Presentation Authors: Graziano Vignolini, Arcangelo Sebastianelli, Alessandro Pili, Campi Riccardo*, Francesco Sessa, Isabella Greco, Nicola Mormile, Pietro Spatafora, Mauro Gacci, Sergio Serni, Firenze, Italy
Introduction: Robot-assisted cystectomy (RARC) with intracorporeal ileal neobladder can be offered to selected patients with muscle-invasive or high-risk non-muscle invasive bladder cancer. However, it represents a challenging surgical procedure with high morbidity rates and long operative time. As a high-volume robotic center with a longstanding experience in open reconstructive surgery, we started a robotic program for RARC and herein we describe our step-by-step technique and preliminary results of RARC with hybrid modified vescica ileale padovana (mVIP) neobladder reconstruction, aiming to reduce morbidity and operative time.
Methods: Between March 2018 and July 2018 selected patients with clinical T2N0M0 bladder cancer underwent RARC with hybrid mVIP reconstruction at our institution. Patients followed the ERAS protocol.All the procedures were performed by a single surgeon with extensive experience in robotic urologic surgery and open radical cystectomy and ileal neobladder reconstruction.Surgical technique for RARC replicated the principles of Collins technique with specific technical modifications. We used GelPOINT hand-assisted device and early clamping and section of the urethra (with a 12ch catheter), in order to obtain a timely removal of the tumor-bearing bladder and lymph nodes avoiding potential tumor seeding, and to perform an extracorporeal bowel anastomosis and neobladder posterior wall and neck reconstruction. RARC was performed with DaVinci Si/Xi platform in a 4 arms configuration using a 0Â° lens. After induction of general anesthesia, with patient lying in supine position a 5 cm midline supraumbilical incision was made for GelPOINT access device. A step-by-step overview of the reconstructive surgical technique is shown in the video accompanying the abstract.
Results: Overall, 5 patients underwent RARC with hybrid mVIP during the study period (4 males, 1 female). Median follow-up was 5 months. Median console time was 625 min. Median hospital stay was 11 days. Postoperative surgical complications occurred in 3/5 patients, including: 1 leakage from the urethro-neobladder anastomosis which required a prolonged catheterization time (31 days) and 2 early Clavien-Dindo Grade I, leading to the outage of ERAS protocol. No Clavien-Dindo > II or bowel complications were recorded and no cancer recurrences were observed.
Conclusions: RARC with hybrid neobladder reconstruction is technical feasible and achieves favorable safety outcomes. Hybrid reconstruction allows a better control of the ileal anastomosis and a reduction of surgical time, retaining the advantages of mini-invasivity and intracorporeal ureteral and urethral anastomosis. Moreover, the use of GelPOINT device and early clamping of the urethra may increase oncological safety.