|Year : 2019 | Volume
| Issue : 8 | Page : 51-55
Modified U-Shaped ileal neobladder designed for facilitating neobladder-urethral anastomosis in extracorporeal reconstruction after robotic-assisted radical cystectomy
Su-Wei Hu1, Chia-Chang Wu2, Kuan-Chou Chen2, Chen-Hsun Ho2
1 Department of Urology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
2 Department of Urology, Shuang Ho Hospital, New Taipei City; Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
|Date of Web Publication||22-Mar-2019|
Dr. Chen-Hsun Ho
No. 291, Zhongzheng Road, Zhonghe, New Taipei City, 235
Source of Support: None, Conflict of Interest: None
Background/Objective: To report the initial experience and the early outcomes of a modified U-shaped ileal neobladder, which was developed to facilitate the neobladder-urethral anastomosis by minimizing the anastomotic tension.
Patients and Methods: Between June 2015 and December 2016, two male and two female patients (median age: 65.5 years, range: 43–72 years) underwent the modified U-shaped ileal neobladder after robotic-assisted radical cystectomy (RARC). The most mobile and dependent ileal segment was first selected intracorporeally as the site for later neobladder-urethral anastomosis. The neobladder was formed extracorporeally, and the previously selected ileal segment formed the most dependent portion of the neobladder. The neobladder-urethral anastomosis was completed after robotic redocking.
Results: The median follow-up was 8 months (3–21 months). The median operative time, console time, and extracorporeal reconstruction time were 620 min (534–674 min), 372 min (314–420 min), and 151 min (128–215 min), respectively. In all patients, the neobladder-urethral anastomosis was completed intracorporeally with minimal tension. The median hospital time after the surgery was 14.5 days (14–19 days). Postoperatively, the median peak flow rate and void volume were 10 ml/s (4–35 ml/s) and 258 ml (88–775 ml). The median postvoid residual was 20 ml (10–53 ml). At daytime, two were completely continent; the other two reported mild (1–2 pads) and moderate (>2 pads) incontinence at the postoperative 3 and 4 months, respectively. Three reported nocturnal enuresis.
Conclusions: Our initial experience demonstrated that the modified U-shaped neobladder designed for minimizing the anastomotic tension is safe and feasible with its satisfactory functional outcomes.
Keywords: Bladder cancer, neobladder, radical cystectomy, robotics, urinary diversion
|How to cite this article:|
Hu SW, Wu CC, Chen KC, Ho CH. Modified U-Shaped ileal neobladder designed for facilitating neobladder-urethral anastomosis in extracorporeal reconstruction after robotic-assisted radical cystectomy. J Can Res Ther 2019;15, Suppl S1:51-5
|How to cite this URL:|
Hu SW, Wu CC, Chen KC, Ho CH. Modified U-Shaped ileal neobladder designed for facilitating neobladder-urethral anastomosis in extracorporeal reconstruction after robotic-assisted radical cystectomy. J Can Res Ther [serial online] 2019 [cited 2020 Nov 28];15:51-5. Available from: https://www.cancerjournal.net/text.asp?2019/15/8/51/231424
| > Introduction|| |
Radical cystectomy is currently the standard treatment for muscle-invasive or high-risk nonmuscle-invasive bladder cancer., Of the various types of urinary diversion, although required longer operating time and is more complex, ileal neobladder maximally preserves the normal bladder function and provides better quality of life., Robotic-assisted radical cystectomy (RARC) is gaining popularity in the past decade, and available data confirmed that the intermediate-term oncological outcome in RARC is comparable to that of open surgery.,, We developed a modified U-shaped ileal neobladder for RARC to facilitate the neobladder-urethral anastomosis. The detailed techniques, initial experiences, and early outcomes are reported.
| > Patients and Methods|| |
Patients with muscle-invasive bladder cancer or T1 tumors with other high-risk features including large tumor size, multiple tumors, lymphovascular invasion, associated carcinoma in situ, and/or in patients with long life expectancy were offered the procedure of RARC. The type of urinary diversion was selected after a detailed discussion with the patients, with full consideration and explanation. Contraindications to orthotopic neobladder included tumor in the urethra, urethral stricture, abnormal abdominal straining, renal insufficiency, and previous pelvic radiotherapy.
The current study enrolled patients who underwent RARC with the modified U-shaped neobladder between June 2015 and December 2016. All the surgeries were performed by a single surgeon (C.H. Ho) in our facility. The demographic data and perioperative data were obtained through the medical records. Postoperatively, the bladder function was assessed with uroflowmetry. Postvoid residual volume was obtained by clean intermittent catheterization. The continence status (daytime and nighttime) was evaluated by direct patient questioning. The function of the ureteroileal anastomosis was evaluated with postoperative sonography or computed tomography.
After induction of general anesthesia, the patient is placed in lithotomy position, and the table is placed in the 26° Trendelenburg position. A six-port technique is used with the camera port placed 3 cm above the umbilicus in the midline. Radical cystectomy and extended pelvic lymph node dissection are done first, using the technique as described before. Ureters are dissected close to the ureterovesical junction and divided between two Hem-o-Lok clips (Weck). On both proximal clips, a 15-cm stay suture is placed to facilitate the identification of the ureters during the later reconstruction. Once the urethra is transected and the bladder is fully detached from the surrounding tissue, the bladder specimen is immediately bagged with a 15-mm Endo Catch (Covidien). The lymphadenectomy specimens are bagged with a 10-mm Endobag (Covidien). The left ureter is transposed to the right side through a window made under the sigmoid mesocolon. A 15-cm stay suture is placed on the distal ileum located 20 cm proximal to the ileocecal valve [[Figure 1], point A]. The ileum is mobilized downward to the urethra, and the bowel segment which reaches the urethra with the least tension is identified and marked with another 15-cm stay suture [[Figure 1], point B].
|Figure 1: The point A indicates the site 15 cm proximal to the ileocecal valve. The point B indicates the most mobile and dependent ileal segment, which reaches the urethral stump at the least tension|
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The Trendelenburg position is decreased to 10–15°. A 5–6 cm minilaparotomy was made by caudally extending the supraumbilical wound for the camera port, and an Alexis wound retractor (applied medical) is placed. All specimens in the bag are removed. Then, the stay sutures marking the terminal ileum [[Figure 1], point A], the previously selected ileal segment for urethral anastomosis [Figure 1], point B], and bilateral ureteral ends were pulled out through the minilaparotomy. A 55-cm ileal segment proximal to the terminal ileum [[Figure 1], point A] is isolated. The mesentery is divided as proximally as possible with the maximal preservation of blood supply. The continuity of the ileum is restored in a side-to-side fashion by using a 60-mm GIA stapler (Covidien), and the open ends of the ileal limbs are closed by using a second 60-mm GIA stapler (Covidien). The first 45-cm segment is detubularized, and the most proximal 10-cm segment is left as the afferent limb [[Figure 1], left]. The isolated ileal segment is then folded into the so-called “modified U-shape”: the distal portion is placed in a U-shape, with the point B being the lowest point, which is left for urethral anastomosis; the proximal portion is placed in 2–3 folds [[Figure 1], middle]. The posterior wall of the neobladder is closed using multiple running sutures 3-0 Vicryl in a whole layer fashion. After the posterior part is sutured, the distal half of the anterior part of the reservoir is sutured while the most distal part is left open for urethral anastomosis. The proximal half of the anterior part is left open and is closed later until ureteral anastomosis is finished. Both ureters are spatulated for 2 cm and are anastomosed to the afferent limb using the Wallace technique with continuous 4-0 Vicryl sutures. Each ureter is catheterized with a 6-Fr single J stent. Both catheters are exteriorized through the anterior wall of the pouch and are secured by suture. The proximal half of the anterior part of the neobladder is then closed [[Figure 2], left]. The neobladder is filled with 150–200 mL normal saline to test its watertight integrity. The whole bladder along with the catheters is then carefully put into the abdominal cavity. The minilaparotomy is partially closed and the most cephalad 1 cm is left for camera port insertion.
|Figure 2: Left: A modified U-shaped neobladder was formed through a minilaparotomy. Right: Cystography of the neobladder|
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Pneumoperitoneum is obtained again, and the robotic da Vinci is redocked. A neobladder-urethral anastomosis is completed intracorporeally. A 16-F Foley catheter is placed under vision before the anastomosis is completed. The distal ends of bilateral ureteral catheters are pulled out through an addition 5-mm trocar placed in the suprapubic area. We do not place a suprapubic catheter. Two drains are placed.
Data are presented as the median (range) or as number (%). The operation time is defined as the time between the initial skin incision and the completion of wound closure. The console time is defined as the total time during which the surgeon performed any procedure using the robotic system. The extracorporeal reconstruction time is defined as the time during which the surgeon performed small bowel isolation, division, and reanastomosis, neobladder formation, and ureteroileal anastomosis. The daytime continence is defined as the need for <1 pad, mild incontinence is defined as the need for 1–2 pads, and moderate incontinence is defined as the need for >2 pads. Nocturnal enuresis is defined as the need for ≥1 pad.
| > Results|| |
Between June 2015 and December 2016, four patients (two males and two females) underwent RARC with extracorporeal reconstruction of the modified U-shaped ileal neobladder. The median age of patients was 65.5 years (43–72 years), and the median body mass index was 22.7 kg/m2 (22.8–28.7 kg/m2). The median follow-up was 8 months (3–21 months). The median operative time (skin-to-skin) was 620 min (534–674 min). The median time of console plus extracorporeal reconstruction was 555 min (442–573 min). The median extracorporeal reconstruction time was 151 min (128–215 min). The median blood loss was 300 ml (50–1250 ml). The median lymph node yield was 23 (13–28). All the neobladder-urethral anastomosis was successfully completed intracorporeally with minimal tension. The median length of midline incision for specimen retrieval and extracorporeal reconstruction was 5.5 cm (5–6 cm).
None experienced intra-abdominal urinary leakage. One experienced fever, while it subsided soon under empirical antibiotics coverage and there was no obvious infection focus. None had postoperative ileus. The median time to oral diet was 4 days (3–6 days). The median hospital time after the surgery was 14.5 days (14–19 days).
The postoperative uroflowmetry revealed a median maximal urinary flow rate of 10 ml/s (4–35 ml/s) and a median void volume of 258 ml (88–775 ml). The median postvoid residual volume was 20 ml (10–53 ml). The median pre- and post-operative creatinine level was 0.73 mg/dl (0.57–1.06 mg/dl) and 0.80 mg/dl (0.69–1.31 mg/dl), respectively. One had mild hydronephrosis on sonography. At daytime, two patients were completely continent, while the other two reported mild (1–2 pads) and moderate (>2 pads) incontinence at the postoperative three and 4 months, respectively. Three reported nocturnal enuresis and required pad use when sleeping.
| > Discussion|| |
Radical cystectomy remains the golden standard for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the urinary bladder in the current literatures., The procedure consists of three major parts, namely, radical excision of the urinary bladder, extended pelvic lymph node dissection, and urinary diversion. RARC is being widely used in the past decade with data confirmed that the intermediate-term oncological outcome in RARC is comparable to that of open surgery.,, RARC has the advantages of less blood loss, reduced morbidity, and improved convalescence.,, However, compared with open radical cystectomy, urinary diversion remains a technically demanding procedure, and several types of neobladder have been developed for the robotic or laparoscopic settings, such as U-shaped, W-shaped, and Ves. Pa. neobladder.
Neobladder-urethral anastomosis is a critical step in radical cystectomy regardless of the approach. A tension-free anastomosis is the key to obtain a satisfactory functional outcome. However, occasionally, significant mesenteric tension hinders the ileal segment from descending. It is more challenging in RARC, as it is with a steep Trendelenburg position and without the assistance of hands., Failure to approximate the ileal neobladder to the urethra can result in conversion to an open surgery., In the current study, we reported our initial experience of the modified U-shaped ileal neobladder, which was designed for facilitating neobladder-urethral anastomosis at the least tension. In this series, all the neobladder-urethral anastomoses could be achieved successfully with minimal tension. The early functional outcomes in terms of the peak flow rate, functional capacity, postvoid residual volume, and continence status were acceptable. According to these results, we consider the modified U-shaped reservoir a safe and feasible choice of neobladder following radical cystectomy.
Several characteristics of the neobladder contributed to the low-tension or tension-free anastomosis. First, different from the original U-shaped neobladder, the site for urethral anastomosis is located at the turning point of the U-shaped ileal segment; our method makes the urethra be anastomosed to the most dependent ileal segment, which is selected intracorporeally before the extracorporeal reconstruction. This confirmed the recent views of several experts,,, all of which emphasize the early identification of the most mobile and dependent ileal segment which reaches the urethra with the least tension. Second, similar to the original U-shaped neobladder, the current neobladder is with minimal longitudinal folding, which keeps the mesenteric tension at the lowest level. While a more spherical configuration enables the reservoir to contain higher volumes at lower intraluminal pressures and should be viewed as the benchmark of the neobladder, the longer distance between the reservoir and the urethral stump is associated with greater tension. A neobladder with relatively more longitudinal shape is of value whenever a substantial mesenteric tension is felt as the ileum is mobilized downward to the urethra. A recent study has demonstrated the excellent functional outcomes of the U-shaped neobladder by videourodynamic study. As there is no difference between the original U-shape and our modification regarding the relationship between the harvested ileal length and the neobladder capacity, the functional outcomes of our design should be similar to those of the original U-shaped neobladder.
In the current series, we used a hybrid (intracorporeal and extracorporeal) method for urinary diversion. Bowel division, restoration of bowel continuity, neobladder creation, and ureteroileal anastomosis were completed extracorporeally, while the neobladder-urethral anastomosis was done intracorporeal after redocking of the robotics. As total intracorporeal reconstruction is a technically demanding procedure, currently, extracorporeal reconstruction remains the preferred technique in most centers. According to our experience, extracorporeal reconstruction may have several advantages. First, the open technique is familiar for all surgeons, and extracorporeal urinary diversion can shorten the learning curve. Second, the bagged specimens can be retrieved immediately right after the organ is fully resected, which minimizes the risk of spilling of cancer cells. Third, a 5–6 cm minilaparotomy extended through the supraumbilical wound is necessary regardless of the approach. The advantages of minimally invasive surgery still stand. Forth, during the around 2 h for extracorporeal reconstruction, the patient can be placed in a more supine position. This minimizes the potential risk with prolonged Trendelenburg position.
The power of the current study is largely limited by the small case number and short follow-up period. Two patients were only at their postoperative 3 and 4 months, and the functional outcomes, such as the functional capacity and continence status, might further improve. Moreover, while the primary surgeon had only experience of 15 laparoscopic and 15 robotic radical cystectomies before the current study, the surgical techniques were still progressing. We did observe a trend of improvement in the operative parameters such as the operative time and blood loss. However, this also suggested that the current technique was an easier alternative.
| > Conclusions|| |
Our initial experience demonstrated that the modified U-shaped neobladder ensures neobladder-urethral anastomosis at the least tension. The satisfactory early outcomes prove it a safe and feasible alternative of neobladder. Further experience and longer follow-up are still required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]