Genital Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Neobladder & Paravaginal Repair

Abstract

Objective: Vaginal prolapse is a known complication after radical cystectomy, requiring additional procedures in 10% of the patients.¹ This results from loss of level I and II vaginal support due to the removal of pelvic structures. In addition, a neobladder urinary diversion, with Valsalva voiding, predisposes to vaginal prolapse. A genital-sparing approach with paravaginal repair can help prevent such complications.

Methods: The genital sparing technique preserves the uterus, fallopian tubes, ovaries, and vagina, while paravaginal repair involves suturing of the lateral vaginal wall to the arcuate fascia located on the medial aspect of the obturator internus muscle. The procedure begins by placing the patient in a lithotomy position, with a steep Trendelenburg. Standard 6 port cystectomy configuration is utilized with an additional 15 mm port for bowel anastomosis. Initially, the ureters and lateral bladder space are mobilized. Posteriorly a dissection plane is developed separating the bladder from the anterior vaginal wall. Distal dissection is carefully performed in that plane to avoid disrupting the urethral-external sphincter complex. Then the bladder is dropped from anterior attachments, the Dorsal venous complex (DVC) and bladder neck are exposed. Urethra is transected distal to the bladder neck, after circumferential mobilization, to complete the cystectomy, again avoiding disruption of the continence mechanism, and opening the endo-pelvic fascia. Cystectomy and pelvic lymph node dissection are completed in a standard fashion. The arcuate fascia is identified bilaterally for level I paravaginal repair. The lateral aspect of the paravaginal tissue is secured to this ligament, using 3 interrupted Polydioxanone (PDS) sutures, bilaterally. An ileal "Hautman's W pouch" neobladder is constructed using 50 cm of the small intestine, similar to the previously reported technique.² Bricker-type uretero-ileal anastomosis is performed over a double J stent. Bowel continuity is restored by a side-to-side anastomosis using endo-GIA (gastrointestinal anastamosis EndoGIA^TM ) staplers.

Results: No intra or postoperative complications were noted. Robot dock time was 8 hours and 23 minutes with an EBL of 100 mL. The patient was discharged on post operative day (POD) 6 and Foley catheter with ureteral stents was removed on POD 27 after a cystogram confirmed no leaks. At 6-month follow-up, the patient reported good continence using a single pad, voiding every 3-4 hours. Fluoro-urodynamics demonstrated 651 mL capacity, low-pressure voiding, minimal residual urine, and no reflux. No prolapse was noted on fluoroscopy and pelvic examination with the Valsalva maneuver. The patient reported a good satisfaction level, regarding her urinary symptoms.

Conclusion: We report satisfactory short-term outcomes of a feasible technique to prevent postcystectomy prolapse; however, long-term follow-up of a larger cohort can help establish its efficacy.