Lower Detrusor Apron-sparing Robot-assisted Radical Cystectomy and Intracorporeal Neobladder Reconstruction: Technique and Preliminary Outcomes

Abstract

Background: Prior studies on robot-assisted laparoscopic prostatectomy (RALP) have shown that preservation of the anterior periprostatic structures is associated with good functional outcomes in terms of urinary continence and erectile function. With this in mind, we developed a technique for preservation of the lower part of the detrusor apron (LDA) and anterior periprostatic structures at the time of robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.

Objective: To describe our LDA-sparing RARC technique and to assess its safety and outcomes.

Design, setting, and participants: We retrospectively evaluated 11 patients who underwent LDA-sparing RARC and ICNB reconstruction at our centre from January 2017 to May 2021.

Surgical procedure: In brief, after developing the plane posterior to the bladder and prostate, the dissection proceeds laterally on both sides of the prostate in an effort to identify the prostatic pedicle. At this point, the bladder pedicles are sectioned in an antegrade fashion. Once the prostate is reached, the dissection is continued laterally by developing the plane that was previously identified. The neurovascular bundles and the lateral and anterior periprostatic structures are conserved in toto. Neobladder reconstruction is performed intracorporeally.

Outcome measurements: Postoperative complications, urinary continence (UC), and erectile function (EF).

Results and limitations: The median console time was 290 min. The 30-d complication rate was 36%, with two Clavien-Dindo grade II and two grade III complications that were not attributable to the novel surgical technique. At 12 mo, all patients reported daytime UC or use of a safety pad; at night, seven patients were continent or used a safety pad. Regarding 12-mo EF, four patients were potent without a need for medications, while six were potent with the use of oral phosphodiesterase type 5 inhibitors and one with the use of intracavernosal injections. Limitations include the small number of cases.

Conclusions: LDA-sparing RARC is an applicable and reproducible procedure. Our results suggest that this approach is associated with good functional outcomes in terms of UC and EF.

Patient summary: We describe a novel approach for robot-assisted removal of the bladder that allows greater preservation of nerve bundles and other structures. Our study shows that the technique is safe and associated with good outcomes for urinary function and erectile function for patients eligible for this surgical procedure.

Keywords: Bladder cancer; Functional outcomes; Robotic surgery.