Robotic radical cystectomy: NVB sparing technique in the male

12th South Eastern European Meeting, 23-24 September 2016, Sarajevo (BA)

V5

Robotic radical cystectomy: NVB sparing technique in the male Eur Urol Suppl 2016; 15(10);e1340

Atmaca A.F.1, Canda A.E.1, Arslan M.E.2, Bedir F.3 1

Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Dept. of Urology, Ankara, Turkey, 2Ankara Ataturk Training & Research Hospital, Dept. of Urology, Ankara, Turkey, 3Erzurum Training & Research Hospital, Dept. of Urology, Erzurum, Turkey INTRODUCTION & OBJECTIVES: In this video robotic radical cystectomy (RARC) with neurovascular bundle (NVB) sparing technique in the male is presented. MATERIAL & METHODS: A 60-year old male patient who was diagnosed with pT2 high grade urothelial cell carcinoma (UCC) of the urinary bladder with squamous differentiation was referred to our institution. Thorax and abdomino-pelvic computerized tomography (CT) was normal. A RARC was planned. RESULTS: Console time was 110 minutes and estimated blood loss was 100 cc. Pathology revealed pT2 high-grade UCC with squamous differentiation with clear surgical margins. A transperitoneal approach is used. RARC is performed in the steep (30°) Trendelenburg position. A total of 6 abdominal ports are placed, four 8 mm sized robotic trocars for robotic instruments and for 3D-HD camera, a 12 mm sized trocar for bedside assistance and a 15-mm sized trocar for laparoscopic bowel staplers (Picture 1). A 0o lens is used.Initially, both ureters without damaging their adventitia are dissected. After a sufficient length is obtained, ureters are double clipped and cut where they enter the bladder, and the distal most parts are sent for frozen section analysis. Thereafter, posterior dissection of the prostate is performed, starting with incising the peritoneum on the anterior wall of the Douglas pouch. Seminal vesicles (SVs) are identified and the Denonvilliers fascia is opened. Lateral bladder pedicles are cut with a vessel sealing device down to the level of SVs. Thereafter, no energy is used in order not to cause neurovascular bundle (NVB) thermal injury. Therefore, endoclips are applied on both sides in order to dissect and ligate prostatic and bladder pedicles. Peritoneum is incised on both sides starting from the umbilicus on the lateral sides of the medial umbilical ligaments. The endopelvic fascia is identified and is opened, and high anterior release of the periprostatic fascia over the prostatic capsule is performed. Bladder is completely released including the urachus. Deep dorsal vein is ligated by using the slip knot suture and cut. By preserving a long urethral length, urethra is cut and an endoclip is applied on the Foley catheter before cutting it. Thereafter, posterior plate is cut and cystectomy is completed. Sampling of the urethra for frozen section is performed. CONCLUSIONS: NVB sparing RARC is a safe minimally invasive procedure with acceptable morbidity; excellent operative, pathological and oncological outcomes.

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