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| Totally intracorporeal robot-assisted urinary diversion for bladder cancer (part 2). Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder |
Hugo Otaola-Arcaa,b,Kulthe Ramesh Seetharam Bhatc,Vipul R. Patelc,Marcio Covas Moschovasc,Marcelo Orvietob,*( )
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a Department of Urology, Clínica Alemana, Santiago, Chile
b School of Medicine, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
c Department of Robotic Surgery, AdventHealth Global Robotics Institute, Celebration, FL, USA |
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Abstract Objective: To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images. Methods: We performed a non-systematic review of the literature with the keywords “bladder cancer”, “urinary diversion”, “radical cystectomy”, and “neobladder”. Results: Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer “U” neobladder (70%) followed by the Hautmann “W” modified neobladder (7.5%), the “Y” neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively. Conclusion: The most frequent types of ICONB are Studer “U” neobladder, Hautmann “W” neobladder, “Y” neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.
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Received: 24 December 2019
Available online: 20 January 2021
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Corresponding Authors:
Marcelo Orvieto
E-mail: morvieto@alemana.cl
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| Study characteristics | Baseline and operative data | Complications | Continence at 12 months | | Study | Number of patients | Type of ICUD | Age (year) | Males (%) | Total OT (min) | ICUD OT (min) | EBL (mL) | PSM (%) | F-UP (month) | Early (<30 days) | Late (31-90 days) | Daytime (%) | Nighttime (%) | Potency (%) | | Clavien <III | Clavien ≥III | Clavien <III | Clavien ≥III | | Beecken et al. (2003) [13],a | 1 | Hautmann “W” | 58d | 100.0 | 510d | NA | 200d | 0.0 | 5.0d | 0.0 | 0.0 | 0.0 | 0.0 | NA | NA | NA | | Sala et al. (2006) [44],a | 1 | Hautmann “W” | 70d | 100.0 | 720d | 510d | 200d | 0.0 | 3.0d | 0.0 | 0.0 | NA | NA | 100.0g | 0.0g | NA | | Hussein et al. (2017) [45],a | 5 | Hautmann “W” | 57.0e | 80.0 | 357e | 193e | 225e | 0.0 | Min: 3 | 40.0 | 20.0 | 0.0 | 0.0 | NA | NA | NA | | Pruthi et al. (2010) [14],b | 12 | IC (75%)
Studer “U” (25%) | 60e | 75.0 | 318e | NA | 221e | NA | Min: 3 | 41.6 | 0.0 | 16.6 | 0.0 | NA | NA | NA | | Romero-González et al. (2011) [15],a | 1 | Studer “U” | 79d | 100.0 | 420d | 240d | 500d | 0.0 | 7.0h | 0.0 | 0.0 | NA | NA | NA | NA | NA | | Jonsson et al. (2011) [[16], [17], [18]],c | 45 | IC (20%)
Studer “U” (80%) | 73f
60f | 55.0
91.6 | 460f
480f | NA | 350f
480f | 2.2 | 32.0f
24.0f | 11.1
19.4 | 33.3
8.3 | 11.1
16.6 | 22.2
13.8 | NA
97.0 | NA
83.0 | NA
93.7 | | Akbulut et al. (2011) [19],a | 12 | ONB Studer “U” | 60e | 100.0 | 600e | NA | 455e | 0.0 | 7.1e | 50.0 | 16.0 | 25.0 | 16.6 | 100.0 | 71.4 | 25.0 | | Schumacher et al. (2011) [20],a | 48 | IC (20%)
Studer “U” (80%) | 62f | 84.4 | 477f | NA | 550f | 2.2 | 24.0e | 17.7 | 22.2 | 13.3 | 17.8 | NA | NA | NA | | Goh et al. (2012) [21],c | 15 | IC (47%)
Studer “U” (53%) | 69f
63f | 100.0
75.0 | 450f
450f | NA | 200f
225f | 0.0
0.0 | 3.3f
3.0f | 71.4
62.5 | 0.0
25.0 | 14.2
0.0 | 0.0
12.5 | NA
75.0 | NA
NA | NA
NA | | Canda et al. (2012) [22],a | 27 | IC (7%)
Studer “U” (93%) | 61.4e | 92.5 | 594e | NA | 429e | 3.7 | 6.3e | 33.3 | 14.8 | 14.8 | 11.1 | 64.7 | 17.6 | NA | | Haddad et al. (2013) [23],a | 1 | Studer “U” | 73d | 100.0 | 368d | 180d | 900d | 0.0 | 3.0d | 100.0 | 0.0 | NA | NA | NA | NA | NA | | Collins et al. (2013) [24],a | 113 | IC (38%)
Studer “U” (62%) | 69.9e
59.8e | 74.4
88.5 | 292f
420f | NA | 200f
500f | 11.6
1.5 | 4.0f
30.0f | 32.5
12.8 | 53.4
31.4 | 0.0
14.2 | 23.2
21.4 | NA | NA | NA | | Tyritzis et al. (2013) [25],a | 70 | Studer “U” | 59.8e | 95.7 | 420f | NA | 500f | 1.4 | 30.3f | 17.0 | 31.4 | 12.8 | 18.6 | 73.8 | 61.5 | 51.6 | | Desai et al. (2014) [26],c | 37 | IC (51%)
Studer “U” (49%) | 75f
62f | 84.0
72.0 | 386f
387f | 92f
124f | 250f
200f | 10.0
0.0 | 16.0f
12.0f | 42.0
67.0 | 27.0
6.0 | 47.0
67.0 | 32.0
17.0 | NA | NA | NA | | Collins et al. (2014) [27],a | 80 | Studer “U” | 64.0e | NA | 420f | NA | 475f | 4.0 | 31.0e | 17.0 | 27.0 | 11.0 | 19.0 | 87.0 | 80.0 | 69.0 | | Abreu et al. (2014) [28],c | 103 | IC (55%)
Studer “U” (45%) | 72f
60.5f | 75.0
89.0 | 396f
462f | NA | 250f
200f | 7.0
0.0 | NA | 42.0
41.0 | 23.0
21.0 | NA | NA | NA | NA | NA | | Desai et al. (2014) [32],a | 132 | Studer “U” | 60e | 86.4 | 456e | NA | 430e | 0.8 | 25.1e | 31.8 | 15.2 | 14.4 | 12.9 | 84.0h | 84.0h | NA | | Butt et al. (2015) [29],a | 4 | Studer “U” | 61.8e | 100.0 | 522e | NA | 237e | 0.0 | 21.0e | 50.0 | 0.0 | 25.0 | 25.0 | 100.0 | 75.0 | NA | | Atmaca et al. (2015) [30],a | 32 | Studer “U” | 62.2e | 90.6 | 585f | NA | 412f | 6.3 | Min: 9 | 62.5 | 19.0 | 15.6 | 6.3 | 84.6 | 46.1 | NA | | Schwentner et al. (2015) [31],a | 62 | Studer “U” | 63.6e | 80.6 | 476e | 183e | 385e | 6.4 | 37.3e | 24.2 | 25.8 | NA | NA | 88.0 | 55.1 | 54.0 | | Sim et al. (2015) [38],a | 101 | IC (28%)
Studer “U” (72%) | 76.1e
62.1e | 89.3
78.0 | 350e
452e | 133e
178e | 347e
347e | 14.3
6.8 | 22.5e
32.4e | 21.4
28.7 | 14.2
27.3 | 0.0
1.3 | 7.1
15.0 | NA
89.2 | NA
67.6 | 100.0
48.0 | | Koupparis et al. (2015) [33],b | 102 | IC (11%)
Studer “U” (89%) | 68.2e | 69.6 | NA | NA | NA | NA | NA | Early and late Clavien <III: 23.0
Early and late Clavien ≥III: 9.0 | NA | NA | NA | | Nyame et al. (2016) [34],a | 3 | Studer “U” | 35.3e | 100.0 | 473e | NA | 266e | 0.0 | 28.1e | 66.6 | 0.0 | 0.0 | 0.0 | 100.0 | 100.0 | 100.0 | | Almassi et al. (2016) [35],a | 19 | Studer “U” | 55.0e | 94.7 | 486e | NA | 300f | NA | NA | Early and late Clavien <III: 36.8
Early and late Clavien ≥III: 5.2 | NA | NA | NA | | Satkunasivam et al. (2016) [36],b | 28 | Studer “U” | 63f | 100.0 | NA | NA | NA | NA | 9.4f | NA | NA | NA | NA | 41.6 | 37.5 | NA | | Koie et al. (2018) [37],a | 22 | Studer “U” | 65f | 95.5 | 430f | 553f | 300f | 0.0 | 33.4f | 31.8 | 0.0 | 0.0 | 4.5 | 93.4 | 93.4 | NA | | Porreca et al. (2018) [39],c | 24 | IC (46%)
Studer “U” (54%) | 68f | 91.7 | 370f
410f | 106f
172f | 390f
440f | 9.0
0.0 | 6.5f
6.0f | 9.0
15.3 | 0.0
7.6 | 0.0
30.7 | 0.0
7.6 | 84.0 | 69.0 | 45 | | Chow et al. (2018) [40],b | 26 | IC (81%)
Studer “U” (15%) | 70f | 80.0 | 362f | NA | 300f | 4.0 | NA | Early and late Clavien <III: 62.2
Early and late Clavien ≥III: 19.0 | NA | NA | NA | | Lenfant et al. (2018) [41],b | 74 | IC (47%)
Studer “U” (53%) | 65f | 81.1 | 320f | NA | 400f | 8.1 | 15.0f | 37.8 | 9.4 | 6.7 | 12.1 | NA | NA | NA | | Porreca et al. (2019) [42],a | 100 | URS (17%)
IC (32%)
Studer “U” (51%) | 69f | 90.0 | 410f | 60f
120f
180f | 200f | 3.0 | 14.0f | 25.0 | 9.0 | 9.0 | 10.0 | NA
NA
90.2 | NA
NA
70.6 | 31.0 | | Brassetti et al. (2019) [43],a | 113 | IC (43%)
Studer “U” or Padua (57%) | 69e | 82.0 | 382e | NA | NA | 8.0 | NA | Clavien ≥III: 20.0 | NA | NA | NA | | Kang et al. (2012) [50],b | 4 | IC (75%)
Camey (35%) | 69.5e | 75.0 | 510e
585e | NA | 400e
500e | 0.0
0.0 | Min: 3 | 25.0 | 0.0 | 0.0 | 0.0 | NA | NA | NA | | Tan et al. (2015) [51],a | 20 | Pyramid pouch | 57.2e | 95.0 | 330f | 150f | 330f | NA | 21.5f | 70.0 | 0.0 | 70.0 | 25.0 | 95.0h | 70.0h | NA | | Sim et al. (2015) [46],a | 1 | “Y”-pouch | 67d | 100.0 | 340d | NA | Minimald | NA | NA | 0.0 | 0.0 | 0.0 | 0.0 | NA | NA | NA | | Asimakopoulos et al. (2016) [47],a | 40 | “Y”-pouch | 57e | 100.0 | 315f | NA | 395f | 2.5 | 26.5f | 27.5 | 2.0 | 27.5 | 5.0 | 100.0 | 72.0 | 72.0 | | Simone et al. (2018) [48],a | 45 | Padua | 65f | 71.1 | 305f | NA | 210f | 0.0 | Min: 24 | 24.4 | 0.0 | 33.3 | 8.8 | 73.3 | 55.5 | NA | | Simone et al. (2018) [49],a | 64 | Padua | 62.5e | 78.1 | NA | NA | NA | 0.0 | Min: 24 | Early and late Clavien <III: 35.9
Early and late Clavien ≥III: 6.3 | NA | NA | NA | | Cacciamani et al. (2019) [52],a | 15 | ra-VIP | 60f | 93.0 | 390f | NA | 300f | 7.0 | 17.0f | 13.0 | 33.0 | 0.0 | 7.0 | 62.0 | 38.0 | NA | | Minervini et al. (2018) [53],a | 18 | FloRIN | 66f | 89.0 | 450f | NA | NA | NA | NA | 22.2 | 16.6 | NA | NA | 77.8 | 66.7 | NA | | Hussein et al. (2018) [54],b | 1 094 | IC (79%)
ONB (21%) | 67e | 71.0 | 357f | NA | 300f | 7.0 | 11.0f | Early and late Clavien <III: 39.0
Early and late Clavien ≥III: 11.0 | NA | NA | NA |
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Study characteristics, baseline, operative data, and complications after robot-assisted intracorporeal orthotopic neobladder.
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Schematic figure demonstrating the step-by-step creation of the robotic Hautmann “W” ICONB (Adapted from Hussein et al. [45]). (A) Port configuration. Four robotic and two assistant ports. An additional 12 mm suprapubic port is placed to ease restoration of bowel continuity. (B) Identification of the bowel segment. A segment of 45-50 cm of the ileum 15-20 cm proximal to the ileocecal valve is isolated and divided into a right and left limb. (C) Bowel detubularization and construction of the posterior plate. The bowel is detubularized by incising it along its anti-mesenteric border and folded so that the edges of the ascending and descending loop are sutured together. (D) Urethro-ileal anastomosis. Van Velthoven tension-free UIA is performed over a 22 Ch catheter. (E) Closure of the lower half of the anterior wall. Only the lower half of the anterior wall of the neobladder is sutured. (F) Uretero-ileal anastomosis. An end-to-side uretero-ileal anastomosis is made on each chimney after ureteral spatulation. (G) Closure of the anterior wall of the neobladder. The remaining anterior wall of the neobladder is closed in a T-shaped manner.
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Schematic figure demonstrating the step-by-step creation of the robotic Karolinska-modified Studer “U” ICONB (Adapted from Wiklund and Poulakis [18]). (A) Port configuration. Four robotic and two assistant ports. (B) Identification of the bowel segment. A segment of 55-60 cm of the ileum 20-25 cm proximal to the ileocecal valve is isolated. (C) Construction of the posterior plate and closure of the anterior wall of the neobladder. The intestinal segment is detubularized. The medial edges of the right and left ileal limbs are sutured together to create the posterior plate. The open edge of the right limb is folded anteriorly towards the left limb. The cranial part of the right limb is folded and sutured to the left limb to create the anterior wall. The most proximal part of the anterior wall is kept open to facilitate the passage of ureteral stents. (D) Stent placement. Simple-J ureteric stents introduced through the window in the anterior wall. (E) Uretero-ileal anastomosis and closure of the anterior wall of the neobladder. Wallace anastomosis is made over the ureteric stents, and the window in the anterior wall of the neobladder is closed with a running barbed suture.
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Schematic figure demonstrating the step-by-step creation of the robotic University of Southern California (USC)-modified Studer “U” ICONB (Adapted from Chopra et al. [56]). (A) Identification of the bowel segment. A segment of 65 cm of the ileum is isolated. The most mobile and dependent loop that reaches the urethra is marked as the UIA point. Posteriorly, five separate landmark points are marked. (B) Bowel detubularization, creation of the posterior plate, and rotation. The bowel detubularized (from the 44-cm to 0-cm point) and the medial edges of the matching segments are sutured to create the posterior plate. The posterior plate is rotated 90° counterclockwise. (C) Bowel segment layout after rotation. (D) Urethro-ileal anastomosis and cross folding of the pouch. An urethro-ileal anastomosis is made on the 11-cm point, and the pouch is cross folded to approximate the intestinal edges that will create the anterior wall. (E) Closure of the anterior wall. The cross folded intestinal edges are sutured together to create the anterior wall. (F) Uretero-ileal anastomosis. An end-to-side uretero-ileal anastomosis is performed. APP, apex of the posterior plate; UIA, urethro-ileal anastomosis.
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Schematic figure demonstrating the step-by-step creation of the robotic pyramid pouch ICONB (Adapted from Tan et al. [51]). (A) Port configuration. Four robotic and two assistant ports. (B) Identification of the bowel segment. A segment of 50 cm of the ileum >15 cm proximal to the ileocecal valve is isolated. (C) Urethral-ileal anastomosis, bowel detubularization, and formation of the posterior plate. After performing the urethral-ileal anastomosis, the bowel is detubularized (except for the 2 cm uppermost portion of both limbs), and the medial edges of both segments are sutured together. (D) Closure of the distal part of the anterior wall. The first 10 cm of the anterior plate is sutured, from distal to proximal. Two lateral stays are placed in the midway of the remaining bowel segment. (E) Neobladder construction. The closure of the folded bowel was made from lateral to medial in the coronal plane. (F) Uretero-ileal anastomosis. An end-to-side uretero-ileal anastomosis is performed over the proximal end of both ileal limbs.
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Schematic figure demonstrating the step-by-step creation of the robotic Y-shaped ICONB (Adapted from Asimakopoulos et al. [47]). (A) Identification of the bowel segment. A segment of 40 cm of the ileum 15-20 cm proximal to the ileocecal valve is isolated. (B) Urethro-ileal anastomosis. After performing the urethro-ileal anastomosis, the ileal segment remains as two ileal limbs. (C) Detubularization of the bowel. The two limbs are detubularized in the antimesenteric border. (D) Construction of the posterior plate. The medial edges of the detubularized limbs are sutured together to create the posterior plate. (E) Folding the pouch. The proximal part of the posterior plate is folded anteriorly. (F) Creation of the anterior wall. The anterior wall is closed with running sutures, creating a “heart shape”. (G) Uretero-ileal anastomosis. An end-to-side uretero-ileal anastomosis is performed over the proximal end of both ileal limbs.
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Schematic figure demonstrating the step-by-step creation of the robotic Padua ICONB (Adapted from Simone et al. [48]). (A) Port configuration. Four robotic and two assistant ports. (B) Identification of the bowel segment. A segment of 42 cm of the most dependent portion of the ileum. (C) Detubularization of the distal part of the ileum (8 cm). The most distal part (8 cm) of the small bowel is detubularized (8 cm), and an incision in the left horn is made to insert the stapler. (D) Creation of the neobladder neck. The neobladder neck is created with a stapler. (E) Detubularization of the proximal part of the ileum (24 cm). The remaining ileum (24 cm) is detubularized. (F) First fold. The first 8-cm ileum segment is folded and sutured to the second 8-cm segment. (G) Second fold. The next 8-cm ileum segment is folded over the previous to configure the posterior plate. (H) Completion of the posterior plate of the neobladder. The adjacent edges of the folded ileum are suture together. (I) Urethro-ileal anastomosis, uretero-ileal anastomosis, and completion of the neobladder. A tension-free urethro-ileal anastomosis is performed in the neobladder neck, an end-to-side uretero-ileal anastomosis is performed over the posterior wall, and the neobladder is finally completed with the closure of the anterior wall.
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| Intestinal segment | Advantages | Disadvantages | | Stomach | ◆ Option for patients with prior pelvic radiotherapy | ◆ Hypokalemic-hypochloremic metabolic alkalosis | | ◆ Beneficial for patients with renal and/or liver dysfunction | ◆ Hematuria-dysuria syndrome | | ◆ Low mucus production | | Jejunum | ◆ Option for patients with prior pelvic radiotherapy | ◆ Hyperkalemic-hypochloremic metabolic acidosis | | ◆ Nausea/vomiting | | Ileum/ileocecum | ◆ More compliant and less contractile than colon and stomach | ◆ Hypokalemic-hyperchloremic metabolic acidosis | | ◆ Fat and bile salt malabsorption | | ◆ Diarrhea | | ◆ Vitamin B12 deficiency | | ◆ Bone demineralization | | Colon | ◆ Option for patients with prior pelvic radiotherapy | ◆ Hypokalemic-hyperchloremic metabolic acidosis, significant mucus production | | ◆ Bone demineralization | | ◆ Pyelonephritis | | ◆ Risk of adenocarcinoma at the anastomosis |
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Comparison of intestinal segments used for the construction of the neobladder (adapted from Tan et al. [60]).
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