Robotic Cystectomy for Bladder Cancer Removal Video

Learn about a Minimally Invasive, Open Robotic Cystectomy for Bladder Cancer Removal. Minimally invasive surgical techniques allow urologists to operate via smaller rather than larger incision ports; this results in faster recovery times, fewer co...
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Open radical cystectomy is the gold standard treatment for muscle-invasive bladder cancer. Efforts to reduce the operative morbidity of radical cystectomy have fostered interest in minimally invasive approaches. However, there are concerns regarding minimally invasive radical cystectomy including the absence of long-term oncologic and functional outcomes as well as concern that the lymphadenectomy could be suboptimal. Previous reports comparing open versus minimally invasive radical cystectomy have focused on perioperative outcomes. However, direct comparison between open and robotic radical cystectomy of early oncologic parameters such as lymph node yield and margin status are lacking. In this study, we provide a comparison of perioperative in early pathologic outcomes in a consecutive series of open and robotic radical cystectomies. From February to December 2006, 43 consecutive patients underwent radical cystectomy by a single surgeon at our institution. 22 were performed open, 21 were robotic. We begin with a demonstration about technique of robotic radical cystectomy. 12 mm ports are used with the camera and right-sided assistant. Two 8 mm robotic ports are placed inferior and lateral to the camera port. 5 mm ports are for suction and the left-sided assistant. The 5 mm left-sided port can be changed for a 12 mm port to accommodate a stapling device. We use the bipolar electrocautery in the left robotic arm and the monopolar scissor in the right. Posterior dissection begins with identification of the vas deferens, depicted here on the left side. The vas is dissected down towards the seminal vesicles behind the bladder to access the posterior plane. With the seminal vesicles elevated, the posterior plane is develop distally. Next, the peritoneum is incised and the colon is reflected medially to identify the ureter as it crosses over the iliac vessels. The ureter is then dissected proximally and distally down to the level of the bladder where it is doubly clipped and divided. The lateral plane between the bladder and pelvic sidewall is developed with sweeping motions shown here on the right side. With the lateral and posterior planes developed, the pedicles are exposed and controlled. The lateral dissection concludes exposure of the endopelvic fascia. The endopelvic fascia is incised shown here in this non-nerve sparing procedure using the electrocautery. The remaining pedicles are controlled with clips. At this point, the bladder is dissected off the anterior abdominal wall by incising the peritoneum lateral to the medial umbilical ligaments, which are then divided along with the urachus. With the bladder dissected off the anterior abdominal wall, the anterior surface of the prostate is exposed, and the dorsal venous complex is controlled with a 0 microsuture. A back bleeding stitch is placed on the prostate side and dorsal venous complex is divided with electrocautery. The urethra is then divided, shown here using electrocautery in a patient who was undergoing a non-nerve sparing procedure with ileal conduit diversion. Prostate pedicles and lateral prostatic dissection are performed in a fashion similar to that in robotic prostatectomy. The specimen is then freed and placed in an Endocatch retrieval bag. In order to transpose the left ureter to the right side, a blunt suction device is passed posterior to the sigmoid mesocolon and a Marilyn dissector is brought through this plane. The suture attached to the left ureteral clip is grasped and the left ureter is brought to the sigmoid mesentery to the right side. The adventitia overlying the external iliac arteries incised shown here on the right. The arteries diluted of lymphatic and adipose tissue laterally out to genitofemoral nerve, distally to the pelvic sidewall including the node of Cloquet, proximally to the mid-common iliac artery and posteriorly to the obturator nerve shown here. Urinary diversion is performed extracorporeally through a 5-7 cm incision extended from

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