EDUCATION > Educational Programs > E-Learning > Urologic Robotic Surgery

Urologic Robotic Surgery Course

After completing this module, the learner should be able to:

  • Describe the surgical steps involved with the safe performance of robot assisted radical cystectomy (RARC).
  • State the indications and contraindications for the robotic approach to urologic surgical procedures.
  • Identify errors that can occur with the system during robotic surgery conditions.
  • Describe the steps involved with safe operation of the daVinci Surgical System (Intuitive Surgery Inc, Sunnyvale, CA).
  • Describe complications that can occur during urologic robotic surgery and describe methods to avoid and manage the complications.

Authors

Khurshid Guru, MD
Associate Professor of Oncology
Rosswell Park Cancer Institute
Buffalo, NY
Disclosures: Intuitive Surgical, Inc.: Other-Speaker

Raj S. Pruthi, MD, FACS
Chief of Urology
Professor of Surgery/Urology
Division of Urologic Surgery
The University of North Carolina
Chapel Hill, NC
Disclosures: GTx: Scientific Study or Trial

Erik Castle, MD
Associate Professor of Urology
Department of Urology
Mayo Clinic Hospital
Phoenix, AZ
Disclosures: Baxter: Consultant or Advisor; Ethicon Endosurgery: Other-Honorarium

UROLOGIC ROBOTIC SURGERY COURSE

Radical Cystectomy

Contents:

  1. Abstract
  2. Indications and Contraindications
  3. Patient and Pre-Operative Preparation
  4. Technique
  5. Lateral Pelvic Space
  6. Periureteric Space
  7. Lateral Pelvic Space and Periureteric Space
  8. Anterior Rectal Space
  9. Postoperative Care
  10. Summary
  11. Conclusions
  12. Tables
  13. Figures
  14. References

Abstract

Robot assisted radical cystectomy (RARC) is an alternative approach for treatment of bladder cancer. The technique of RARC allows precise and rapid removal of the bladder with minimal blood loss, decreased fluid shifts, and smaller surgical incisions, which will theoretically translate into less patient morbidity. Herein, we describe the operative technique of RARC, robot assisted extended pelvic lymph node dissection, and extra-corporeal urinary diversion along with a brief review of the published literature.

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Indications and Contraindications

The indication for radical cystectomy includes tumor invasion of muscularis propria, refractory carcinoma in-situ, recurrent multifocal superficial disease refractory to repeat transurethral resection with or without intravesical therapy, and may be considered for initial therapy in high grade T1 disease in select cases. Two intraoperative situations that are absolute contraindications to proceeding with RARC include: compromised ventilation with positioning and abdominal insufflation; and CO2 retention resulting in unmanageable acidosis. Relative contraindications: abnormal anatomy, morbid obesity, prior radiation, and prior abdominal or pelvic surgery.

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Patient and Pre-Operative Preparation

  1. Laboratory:
    Basic Metabolic Panel
    Liver Function Tests
    Complete Blood Count
  2. Abdominal/pelvic CT or MRI scan
  3. Some patients should be considered for neoadjuvant chemotherapy.15
  4. Bowel preparation is not necessary if ileum is to be used but may ask patient to limit to clears the day before surgery.
  5. Preoperative education for urinary diversions and appliances.

Anesthesia and Patient Positioning

Broad-spectrum antibiotics are administered within one hour of surgical incision. Sequential compression devices are placed on the lower extremities. A orogastric tube is placed. An arterial line may be inserted to monitor blood gases (potential acidosis, hypercapnia). A Foley urethral catheter is placed after the patient is prepped.

The patient is placed in low lithotomy position with arms tucked to the side. Care must be taken to assure the patient's hands and elbows are adequately padded (injury is possible for long cases). The patient is placed in extreme/maximal Trendelenburg and should be tested prior to draping. A chest strap may be employed. Shoulder harnesses should be avoided due to impingement complications.

Operating Room Equipment

  1. 0° (degree) and 30° (degree) lens are required.
  2. Robotic instruments (based on surgeon performance): Maryland bipolar, cadieré forceps, monopolar scissors or hook, fenestrated bipolar, Prograsp, and two needle drivers. (Intuitive Surgical, Sunnyvale, CA)
  3. Additional: endovascular stapler, locking clips, suction-irrigator, and atraumatic laparoscopic grasper.

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Technique

Various approaches have been used for RARC and it should be noted that the "order" of steps described below includes the completion of the lymphadenectomy before the radical cystectomy. A conceptual approach to technique is "technique of spaces" which uses an anatomic approach by developing surgical spaces and completing lymphadenectomy after cystectomy. This technique will be referenced throughout the steps in italics to identify which steps correlate to the respective part of the "technique of spaces". In female patients undergoing a cystourethrectomy, periurethral incision may be performed prior to the laparoscopic/robotic portion of the procedure and is encouraged.

Port Placement

A total of six ports are utilized. One 12 mm camera port, two 8 mm robotic arm ports, 12 mm (or 15mm to facilitate LAD specimen removal) and 5 mm assistant ports on the right, and one additional 8 mm 4th arm port on the left. If a three arm system is used, then an additional 5 mm assistant port can be placed.

The ports are arranged in an "inverted-V" fashion as diagrammed (Figure 1). Access and establishment of the pneumoperitoneum can be performed with a Veress or Hassan technique. The camera port is placed in the midline 1-4 cm cephalad to the umbilicus. The two 8 mm robotic ports are placed 8-10 cm lateral to midline and 1 cm above the level of the umbilicus. The two assistant ports on the right are placed lateral to the right robotic port and the fourth arm port is placed superior-lateral to the left robotic port.

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Lateral Pelvic Space

Mobilization of the Sigmoid and Left Colon

A 0 degree or 30 degree down lens can be used at the outset of the procedure. A 30 degree lens may be preferred for the LAD for better visualization of the retroperitoneum. The peritoneum lateral to the left colon is incised allowing access to the left ureter and vessels.

Development of the Left Paravesical Space

With the left medial umbilical ligament identified, the peritoneum lateral to the ligament and medial to the left iliac vessels should be incised. Blunt dissection is employed to expose the endopelvic fascia. In male patients, dividing the vas deferens allows the bladder to be retracted medially.

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Periureteric Space

Identification, Mobilization and Division of the Left Ureter

The left ureter is identified crossing over the iliac vessels and periureteral tissueis preserved. The left umbilical artery or left superior vesical artery is seen lateral to the insertion of the ureter into the bladder. The ureter is clipped with a locking clip that has a suture pre-tied to the clip. This suture should be at least 10 to 12 inches facilitating delivery into the extraction incision for extracorporeal reconstruction. Cephalad mobilization of the ureter should be done before dividing the ureter distally. Frozen sections can be sent.

Perform the Left Pelvic Lymphadenectomy

The authors currently use a Maryland bipolar in one hand and monopolar scissors in the other hand. The dissection is begun on the left external iliac artery. A "split-and-roll" technique is utilized. The dissection should be carried proximally up to the bifurcation of the aorta. Great care should be taken during dissection along the external and common iliac veins due to the collapsed nature of the veins from the pressure of the pneumoperitoneum. By following a line directly posterior to the point where the external iliac vein crosses the pubic ramus, one can find the obturator nerve and vessels. The hypogastric artery should be skeletonized. Locking clips can be used a the discretion of the surgeon but the authors recommend at least using one clip on the distal and proximal borders of the LAD packet to minimize the risk of lymph leak.

In order to maximize the removal of lymph nodes from the pelvis, dissection should be carried lateral to the external iliac vessels ("space of Marcille"). This facilitates removal of the proximal internal iliac lymph nodes and lymph nodes posterior and inferior to the obturator nerve. Lymph nodes can be removed in separate packets with 10 mm specimen retrieval bags.

The dissection performed along the lateral border of the pelvic vessels should be carried proximally up to the aortic bifurcation. A small arterial branch to the psoas muscle may be encountered along the proximal portion of the external iliac artery and can be spared or clipped and divided. The inferior vena cava will be easily visualized along the proximal and lateral border of the right common iliac artery.

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Lateral Pelvic Space and Periureteric Space

Development of the Right Paravesical Space, Right Ureter, and Right Lymphadenectomy

The right paravesical and the lateral pelvic spaces is developed similar to the left (Figure 2 and Figure 3). Similar dissection as done on the left but it should be noted that the incision in the retroperitoneum on this side should be extended over the right side of the sigmoid mesentery to develop the preaortic space. The incision of the peritoneal surface allows for creation of an adequate space for passage of the left ureter.

Identification, Ligation, and Division of the Superior Vesical Arteries

The umbilical and superior vesical arteries are clearly seen at the completion of the lymphadenectomy and are clipped. Clipping or stapling is recommended and may allow for more distal dissection of the ureters. If the ureters have not already been tagged with a pre-tied clip, then one should switch instruments to needle drivers and tag the distal ends of both ureters.

Transferring the Left Ureter Through the Sigmoid Mesentery

The left ureter can be transposed behind the sigmoid mesentery with the help of the right side assistant. The right side assistant should gently advance a blunt-tipped instrument below the mesentery along the anterior surface of the aorta. The sigmoid is moved to the right and the advanced instrument tip should be visualized. The tag on the left ureter can be grasped and the ureter should easily pass through the mesenteric window.

Tagging the Distal Ileum with 8-10 Inch 2-0 Polyglactin Suture

The ileum should be tagged with a 2-0 polyglactin suture. This too should be left at least 10-12 inches in length. It is often helpful to mobilize the lateral attachments of the cecum so as to facilitate delivery of the ileum into the abdominal incision and make identification of the distal portion of the ileum easier.

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Anterior Rectal Space

Development of the Pre-Rectal and Posterior Vesical Space (Figure 2 and (Figure 4)

The camera lens can be changed to a 0° (degree) lens for optimal visualization. The peritoneum extending from the posterior bladder to the anterior sigmoid should be incised (Figure 2 and (Figure 5). One must employ the assistant(s) to retract the bladder and its posterior structures anteriorly. In male patients, Denovillier's fascia needs to be incised to carry the dissection as far caudad as possible. The dissection should be carried down to the rectourethralis muscle as this is easier now rather than after the bladder is completely mobilized.

In female patients, the dissection is carried along the anterior vaginal mucosa in a vaginal sparing procedure. If the anterior vaginal wall will not be spared then a sponge-stick placed in the vagina allows identification of the vaginal cuff. Incision of the vaginal apex can be performed with the hook electrode monopolar scissors. Although some gas may escape through vaginal opening, a sponge-stick seems to occlude the vagina sufficiently. The dissection is then carried down to the posterior aspect of the periurethral incision that may have been made at the beginning of the operation. In a nerve sparing procedure for women, the incision of the vagina should be as anterolateral as possible. Lateral vaginal tissue should be preserved to spare any neurovascular tissue coursing along the anterolateral aspect of the vagina.

Preservation of the Neurovascular Bundles

In nerve sparing procedures, the neurovascular bundles are encountered as they project off the postero-lateral aspects of the prostate down to the anterior surface of the colon. The bundles can be mobilized by releasing lateral fascia anterior to the bundles along the surface of the prostate or vagina. The inferior vesical pedicles and prostate pedicles should be clipped and divided with cold scissors to avoid neurovascular injury. Once the nerves are mobilized, the remaining posterior and lateral attachments of the bladder and/or prostate can be completed. At this point, the remaining bladder attachments should only be the urachus, anterior attachments, prostate, and urethra. The urachus can now be mobilized and divided.

Complete the Apical Dissection

The endopelvic fascia should be incised bilaterally. The apical dissection of the prostate or vagina is then completed. At this point the dorsal venous complex can be ligated with a 1 polyglactin suture in a figure of eight fashion. Although an endovascular stapler can be employed for this step, suture ligation allows for better visualization and identification of the urethra and prevents bleeding during the extracorporeal reconstruction when the pneumoperitoneum has been released.

Dissection, Ligation and Division of the Urethra

It is very important to dissect a generous urethral stump even in cases without a planned neobladder. This allows for easier application of a locking clip or suture ligation to prevent tumor spillage during division. A frozen section can be taken.

Specimen Extraction

The specimen is entrapped in a 15 mm specimen retrieval bag and extracted though a 5-6 cm infraumbilcal or periumbilical incision. Prior to extraction, the tags on the ureters and the ileum should be grasped in a locking grasper by the bedside assistant to allow delivery into the extraction incision.

Creation of Ileal Conduit/Neobladder Urinary Diversion

The urinary diversion can be created through the extraction incision. An ileal conduit can be done in standard open fashion through the incision. For neobladders, variations of technique have been described. In some cases, it is easier to simply make the extraction incision lower and close to the pubic symphisis, allowing for placement of anastomotic sutures in an "open" fashion and is an option in many patients.

If the urethroneovesical anastomosis is to be done robotically then a urethral catheter should be passed through the urethra and delivered through the extraction incision. The distal portion of the catheter can then be inserted into the anticipated urethral anastomotic site, and anastomotic sutures (2-0 Monocryl – UR-6 or 3-0 RB-1-Ethicon Inc.) can be pre-placed in the posterior lip of the anastomosis. Gentle traction of the urethral catheter will allow for easier downward traction on the neobladder into the pelvis and down to the urethral stump. Stents can be left in the neobladder or sutured to the tip of the catheter if possible.

Placement of Abdominal Drains and/or Suprapubic Tube

One or two abdominal drains can be placed through the existing port sites. Although not routinely used, if one chooses to place a suprapubic tube, the urethral catheter should be withdrawn into the urethra to prevent damage to the balloon of the catheter. Ports should be closed based on surgeon preference.

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Postoperative Care

The orogastric tube is removed after surgery. Antibiotic regimen can be limited to the first 24 hours. Intravenous narcotics and/or ketorolac are adequate for pain management.

Early ambulation is recommended starting on the first post-operative day. A liquid diet is started once bowel function returns in the form of flatus. Third spacing is minimal and additional fluid boluses are often not needed.

Ureteral stents, abdominal drains, loopograms and cystograms should be managed according to surgeon preference. Currently, the authors remove stents from a urostomy at 7-10 days. Foley's are removed from neobladders in 14-21 days. If the stents were not secured to the Foley urethral catheter during creation of the neobladder, then they are removed cystoscopically.

It should be noted that patients can be discharged home rather quickly which may require leaving drains or stents in place until the first office follow-up. Some patients may have a continued leak of lymphatic fluid through a drain site up through the fifth or sixth post-operative day and from the urethra up to 2 weeks. This drainage is self-limiting and uniformly resolves.

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Summary

Radical cystectomy and urinary diversion remains the cornerstone for the surgical management of bladder cancer. Despite its effectiveness, the procedure is associated with significant morbidity with mortality rates approaching 2%.1 Urology has embraced minimally invasive surgery which has been clearly seen by the shift in approach to radical nephrectomy2 and radical prostatectomy.3

In 2003, Menon et al. published the first series of robot assisted radical cystectomy (RARC) and urinary diversion.4 Several technical and physiologic aspects of RARC may potentially translate into decreased morbidity for our patients. Decreased blood loss, less insensible losses, less retractor strain and less fluid shifts and all potential benefits. In addition, less bowel manipulation may translate into shorter ileus. Ng et al reported decreased blood loss, transfusion rate, hospital stay, and complication rate with RARC compared to open radical cystectomy.5

Despite these benefits, RARC has been approached with caution over oncologic concerns. Urothelial cell carcinoma of the bladder is a lethal disease with survival of 15% at 2 years if muscle invasive disease is left untreated.6 The "quality" of a radical cystectomy affects patients' survival.7 Two areas that need to be addressed with RARC, are maintaining negative surgical margins and performing an adequate pelvic lymph node dissection (PLND). Several recent reports of RARC have addressed and shown positive surgical margin rates of 0-7.2% 5,8 which are comparable to open radical cystectomy literature.9 The incidence of lymph node involvement at the time of radical cystectomy is approximately 25%.10 A proper PLND is required to help identify patients who may benefit from adjuvant chemotherapy.11,12 Recent literature suggest that experienced surgeons are performing an adequate PLND at the time of RARC with node counts ranging from 18-25.5,8,13 Pruthi and Wallen reported short-term cancer outcomes in 50 patients.8 They had a mean follow-up 13.2 months and experienced an overall and disease-specific survival of 90 and 94%, respectively. Survival data from the Mayo Clinic Arizona and Tulane University has been published.14 There was a total of 80 patients, 59 of which had >6mo follow-up and comprised the study group. The mean follow-up was 25 months (range 6-49). The overall survival at 12, 24, and 36 months was 82, 69, and 69%, respectively, and recurrence free survival at 12, 24, and 36 months was 82, 71, 71%, respectively.

Accessory Instruments:
- Allen stirrups (yellow fins)
- Egg crates & gel pads customized to cover pressure points
- Scope Warmer
- Endo-catch Bag; 15mm (bladder specimen)
- Endo-pouch retriever for lymph nodes; 10 mm (lymph nodes)
- Rectal Tube 24 French (If needed)
- Foley Catheter 24 French 30cc balloon
- Hem-o-lok (Weck Clip); (ML, L, XL)
- Irrigation Suction System
- Suction Irrigation probe

Laparoscopic Instruments & Trocars:
- Pneumo-needle insufflation needle with luer lock
- MicroFrance grasper
- Needle holder
- Non-Ratcheted curved scissors
- 10/12 mm Trocar (1)(Camera port)
- 5 mm Trocar (1)(Suction port)
- 15 mm Trocar (1)(Right assistant port)

Robotic Instruments:
- Endo-wrist Fenestrated bipolar (1)
- Round Tip Scissors (1)
- Hook Permanent cautery or Thermal Scissor (1)
- Needle driver large (2)
- Cobra Grasper (1)

Sutures: (Surgeon Preference)
- Vicryl CT-2 (control of dorsal venous complex)
- Silk CT-1 424H (Tagging of ureters)
- 3.0 Monocryl RB-1 Y215H/Y305H (neobladder-urethral anastomosis)

Stapler (vascular):
- Endo GIA Roticulator (Universal)(Autosuture- Covidien) 45-2.5; (4-6 refills available in OR room)

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Conclusions

The results of current published reports of laparoscopic and robot assisted radical cystectomy are encouraging and demonstrate the technical feasibility of managing muscle invasive bladder cancer with minimally invasive surgery. These suggest that an adequate resection can be performed along with an extended pelvic lymphadenectomy. All forms of urinary diversions can be created and offered to patients. Long term oncologic efficacy is needed but urologists will be able to add robot assisted radical cystectomy to the armamentarium of treatment modalities for bladder cancer.

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Tables

Table 1. Male Radical Cystectomy: Technique of Spaces

Surgical Step

Lens

Right
Robotic Instrument

Left
Robotic Instrument

Fourth
Robotic
Arm

Right Assistant Port

Port placement/ Lysis of adhesions

30 up

-

-

-

Microfrance grasper/ Non-Ratcheted Curved Scissors

Peri-ureteral space

0

Round Tip Scissors

Fenestrated Precise Bipolar

Cobra Retracts the Sigmoid

Suction

Lateral Pelvic Space

0

Monopolar Cautery Hook

Fenestrated Bipolar

Cobra Retracts the Bladder

Suction

Anterior Rectal Space

0

Round Tip Scissors

Fenestrated Bipolar

Cobra lifts the Bladder Anteriorly

Suction

Control of Vascular Pedicle& Division of Ureters

0

Round Tip Scissors

Fenestrated Bipolar

-

Hem-o-lok (Weck)Clip/Endovascular Stapler

DVC Control

0

Needle Driver

Needle Driver

Cobra Grasper Retracts Bladder Specimen

Suction

Extended pelvic lymph node dissection

0

Monopolar Cautery scissor Hook

Fenestrated Bipolar

-

Suction

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Figures

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

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References

  1. Lowrance WT, Rumohr JA, Chang SS, Clark PE, Smith JA, Jr., Cookson MS. Contemporary open radical cystectomy: analysis of perioperative outcomes. J Urol. Apr 2008;179(4):1313-1318; discussion 1318.
  2. Portis AJ, Yan Y, Landman J, et al. Long-term followup after laparoscopic radical nephrectomy. J Urol. Mar 2002;167(3):1257-1262.
  3. Badani KK, Kaul S, Menon M. Evolution of robotic radical prostatectomy: assessment after 2766 procedures. Cancer. Nov 1 2007;110(9):1951-1958.
  4. Menon M, Hemal AK, Tewari A, et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int. Aug 2003;92(3):232-236.
  5. Ng CK, Kauffman EC, Lee MM, et al. A Comparison of Postoperative Complications in Open versus Robotic Cystectomy. Eur Urol. Jun 10 2009.
  6. Prout GR, Marshall VF. The prognosis with untreated bladder tumors. Cancer. May-Jun 1956;9(3):551-558.
  7. Herr HW, Faulkner JR, Grossman HB, et al. Surgical factors influence bladder cancer outcomes: a cooperative group report. J Clin Oncol. Jul 15 2004;22(14):2781-2789.
  8. Pruthi RS, Wallen EM. Is robotic radical cystectomy an appropriate treatment for bladder cancer? Short-term oncologic and clinical follow-up in 50 consecutive patients. Urology. Sep 2008;72(3):617-620; discussion 620-612.
  9. Herr H, Lee C, Chang S, Lerner S. Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report. J Urol. May 2004;171(5):1823-1828; discussion 1827-1828.
  10. Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. Feb 1 2001;19(3):666-675.
  11. Ruggeri EM, Giannarelli D, Bria E, et al. Adjuvant chemotherapy in muscle-invasive bladder carcinoma: a pooled analysis from phase III studies. Cancer. Feb 15 2006;106(4):783-788.
  12. Adjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis of individual patient data Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Eur Urol. Aug 2005;48(2):189-199; discussion 199-201.
  13. Guru KA, Sternberg K, Wilding GE, et al. The lymph node yield during robot-assisted radical cystectomy. BJU Int. Jul 2008;102(2):231-234; discussion 234.
  14. Martin AD, Nunez RN, Pacelli A, et al. Robot-assisted radical cystectomy: intermediate survival results at a mean follow-up of 25 months. BJU Int. Nov 9 2009.
  15. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. Aug 28 2003;349(9):859-866.

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Module 9 Radical Cystectomy Posttest Available 1.50 credits/hours

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