EAU 2019: The "Ten Commandments" of Intracorporeal Ileal Conduit During Robot-Assisted Radical Cystectomy

Barcelona, Spain (UroToday.com) Robotic-assisted radical cystectomy with urinary diversion has become increasingly employed as an alternative surgical option to open radical cystectomy with urinary diversion for patients with muscle-invasive bladder cancer.  Earlier in the robotic cystectomy learning curve, many surgeons performed an extracorporeal urinary diversion due to an early lack of described techniques to perform a fully intracorporeal urinary diversion.  Over the last several years, however, many surgeons have described their techniques for performing a fully intracorporeal urinary diversion.

Dr. Tushar Aditya Narain, from the Post Graduate Institute of Medical Education and Research, Department of Urology, in Chandigarh, India presented his “10 commandments” of intracorporeal ileal conduit urinary diversion during robotic-assisted radical cystectomy as part of the 2019 European Association of Urology’s Annual meeting in Barcelona, Spain. Dr. Narin has performed over 25 of these procedures now and feels as though he has developed several “tricks and tips” that can be helpful in successfully creating the urinary diversion.

After robotic-assisted radical cystectomy is created, Dr. Narain’s first step is to identify the ileocecal junction and place a stay suture in the bowel roughly 15cm proximal to this.  He then creates an ileal conduit of adequate length based on the mesenteric length and thickness of the patient’s abdominal wall.  He uses an endo-GIA stapler to transect both the proximal and distal ends of what will become the conduit.  He next brings the proximal and distal aspects of what will become his side-to-side enteroenterostomy superior.   He creates this anastomosis again using an endo-GIA stapler and uses two staple loads to ensure an adequate luminal caliber.  He uses a third staple load to close the open aspect of the side-to-side anastomosis.   He inverts the staple lines using Vicryl sutures and reinforces the “crotch” end of the anastomosis using a Vicryl suture.

At this point, he closes the mesenteric defect in the bowel in order to prevent an internal hernia post-operatively.  Moderators both felt that this is an important step of this procedure, be it open or robotic.  He then identifies the previously isolated ureters and performs an end-to-side vesicoureteral anastomosis in a running fashion using Vicryl sutures.  He places 4.8 Double-J stents prior to completion of the anastomosis to ensure patency.  These are removed post-operatively with a flexible cystoscope.

After this, he creates his stoma.  Both Narain and the moderators stressed the importance of visualizing the ileal conduit while delivering the ileal conduit through the abdominal wall to ensure there is no twisting of the mesentery or disruption of the anastomoses.  These should all be off of tension to decrease the risk of stricture.  The stoma is then matured in the usual fashion.

Narain’s video showed that as a surgeon gains experience with a fully intracorporeal technique, this can be accomplished in a safe and expeditious fashion.  Moderators, who also perform intracorporeal urinary diversions note that the technique becomes significantly easier as surgeon volume increases.  They also stressed that some points of the procedure may be able to be avoided, such as the use of stay sutures and reinforcing sutures in the enteroenterostomy as surgeon case volume increases.

Presented by: Tushar Aditya Narain, MBBS, MS, M.Ch.,  Assistant Professor at the Department of Urology, Postgraduate Institute of Medical Education and Research, Department of Urology, Chandigarh, India

Written by: Brian Kadow, MD Society of Urologic Oncology Fellow, Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.