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Maqboul et al. Mini-invasive Surg 2021;5:44 https://dx.doi.org/10.20517/2574-1225.2021.54 Page 3 of 19

review will focus on the Karolinska modified Studer U technique, which is the procedure that the authors
have the most experience in and was also the most common technique used in our series review [Table 1].

Patient preparation, set up, and trocar positioning
Most high-volume robotic centers will engage in ERAS protocols for robotic cystectomy and ICUD .
[7]
Regarding preoperative patient advice, ERAS protocols now recommend written and oral counselling and
education on the nature of the procedure and postoperative care as well as preoperative medical
optimization. Mechanical bowel preparation can be avoided; suitable patients should be encouraged to have
preoperative carbohydrate loading. In the 24 h prior to surgery, they should adopt a low residue diet, with
solids and clear fluids for 6 and 2 h respectively .
[7]

In the operating room (OR), the patient is placed under general anesthesia and in the lithotomy position
with the operating table at maximum Trendelenburg position. Pneumatic calf compression is applied to
reduce the risk of deep vein thrombosis, the patient’s arms are fixed along their sides, and a body warmer is
used over the thorax to prevent hypothermia. Antibiotic prophylaxis with broad-spectrum antibiotics
should be given at induction, and low molecular weight heparin is given in the early postoperative period
and continued for 4 weeks post-surgery.

Trocar positioning is a crucial part of the procedure; the operation can proceed smoothly by setting up the
robotic arms and instrument positions. With the Da Vinci Xi system, the 8 mm camera port is placed first,
1-2 cm to the left of the midline and 3-5 cm above the umbilicus. Next, two further robotic 8 mm ports are
placed 8-10 cm right and left of the midline at the level of the umbilicus. The left-sided assistant port is
2-3 cm above and medial to the anterior superior iliac spine (ASIS), as well as 8-10 cm away from the left-
sided robotic port. It is a 15 mm port that allows the bowel stapler to pass through during the bowel work
and anastomosis. At other times, a robotic 8 mm port with the instrument can be telescoped through it as
the “fourth arm”. The final two ports are 12 mm assistant ports, the first symmetrically between the camera
and right robotic port, and far right, 8-10 cm from the right robotic port, approximately 2-3 cm superior
and medial to the right ASIS . Next, we discuss the neobladder formation and skipping cystectomy part.
[8]
THE STUDER U MODIFIED NEOBLADDER (SEE FIGURES 1-18 AND THE “TIPS AND
TRICKS” SECTION)
The original description of the Studer U orthotopic neobladder has been modified according to Wiklund
[8]
and Poulakis for robotic intracorporeal reconstruction. Although other robotic centers may have their
[9]
own modifications to Studer’s original technique, the fundamental steps are the same . After trocar
placement, the RARC and extended pelvic lymph node dissection (EPLND) are carried out before the RIN.
For the purposes of standardization and education, the RIN procedure is then broken down into the
following modules:

Demarcation of the neobladder bowel segment [Figure 1]: 50 cm of ileum is identified, at least 25 cm away
from the ileo-cecal junction, and brought down into the pelvis in a U shape. The “tip” of the U is the site of
the urethro-ileal anastomosis (UIA). The right ileal limb above the UIA will be 10 cm in length, and the left
ileal limb will be 40 cm in length. Bringing the ileum down to the urethra is generally easier in females.

Urethro-ileal anastomosis [Figures 2 and 3]: in keeping with the Rocco principle and to allow a tension-free
anastomosis, the posterior aspect of ileal serosa is sutured to the sub-urethral tissues. Following this, a 2 cm
incision is made through the ileum into the lumen, and the formal anastomosis is completed using double-
needle 3-0 monofilament synthetic absorbable suture (Biosyn). The first sutures are placed on the urethra in