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Page 4 of 6 Chen et al. Mini-invasive Surg 2021;5:54 https://dx.doi.org/10.20517/2574-1225.2021.69

traction on the sigmoid colon.

Intracorporeal ileal conduit creation
We begin the intracorporeal reconstruction portion of the case with the bipolar forceps at the 6 o’clock
position, needle driver at 9 o’clock, and Cadiere forceps at 3 o’clock. The left ureter is tunneled under the
presacral space and sigmoid colon, with the Cadiere forceps pulling the ureter through into the right
retroperitoneum. The ileocecal valve is then identified, and a 3-0 Vicryl stay stitch is placed 30 cm from the
valve, with a 15 cm segment of ileum marked out for the conduit. At this time, we switch the needle driver
to the 3 o’clock position and Cadiere to 9 o’clock, and monopolar scissors at 6 o’clock. Ligasure is used to
take down the mesentery. The monopolar scissors are used to open up the bowel at both ends. The Endo-
GIA stapler is advanced through the 12 trocar assistant port, and a stapled side-to-side small bowel
anastomosis is performed at the first and second corners of each end of the bowel. This is first stapled across
longitudinally, and then stapled again to seal the edge of the side-to-side anastomosis. Additional 3-0 Vicryl
is used to buttress the staple line. We then orient the proximal segment of the ileal conduit towards the
pelvis and the distal end towards the skin.

The right ureter is trimmed, with the distal ureter sent for frozen pathology. The ureter is then spatulated
and anastomosed to the conduit in an end-to-side fashion with a running 4-0 Vicryl in a Bricker style. This
is done with the Cadiere at the 6 o’clock position to hold the conduit down and the bipolar forceps holding
the ureter up - it must be noted that no assistant is needed for the anastomosis. We similarly prepare,
spatulate, and anastomose the left ureter to the proximal end of the ileal conduit in an end-to-side fashion
in the Bricker style.

Before each anastomosis is closed, we place single-J ureteral stents inside each ureter in the following
fashion. Through the gel point, we insert a laparoscopic right angle holding a Motion wire inside the 2.5 cm
right lower quadrant incision beside the robotic instruments. The wire is then passed from the distal to the
proximal end of the conduit using the laparoscopic right angle, and pulled through with the Cadiere
forceps. The wire is then advanced into the ureter, and the single-J stent is advanced over the wire up the
ureter until resistance is felt. The same step is used to place a stent up the ureter. After the conclusion of the
ureteral-ileal anastomoses, the single j is secured to the distal part of the conduit with a long 0 Vicryl suture,
the tail of which can be followed through the gel point. Eventually, a 15 round JP drain is inserted into the
pelvis via the 5 mm port, which we suture to the skin with a 2-0 nylon. The robot is then undocked, the
pneumo removed, and the specimen is removed through the SP incision. If needed, the incision is
lengthened slightly to accommodate the sample. At this point, pulling gently on the 0 Vicryl previously
placed, we can recover the distal part of the conduit, grab it with a ring forceps and bring it out through the
SP incision. The stoma is then secured with 3-0 Vicryl to the fascia with seromuscular bites, and then the
end of the stoma is matured, securing it to the dermis with seromuscular to mucosa to dermal sutures
circumferentially, taking care not to suture the mesentery of the ileum. The stents are then trimmed and
brought into a urostomy bag.

RESULTS
[5-7]
A total of 3 articles were found in the literature that summarized early patient outcomes after SP RARC .
Including our institution, a total of 21 patients were included in the final analysis. The average patient age
was 68 years old, 16 of the 21 patients were male, and 13 of the 21 patients had intracorporeal urinary
diversions. The average operative time was 366 min with average estimated blood loss of 185. Average
length of stay was 5.4 days. Among these patients, there were three 30-day 188 complications noted and five
90-day complications, all of which were Clavian II or lower [Table 1].