Initial Experience of Robot-Assisted Radical Cystectomy with Total Intracorporeal Urinary Diversion: Comparison with Extracorporeal Method

Purpose: To report our surgical technique and initial experience with robot-assisted laparoscopic radical cystectomy (RARC) with total intracorporeal urinary diversion compared with an extracorporeal method. Subjects and Methods: In total, 42 patients underwent RARC by a single surgeon at our institute for clinically localized bladder cancer. Among these, 4 patients underwent RARC with complete intracorporeal urinary diversion. An ileal conduit was achieved in 3 patients, and an orthotopic neobladder was created in 1 patient. Our surgical technique is presented in detail, and the intracorporeal cases were compared with 38 previous extracorporeal diversion cases for perioperative outcome, postoperative oncologic outcome, and complications. Results: Three men and 1 woman underwent complete intracorporeal urinary diversion. In patients receiving ileal conduits the mean total operative time was 510 minutes, and the estimated blood loss was 400 mL. In the patient receiving an ileal neobladder the total operative time was 585 minutes, and the estimated blood loss was 500 mL. Mean time to flatus was 60 hours, and no intraoperative or postoperative major complications occurred. Surgical margins were negative with no positive lymph nodes. Compared with extracorporeal cases, the mean total operative time for RARC was significantly longer, but perioperative outcomes of estimated blood loss, time to flatus, and postoperative oncologic outcomes were not significantly different. Conclusions: Our initial experience showed that RARC with complete intracorporeal urinary diversion is feasible based on perioperative data and oncologic features. However, in this small case series, we observed no definite benefits associated with intracorporeal urinary diversion over extracorporeal urinary diversion except for better cosmesis. Long-term, large-scale, prospective comparative studies will be needed to demonstrate the benefit of intracorporeal urinary diversion.