Studer urinary diversion leads to better wound healing with excellent cosmetic result (Figure22).

Fig. 22 .
Fig. 22. Postoperative 6 th -month abdominal appearance of a male patient who underwent robotic-assisted laparoscopic bilateral neurovascular bundle sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal Studer pouch formation for bladder cancer.(Archive of Ankara Atatürk Training and Research Hospital, 1 st Urology Clinic, Ankara, Turkey)